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Bethell MA, Mahoney HR, Adu-Kwarteng K, Kiwinda LV, Clark AG, Hammill BG, Boachie-Adjei YD, Anakwenze O, Péan CA. The impact of socioeconomic factors on 90-day postoperative readmissions and cost in shoulder arthroplasty patients. J Shoulder Elbow Surg 2025;34:1347-1355. [PMID: 39528043 DOI: 10.1016/j.jse.2024.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 08/31/2024] [Accepted: 09/03/2024] [Indexed: 11/16/2024]

Abstract

BACKGROUND

Understanding the impact of Social Drivers of Health on shoulder arthroplasty is pivotal for the development of equitable value-based payment models that enhance the quality of patient care. This investigation aims to understand the influence of Area Deprivation Index (ADI) on hospital admissions, readmissions, and associated costs postshoulder arthroplasty.

METHODS

We conducted an analysis using US Medicare claims data from 2019 to 2021, identifying patients who received shoulder arthroplasty in either an inpatient or outpatient setting using Current Procedural Terminology codes. Our primary outcomes were 90-day unplanned readmissions and postprocedure 90-day care costs. The ADI was our primary exposure variable, calculated at the census block level. Our analysis adjusted for multiple factors using a stepwise modeling approach including patient demographics, 29 Elixhauser comorbid conditions, Medicaid-dual eligibility, and end-stage renal disease status using logistic regression models.

RESULTS

A total of 145,435 patients were included in our study. The average age of patients in our cohort was 74.5 year old, with 59.5% being female. Patients in the high ADI group had a higher readmission rate than the lowest ADI group (8.5% vs 6.0%, P < .001).When controlling for confounding factors, there was an independent association between high ADI and readmission (odds ratio {OR}: 1.28 [95% confidence interval {CI} 1.12, 1.46]). Overall, we saw a dose-dependent relationship between ADI and readmission, with the association growing stronger as ADI increased. Conversely, we found a negative association with ADI and high-costs. (High ADI group OR: 0.80 [95% CI 0.70, 0.91]). Patients in the high socioeconomic status (SES) group had higher health care contact days during the 90-day follow-up period, with a median of 16 visits (interquartile range [IQR] 8, 23), compared to 13 visits (IQR 6, 22) in the middle SES group and 10 visits (IQR 5, 20) in the low SES group (P < .001).

CONCLUSION

Socioeconomic disparities significantly influence the outcomes of primary shoulder arthroplasty, as indicated by higher readmission rates for low SES patients. Notably, our analysis shows a strong, independent association between ADI and readmission. Moreover, patients with higher SES incurred greater costs within a 90-day period potentially due to increased resource utilization.

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Farronato DM, Pezzulo JD, Juniewicz R, Rondon AJ, Cox RM, Davis DE. Effects of socioeconomic burden on opioid use following total shoulder arthroplasty. J Shoulder Elbow Surg 2024;33:2596-2603. [PMID: 38852706 DOI: 10.1016/j.jse.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 06/11/2024]

Abstract

BACKGROUND

Preoperative opioid users experience worse outcomes and higher complication rates compared to opioid-naïve patients following shoulder arthroplasty. This study evaluates the effects of socioeconomic status, as measured by the Distressed Communities Index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery.

METHODS

A retrospective review of patients who underwent primary shoulder arthroplasty (Current Procedural Terminology code 23472) from 2014 to 2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index, DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents was gathered.

RESULTS

Individuals from distressed communities used more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations, respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared with prosperous, comfortable, and mid-tier, respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs. 21.3%, P < .001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs. 21.7%, P = .002).

CONCLUSIONS

Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.

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Mayfield CK, Liu KC, Abu-Zahra MS, Bolia IK, Gamradt SC, Weber AE, Liu JN, Petrigliano FA. Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications: a nationwide matched cohort analysis from 2016-2020. J Shoulder Elbow Surg 2024;33:e233-e247. [PMID: 37852429 DOI: 10.1016/j.jse.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 10/20/2023]

Abstract

BACKGROUND

Inflammatory arthritis (IA) represents a less common indication for anatomic and reverse total shoulder arthroplasty (TSA) than osteoarthritis (OA). The safety and efficacy of anatomic and reverse TSA in this population has not been as well studied compared to OA. We analyzed the differences in outcomes between IA and OA patients undergoing TSA.

METHODS

Patients who underwent primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) from 2016-2020 were identified in the Premier Healthcare Database. Inflammatory arthritis (IA) patients were identified using International Classification of Diseases, Tenth Revision, diagnosis codes and compared to osteoarthritis controls. Patients were matched in a 1:8 fashion by age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, and patient comorbidities were compared. Multivariate regression was performed following matching to account for any residual confounding and 90-day complications were compared between the 2 cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05.

RESULTS

Prior to matching, 5685 IA cases and 93,539 OA controls were identified. Patients with IA were more likely to be female, have prolonged length of stay and increased total costs (P < .0001). After matching and multivariate analysis, 4082 IA cases and 32,656 controls remained. IA patients were at increased risk of deep wound infection (OR 3.14, 95% CI 1.38-7.16, P = .006), implant loosening (OR 4.11, 95% CI 1.17-14.40, P = .027), and mechanical complications (OR 6.34, 95% CI 1.05-38.20, P = .044), as well as a decreased risk of postoperative stiffness (OR 0.36, 95% CI 0.16-0.83, P = .002). Medically, IA patients were at increased risk of PE (OR 2.97, 95% CI 1.52-5.77, P = .001) and acute blood loss anemia (OR 1.27, 95% CI 1.12-1.44, P < .0001).

DISCUSSION AND CONCLUSION

Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA. Surgeons should consider these potential complications and employ a multidisciplinary approach in preoperative risk stratification of IA undergoing shoulder replacement.

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Marigi EM, Sperling JW, De Marinis R, Gupta P, Hassett LC, Soza F, Sanchez-Sotelo J. Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023;3:494-498. [PMID: 37928990 PMCID: PMC10624987 DOI: 10.1016/j.xrrt.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]

Sridhar S, Mouat-Hunter A, McCrory B. Rural implementation of the perioperative surgical home: A case-control study. World J Orthop 2023;14:123-135. [PMID: 36998383 PMCID: PMC10044325 DOI: 10.5312/wjo.v14.i3.123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/01/2023] [Accepted: 02/15/2023] [Indexed: 03/17/2023] Open

Abstract

BACKGROUND

Perioperative surgical home (PSH) is a novel patient-centric surgical system developed by American Society of Anesthesiologist to improve outcomes and patient satisfaction. PSH has proven success in large urban health centers by reducing surgery cancellation, operating room time, length of stay (LOS), and readmission rates. Yet, only limited studies have assessed the impact of PSH on surgical outcomes in rural areas.

AIM

To evaluate the newly implemented PSH system at a community hospital by comparing the surgical outcomes using a longitudinal case-control study.

METHODS

The research study was conducted at an 83-bed, licensed level-III trauma rural community hospital. A total of 3096 TJR procedures were collected retrospectively between January 2016 and December 2021 and were categorized as PSH and non-PSH cohorts (n = 2305). To evaluate the importance of PSH in the rural surgical system, a case-control study was performed to compare TJR surgical outcomes (LOS, discharge disposition, and 90-d readmission) of the PSH cohort against two control cohorts [Control-1 PSH (C1-PSH) (n = 1413) and Control-2 PSH (C2-PSH) (n = 892)]. Statistical tests including Chi-square test or Fischer’s exact test were performed for categorical variables and Mann-Whitney test or Student’s t-test were performed for continuous variables. The general linear models (Poisson regression and binomial logistic regression) were performed to fit adjusted models.

RESULTS

The LOS was significantly shorter in PSH cohort compared to two control cohorts (median PSH = 34 h, C1-PSH = 53 h, C2-PSH = 35 h) (P value < 0.05). Similarly, the PSH cohort had lower percentages of discharges to other facilities (PSH = 3.5%, C1-PSH = 15.5%, C2-PSH = 6.7%) (P value < 0.05). There was no statistical difference observed in 90-d readmission between control and PSH cohorts. However, the PSH implementation reduced the 90-d readmission percentage (PSH = 4.7%, C1-PSH = 6.1%, C2-PSH = 3.6%) lower than the national average 30-d readmission percentage which is 5.5%. The PSH system was effectively established at the rural community hospital with the help of team-based coordinated multi-disciplinary clinicians or physician co-management. The elements of PSH including preoperative assessment, patient education and optimization, and longitudinal digital engagement were vital for improving the TJR surgical outcomes at the community hospital.

CONCLUSION

Implementation of the PSH system in a rural community hospital reduced LOS, increased direct-to-home discharge, and reduced 90-d readmission percentages.

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Kunutsor SK, Barrett MC, Whitehouse MR, Craig RS, Lenguerrand E, Beswick AD, Blom AW. Incidence, temporal trends and potential risk factors for prosthetic joint infection after primary total shoulder and elbow replacement: Systematic review and meta-analysis. J Infect 2020;80:426-436. [DOI: 10.1016/j.jinf.2020.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/16/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023]