Insurance Status Impacts Complication Rates after Shoulder Arthroplasty

    Patients undergoing shoulder arthroplasty who have Medicaid, Medicare, or no health insurance experience higher complication rates than patients who have private insurance, according to a study published in Journal of Shoulder and Elbow Surgery.

    The findings demonstrate disparities in acute postoperative outcomes for shoulder replacement surgery based on insurance status.

    Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, the researchers analyzed data from more than 100,000 patients who had undergone hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty, including:

    • 68,578 Medicare patients
    • 27,159 private insurance patients
    • 3,544 Medicaid or uninsured patients
    • 4,009 patients with other types of insurance

    Overall, the perioperative medical and surgical complication rate was 17.2% and the mortality rate was 0.20%.

    However, the investigators found significantly higher medical, surgical, and overall complication rates among Medicare patients (20.3%) and Medicaid/uninsured patients (16.9%) compared with privately insured patients (10.5%).

    When the data were matched and analyzed, the researchers found no differences in the complication rates between Medicaid/uninsured and Medicare patients. However, the Medicaid/uninsured and Medicare patients had significantly more medical and surgical complications when compared with the privately insured patients.

    According to the investigators, the discrepancy in the complication rates may be the result of a lack of access to preoperative and postoperative care due to poor socioeconomic status or education level for patients who have government-sponsored insurance.

    Additionally, patients with Medicaid or no insurance may lack access to high-volume shoulder surgeons, which may also contribute to the higher complication rates. The investigators also found that patients with private insurance are more likely to go to higher-volume hospitals for their procedure.

    “Studies in the literature have shown that patients with Medicaid or no insurance have a higher mortality rate after penetrating trauma compared to private insured patients,” said lead author Xinning Li, MD, assistant professor of orthopaedic surgery at Boston University School of Medicine. “Patients with Medicaid also have higher medical complication rates after spine surgery.

    “We report similar findings that patients with government-sponsored insurance are more likely to have medical and surgical complications compared to privately insured patients after shoulder replacement surgery. Thus, insurance status should be considered an independent risk factor for medical and surgical complications in patients undergoing shoulder replacement surgery.”

    Dr. Li believes future research should focus on clinical and socioeconomic factors to determine the reason for differences in the postoperative complications and outcomes between patients with government-sponsored insurance and those with private insurance.

    “Understanding that disparities in patient care exist is an important first step. Patients with no insurance or Medicaid/Medicare insurance do not have the same access to care compared to someone with private insurance,” Dr. Li said.

    “The next logical question to ask is why these disparities exist, and subsequently, what can be done to eliminate its occurrence to improve patient care while minimizing postoperative complication.”


    Li X, Veltre DR, Cusano A, et al. Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. Published online February 10, 2017. doi: http://dx.doi.org/10.1016/j.jse.2016.12.071