The effect of Area Deprivation Index on clinical outcomes after total shoulder arthroplasty

Socioeconomic status (SES), as measured by the Area Deprivation Index (ADI), is associated with differences in pre-operative status and post-operative outcomes in patients undergoing total shoulder arthroplasty (TSA). The effect of SES on TSA outcomes remains unclear, as studies thus far report mixed findings overall. The purpose of this study is to determine the association between SES at the neighborhood level, using ADI scores, and patient-reported outcome measures (PROMs) following TSA.

A retrospective review of a prospectively collected single-institution database was performed to identify patients who underwent primary TSA (Advita Ortho) with a minimum 2-year follow-up. Patient addresses were collected and converted to ADI scores. Patients were divided into quartiles of ADI, and the most deprived (ADI_High) and least deprived (ADI_Low) quartiles were compared. Pre- and post-operative range of motion (ROM) and PROM, along with complication and revision rates at the last follow-up, were obtained. For ROM, visual analog scale pain, global function score and American Shoulder and Elbow Surgeons scores, the Minimal Clinically Important Difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) were defined by previously established threshold values. Multivariable logistic regression models were estimated to characterize the association of the ADI with MCID, SCB, and PASS attainment along PROM domains.

A total of 599 procedures with a minimum of 2-year follow-up and ADI score were grouped into distinct quartiles for analysis, and the ADI_Low (n = 150, ADI 0-25) and ADI_High (n = 150, ADI 67-100) groups were compared. ADI_High demonstrated inferior pre-operative ROM and PROM compared to ADI_Low. These differences decreased post-operatively, remaining statistically but not clinically significant for visual analog scale pain, global shoulder function, and American Shoulder and Elbow Surgeons scores. Each group achieved MCID, SCB, and PASS at similar rates. ADI was not a significant predictor of achieving MCID, SCB, and PASS thresholds.

SES impacts pre-operative disease severity and absolute post-operative outcomes after TSA but does not significantly limit the capacity for clinically meaningful improvement. Disadvantaged patients derive similarly substantial benefit from surgery compared to those from higher SES backgrounds.