Disparities in postoperative total shoulder arthroplasty outcomes between Black and White patients

The Effect of Socioeconomic Status and Social Deprivation on Outcomes Following Reverse Shoulder Arthroplasty: Data From an Urban Academic Center

PURPOSE

Rotator cuff tear arthropathy (CTA) and glenohumeral osteoarthritis pose notable financial and symptomatic burdens on the aging population. This study aims to determine how social determinants of health affect patient-reported outcomes following reverse total shoulder arthroplasty (rTSA), the surgical treatment for cuff tear arthropathy and glenohumeral osteoarthritis.

METHODS

A single-center retrospective review was conducted for patients who underwent rTSA between 2017 and 2022. Zip codes were used to determine income levels, as defined by the U.S. Department of Housing and Urban Development (HUD) and the Federal Reserve (FED). Social disadvantage was quantified using Social Deprivation Index (SDI). The American Shoulder and Elbow Score (ASES) was obtained by chart review or calls at a minimum 2-year follow-up. Statistical analysis was notable done using analysis of variance, Kruskal-Wallis, and Pearson chi-square tests.

RESULTS

A total of 121 patients met inclusion criteria. Of those included, 101 patients (83%) had 2-year ASES scores. Patients were divided into three cohorts based on HUD income status, FED income status, and SDI score. A difference was observed in 2-year ASES scores when stratified by HUD subgroups (P = 0.011); however, no difference was observed in 2-year ASES scores between FED or SDI subgroups. Analysis yielded no differences in pain scores, range of motion, total length of hospital stay, complications, or revision rates between all subgroups (all, P > 0.05).

DISCUSSION

The results of this study yielded no notable difference in postoperative ASES scores between FED classes or SDI subgroups. Although a difference was observed in ASES scores between HUD classes, it may be clinically negligible. Contrary to previous literature, socioeconomic status and social deprivation did not affect postoperative outcomes within our patient population.

CONCLUSION

Social determinants of health did not affect outcomes of patients undergoing a rTSA within the first 2 years after surgery.

LEVEL OF EVIDENCE

III.

Patient race and ethnicity are associated with higher unplanned 90-day emergency department visits and readmissions but not 10-year all-cause complications or reoperations: a matched cohort analysis of primary shoulder arthroplasties

Background

Within orthopedic surgery, there remain limited data evaluating the impact of racial and socioeconomic disparities on outcomes of primary shoulder arthroplasty (SA) over time. As such, we analyzed both short- and longer-term outcome differences in complications, reoperations, and revision surgery of primary SA when performed in non-White patients when compared to a matched cohort of White patients who had undergone SA.

Methods

Over a 39-year period (1981-2020), an institutional Total Joint Registry Database was utilized to identify all non-White patients (Asian/Pacific Islander, Black, Hispanic or Latino, American Indian/Alaska Native, other) who underwent primary SA with a minimum of 2 years of follow-up. The search identified 275 primary SA (46 hemiarthroplasties, 97 anatomic total shoulder arthroplasties, and 132 reverse total shoulder arthroplasties). The ethnicity composition was 8.7% Asian, 27.3% Black, 37.8% Hispanic, 12.4% American Indian, and 13.8% other. This cohort was matched 1:2 according to age, sex, diagnosis, implant, and surgical year to a control group of 550 White patients who had undergone SA. The rates of medical and surgical complications, reoperations, revisions, and implant survivorship were assessed. The mean follow-up time was 6.3 years (range, 2 to 40 years).

Results

Comparisons between the non-White and White matched cohorts demonstrated a higher rate of tobacco use (14.2% vs. 10.5%; P < .001), diabetes (21.5% vs. 11.8%; P < .001), length of stay (1.9 vs. 1.6 days; P = .014), and a lower rate of private commercial insurance (27.3% vs. 44.5%; P < .001 in the non-White cohort. Within the first 90 days after surgery, non-White patients had a higher rate of emergency department visits (5.5% vs. 0.9%; P < .001) and unplanned readmissions (2.9% vs. 0.7%; P = .014). After the first 90 postoperative days, there were no differences regarding medical (1.8% vs. 0.7%; P = .135) or surgical complications (12.0% vs. 13.6%; P = .446). Ten-year survivorship free of all-cause complication (76.8% vs. 81.5%; P = .370), reoperation (84.9% vs. 89.8%; P = .492), and revision (89.3% vs. 91.4%; P = .715) were similar between the non-White and White cohorts.

Discussion

After accounting for age, sex, and surgical indication, patient race and ethnicity were not associated with an increased risk of long-term all-cause complications, reoperations, or revision surgery after primary SA. However, within the first 90 postoperative days, non-White patients had a higher likelihood of unplanned emergency room visits and readmissions.

Rotator Cuff Repair: Racial Disparities in Operative Time and Utilization of Arthroscopic Techniques

Background Racial disparities are prevalent within the field of orthopedics and include the utilization of varying resources as well as outcomes following surgery. This study investigates racial differences between Black and White patients in the surgical treatment of rotator cuff repair (RCR) and 30-day postoperative complications following RCR. Materials and methods Data were drawn from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to create a study population consisting of Black and White patients who underwent RCR between 2015 and 2019. A bivariate analysis was conducted to compare patient demographics and comorbidities. Multivariate logistic regression, controlling for all significantly linked patient demographics and comorbidities, was performed to examine the relationships between Black race and complications. Results Our analysis included 32,073 patients, of whom 3,318 (10.3%) were Black and 28,755 (89.7%) were White. The female gender, younger age groups, greater BMI groups, ASA classification ≥3, cigarette use, and comorbid congestive heart failure (CHF), diabetes, and hypertension were all significantly associated with patients who identified as Black. We found no significant differences in 30-day postoperative complications between Black and White patients. Furthermore, Black patients were found to be independently associated with a greater likelihood of undergoing arthroscopic RCR versus open RCR, as well as experiencing a longer total operation time of ≥80 minutes. Conclusions We report no differences in 30-day postoperative complications between Black and White patients undergoing RCR between 2015 and 2019. However, Black race was independently associated with higher rates of arthroscopic RCR and longer operative times.

Racial Disparities in 30-day Readmission After Orthopaedic Surgery: A 5-year National Surgical Quality Improvement Program Database Analysis

BACKGROUND

Readmission rate after surgery is an important outcome measure in revealing disparities. This study aimed to examine how 30-day readmission rates and causes of readmission differ by race and specific injury areas within orthopaedic surgery.

METHODS

The American College of Surgeon-National Surgical Quality Improvement Program database was queried for orthopaedic procedures from 2015 to 2019. Patients were stratified by self-reported race. Procedures were stratified using current procedural terminology codes corresponding to given injury areas. Multiple logistic regression was done to evaluate associations between race and all-cause readmission risk, and risk of readmission due to specific causes.

RESULTS

Of 780,043 orthopaedic patients, the overall 30-day readmission rate was 4.18%. Black and Asian patients were at greater (OR = 1.18, P < 0.01) and lesser (OR = 0.76, P < 0.01) risk for readmission than White patients, respectively. Black patients were more likely to be readmitted for deep surgical site infection (OR = 1.25, P = 0.03), PE (OR = 1.64, P < 0.01), or wound disruption (OR = 1.45, P < 0.01). For all races, all-cause readmission was highest after spine procedures and lowest after hand/wrist procedures.

CONCLUSIONS

Black patients were at greater risk for overall, spine, shoulder/elbow, hand/wrist, and hip/knee all-cause readmission. Asian patients were at lower risk for overall, spine, hand/wrist, and hip/knee surgery all-cause readmission. Our findings can identify complications that should be more carefully monitored in certain patient populations.

Predictors of Higher Costs Following Reverse Total Shoulder Arthroplasty

Objectives

The rising popularity of reverse total shoulder arthroplasties (RTSA) demands attention to its growing costs on the healthcare system, especially with the implementation of bundled payments. Charges associated with patients' inpatient stays can be mitigated with a better understanding of the drivers of cost following RTSA. In this study, we evaluate potential pre-operative and post-operative factors associated with higher inpatient costs following RTSA.

Methods

We identified 59,925 patients who underwent RTSA using the National Inpatient Sample between 2016 and 2019. Total inpatient hospital charges were collected, and patients were divided into "normal cost" or "high cost" groups. The high cost group was defined as patients with total costs greater than the 75th percentile. Univariate and multivariate analyses were performed on pre-operative demographic and comorbidity variables as well as post-operative surgical and medical complications to predict factors associated with higher costs. T-tests and Chi-squared tests were performed, and odds ratios were calculated.

Results

The mean total charges were $141.213.93 in the high cost group and $59,181.94 in the normal cost group. Following multivariate analysis, non-white patients were associated with higher costs by 1.31-fold (P<0.001), but sex and age were not. Cirrhosis and non-elective admission had higher odds of higher costs by 1.56-fold (P<0.001) and 3.13-fold (P<0.001), respectively. Among surgical complications, there were higher odds of high costs for periprosthetic infection by 2.43-fold (P<0.001), periprosthetic mechanical complication by 1.28-fold (P<0.001), and periprosthetic fracture by 1.56-fold (P<0.001). Medical complications generally had higher odds of high costs than surgical complications, with deep vein thrombosis having nearly five times (P<0.001) and myocardial infarction almost four times (P<0.001) higher odds of high inpatient costs.

Conclusion

Post-operative medical complications were the most predictive factors of higher cost following RTSA. Pre-operative optimization to prevent infection and medical complications is imperative to mitigate the economic burden of RTSA's.