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Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature; however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge vs. inpatient SA in a cohort of patients considered higher risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3. Data from Kaiser Permanente's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018 to 2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge vs. ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism, and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10. The cohort included a total of 1814 SA patients, of whom 1005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR] = 0.64, one-sided 95% upper bound [UB] = 0.89) and overall complications (OR = 0.67, 95% UB = 1.00). We lacked evidence in support of noninferiority for 90-day ED visit (OR = 0.96, 95% UB = 1.18), cardiac event (OR = 0.68, 95% UB = 1.11), or venous thromboembolism (OR = 0.91, 95% UB = 2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis. In a cohort of over 1800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay, and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting. [ABSTRACT FROM AUTHOR]

The use of alternative antibiotics to cefazolin has been associated with increased risk of infection after shoulder arthroplasty. Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin and may reduce the occurrence of infection after shoulder arthroplasty, but the financial viability of this practice is unclear. We used break-even modeling to determine the economic viability of routine preoperative allergy testing for infection prevention in total shoulder arthroplasty patients reporting penicillin and cephalosporin allergies. Allergy testing cost ($248.24), infection rates after shoulder arthroplasty following use of noncefazolin antibiotics (3.09%), and infection-related care costs ($55,243) were derived from the literature. A break-even equation using these variables was developed to determine the absolute risk reduction (ARR) in the infection rate that would economically justify the routine implementation of preoperative allergy testing. The number needed to treat was calculated from the ARR. Preoperative allergy testing is considered economically justified if it prevents at least 1 infection out of 223 shoulder arthroplasties (ARR = 0.45%). These protocols remained economically viable at varying allergy testing costs, initial infection rates, and infection-related care costs. Routine preoperative penicillin allergy testing is an economically justified infection prevention strategy among patients reporting penicillin and cephalosporin allergies in the setting of elective shoulder arthroplasty. Widespread implementation of this practice may considerably reduce the economic and societal burden associated with prosthetic infections. [ABSTRACT FROM AUTHOR]

Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption. We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables. Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P =.002), more self-reported allergies (P =.007), and worse American Shoulder and Elbow Surgeons scores (P =.001), visual analog scale pain scores (P =.020), forward elevation (P <.001), and external rotation (P =.022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P >.05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P =.012) but did not differ in terms of total hospitalization costs (P =.65) or total inpatient opioid consumption (P =.721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P =.035). LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning. [ABSTRACT FROM AUTHOR]

There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty. We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores. Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P =.51), SANE (P =.50), and ASES (P =.72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [ P =.56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [ P =.42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [ P =.88]. No differences in hospitalization costs were noted between groups (P =.77). Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum. [ABSTRACT FROM AUTHOR]

People are increasingly turning to online search engines for health information. We analyzed Google search queries to determine the most frequently asked topics and questions related to shoulder arthroplasty and the sources of the websites provided to address these questions. Search terms for shoulder arthroplasty were entered into Google. Machine learning–based natural language processing algorithms within Google were used to mine search logs to identify frequently asked questions about shoulder arthroplasty. These questions with their associated websites were extracted and categorized by two independent reviewers. A total of 300 questions were extracted with 156 associated websites. The most popular question topics were related to the timeline of recovery (16.3%), ability to perform specific activities (15.7%), technical details of surgery (14.3%), and activity restrictions (12%). Frequently asked questions had to do with the fastest means of recovery, duration of physical therapy, sling use, time spent sleeping upright in a recliner, time off work, location of surgical incision, resumption of sports, and the ability to use the bathroom. The most common websites provided to address the questions were academic (25.3%), private practice (23%), and government (20.3%). The most frequently asked questions on Google about shoulder arthroplasty centered around postoperative rehabilitation and restrictions, with information originating from variable sources. Our data can be used to counsel patients and set expectations about recovery and serve as a framework for the development of targeted patient education materials. Level VI; Descriptive Study [ABSTRACT FROM AUTHOR]

The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs. We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores. Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤.001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (−9.75 points) and SANE (−7.63 points) scores and greater residual pain (+1.13 points) (all P ≤.001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P <.001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P <.001). Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the cost-effectiveness of the most commonly used type of antimicrobial silver-impregnated occlusive dressing (Aquacel Ag, ConvaTec, Oklahoma City, OK, USA) for prosthetic shoulder infection (PSI) prevention after shoulder arthroplasty. Data regarding the cost of silver-impregnated occlusive dressing, cost to treat a PSI and initial infection rates after shoulder arthroplasty were calculated from available literature. Using a break-even economic analysis, we developed an equation that incorporated these variables to determine the absolute risk reduction (ARR) in infection rate required to make the use of this dressing cost-effective. To provide a widely applicable and reusable model, multiple simulations were performed at varying unit costs, infection rates, and PSI-related care costs. At a dressing cost of $34.00 and presuming a cost of $50,230 for treating a PSI, these dressings are considered cost-effective if their use prevents at least 1 infection in 1471 TSA (ARR of 0.068% from the initial infection rate of 0.7%). The cost-effectiveness of this dressing was maintained through a realistic range of dressing and PSI treatment costs, while initial infection rate was found not to influence cost-effectiveness. Antimicrobial silver-impregnated occlusive dressings represent a cost-effective infection prevention strategy after shoulder arthroplasty. The presented model serves as a useful resource to aid in weighing the economic effects of implementing any potential prophylactic measures aimed at minimizing infections after shoulder arthroplasty. Level IV; Economic Decision Analysis [ABSTRACT FROM AUTHOR]

Patients undergoing elective shoulder arthroplasty have highly variable pain experiences. We sought to characterize preoperative patient characteristics associated with fast and slow pain relief after elective total shoulder arthroplasty and evaluated whether differences in early pain recovery predicted longer term pain relief. We identified 324 patients undergoing elective primary shoulder arthroplasty, reverse and anatomic, between 2015 and 2018 from our prospective registry. Postoperative pain relief was defined as the difference in preoperative and 2-week postoperative pain intensity. Three groups were then created: fast responders (top decile), slow responders (bottom decile), and normal responders. Multinomial regression was used to identify preoperative patient factors associated with either slow or fast pain responses. Factors associated with a fast pain response included older age and being married. A slow pain response was associated with being unmarried. Pain intensity was lower in the fast responders at 6 weeks (0.60 ± 0.80 vs. 3.4 ± 2.50, P <.05) and 3 months (0.60 ± 0.90 vs. 2.60 ± 2.30, P <.05), but there was no difference at 1 year (0.30 ± 0.60 vs. 1.00 ± 1.10, P =.068) and 2 years (0.50 ± 1.30 vs. 1.40 ± 2.10, P =.183) postoperatively. The postoperative pain experience after shoulder arthroplasty seems to be influenced by patient age and marital status. Patients with marginal improvement in pain relief should be counseled that their recovery may be more prolonged, but by the 1-year mark they are likely to achieve comparably low pain levels to other patients. Level III; Retrospective Design; Prognosis Study [ABSTRACT FROM AUTHOR]

Newer strategies to decolonize the shoulder of Cutibacterium acnes may hold promise in minimizing the occurrence of infections after shoulder arthroplasty, but little is known about their cost-effectiveness. Break-even models can determine the economic viability of interventions in settings with low outcome event rates that would realistically preclude a randomized clinical trial. We used such modeling to determine the economic viability of benzoyl peroxide and hydrogen peroxide for infection prevention in shoulder arthroplasty. Skin decolonization protocol costs ($11.76 for benzoyl peroxide; $0.96 for hydrogen peroxide), baseline infection rates for shoulder arthroplasty (0.70%), and infection-related care costs ($50,230) were derived from institutional records and the literature. A break-even equation incorporating these variables was developed to determine the absolute risk reduction (ARR) in the infection rate to make prophylactic use economically justified. The number needed to treat was calculated from the ARR. Topical benzoyl peroxide is considered economically justified if it prevents at least 1 infection out of 4348 shoulder arthroplasties (ARR = 0.023%). Hydrogen peroxide is economically justified if it prevents at least 1 infection out of 50,000 cases (ARR = 0.002%). These protocols remained economically viable at varying unit costs, initial infection rates, and infection-related care costs. The use of topical benzoyl peroxide and skin preparations with hydrogen peroxide are highly economically justified practices for infection prevention in shoulder arthroplasty. Efforts to determine drawbacks of routine skin decolonization strategies are warranted as they may change the value analysis. [ABSTRACT FROM AUTHOR]