Risk factors for adverse outcomes after shoulder arthroplasty

It is being increasingly recognized that patient characteristics - rather than shoulder characteristics - are the most important factors in determining the outcome of shoulder arthroplasty. For example, a recent article, Comparison of reverse shoulder arthroplasty and total shoulder arthroplasty for patients with inflammatory arthritis, pointed to the challenges of managing the shoulder with rheumatoid arthritis: high rates of cuff tear with anatomic arthroplasty and high rates of acromial and spine fractures after reverse total shoulder.

The authors of Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty, considered another set of patient characteristics that have a strong influence on patient outcome after arthroplasty: poor education, poverty, and social deprivation and adverse environment. They compared revision rates of 5190 patients with these social determinants of health (SDOH) to 5190 matched patients without.

Economic disparities made up 89.2% of the SDOH cohort, followed by social (14.3%), environmental (8.0%), and educational (1.9%), although it is evident that some or indeed all of these may co-exist in a given patient.

Compared with the control cohort, SDOHs were associated with almost twice the risk of major complications as well as increased rates of minor complications, readmissions, and ED visits.

SDOHs were also associated with increased risks of aseptic loosening, instability, and ipsilateral revision as well as increased length of stay and costs of care.

Comment: One of the important aspects of this study is that it used adverse events as the primary outcome of interest in a defined patient population. This measure is not subject to the problem of patients lost to followup which confounds clinical followup studies and systematically excludes patients who are educationally, financially and socially compromised.

It teaches us that considering shoulder arthroplasty in each individual requires an understanding of three "E"s: education, economics and environment. Those with compromised social determinants of health require special attention to the advisability of proceeding with arthroplasty and to anticipating and planning to mitigate the risks of medical and surgical problems. The surgical team has the responsibility for taking extra time and care to communicate these concerns to the patient and their family before surgery, recognizing limited health literacy. This may be challenging in patients with lower levels of education or for whom English is not their primary language. Equally important is assuring that the patient has enhanced social support following surgery coupled with careful surveillance for possible adverse events.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

The effect of economic and educational disparities on outcomes of shoulder arthroplasty - what can be done to address it?

While there is great interest in the use of new technologies to improve patient outcomes from shoulder arthroplasty, as pointed out by the authors of  Assessing the Value to the Patient of New Technologies in Anatomic Total Shoulder Arthroplasty, it may be that the greatest opportunity for improving the outcomes of shoulder arthroplasty lies not in new technologies, but rather in refining the indications for the procedure, careful patient selection, careful choice of implants, and optimizing surgical technique.

Earlier this year we posted, What is the effect of socioeconomic status on patients with glenohumeral osteoarthritis?, showing the patient's socioeconomic status has a major impact on the clinical manifestations of shoulder arthritis. In Surgeon and hospital shoulder arthroplasty volume affect patient outcome - more on this it was shown that socioeconomic status is associated with access to more experienced surgeons. 

A recent review was dedicated to The Impact of Socioeconomic Status on Outcomes in Orthopaedic Surgery

Pursuing this theme, the authors of Economic and Education Disparities are Associated with an Increased Risk of Revision Surgery Following Shoulder Arthroplasty investigated how non-medical factors such as social determinants of health (SDOH) associate with minimum one year outcomes following shoulder arthroplasty.

Patients were divided into two cohorts based on the social determinants of health (SDOH) including economic, educational, social, and environmental disparities. There were 5,190 patients in each cohort. The groups were matched with respect to age, sex, obesity, drug abuse, smoking, and Charson Comorbidity Index.

Economic disparities made up the largest portion of the SDOH cohort, followed by social, environmental, and educational. 

Compared to the control cohort, SDOH were associated with an increased risk of major complications, minor complications, readmission, and ED visits within 90 days following surgery. Additionally, SDOH were associated with an increased risk of aseptic loosening, instability, and revision at one year postoperatively.

While the surgical costs were similar, there was a statistically significant increase in the 90 day post operative cost and the length of stay.

The authors concluded that economic, educational, social, environmental, and educational disparities are associated with increased rates of adverse outcomes following surgery, including revision surgery, ED visits, length of stay, and overall cost.

Comment: This study again confirms that disadvantaged patients have on average poorer outcomes and increased costs of care. While economic, social, environmental, and educational disparities are identified as risk factors for suboptimal outcomes, the prospect of trying to modify the impact of these risk factors is daunting - so daunting that authors shy away from providing possible solutions. Considering a patient with disabling shoulder arthritis who also has economic, social, environmental, and/or educational disadvantages, what should a surgeon do? Should these risk factors for suboptimal outcomes change her or his tipping point for surgery? Can health care systems muster the resources to provide the essential additional support for disadvantaged patients needing arthroplasty? Or is it like the weather, "everyone talks about it, no one does a thing about it"?

An approach is to recognize that, in most cases, shoulder arthroplasty is an elective procedure. Thus the surgeon should take time to understand the challenges that recovering from surgery would place on the patient and to consider to what degree these can be managed. Then the surgeon and the patient can discuss whether proceeding with arthroplasty carries more benefit and less risk than non-operative management of the shoulder arthritis.

To add this blog to your reading list in Google Chrome, click on the reading list icon

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

What is the effect of socioeconomic status on patients with glenohumeral osteoarthritis?

 Lower Socioeconomic Status Is Associated With Worse Preoperative Function, Pain, and Increased Opioid Use in Patients With Primary Glenohumeral Osteoarthritis

These authors sought to characterize the role of socioeconomic status (SES) in 982 patients undergoing primary anatomic total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis (OA).

They assessed patient demographics, comorbidities, patient-reported outcome scores, range of motion, and preoperative opioid use. Each patient was assigned to a quartile according to the Area Deprivation Index (ADI) using their home address (see this link).

The map for Texas shows a huge variation in the ADI, ranging from most disadvantaged 
(dark red) to least disadvantaged (blue).

They found that the most disadvantaged patients (lower SES) had 

a higher body mass index

higher rates of preoperative opioid use 

higher rates of diabetes.

more preoperative pain (Constant—Pain and American Shoulder and Elbow Surgeons [ASES]—Pain) and

lower function (Constant—ADL, Constant—Total, and ASES). 

Multivariate regression identified that male patients and advanced age at surgery had better reported ASES pain scores, while preoperative opioid use, chronic back pain, and the most disadvantaged quartile were associated with worse ASES pain scores.

Comment: This study provides a means for stratifying an important characteristic of patients having shoulder arthroplasty: their socioeconomic status. The authors suggest that the area deprivation index is a better measure of socioeconomic status than insurance status alone because its methodology accounts for factors such as income/poverty, education, employment, housing, and occupation.

A notable finding of this study is that SES was directly correlated with the preoperative patient assessed comfort and function as shown below

This is important because preoperative ASES score is recognized as a strong predictor of the postoperative ASES score.

This study suggests that patients who are identified as socioeconomically disadvantaged are likely to benefit from preoperative attention to their overall health, nutrition, pain management and home support systems.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

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.

=====

The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Relationship of low income to surgical outcome

Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty.

In past posts we discussed the "4Ps" that influence the result of surgery: the Problem (e.g. arthritis or massive cuff tear) , the Patient with the problem (e.g. age, gender, smoking, socioeconomic factors) , the Procedure to be performed (e.g. hemiarthroplasty, reverse total shoulder) and the Physician performing the procedure (e.g. extent of training, annual volume of similar cases).

This article focuses on the second P, socioeconomic factors and their relationship to the results of total knee replacement in young patients. The authors surveyed 661 patients 1 to 4 years after primary TKA for noninflammatory arthritis. While this study concerns total knees, its findings are likely to hold true for elective surgery as well.

They found that patients reporting incomes of less than $25,000 were less likely to be satisfied with  outcomes and more likely to have functional limitations than patients with higher incomes. At a lower level of association, women and minority patients were more likely to have functional limitations. Employment status and educational level at the least impact on satisfaction and function. The choice of implant did not have a significant effect on the outcome of surgery.

While much of our literature focuses on the type of procedure and the choice of implant, this study clearly demonstrates that the second P - the patient - has a strong influence on the result. Or as Osler said, "It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has."

The reasons behind the association of low income with poorer outcome are as yet unknown. Readers may wish to visit a recent post regarding the relationship between revision and type of insurance. 

In an age of 'pay for performance', it will be essential that the incentives placed on good performance do not create an incentive to inappropriately avoid treating patients with lower incomes or those on Medicare and Medicaid.

===
Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


See the countries from which our readers come on this post.