Health Literacy and Outcomes of Shoulder Arthroplasty Using the Campbell Assessment of Shoulder Education (CASE) Score

Background The relationship between patient health literacy and surgical outcomes is an increasingly popular topic within healthcare circles. To our knowledge, no specific assessment of shoulder health literacy has been validated in the literature, and the role that health literacy has in the outcomes of shoulder-arthroplasty patients is unclear. Purpose This study aimed to validate the first shoulder-specific health literacy assessment and determine its association with outcomes after shoulder arthroplasty. We hypothesized patients with lower health literacy undergoing shoulder arthroplasty would have worse outcomes. Methods A prospective cohort of patients with shoulder pathology (age>18) were administered the Campbell Assessment of Shoulder Education (CASE) questionnaire and the Literacy in Musculoskeletal Problems survey form (LiMP). We calculated the association between CASE and LiMP survey results by Spearman correlation to validate the CASE questionnaire. A separate prospective cohort of patients undergoing reverse or anatomic total shoulder arthroplasty were then administered the CASE questionnaire at the 3-month postoperative timepoint. We compared pre- and postoperative demographics, American Shoulder Elbow Score (ASES), visual analogue scale (VAS), single assessment numeric evaluation (SANE), and range-of-motion scores for all patients and compared all outcome variables among groups using the health literacy assessment scores. Results Patients undergoing total shoulder arthroplasty (N = 202) responded to the questionnaire. The results show a moderate positive association between LIMP and CASE score in the evaluation of health literacy (r = 0.572, p < 0.001). Patients with poor shoulder literacy (CASE scores < 4) demonstrated higher preoperative VAS scores (6.4 vs. 5.4, p = 0.005); however, this difference diminished 3 months postoperatively (2.2 vs 1.8, p = 0.121). Patients with poor shoulder literacy did not show inferior ASES (67.7 vs. 69.3, p = 0.548) or SANE (62.9 vs. 61.2, p = 0.612) scores 3 months postoperatively. We found no differences in external rotation (36.6 vs. 39.7, p = 0.143), internal rotation (40.7 vs. 40.0, p = 0.724), or forward elevation (128.1 vs 136.0, p = 0.081) between groups at the 3-month timepoint. Conclusions The CASE tool demonstrated acceptable sensitivity, specificity, and correlation metrics compared with the previously validated LiMP assessment, which indicated it is a reliable tool in evaluating musculoskeletal-specific health literacy. Although inferior shoulder health literacy correlated with worse preoperative VAS score, it was not predictive of postoperative motion or patient-reported outcomes. While inferior shoulder health literacy was correlated with worse preoperative VAS score, it was not predictive of postoperative motion or patient-reported outcomes. Low shoulder-specific health literacy, as measured by CASE, was not predictive of worse short-term postoperative outcomes in this cohort.