Determinants of prolonged hospitalisation following shoulder arthroplasty: a systematic review of patient and health system factors

Background

Shoulder arthroplasty utilisation is rising rapidly worldwide, driven predominantly by reverse procedures, with volumes projected to exceed 350,000 annually in the United States by 2025. Hospital length of stay (LOS) is a key driver of cost and resource utilisation, yet no comprehensive synthesis of patient- and health system-related predictors exists.

Methods

This systematic review adhered to PRISMA 2020 and SWiM guidelines. Five databases (PubMed, Embase, Medline, Scopus, Web of Science) were searched from inception to July 2025. Eligible studies assessed factors influencing LOS or prolonged hospitalisation following shoulder arthroplasty. Qualitative synthesis was conducted due to heterogeneity.

Results

A total of 52 studies comprising 2,153,034 patients were included. Advancing age (commonly ≥75–80 years; LOS increase 0.4-1.8 days; OR 1.8-3.6) and female sex (OR 1.5-2.8) were the most consistent predictors of prolonged LOS. Morbid obesity (BMI ≥40 kg/m2; LOS increase 0.3-0.9 days), non-White ethnicity (particularly Black patients; LOS increase 0.1-0.5 days), adverse social determinants (e.g., living alone; OR 1.4-1.6), public insurance (Medicaid/Medicare; OR 1.6-4.8), and low hospital or surgeon volume (LOS increase 0.4-0.9 days) were also independently associated with longer stays.

Conclusion

Prolonged LOS after shoulder arthroplasty is multifactorial, with non-modifiable demographic factors compounded by modifiable social and structural elements. These findings provide an evidence-based framework for risk stratification, preoperative optimisation, and health system redesign to facilitate safe LOS reduction and equitable care amid escalating procedural demand.