Department of Orthopedic Surgery Sports Medicine & Shoulder Surgery, University of California, San Francisco, CA, USA.
Department of Orthopedic Surgery Sports Medicine & Shoulder Surgery, University of California, San Francisco, CA, USA.
J Shoulder Elbow Surg. 2021 Jan;30(1):65-71. doi: 10.1016/j.jse.2020.04.028. Epub 2020 Jun 9.
Disparities associated with socioeconomic status (SES) and insurance coverage have been shown to affect outcomes in different medical conditions and surgical procedures. We hypothesized that patients insured by Medicaid will be associated with lower follow-up rates and inferior outcomes relative to those with Medicare or private insurance.
Patients undergoing shoulder arthroplasty, including anatomic total shoulder arthroplasty, reverse arthroplasty, and hemiarthroplasty, were enrolled preoperatively in an institutional database. Preoperative demographics, payor (Medicaid, Medicare, or private insurance), and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores were recorded. Postoperatively, patients completed ASES scores at multiple time points. Follow-up completion rate was calculated as the number of follow-up visits completed relative to possible visits. Continuous variables were compared between groups with 1-way analyses of variance, and chi-squared tests were used for categorical variables. Significance was defined as P < .05.
There were 491 shoulder replacements performed for 438 patients from 2012-2017. The mean follow-up completed percentage was significantly lower (P < .001) for Medicaid patients (62.6% ± 33.7%) relative to Medicare patients (80.2% ± 26.7%; P < .001) and private insurance patients (77.8% ± 22.1%; P = .001). The ASES Composite score increased significantly for all patients from baseline to final follow-up. At each time point, including before surgery and each postoperative time point, patients with Medicaid insurance had significantly lower ASES Composite scores. The final ASES Composite score was significantly lower in the Medicaid patients (66.1 ± 28.7) relative to private insurance patients (78.3 ± 20.8; P = .023). Medicaid patients had significantly lower preoperative (P < .001) and postoperative (P = .018) ASES Pain subscores. In multivariate regression analysis, Medicaid insurance was associated with both inferior preoperative and postoperative ASES scores relative to patients with Medicare or private insurance.
We observed that all patients, regardless of insurance payor, improved by similar magnitudes after shoulder arthroplasty, though patients with Medicaid insurance had significantly lower preoperative and postoperative ASES scores, primarily because of the ASES Pain subscore. Patients with Medicaid insurance also have lower follow-up rates than other payors.
社会经济地位（SES）和保险覆盖范围相关的差异已被证明会影响不同医疗状况和手术程序的结果。我们假设，与医疗保险或私人保险相比，医疗补助保险的患者的随访率较低，结果较差。
在机构数据库中术前招募接受肩部关节置换术（包括解剖全肩关节置换术、反肩关节置换术和半肩关节置换术）的患者。记录术前人口统计学数据、支付者（医疗补助、医疗保险或私人保险）和基线美国肩肘外科医生标准化肩部评估表（ASES）评分。术后，患者在多个时间点完成 ASES 评分。随访完成率计算为已完成的随访就诊次数与可能就诊次数的比值。使用单向方差分析比较组间的连续变量，使用卡方检验比较分类变量。定义显著性为 P<.05。
2012-2017 年间，共进行了 491 例肩部置换术，涉及 438 名患者。医疗保险患者的随访完成率明显较低（P<.001）（62.6%±33.7%），与医疗保险患者（80.2%±26.7%；P<.001）和私人保险患者（77.8%±22.1%；P=.001）相比。所有患者的 ASES 综合评分从基线到最终随访均显著增加。在每个时间点，包括术前和每个术后时间点，有医疗保险的患者的 ASES 综合评分均显著较低。医疗保险患者的最终 ASES 综合评分明显低于私人保险患者（66.1±28.7）（P=.023）。医疗保险患者的术前（P<.001）和术后（P=.018）ASES 疼痛评分均显著较低。在多变量回归分析中，与医疗保险或私人保险患者相比，医疗保险与术前和术后 ASES 评分均较低相关。
我们观察到，所有患者无论保险支付者如何，在肩部置换术后都有相似程度的改善，但医疗保险患者的术前和术后 ASES 评分均显著较低，主要是因为 ASES 疼痛评分。医疗保险患者的随访率也低于其他支付者。
