Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty

Abstract

Background: There is limited literature exploring how nonmedical factors such as social determinants of health (SDOHs) are associated with postoperative outcomes following shoulder arthroplasty.

Methods: A retrospective cohort review of the Pearl Diver Database was used to capture patients undergoing either primary anatomic total or reverse shoulder arthroplasty from the fourth quarter of 2015 to the third quarter of 2019 with at least 1 year of active longitudinal follow-up. Patients with proximal humeral fractures, stress fractures, or septic arthritis were excluded. The included patients were then divided into 2 cohorts based on the presence of current SDOHs or a history of SDOHs. The SDOH cohort comprised 4 non-mutually exclusive categories: economic, educational, social, and environmental disparities. Subsequently, a control cohort was matched at a 1:1 ratio to the SDOH cohort. Primary outcome measures were assessed using a logistic regression and consisted of the following 90-day postoperative complications: minor and major medical complications and infection. Emergency department (ED) visits and readmissions for any cause were also assessed. Additionally, the following 1-year outcomes were assessed: aseptic loosening, instability, and revision arthroplasty. Surgical costs and 90-day postoperative costs were collected using averaged insurance reimbursements for both the control and SDOH cohorts.

Results: There were 5190 patients in each cohort. Economic disparities made up the largest portion of the SDOH cohort (n = 4631, 89.2%), followed by social (n = 741, 14.3%), environmental (n = 417, 8.0%), and educational (n = 99, 1.9%) disparities. Compared with the control cohort, SDOHs were associated with an increased risk of major complications (2.3% vs. 1.4%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.29-1.87; P < .001), minor complications (5.7% vs. 3.8%; OR, 1.62; 95% CI, 1.21-1.95; P = .001), readmissions (4.3% vs. 2.8%; OR, 1.56; 95% CI, 1.26-1.84; P < .001), and ED visits (15.2% vs. 11.0%; OR, 1.45; 95% CI, 1.29-1.63; P < .001) within 90 days following surgery. Additionally, SDOHs were associated with an increased risk of aseptic loosening (1.1% vs. 0.6%; OR, 1.85; 95% CI, 1.20-2.65; P = .006), instability (4.0% vs. 2.2%; OR, 1.80; 95% CI, 1.43-2.28; P < .001), and ipsilateral revision (9.2% vs. 7.6%; OR, 1.24; 95% CI, 1.08-1.43; P < .001) at 1 year postoperatively compared with the control cohort.

Conclusion: SDOHs are associated with increased rates of adverse outcomes following shoulder arthroplasty including revision surgery, ED visits, length of stay, and overall cost compared with matched controls without SDOHs. Specifically, economic and educational disparities are associated with increased rates of adverse outcomes following surgery including revision surgery, ED visits, length of stay, and overall cost.

Keywords: Anatomic total shoulder arthroplasty; complications; cost; educational disparities; reverse total shoulder arthroplasty; revision surgery.