Abstract
BACKGROUND: With increasing efforts to transition shoulder arthroplasty to the ambulatory surgery setting, there is increased interest in predictive factors of failure of same-day discharge (SDD). The purpose of this study was to identify predictors of failing SDD, defined as requiring at least an overnight hospital stay after shoulder arthroplasty, and to develop a predictive model to identify which patients may require postoperative hospital admission.
METHODS: A retrospective review of a consecutive series of patients with rotator cuff arthropathy or osteoarthritis treated with primary anatomic or reverse total shoulder arthroplasty between January 2019 and June 2023 was conducted. Inclusion criteria included patients intended for SDD, whereas patients who underwent arthroplasty for fractures, patients younger than 45 years, and patients with incomplete data were excluded. Data on demographics, Charlson Comorbidity Index, preoperative opioid use, and preoperative steroid injections were collected. In addition, intraoperative metrics including American Society of Anesthesiologists score, surgical/anesthesia time, surgical start time, and blood loss were recorded. Multivariate logistic regression was used to identify predictors of failure of SDD. Results were displayed as odds ratios (OR) and 95% confidence intervals. The α threshold was set to P < .05.
RESULTS: A total of 333 patients (69 anatomic total shoulder arthroplasty and 264 reverse total shoulder arthroplasty) were included with 92 failures of SDD (27.6%). According to multivariate results, we found older age (OR: 1.44, P = .004), anesthesia start time per hour later in the day (OR: 6.03, P = .017), preoperative opioid use within the past year (OR: 1.82, P = .046), and female sex (OR: 2.76, P = .001) as statistically significant risk factors for not achieving SDD. In addition, each half-hour increase in length of time under anesthesia was statistically significant, increasing odds of failing SSD by 4.28 per half hour (P < .001). A diagnosis of rotator cuff arthropathy had 3.40 greater odds of failing to achieve SDD as compared with a diagnosis of osteoarthritis (P < .001). Overall, the model had a high level of predictability, yielding a receiver operating characteristic curve area under the curve of 83%.
CONCLUSIONS: Older age, rotator cuff arthropathy, female sex, preoperative opioid use, and prolonged anesthesia exposure were significant predictors of failure of SDD after shoulder arthroplasty. These results support the utility in risk stratification strategies of patients to accurately triage them into SDD pathways. In addition, our results suggested that collaboration between surgeons and anesthesia teams may allow for more accurate risk stratification and optimization of resource utilization when deciding which patients are appropriate candidates for SDD.