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.

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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).