Thursday, March 22, 2018

Economic status and shoulder arthroplasty outcomes

The effect of lower socioeconomic status insurance on outcomes after primary shoulder arthroplasty

These authors compared minimum two-year functional and patient-reported outcomes for primary shoulder arthroplasty in 143 patients (64 Medicare/Medicaid, 79 private insurance)  aged younger than 65 years with lower socioeconomic insurance compared with those with private insurance.

Age, race, diagnosis, and type of arthroplasty were similar between groups. Patients with Medicare/Medicaid insurance demonstrated worse PROs before and after surgery, despite similar range of motion at both assessments. Despite poorer PROs postoperatively, both groups demonstrated similar improvements after surgery.

For example the patients with lower socioeconomic insurance had preoperative and postoperative SST scores averaging 2.5 and 8.5 respectively in comparison to 3.7 and 9.5 for the private insurance group.

The socioeconomically disadvantaged group experienced more complications (14% vs. 9%, P = .3) and reoperations (11% vs. 6%, P = .2), with 7 of 9 complications undergoing reoperation. Three total shoulder arthroplasties (TSAs) developed postoperative rotator cuff insufficiency and were converted to an RSA. Periprosthetic fractures occurred in 2 RSAs, with 1 requiring open reduction and internal fixation. Aseptic glenoid loosening developed in 2 TSAs, with 1 being revised to an RSA 10 years after the index procedure. One RSA was revised due to subjective subluxations associated with pain. Another RSA had a reported dislocation, which was reduced in a closed fashion at another institution.

The private insurance group experienced 7 complications, with 4 undergoing reoperation. Postoperative rotator cuff insufficiency developed in 2 TSAs, with 1 electing to undergo revision to a RSA. Aseptic glenoid loosening developed in 1 TSA, but the patient chose not to pursue revision surgery. Another TSA underwent nonoperative treatment for a periprosthetic fracture. One TSA was treated for a presumed infection in a staged fashion. One RSA sustained a traumatic disruption of the glenoid baseplate secondary to a fall, requiring revision RSA. One TSA required reoperation to remove a retained piece of metal after primary arthroplasty.

Comment: This study suggests that economic status of itself should not be an indication for or against shoulder arthroplasty.

We suggest that social health, physical health, and mental health are much more important considerations in determining which patients are likely to benefit from this elective surgery. These data were collected in this study; it would have been illuminating to see a multivariate analysis of the effect of these and other variables on the outcome of shoulder arthroplasty.

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