Distressed Communities Demonstrate Increased Readmission and Healthcare Utilization Following Shoulder Arthroplasty.

Abstract

Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative healthcare utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the healthcare system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty. A retrospective review of 6,170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; CPT code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient ZIP Code, and Charlson Comorbidity Index (CCI) were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic wellbeing to generate a single score. Zip codes are then classified by scores into five categories based on national quintiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits. Amongst all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (Odds Ratio=1.77, p=0.045). Patients from comfortable (Relative Risk=1.12, p<0.001), mid-tier (Relative Risk=1.13, p<0.001), at-risk (Relative Risk=1.20, p<0.001), and distressed (Relative Risk=1.17, p<0.001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (Relative Risk=0.92, p<0.001), mid-tier (Relative Risk=0.88, p<0.001), at-risk (Relative Risk=0.93, p=0.008), and distressed (Relative Risk=0.93, p=0.033) communities respectively were a lower risk of making calls compared to prosperous communities. Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased healthcare utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive healthcare utilization, benefiting both patients and providers alike.