Effect of Insurance Type on Access to Orthopedic Care for Pediatric Trigger Thumb

A Framework for Addressing Health Disparities in Adult Neurogenic Lower Urinary Tract Dysfunction-Systematic Review and Neurogenic Bladder Research Group Recommendations

The systematic review and workshop recommendations by the Neurogenic Bladder Research Group offer a comprehensive framework for evaluating health disparities in adult neurogenic lower urinary tract dysfunction (NLUTD). The study acknowledges the multifaceted nature of health, highlighting that medical care, though critical, is not the sole determinant of health outcomes. Social determinants of health significantly influence the disparities seen in NLUTD. This report calls for a shift in focus from traditional urologic care to a broader, more inclusive perspective that accounts for the complex interplay of social, economic, and health care factors in managing NLUTD.

Racial and Ethnic Disparities in Pediatric Musculoskeletal Care

PURPOSE OF REVIEW

This article provides a review of recent published research studying racial, ethnic, and socioeconomic disparities in pediatric musculoskeletal care.

RECENT FINDINGS

Disparities in pediatric musculoskeletal care are demonstrated in two general realms: access to care and health outcomes. Though initiatives have been proposed or enacted to address disparities, underrepresented minorities and patients from lower socioeconomic statuses continue to face barriers across the spectrum of orthopedic care and poorer ultimate outcomes after both non-operative and operative management. Minority pediatric patients and those from lower socioeconomic statuses experience delays across the spectrum of orthopedic care for both urgent and non-urgent conditions. They wait longer between injury date and initial orthopedic evaluation, longer to receipt of diagnostic imaging, and longer to ultimate treatment than their counterparts. When finally able to obtain musculoskeletal care and treatment, they are at higher risk of poor in-hospital outcomes and inpatient complications, worse patient reported outcomes, and suboptimal pain management. In the outpatient setting, they receive less physical therapy and follow-up clinic visits, resulting in greater stiffness and strength deficits, and are ultimately less likely to meet return to sport criteria.

After Anterior Cruciate Ligament Injury, Patients With Medicaid Insurance Experience Delayed Care and Worse Clinical Outcomes Than Patients With Non-Medicaid Insurance

Purpose

To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction.

Methods

A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups.

Results

In total, 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group, overall mean follow-up of 3.1 ± 0.8 years). The Medicaid group demonstrated lower annual income (P < .001) and a lower level of completed education compared with the non-Medicaid group (P < .001). Patients who received Medicaid had a greater duration between time of initial knee injury and surgery compared with the those in non-Medicaid group (11.8 ± 16.3 months vs 6.1 ± 16.5 months, P < .001). At the time of follow-up, patients in the non-Medicaid group had a significantly greater International Knee Documentation Committee score compared with patients who received Medicaid (82.5 ± 13.8 vs 75.3 ± 20.8, P = .036).

Conclusions

Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively.

Level of Evidence

Level III, retrospective cohort study.

Sociodemographic Disparities in Craniosynostosis: A Systematic Review

OBJECTIVE

Given the consequences of delayed treatment and diagnosis of craniosynostosis, this study reviews the literature on sociodemographic risk factors and disparities associated with delayed craniosynostosis treatment.

DESIGN

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search of PubMed/Medline and Embase was performed by two independent reviewers. Included studies discussed craniosynostosis health disparities. Demographic characteristics and outcomes were analyzed.

SETTING

Not applicable.

PATIENTS

Patients with craniosynostosis.

INTERVENTIONS

Standard surgical intervention for craniosynostosis.

RESULTS

Our literature search yielded 273 studies, of which 18 were included for analysis. Included studies represented data from 31 256 U.S. patients with craniosynostosis. Sixty percent of patients (n = 16 510) were White, 13.8% were Hispanic/Latino, 6.2% were Black/African American, 1.3% were Asian, 0.3% were American Indian or Alaska Native, and 0.1% were Native Hawaiian or Pacific Islander. Average age at surgery was 6.36 months for White patients, 10.63 months for Black patients, and 9.18 months for Hispanic patients. Minority racial and/or ethnic status was a risk factor for delayed presentation, and increased incidence of open surgery, complication rates, hospital charges, operative time, anesthesia duration, and hospital length of stay. Government-funded health insurance was associated with delayed intervention and increased complications.

CONCLUSIONS

Minority craniosynostosis patients experience delays in intervention and increased complication rates. Our findings highlight the importance of expedited and equitable referrals, screenings, and treatment, and the need for a standardized approach to investigating longitudinal demographic and outcomes data in this population.

Association between hyperlipidemia and trigger finger: A nationwide population-based cohort study

The cause of trigger fingers remains uncertain. High lipid levels in the blood may reduce blood supply to the distal fingers and promote inflammation. We aimed to explore the association between hyperlipidemia and trigger finger. A nationwide population-based cohort study using longitudinal data from 2000 to 2013, 41,421 patients were included in the hyperlipidemia cohort and 82,842 age- and sex-matched patients were included in the control cohort. The mean age was 49.90 ± 14.73 years in the hyperlipidemia cohort and 49.79 ± 14.71 years in the control cohort. After adjusting for possible comorbidities, the hazard ratio of trigger finger in the hyperlipidemia cohort was 4.03 (95% confidence interval [CI], 3.57-4.55), with values of 4.59 (95% CI, 3.67-5.73) and 3.77 (95% CI, 3.26-4.36) among male and female patients, respectively. This large-scale population-based study demonstrated that hyperlipidemia is correlated to trigger finger.

Slipped Capital Femoral Epiphysis, Food Deserts, Poverty, and Urban/Rural Residence: Is There a Link?

BACKGROUND

Childhood obesity is increased in food deserts, a community with little to no access to healthy food. As obesity is associated with slipped capital femoral epiphysis (SCFE), it was the purpose of this study to analyze the prevalence of SCFE patients by food desert location and its interaction with rural/urban location.

METHODS

A retrospective review of all consecutive patients with idiopathic SCFE treated at our institution over 11 years was performed. From the patient's address, the US Census Bureau tract in which the patient resided was determined. Using the census tract code, it was ascertained if the patient lived in a food desert and urban or rural location. Standard statistical analyses were performed; a P <0.05 was considered statistically significant.

RESULTS

There were 177 SCFE patients: 79 girls, 98 boys, 106, White, and 69 nonWhite. The average age at diagnosis was 12.1±1.7 years, the average symptom duration 4.1±5.1 months, and the average weight percentile 94±10. Of these 177 patients, 26.5% lived in a food desert, which was higher than the expected 17.5% ( P =0.023). Those living in a food desert were more commonly nonWhite (60% vs. 32%, P =0.0014). There were 25% from rural areas and 75% from urban areas. No rural SCFE patients lived in food deserts whereas 34% of urban patients lived in food deserts. The average poverty rate of the SCFE patient census tracts was 19%, no greater than the expected 15% ( P =0.32). SCFE patients living in rural census tracts had a lower poverty rate ( P <10 -6 ).

CONCLUSIONS

There is a correlation with the prevalence of SCFE patients by residence in a "food desert", but not with rural/urban locale or poverty status in Indiana. Further research will be needed to see if these findings apply to other states within the United States and other parts of the world.

LEVEL OF EVIDENCE

III.

An evaluation of pelvic floor disorders in a public and private healthcare setting

INTRODUCTION AND HYPOTHESIS

The objectives were to determine whether a difference exists in the duration of pelvic floor disorder (PFD) symptoms among patients presenting to urogynecologists in two healthcare systems: private and county; and to elucidate differences in baseline characteristics, type of PFDs, symptom severity and management, stratified by healthcare plans.

METHODS

A multi-center retrospective study was conducted including new patients presenting to three urogynecology clinics between March 2016 and May 2018: one private clinic (site A) and two public clinics in the same county healthcare system (sites B and C). Baseline data included age, race, BMI, parity, and comorbidities. Primary outcome was "time to presentation" defined as PFD duration in months. Secondary outcomes were symptom severity and PFD management, analyzed by healthcare setting and insurance type.

RESULTS

A total of 1,055 private and 439 public patients were included. Patients in the public setting were younger (54 vs 61 years, p<0.001), largely Hispanic (76% vs 14%, p<0.001), of higher parity (4 vs 3, p=0.001), and had more comorbidities, with a predominance of county-funded healthcare plans. There was no difference in duration of symptoms between the public and private groups respectively (54 vs 56 months, p=0.94). Patients in the public setting had more severe urinary incontinence (3 vs 2 pads/day, p<0.001) and prolapse (stages 3-4, 71% vs 61%, p=0.004); however, they had lower rates of surgical management for stress incontinence and prolapse. Differences in fecal incontinence could not be evaluated owing to small sample size.

CONCLUSIONS

Public patients presented younger with more severe symptoms but had lower rates of surgery for PFDs traditionally managed surgically.

Socioeconomic status does not change decision-making in the treatment of distal radius fractures at a level 1 trauma center

Objectives

To compare operative rates, total hospital charges, and length of stay between different socioeconomic cohorts in treating distal radius fractures (DRFs).

Design

A retrospective cohort study.

Setting

Large public level 1 trauma center.

Patients

A retrospective search of all trauma activations over a 7-year period (2013-2020) yielded 816 adult patients diagnosed with DRF. Patients were separated into cohorts of socioeconomic status based on 2010 US Census data and insurance status.

Intervention

DRFs were treated either nonoperatively using closed reduction and splinting or operatively using open reduction and internal fixation, closed reduction percutaneous pinning, or external fixator application.

Main Outcome Measurements

Operative rates of DRF, total hospital charges, and length of stay.

Results

Patients who were uninsured or in the low-income socioeconomic cohort had no significant difference in operative rates, total hospital costs, or length of stay when compared with their respective insured or standard income groups. Younger patients and those with OTA/AO type C, bilateral, or open DRFs were more likely to undergo operative intervention.

Conclusions

This study demonstrates that low socioeconomic status based on annual household income and insurance status was not associated with differences in operative rates on DRFs, length of stay, or total hospital charges. These results suggest that outcome disparities between groups may be caused by postoperative differences rather than treatment decision-making. Although this study investigates access to surgical care at a publicly funded level 1 trauma center, disparities may still exist in other models of care.

Level of Evidence

Prognostic Level III.

What's New in Pediatric Orthopaedic Health Care Disparities?

BACKGROUND

Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future.

METHODS

We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers.

RESULTS

A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care.

CONCLUSIONS

Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable.

LEVEL OF EVIDENCE

Level IV-narrative review.

Do Patient Demographics and Socioeconomic Status Influence Severity and Time to Diagnosis in Children With Stable Slipped Capital Femoral Epiphysis?

BACKGROUND

The time to diagnosis in stable slipped capital femoral epiphysis (SCFE) is often several months because of nebulous history, symptoms of knee/thigh pain, and Medicaid insurance. This study examined the impact of socioeconomic status and demographics on the time to diagnosis and SCFE severity in Indiana children.

METHODS

A retrospective review of all patients at a tertiary children's hospital with SCFE from January 2010 through March 2021 was performed. Standard demographic data and type of insurance was collected. Neighborhood Atlas Mapping was used to determine the state decile of the area deprivation index (ADI), a measure of socioeconomic status using 17 variables related to income, employment, education, and housing. Statistical analyses consisted of standard univariate and bivariate analyses; logistic regression analysis was used to determine predictors of a mild SCFE. A P<0.05 was considered statistically significant.

RESULTS

There were 142 patients; 81 male and 61 female. The average age was 12.2±1.7 years, lateral epiphyseal shaft angle of 35±19 degrees, and symptom duration of 4.5±5.0 months. There was no correlation between ADI state deciles and lateral epiphyseal shaft angle (r2=0.008) or symptom duration (r2=0.019). Insurance status and race differed by ADI deciles. In the first decile (least disadvantaged), 44% had government insurance and 89% were White; in the 10th decile (most disadvantaged), 95% had government insurance and 38% were White. Predictors of a mild SCFE were female sex [odds ratio (OR): 3.2 [1.5, 7.0]; P=0.004], symptom duration <3 months [OR: 5.3 (2.4, 11.7); P=0.00004], and White race [OR: 2.4 (1.3, 6.2); P=0.01]. Insurance status and ADI were not significant.

CONCLUSIONS

Contrary to other studies, neither insurance or socioeconomic status were associated with a delay in diagnosis or SCFE severity. The symptom duration in children with SCFE does not appear to be decreasing over the last several decades. Further investigation is required as to why.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures

BACKGROUND

Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity.

METHODS

Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly.

RESULTS

There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07.

CONCLUSION

Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.

Delayed Referral for Adult Traumatic Brachial Plexus Injuries

PURPOSE

The treatment of traumatic brachial plexus injury (BPI) is time-sensitive, and early nerve reconstruction is associated with superior nerve recovery. The objective of this study was to determine the rate of delayed referral to our centers for traumatic BPI, identifiable causes of delayed referral, and factors associated with delayed referral to a brachial plexus surgeon.

METHODS

We identified 84 patients with traumatic BPI referred to and evaluated by brachial plexus surgeons at 2 tertiary care referral centers from 2015 to 2019. Delayed referral was defined as more than 3 months from the date of injury to the date of initial evaluation by a brachial plexus surgeon. Causes of delayed referral were identified by review of the medical record. Bivariate analysis and multivariable logistic regression were used to identify factors associated with delayed referral.

RESULTS

Mean age of the 84 patients in the study was 45 years; 69% were male. The most common pattern of BPI was global palsy (39%), followed by upper-trunk palsy (23%) and infraclavicular palsy (15%). Median time from injury to surgical evaluation was 2 months (interquartile range, 2-4 months). Thirty-seven patients had a delayed referral (44%). Multivariable logistic regression analysis showed that the hospital to which the patient was referred, Medicare insurance, and motorcycle accident as the mechanism of injury were associated with a delayed referral.

CONCLUSIONS

Nearly half of traumatic BPI patients evaluated at 2 tertiary referral centers in a large metropolitan area in the United States presented in a delayed time frame. Both modifiable and nonmodifiable associations with delayed referral were identified. Patients with Medicare insurance had increased odds of delayed referral.

CLINICAL RELEVANCE

Establishment of multidisciplinary BPI specialty centers, outreach to local and regional hospitals, and development of referral algorithms and pathways may improve timeliness of referrals.

Impact of Insurance Type on Self-Reported Symptom Severity at the Preoperative Visit for Carpal Tunnel Release

PURPOSE

Prior studies evaluated the impact of insurance type on access to hand care. However, there is limited literature quantifying whether patient symptoms are worse at the time of intervention. Our primary null hypothesis was that insurance type would not be associated with Patient-Reported Outcomes Measure Information System (PROMIS) Upper-Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores at the preoperative visit before carpal tunnel release (CTR).

METHODS

Between December 2016 and November 2018, patients with known carpal tunnel syndrome presenting to a tertiary academic hand clinic for the preoperative visit within 3 months of CTR, completed PROMIS UE, PF, PI, and Depression computer adaptive tests. Patient characteristics were recorded, including insurance type as commercial, Medicare, Medicaid, or workers' compensation. Multivariable linear regression was used to determine which variables were associated with PROMIS scores at the preoperative visit before CTR.

RESULTS

A total of 301 patients were included in the analysis. All PROMIS domains were significantly different by insurance type; Medicaid patients had the worst preoperative score for all domains in bivariate analysis. In multivariable linear regression modeling, commercial insurance was associated with better preoperative PROMIS UE, PF, PI, and Depression scores.

CONCLUSIONS

Commercial insurance is associated with significantly better preoperative PROMIS PF, PI, and Depression scores compared with other insurance types (ie, Medicaid, Medicare, and Workers' compensation). This may be the result of a number of factors, including differences in access to hand care or life circumstances that allow for only certain individuals to seek hand care early on in the disease process. However, further research is warranted to determine more definitively why this association exists.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.