A recent duo of studies led by clinician-researchers at New England Baptist Hospital (NEBH), part of Beth Israel Lahey Health, explored patient-related variables that could be used to predict and potentially modify adverse outcomes for patients undergoing total joint arthroplasty, aka joint replacement. 

Total Joint Replacement May Outweigh the Risks for Patients Who Are Unhoused 

In a recent issue of the Journal of the American Academy of Orthopedic Surgeons, NEBH physician-researchers evaluated outcomes of patients who underwent total hip or total knee arthroplasty while unhoused. One of the first to analyze outcomes for this population treated at an urban, academic, safety net hospital, the study found that – with careful pre-operative planning and post-operative support – the quality of life-enhancing benefits of total joint replacement can outweigh potential risks posed by the unique challenges of patients who are experiencing homelessness.

“Housing status is a key determinant of health and is linked with imbalanced access to care, including frequent use of acute care and lack of regular follow-up for chronic conditions, such as arthritis and joint pain,” said corresponding author Eric L. Smith, MD, FOAO, chief of arthroplasty at NEBH. “While total joint replacement has been shown to improve quality of life, surgeons often hesitate to perform elective surgeries on patients who are experiencing homelessness, but outcomes in this population remain poorly understood.”  

Smith and colleagues retrospectively reviewed 442 patients who underwent unilateral knee or hip replacement surgery between June 2016 and August 2017, with a minimum follow-up period of two years. Of these 442 patients, 28 self-reported as being unhoused. The patients who were unhoused were markedly younger, tended to be male, and more often struggled with substance misuse, including tobacco, alcohol and illicit drugs.  

The researchers found no significant difference between the two groups in getting to clinical follow-up visits, with 11 percent of unhoused patients missing visits compared to 12 percent of housed patients. However, patients who were unhoused were more than 15 times more likely to have an Emergency Department visit within 90 days of the procedure compared to housed patients. 

Similarly, while the two groups also did not significantly differ in hospital readmission or revision surgery, prosthetic joint infections were more common among unhoused patients and were the primary reason for hospital readmission or revision surgery among this group.  

“The findings of this study underscore that unhoused patients who undergo total joint arthroplasty still experience unique challenges compared with the general patient population,” said Smith. “We believe the best way to manage these challenges lies in a collaborative, support system. With careful preoperative optimization and collaborative support, the benefits of total joint arthroplasty may outweigh the risk of poor outcomes.” 

Limited Health Literacy is Linked to Worse Preoperative Status and Surgical Outcomes for Patients Undergoing Elective Shoulder Arthroplasty 

In the Journal of Shoulder and Elbow Surgery, Andrew Jawa, MD, chief of the Division of Shoulder Arthroplasty at NEBH, and colleagues evaluated the effects of limited health literacy on perioperative outcomes in patients undergoing shoulder arthroplasty. The team found that patients with limited health literacy have worse function, worse pain control and experience prolonged hospital stays following shoulder surgery than people with higher levels of health literacy.  

“Patients with limited health literacy may have difficulty understanding and acting upon medical information, placing them at risk for potential misuse of health services and adverse outcomes,” said Jawa, who is senior author of the paper. “Our study found that limited health literacy affects about a quarter of patients undergoing elective shoulder arthroplasty and, given its association with several adverse outcomes, it is an important factor to consider for postoperative planning.”

Jawa and colleagues retrospectively identified 230 patients who underwent one of two kinds of shoulder arthroplasty between January 2018 and May 2021 from a single surgeon registry. The health literacy of each patient was assessed using a validated screening tool that asked questions like, “How confident are you filling out medical forms by yourself?” and “How often do you have someone help you read hospital materials?” 

Overall, 25 percent of patients were classified as having limited health literacy. Limited health literacy was linked to greater preoperative symptom severity, including higher rates of opioid use, more self-reported allergies and worse pain. Patients with limited health literacy also experienced significantly longer hospital stays, though they did not differ in terms of hospitalization costs.  

“The burgeoning demand and costs associated with shoulder arthroplasty require concerted efforts to optimize resource allocation in the postoperative setting,” said Jawa. “Health literacy represents a domain which may provide an opportunity to achieve this goal while simultaneously addressing a barrier to equitable care.” 

[Source(s): Beth Israel Lahey Health, Newswise]

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