Monday, March 6, 2023

What determines the outcome or rotator cuff repair; is it the patient's insurance?

While much attention is being focused on the details of the technique of rotator cuff repair (RCR), the characteristics of the patient - rather than the technical details - may play an even more important role in determining the outcome.

The authors of Payor type is associated with increased rates of reoperation and health care utilization after rotator cuff repair: a national database study studied the 90 day incidence of medical complications, emergency department visits, and hospital readmissions, as well as 1-year incidence of revision repair, revision to arthroplasty, and cost of care were evaluated using a large national database. Medicaid patients were matched in a propensity scoring methodology in a ratio of 1:10 to Medicare and commercial patients based on age, sex, and various medical comorbidities including coronary artery disease, uncomplicated diabetes mellitus, obesity, tobacco abuse, chronic pulmonary disease, liver disease, peripheral vascular disease, renal disease, cancer, and congestive heart failure.

It is of interest how unhealthy the patients were overall (see table below): 80% had hypertension, 60% had depression, 50% were obese, 50% had chronic pulmonary disease, 50% had diabetes, over 50% used tobacco, 30% had coronary artery disease.  As a group, these patients do not seem to be ideal candidates for elective surgery.

In spite of the matching it can be seen from the table below that the Medicaid population had a higher prevalence for 12 of the comorbidity diagnoses.     

While individually the differences in the prevalence of these comorbidities were not statistically significantly different among the three insurance groups, their cumulative prevalence was 30% greater for the Medicaid group than for the Medicare or commercial insurance groups, indicating that as a group they were less healthy before surgery. These things add up.

The authors reported that 
1. Medicaid insurance was associated with an increased 90-day risk of various medical complications, emergency department (ED) visits, and 1-year revision RCRs compared with Medicare insurance. 

2. Medicaid insurance was also associated with an increased risk of various medical complications, ED visit, and hospital readmission, as well as 1-year risk of revision RCR and conversion to arthroplasty compared with commercially insured patients. 

3. Medicaid insurance was associated with higher 1-year cost of care compared with patients with either Medicare or commercial insurance.

Comment: The authors concluded, "This study shows that payor type impacts outcomes after RCR. Patients with Medicaid insurance were more likely to sustain increased medical complications, revision surgery, and increased health care utilization compared with Medicare and commercially insured patients." 

This conclusion was reached without controlling for disparities in critical determinants of health: economic, social, environmental, and educational charateristics as discussed in Risk factors for adverse adverse outcomes after shoulder arthroplasty. 

In this type of study it is important to avoid a "fundamental attribution error", in other words attributing the effect to type of insurance rather than to differences in medical comorbidities and social determinants of health. A simple test will illustrate: if a patient on Medicaid insurance is scheduled for rotator cuff repair, but the week before suddenly was able to change to commerical insurance, would that change the risk of the adverse outcomes shown in Table III above? 

Irrespective of insurance type, complications such as pulmonary embolism, deep venous thrombosis, transfusion, pneumonia, stroke, myocardial infarction, sepsis, acute anemia, renal failure and urinary tract infections occur more often in patients who are overall less healthy, less wealthy, less educated, as well as less supported by family, friends, and primary care providers.

Surgeons can optimize their outcomes for cuff repair by identifying these factors and mitigating the associated risks before proceeding with this elective procedure. 

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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).