Predictors for failed same-day discharge after total shoulder arthroplasty

Same-day discharge (SDD) after total shoulder arthroplasty (TSA) has gained popularity with expansion of TSA performed in the ambulatory setting. Prolonged post-operative length of stay remains challenging, contributing to increased health-care costs without improved outcomes. Identifying risk factors predictive of failed SDD is critical for optimizing patient selection for outpatient vs. inpatient post-operative care settings. The purpose of this study was to evaluate risk factors associated with failure of SDD after TSA.

This was a retrospective review of 808 patients who underwent primary reverse or anatomic TSA between September 2016 and August 2025 at a single institution. Patients undergoing hemiarthroplasty and revision arthroplasty were excluded. Data collected included demographics, comorbidities, pre-operative laboratory and imaging findings, physical examination metrics, and perioperative pain control. SDD was defined as discharge within 24 hours of surgery; failure was defined as discharge >24 hours after surgery. Logistic regression models were used to evaluate potential predictors of SDD failure, controlling for age, body mass index, sex, laterality, race, and type of arthroplasty. The Benjamini-Hochberg procedure was applied to control for false discovery. Odds ratios with 95% confidence intervals were reported.

Among 808 patients, 377 (46%) achieved SDD. American Society of Anesthesiology (ASA) physical status classification was the only statistically significant predictor of SDD failure (P < .001). Overall, SDD failure rates included: 20% for ASA 1, 36% for ASA 2, 49% for ASA 3, and 71% for ASA 4. No other demographic or intraoperative variables (age, sex, body mass index, race, laterality, arthroplasty type, smoking status, cardiopulmonary disease, prior shoulder surgery, steroid use, and intraoperative factors) demonstrated statistically significant associations with SDD failure.

In this cohort, ASA classification was a significant predictor of failure for SDD after TSA. In particular, ASA Class 3 and 4 patients are at significant risk for length of stay >24 hours. These findings can inform clinical decision-making to optimize outpatient surgical pathways, improve patient counseling, and reduce health-care expenditures.