Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

Payer Status and Racial Disparities in Time to Surgery for Emergent Orthopaedic Procedures

INTRODUCTION

Delay in surgical management for orthopaedic emergencies and severe fracture types can result in notable morbidity and even mortality for patients. Disparities in various facets of orthopaedic care have been identified based on race/ethnicity, socioeconomic status, and payer status, but disparities in time to surgery have been poorly explored. The purpose of this study was, therefore, to investigate whether disparities exist in time to emergent orthopaedic surgery.

METHODS

Patients who underwent surgery for hip fracture, femur fracture, pelvic fracture, septic knee, septic hip, or cauda equina syndrome over 2012 to 2020 were identified using national data. Multivariable linear regression models were constructed, controlling for age, sex, race/ethnicity, payer status, socioeconomic status, hospital setting, and comorbidities to examine the effect of payer status and race/ethnicity, on time to surgery.

RESULTS

Over 2012 to 2020, 247,370 patients underwent surgery for hip fracture, 64,827 for femur fracture, 14,130 for pelvic fracture, 14,979 for septic knee, 3,205 for septic hip, and 4,730 for cauda equina syndrome. On multivariable analysis, patients with Medicaid experienced significantly longer time to surgery for hip fracture, femur fracture, pelvic fracture, septic knee, and cauda equina syndrome (P < 0.05 all). Black patients experienced longer time to surgery for hip fracture, femur fracture, septic knee, septic hip, and cauda equina syndrome, and Hispanic patients experienced longer time to surgery for hip fracture, femur fracture, pelvic fracture, and cauda equina syndrome (P < 0.05 all).

DISCUSSION

The results of this study demonstrate that Medicaid-insured patients, and often minority patients, experience longer delays to surgery than privately insured and White patients. Future work should endeavor to identify causes of these disparities to promote creation of policies aimed at improving timely access to care for Medicaid-insured and minority patients.

LEVEL OF EVIDENCE

III.

Hospital teaching status is an independent predictor of surgical intervention of distal radius fractures

Background

Distal radius fractures are among the most common orthopaedic injuries and are managed both surgically and non-surgically. To date, no study has examined the role hospital teaching status plays in the rates of surgical intervention.

Methods

The Nationwide Inpatient Sample (NIS) was queried for years 2003-2014. Patients with a distal radius fracture were identified using International Classification for Disease, Ninth Revision (ICD-9) disease codes. Surgical intervention was determined using ICD-9 procedure codes. Exclusion criteria were patients younger than age 18, polytrauma, open fractures, records with missing data, and records where the primary procedure was something other than open reduction of a radius or ulna fracture, closed reduction of a radius or ulna fracture, or blank. Chi-squared tests were run for demographic and socioeconomic data to identify significant variables. Significant variables were then included alongside hospital teaching status in a binomial logistic regression model. Significance was defined as P < 0.05.

Results

A weighted total of 98,831 patients were included in the study. Of those, 45,234 (45.8 %) were treated at teaching hospitals. Patients in teaching hospitals were more likely to be younger, male, non-white, and non-Medicare insured than non-teaching hospitals. Injuries were treated surgically in 64.6 % of total cases. Surgical intervention was more common in teaching hospitals than non-teaching hospitals (69.1 % vs. 60.8 %, P < 0.01). After controlling for demographic and socioeconomic factors, patients at teaching hospitals were 31 % more likely to undergo surgical treatment than those at non-teaching hospitals. Other factors that were independently predictive of surgical treatment were age, race, and insurance type.

Conclusion

In the setting of distal radius fractures, teaching hospitals have higher rates of surgical intervention than non-teaching hospitals. These results suggest that the involvement of medical trainees may play a role in the surgical decision-making process.

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act

Importance

Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear.

Objective

To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA.

Design, Setting, and Participants

This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023.

Exposures

Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods.

Main Outcomes and Measures

Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA.

Results

Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change.

Conclusions and Relevance

Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

Trends in and Factors Associated With Surgical Management for Closed Clavicle Fractures

INTRODUCTION

Clavicle fractures are common and have historically been managed nonsurgically. Over time, there are increasing surgical considerations for such injuries. Nonetheless, trends over the past decade are not well characterized.

METHODS

Adult patients presenting for first diagnosis of clavicle fractures were identified from the 2010 to 2020 PearlDiver M151 database. Patients were defined to have undergone surgical management if they received clavicular open reduction and internal fixation within 90 days after fracture diagnosis. Patient age, sex, Elixhauser Comorbidity Index (ECI), geographic region, insurance coverage, fracture anatomic location, and polytraumatic diagnoses were extracted. Factors independently associated with surgical management versus nonsurgical management were assessed with multivariable analysis.

RESULTS

Overall, 50,980 patients with clavicle fractures were identified of whom 6,193 (12.1%) were managed surgically. This proportion increased significantly over the study period (7.4% in 2015 to 13.9% in 2020, P < 0.001). Independent predictors of surgical management included fracture diagnosis in 2020 (versus 2015, odds ratio [OR] 2.36), anatomic location (relative to lateral end, shaft OR 1.84 and sternal OR 3.35), and Midwest region of service (OR 1.26, relative to South) (P < 0.001 for all).

DISCUSSION

A small but increasing minority of patients with clavicle fractures are managed surgically. Clinical factors and nonclinical factors were associated with surgical management.

A prospective assessment of resilience in trauma patients using the Connor-Davidson Resilience Scale

BACKGROUND

Resilience, or the ability to adapt to difficult or challenging life experiences, may be an important mediator in trauma recovery. The primary aim of this study was to describe resilience levels for trauma patients using the validated Connor-Davidson Resilience Scale.

METHODS

Adult trauma patients admitted to a Level 1 trauma center (June 2022-August 2022) were surveyed at the time of admission and by phone between 2 weeks and 1 month after the original survey to obtain follow-up scores. We utilized the validated Connor-Davidson Resilience Scale score, a 25-question survey with 5 subfactors (Tenacity, Positive Outlook, Social Support, Problem Solving, and Meaning and Purpose). Each question was scored from 0 to 4 (maximum score 100, representing the highest resilience). Patient factors were collected from the electronic medical record and trauma health registry. Wilcoxon signed-rank test and multivariable linear regression were used to understand associations with Connor-Davidson Resilience Scale scores.

RESULTS

We enrolled 98 patients. The median age was 50 years (interquartile range 32-67), and 74% were male sex. The baseline median Connor-Davidson Resilience Scale score on admission was 88 (interquartile range 81-94). Follow-up surveys (N = 64) showed a median score of 89.5 (80-90.5) (P = non-significant). No demographic variable was significantly associated with increasing baseline Connor-Davidson Resilience Scale score. Increased length of stay (β = 1.03), insurance (β = -7.50), and unknown race (β = 23.69) were correlated with follow-up Connor-Davidson Resilience Scale scores. The subfactor "Meaning and Purpose" decreased at follow-up but was not statistically significant (P = .05).

CONCLUSION

Validated tools that can accurately distinguish variability in resilience scores are needed for the trauma patient population to understand its relationship with long-term patient health outcomes.

Barriers and facilitators to surgical access in underinsured and immigrant populations

BACKGROUND

Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations.

METHODS

A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies.

RESULTS

Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors.

CONCLUSIONS

Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.

Disparities in Treatment of Closed Distal Radius Fractures in Patients Aged 18-64 Years and ≥65 Years by Insurance Type

PURPOSE

Type of and time to definitive treatment for distal radius fractures can influence the outcomes. The impact of social determinants of health (eg, insurance type) on distal radius fracture care remains unknown despite having health equity implications. Thus, we evaluate the association between insurance type and rate of surgery, the time to surgery, and the complication rate for distal radius fractures.

METHODS

We conducted a retrospective cohort study using the PearlDiver Database. We identified adults with closed distal radius fractures. Patients were divided into subgroups by age (18-64 years, 65+ years) and further stratified on the basis of the insurance type (Medicare Advantage, Medicaid-managed care, and commercial). The primary outcome was the rate of surgical fixation. Secondary outcomes included the time to surgery and 12-month complication rates. Logistic regression modeling was used to calculate the odds ratios for each outcome, adjusting for age, sex, geographic region, and comorbidities.

RESULTS

In patients aged ≥65 years, a lower proportion of Medicaid patients underwent surgery within 21 days of diagnosis compared with Medicare or commercially insured patients (12.1% vs 15.9% or 17.5%, respectively). Complication rates did not differ between Medicaid and other insurance types. In patients aged <65 years, fewer Medicaid patients underwent surgery compared with commercially insured patients (16.2% vs 21.1%). However, in this younger group, Medicaid patients had higher adjusted odds of malunion/nonunion (adjusted odds ratio [aOR] = 1.39 [95% CI, 1.31-1.47]) and subsequent repair (aOR = 1.38 [95% CI, 1.25-1.53]).

DISCUSSION

Although older Medicaid patients experienced lower surgical rates, this may not lead to differential clinical outcomes. However, Medicaid patients aged <65 years experienced lower surgical rates that correlated with the increased rates of malunion or nonunion.

CLINICAL RELEVANCE

In younger patients with a closed distal radius fracture and Medicaid insurance, system and patient-directed efforts should be considered to address delayed time to surgery and a higher odds for malunion/nonunion.

Assessing the Change in Operative Treatment Rates for Acute Midshaft Clavicle Fractures: Incorporation of Evidence-Based Surgery Results in Orthopaedic Practice

In 2007, a randomized controlled trial (RCT) by the Canadian Orthopaedic Trauma Society (COTS) demonstrated better functional outcomes and a lower proportion of patients who developed malunion or nonunion following operative, compared with nonoperative, treatment of midshaft clavicle fractures. The primary aim of the present study was to compare the proportion of midshaft clavicle fractures treated operatively prior to and following the publication of the COTS RCT. An additional exploratory aim was to assess whether the proportion of midshaft clavicle fractures that were treated with surgery for malunion or nonunion decreased.

Methods

This retrospective cohort analysis used population-level administrative health data on the residents of British Columbia, Canada. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes and procedure fee codes. Adult patients (≥18 years) with closed middle-third clavicle fractures between 1997 and 2018 were included. Multivariable logistic regression modeling compared the proportion of clavicle fractures treated operatively before and after January 1, 2007, controlling for patient factors. The Pearson chi-square test compared the proportion of fractures treated operatively for malunion or nonunion in the cohorts.

Results

A total of 52,916 patients were included (mean age, 47.5 years; 65.6% male). More clavicle fractures were treated operatively from 2007 onward: 6.9% compared with 2.2% prior to 2007 (odds ratio [OR] = 3.35, 95% confidence interval [CI] = 3.03 to 3.70, p < 0.001). Male sex, moderate-to-high income, and younger age were associated with a greater proportion of operative fixation. The rate of surgery for clavicle malunion or nonunion also increased over this time period (to 4.1% from 3.4%, OR = 1.26, 95% CI = 1.15 to 1.38, p < 0.001).

Conclusions

We found a significant change in surgeon practice regarding operative management of clavicle fractures following the publication of a Level-I RCT. With limited high-quality trials comparing operative and nonoperative management, it is important that clinicians, health-care institutions, and health-authority administrations determine what steps can be taken to increase responsiveness to new clinical studies and evidence-based guidelines.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trends in the Treatment of Adolescent Clavicle Fractures: Are We Listening to the Evidence?

BACKGROUND

From 1999 to 2011, studies demonstrated an increasing trend toward surgical management of adolescent clavicle fractures. The purpose of this study was to examine more recent trends of surgical management of closed clavicle fractures in adolescent patients over the past decade.

METHODS

A retrospective cohort study was conducted using the PearlDiver database. Patients with clavicle fractures from 2011 to 2021 were identified and stratified by age, sex, and year of their fracture. Categorical variables were compared with a chi square test, and continuous variables were compared with the Welch t test or Mann-Whitney U test.

RESULTS

Overall, there was a significant increase in the percentage of patients surgically treated by open reduction and internal fixation from 2016 to 2021 compared with 2011 to 2015 (8.58% vs. 7.34%, P < 0.001). When stratified by age, both the 10 to 14-year group (3.80% vs. 3.10%, P < 0.001) and the 15 to 18-year group (15.41% vs. 12.84%, P < 0.001) demonstrated significant increases in the percentage of patients surgically treated.

CONCLUSION

Despite increasing literature demonstrating high revision surgery rates for surgical treatment of adolescent clavicle fractures with no difference in functional outcomes, this study demonstrated a notable increase in the rate of surgical treatment of adolescent clavicle fractures from 2011 to 2021 in the United States.

Medicaid insurance is associated with treatment disparities for proximal humerus fractures in a national database analysis

BACKGROUND

Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs.

METHODS

We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010 and 2019 were identified by International Classification of Diseases, Ninth and Tenth Revision diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, noninfectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications.

RESULTS

We included 245,396 patients for analysis. Fourteen percent of Medicaid patients (1789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately insured patients and 16% (13,305/83,068) of Medicare patients (pairwise, P < .001). TTS (Medicaid: 11.7 days, private: 10.6 days [P < .001]; Medicare: 10.7 days [P = .003]) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio: 0.77 [95% confidence interval (CI): 0.63-0.93] for private vs. Medicaid and 0.71 [95% CI: 0.59-0.88] for Medicare vs. Medicaid) and experienced fewer 90-day postoperative complications (adjusted odds ratio: 0.73 [95% CI: 0.62-0.85] for private vs. Medicaid, 0.65 [95% CI: 0.55-0.77] for Medicare vs. Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications.

CONCLUSION

There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers that patients face and minimize health care inequities seen in the treatment of PHFs based on insurance type.

Is Insurance Status Associated With Likelihood of Operative ACL Injury Treatment Compared With Nonoperative Treatment?

Background:

While many factors inform the choice of operative versus nonoperative treatment of injuries to the anterior cruciate ligament (ACL) of the knee, socioeconomic status influences this decision, as has been reported with other procedures.

Purpose:

To identify any associations between insurance status and likelihood of operative treatment of ACL injuries.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

The Nationwide Inpatient Sample database was queried using International Classification of Diseases, 9th Revision codes for ACL injuries and reconstruction from 2001 to 2013. Chi-square analysis was performed to determine significant predictors of operative intervention. Binary logistic regression was used to account for demographic and significant predictor variables. Results were recorded as odds ratios (ORs) and 95% CIs. Significance was defined as P < .05.

Results:

A total of 32,541 patients with ACL injuries were included in the final analysis. Overall incidence of surgical reconstruction was 85.4% (n = 27,805). Multivariable regression revealed that nonprivate insurance types were associated with lower likelihoods of operative reconstruction compared with private insurance: the lowest likelihood of operation was seen in uninsured patients (OR, 0.31; P < .01), followed by Medicare (OR, 0.33; P < .01) and Medicaid (OR, 0.51; P < .01) patients. There was also a decreased likelihood of surgery for elderly (OR, 0.0 [for age ≥75 years]; P < .01) and Black patients (OR, 0.65; P < .01). An increased likelihood of surgery was seen with female patients (OR, 1.14; P < .01). Patients in the highest median household income quartile were more likely to undergo surgery than those in the lowest (OR, 1.36; P < .01).

Conclusion:

Compared with privately insured patients, patients with nonprivate insurance had lower likelihood of surgery. Furthermore, patients in higher income quartiles were more likely to undergo operative fixation. These findings may suggest a need for more precise treatment guidelines and studies that investigate causes of such differences.

Socioeconomic Status Impacts Access to Orthopaedic Specialty Care

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Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care.

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Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States.

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Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes.

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Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.