A previous post (see this link) pointed to the importance of the influence of shoulder characteristics (such as tear chronicity, tear size, the degree of tendon retraction, and the extent of fatty degeneration of the cuff muscles) on the failure rate of rotator cuff repairs. While these factors local to the shoulder are important, a recent article, Social Determinants of Health Influence Clinical Outcomes of Patients Undergoing Rotator Cuff Repair: A Systematic Review, emphasized that characteristics of the patient (unrelated to the shoulder) may be even more important determinants of the outcome of rotator cuff repair.

The authors defined social determinants of health (SDOH) as the collection of environmental, institutional and intrinsic conditions that may bias access to, and utilization of, healthcare across an individual’s lifetime. Using a systematic review of 32 publications (102,372 patients) from 7 countries, they sought to investigate the influences that SDOH have on accessing appropriate orthopedic treatment, as well as its effects on patient-reported outcomes following rotator cuff repair (RCR).

Their multivariate analysis revealed female gender, labor intensive occupation, workers’ compensation claims, comorbidities, tobacco use, federally subsidized insurance, lower education level, racial/ethnic minority status, low-income, place of residence, low volume surgery regions, unemployment, and preoperative narcotic use contribute to delays in access to healthcare, more severe disease state upon presentation, and worse clinical outcomes.

These factors are interdependent. For example, socially disadvantaged patients experience many barriers to accessing care and are more likely to present to low-volume surgeons and low volume facilities. Individuals with a lower education level may have greater difficulty making treatment decisions and complying with post repair guidelines. Patients with subsidized insurance may have poorer overall health and less social support during recovery from surgery. Patients on worker's compensation insurance are more likely to be actively smoking.

Overall the impediments created by SDOH lead to worse clinical and patient-reported outcomes following RCR, including increased risk of postoperative complications, failed repair, higher rates of revision surgery, and decreased ability to return to work.

Comment: In addition to the social determinants of health, other non-shoulder factors are strongly correlated with the symptoms, function, and tipping point for surgery as described in Rotator cuff tears - what determines the patient's comfort and function? The association of insurance status with shoulder surgery outcomes is discussed here: Medicaid insurance and shoulder arthroplasty

Dr. Charles Neer often said, "here is the patient and here is the shoulder - both are equally important". Along these lines, we can conclude that the pathoanatomy of the rotator cuff is only one of the factors influencing the outcome of rotator cuff repair. Social determinants of health, depression, and anxiety may be as important to the outcome as the degree of cuff pathology. Unfortunately, most of these risk factors are not easily modifiable.

Rotator cuff repair is an elective procedure. The surgeon has time to assess both the shoulder and the individual in an effort to choose the treatment most likely to benefit the patient.

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