Social determinants of health disparities impact postoperative complications in patients undergoing total shoulder arthroplasty

Social Determinants of Health Disparities Increase 5-Year Revision Rates but Not Postoperative Complications After Primary Hip Arthroscopy

PURPOSE

To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and 5-year secondary surgery rates after primary hip arthroscopy using a large national database.

METHODS

A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Queries were performed to identify patients who experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH disparities within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. The odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of 5-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis.

RESULTS

A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who did not experience SDOH disparities (age of 41.0 years and 79.6% female sex in both cohorts). The odds of adverse events after arthroscopy were low and did not differ between the SDOH cohort (1.51%) and no-SDOH cohort (1.57%, P = .09). Additionally, there was no difference in the odds of 30-day ED visits between the SDOH cohort (5.65%) and no-SDOH cohort (4.79%, P = .10). The rate of 5-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs 4.1%, P = .02); however, there was no difference in the rate of any secondary surgery between cohorts (11.8% vs 10.4%, P = .10).

CONCLUSIONS

Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of 5-year revision hip arthroscopy compared with a matched-control cohort of patients not experiencing SDOH disparities.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Social Determinants of Health Impact Complications Following Free-Flap Reconstruction for Head and Neck Cancer

OBJECTIVE

Head and neck cancers (HNCs) have increased in prevalence and often require free-flap reconstruction (FFR) after tumor ablation. Postoperative complications following FFR can be high, occurring in as many as 48% and 71% of cases. HNC patients also have many disparities in Social Determinants of Health (SDOH), but the potential impact of SDOH disparities on postoperative complications following FFR has not been formally assessed.

STUDY DESIGN

Retrospective cohort review.

SETTING

Academic Tertiary Care Institution in Northeast United States.

METHODS

Patients that underwent head and neck FFR between January 2018 and December 2021 were analyzed to determine associations between quartiles of the national Area Deprivation Index (ADI), a proxy for SDOH disparity, and various medical and surgical postoperative complications. Associations were assessed using χ2 analysis.

RESULTS

Two hundred four patients were included in the study, and 61 patients had 97 complications. Significant associations between higher national ADI quartile and incidence of several postoperative complications were identified, including any surgical complication (P = .0419), wound dehiscence (P = .0494), myocardial infarction (MI) (P = .0215), and sepsis (P = .0464).

CONCLUSION

There are significant associations between SDOH disparities and postoperative surgical complications, wound dehiscence, MI, and sepsis following head and neck FFR. Addressing SDOH disparities in HNC is pivotal to enhance postoperative outcomes and promote holistic patient care.

Racial and socioeconomic disparities in risk and reason for revision total shoulder arthroplasty

BACKGROUND

With the rise of total shoulder arthroplasty (TSA), revision TSA is also becoming more prominent. However, there is a paucity of literature on potential racial, ethnic, and socioeconomic disparities regarding revision TSA. The purpose of this study is to determine the risk and reason for revision TSA between racial, ethnic, and socioeconomic groups.

METHODS

The National Inpatient Sample was queried from 2016 to 2020 to identify all patients who underwent primary TSA and revision TSA. The risk of revision was calculated for each racial, ethnic, and socioeconomic group between 2016 and 2020 using the total number of revision and primary TSAs. The reason for revision was also compared between cohorts.

RESULTS

Hispanic patients were 13% less likely to undergo revision TSA than White patients after primary TSA (odds ratio [OR] = 0.87). Black and Asian/Pacific Islander patients demonstrated similar risks of revision to White patients. Black and Hispanic patients were 48% and 63% less likely to have mechanical complications as the cause of revision than White patients, respectively (OR = 0.52 and 0.37), and Black patients were 5 times more likely to require revision due to osteolysis (OR = 4.8). Risk of revision TSA was similar between socioeconomic groups. Patients of lower socioeconomic status were less likely to require revision due to mechanical complications or osteolysis than patients in the highest income quartile.

CONCLUSION

Racial, ethnic, and socioeconomic disparities exist in revision TSA, though not to the extent that has previously been investigated in lower extremity total joint arthroplasty. Race was predictive of the reason for revision TSA with Black patients undergoing revision for different reasons on average than White patients. The reasons for revision also differed across income quartiles with lowest income quartile patients differing from those in the highest income quartile. Raising awareness and emphasizing the reduction of variability could aid in further decreasing these disparities and alleviating the impact of social determinants of health on revision TSA.

Trends and predictors of reporting social determinants of health in shoulder surgery

Background

The role of social determinants of health (SDH) in patient outcomes, quality of life, and overall well-being has been well documented. However, the inclusion of these variables in randomized control trials (RCTs) remains limited; thus, the extent of generalizability from such trials is brought into question. The purpose of this study is to explore the rates of reporting SDH variables in RCTs focused on shoulder surgery from the past decade.

Methods

The PubMed database was searched for RCTs with a focus on shoulder surgery from 2013 to 2023. Duplicates, responses to the editor, biomechanical studies, and nonshoulder studies were excluded. Each article was reviewed and data pertaining to patient demographics and socioeconomic covariates. Journal of publication was recorded, and studies from the 5 most common journals were analyzed. These journals were the Journal of Shoulder and Elbow Surgery, the Journal of Bone and Joint Surgery, the American Journal of Sports Medicine (AJSM), the Bone and Joint Journal, and the Journal of the American Medical Association. Multivariate logistic regression was performed to determine the independent effect of study characteristics on the reporting rates of SDH.

Results

A total of 255 articles were reviewed. Of these, 93.3% and 90.2% of articles reviewed reported age and sex, respectively. Employment status was reported in 11.8% of articles. Less than 10% reported race, ethnicity, income, insurance, and housing, with even less performing formal analyses on these variables. Studies that were conducted in the United States, multicenter, had a sample size of 251+, and had a combination of public and private funding which were significantly more likely to report on race and ethnicity. Reporting employment status was significantly associated with being European-based, multicenter, sample size 251+, double-blinded, and published in AJSM. Newer studies were significantly less likely to report education. Only publication in AJSM was significant for reporting income. Study intervention and topic were not significant for any SDH reporting.

Discussion

These data reflect how small of a proportion of RCTs report and analyze on SDH variables. These findings reflect a need for future RCTs to accurately report SDH variables that influence outcomes, such as race, ethnicity, education, employment, income, housing status, and insurance. SDH are infrequently reported and analyzed in RCTs pertaining to shoulder surgery. Academic medical journals should incorporate guidelines to encourage studies to include such variables and enable the assessment of outcomes to apply to a broader population.