Sociodemographic disparities in distance traveled to receive primary shoulder arthroplasty

BackgroundShoulder arthroplasty is a common procedure, but patterns in patient travel distance to undergo this operation are unknown. This study aims to describe the relationships between patient travel distance, patient demographics, and surgical outcomes after primary shoulder arthroplasty. We hypothesized that older age, higher Charlson comorbidity index, white race, and higher socioeconomic status would be associated with increased travel distance.MethodsData from the Healthcare Cost and Utilization Project, American Hospital Association database, and UnitedStatesZipCodes.org Enterprise database were used to collect patient data and geographic coordinates for patients’ home zip codes and the hospitals at which they underwent shoulder arthroplasty. The distances from population-weighted zip code centroid points and hospital coordinates were calculated. The relationships between the distance traveled to receive care and patient demographic data and postoperative adverse outcomes were then assessed using analysis of variance test and logistic regression analysis.ResultsA total of 49,567 patients who underwent elective primary shoulder arthroplasty in Florida and New York between 2005 and 2015 were included for analysis. Age and number of medical comorbidities were inversely related to travel distance (P < .0001). White race (P < .0001), private insurance coverage (P = .03), and anatomic shoulder arthroplasty were each associated with increased travel distance (P < .0001). Hemiarthroplasty patients traveled less distance than patients who underwent anatomic or reverse shoulder arthroplasty (P < .0001). No significant associations were observed between travel distance and postoperative adverse outcomes.ConclusionThis study provides robust evidence of differences in distance traveled to undergo primary shoulder arthroplasty based on patient age, medical comorbidities, race, socioeconomic status, insurance provider, and type of shoulder arthroplasty. Future work may elucidate whether disparities in travel distance are based on patient preference or necessity and may offer additional insights with respect to access to care for this specialized procedure.     

Epidemiology of revision shoulder arthroplasty in the United States: incidence,demographics, and projected volume from 2018 to 2030

BackgroundThorough understanding of surgical indications and type of revision shoulder arthroplasty (SA) performed aids policy making decisions, resource allocation, and research into cost and utilization. The purpose of this study was to determine indications for and the type of revision SA performed in the United States.MethodsHealthcare Cost and Utilization Project National Inpatient Sample database was used to analyze clinical, demographic, and economic data from 61,615 revision SA procedures performed from 2012 to 2018. The prevalence of revision procedures was calculated for population subgroups in the United States that were stratified according to age, sex, diagnosis, primary payer class, and type of hospital using the most recent year of data. The indication for revision and average length of stay after revision surgery were also determined for each type of revision arthroplasty procedure. Linear regression was used to estimate procedures through 2030, using incidence values from 2012 to 2018.ResultsAnnual volume of revision SA in the United States increased by 153% from 5650 procedures in 2012 to 14,300 procedures in 2018. Linear regression predicted a continued increase in this annual volume, increasing to 37,329 revision SA procedures by 2030. The most common SA procedure performed in the revision setting was reverse shoulder arthroplasty and the most common indications for revision were for instability (25%) and infection (21%). Revision SA procedures were most commonly performed in patients aged 60-70 years, with a mean age of 66.6 years and with Medicare insurance (66%). The mean length of hospital stay for revision SA was 3.1 days.ConclusionAnnual volume of revision SA increased by 153% from 2012 to 2018 in the United States with a continued predicted increase through 2030. Instability and infection are the most common indications for surgery. Reverse shoulder arthroplasty was the most commonly performed surgery in the revision setting.     

Minimum clinically important difference for the American Shoulder and Elbow Surgeons score after revision shoulder arthroplasty

BackgroundPatients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6 to 20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold.MethodsPatients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and postoperative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as P< .05.ResultsA total of 46 patients underwent revision TSA with minimum 2-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend toward males being more likely to reach MCID after revision arthroplasty (P= .058). There were also trends toward increased forward flexion and abduction range of motion in patients who met MCID (P= .08, P= .07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (P= .03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (P= .06, P= .10).ConclusionThe MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA.Level of EvidenceLevel III; Retrospective Comparative Treatment Study