Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review

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.

Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study

BACKGROUND

Disparities in orthopedic trauma care have been reported for racial-ethnic minority and socially disadvantaged patients. We examined differences in perioperative metrics by patient race and ethnicity and insurance after pelvic fracture in a national sample in the United States.

MATERIALS AND METHODS

The 2016-2019 National Inpatient Sample was queried for White, Black, and Hispanic patients 18 to 64 years old with private, Medicaid, or self-pay insurance who underwent non-elective pelvic fracture surgery. Associations between combined race and ethnicity and insurance subgroups and perioperative metrics (time to surgery, length of stay, inhospital complications, institutional discharge) were assessed using multivariable generalized linear and logistic regression models. Adjusted percent differences or odds ratios (ORs) were reported.

RESULTS

A weighted total of 14,375 surgeries were included (68.8% in White patients, 16.1% in Black patients, and 15.1% in Hispanic patients; 60.0% private insurance, 26.3% Medicaid, and 13.7% self-pay). Compared with White patients with private insurance, all Black insurance subgroups had longer length of stay (+15.38% to +38.78%, P≤.001), as did Hispanic patients with Medicaid (+28.03%, P<.001), White patients with Medicaid (+13.08%, P<.001), and White patients with self-pay (+9.47%, P=.04). Additionally, compared with White patients with private insurance, decreased odds of institutional discharge were observed for all patients with self-pay (OR, 0.24-0.37, P<.001) as well as White patients with Medicaid (OR, 0.70, P=.003) and Hispanic patients with Medicaid (OR, 0.57, P=.002). There were no significant adjusted associations between race and ethnicity and insurance subgroups and in-hospital complications or time to surgery.

CONCLUSION

These differences in perioperative metrics, primarily for Black patients and patients with self-pay insurance, warrant further examination to identify whether they reflect disparities that should be addressed to promote equitable orthopedic trauma care. [Orthopedics. 202x;4x(x):xx-xx.].

Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis

Background

Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types.

Methods

A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses.

Results

Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007).

Conclusions

Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.

Association Between Race and Short-Term Outcomes Across 3988 Consecutive Single-Level Spinal Fusions

BACKGROUND AND OBJECTIVES

Race has implications for access to medical care. However, the impact of race, after access to care has been attained, remains poorly understood. The objective of this study was to isolate the relationship between race and short-term outcomes across patients undergoing a single, common neurosurgical procedure.

METHODS

In this retrospective cohort study, 3988 consecutive patients undergoing single-level, posterior-only open lumbar fusion at a single, multihospital, academic medical center were enrolled over a 6-year period. Among them, 3406 patients self-identified as White, and 582 patients self-identified as Black. Outcome disparities between all White patients vs all Black patients were estimated using logistic regression. Subsequently, coarsened exact matching controlled for outcome-mitigating factors; White and Black patients were exact-matched 1:1 on key demographic and health characteristics (matched n = 1018). Primary outcomes included 30-day and 90-day hospital readmissions, emergency department (ED) visits, reoperations, mortality, discharge disposition, and intraoperative complication.

RESULTS

Before matching, Black patients experienced increased rate of nonhome discharge, readmissions, ED visits, and reoperations (all P < .001). After exact matching, Black patients were less likely to be discharged to home (odds ratio [OR] 2.68, P < .001) and had higher risk of 30-day and 90-day readmissions (OR 2.24, P < .001; OR 1.91, P < .001; respectively) and ED visits (OR 1.79, P = .017; OR 2.09, P < .001). Black patients did not experience greater risk of intraoperative complication (unintentional durotomy).

CONCLUSION

Between otherwise homogenous spinal fusion cohorts, Black patients experienced unfavorable short-term outcomes. These disparities were not explained by differences in intraoperative complications. Further investigation must characterize and mitigate institutional and societal factors that contribute to outcome disparities.

Cluster Analysis reveals Socioeconomic Disparities among Elective Spine Surgery Patients

This work demonstrates the use of cluster analysis in detecting fair and unbiased novel discoveries. Given a sample population of elective spinal fusion patients, we identify two overarching subgroups driven by insurance type. The Medicare group, associated with lower socioeconomic status, exhibited an over-representation of negative risk factors. The findings provide a compelling depiction of the interwoven socioeconomic and racial disparities present within the healthcare system, highlighting their consequential effects on health inequalities. The results are intended to guide design of fair and precise machine learning models based on intentional integration of population stratification.

Lower Neighborhood Socioeconomic Status May Influence Medical Complications, Emergency Department Utilization, and Costs of Care After 1- to 2-Level Lumbar Fusion

STUDY DESIGN

Retrospective Case-Control Study.

OBJECTIVES

The objectives were to determine whether patients from poor social determinants of health, undergoing primary 1- to 2-level lumbar fusion, demonstrate differences in (1) medical complications, (2) emergency department (ED) utilizations, (3) readmission rates, and (4) costs of care.

SUMMARY OF BACKGROUND DATA

Measures of socioeconomic disadvantage may enable improved targeting and prevention of potentially increased health care utilization. The Area Deprivation Index (ADI) is a validated index of 17 census-based markers of material deprivation and poverty.

MATERIALS AND METHODS

A retrospective query of the 2010-2020 PearlDiver database was performed for primary 1- to 2-level lumbar fusions for degenerative lumbar pathology. High ADI (scale: 0-100) is associated with a greater disadvantage. Patients with high ADI (90%+) were 1:1 propensity score matched to controls (ADI: 0-89%) by age, sex, and Elixhauser Comorbidity Index. This yielded 34,442 patients, evenly matched between cohorts. Primary outcomes were to compare 90-day complications, ED utilizations, readmissions, and costs of care. Multivariable logistic regression models computed the odds ratios (OR) of ADI on complications, ED utilizations, and readmissions. P -values <0.05 were significant.

RESULTS

Patients with a high ADI incurred higher rates and odds of developing respiratory failures (1.17% vs. 0.87%; OR: 1.35, P =0.005). Acute kidney injuries (2.61% vs. 2.29%; OR: 1.14, P =0.056), deep venous thromboses (0.19% vs. 0.17%; OR: 1.14, P =0.611), cerebrovascular accidents (1.29% vs. 1.31%; OR: 0.99, P =0.886), and total medical complications (23.35% vs. 22.93%; OR: 1.02, P =0.441) were similar between groups. High ADI patients experienced higher rates and odds of ED visits within 90 days (9.67% vs. 8.91%; OR: 1.10, P =0.014) and overall 90-day expenditures ($54,459 vs. $47,044; P <0.001).

CONCLUSIONS

Socioeconomically disadvantaged patients have increased rates and odds of respiratory failure within 90 days. ED utilization within 90 days of surgery was higher in socioeconomically disadvantaged patients. Social determinants of health could be used to inform health care policy and improve postdischarge care.

LEVEL OF EVIDENCE

Level III.

Payor type is associated with increased rates of reoperation and health care utilization after rotator cuff repair: a national database study

BACKGROUND

Despite strong evidence supporting the efficacy of rotator cuff repair (RCR), previous literature has demonstrated that socioeconomic disparities exist among patients who undergo surgery. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation after RCR.

METHODS

Patients with Medicare, Medicaid, or commercial payor-type insurance who underwent primary open or arthroscopic RCR between 2010 and 2019 were identified using a large national database. Ninety-day incidence of medical complications, emergency department (ED) visit, and hospital readmission, as well as 1-year incidence of revision repair, revision to arthroplasty, and cost of care were evaluated. Propensity-score matching was used to control for patient demographic factors and comorbidities as covariates.

RESULTS

A total of 113,257 Medicare, 23,074 Medicaid, and 414,447 commercially insured patients were included for analysis. Medicaid insurance was associated with an increased 90-day risk of various medical complications, ED visit (odds ratio [OR]: 2.87; P < .001), and 1-year revision RCR (OR: 1.60; P < .001) compared with Medicare insurance. Medicaid insurance was also associated with an increased risk of various medical complications, ED visit (OR: 2.98; P < .001), and hospital readmission (OR: 1.56; P = .002), as well as 1-year risk of revision RCR (OR: 1.60; P < .001) and conversion to arthroplasty (OR: 1.4358; P < .001) compared with commercially insured patients. Medicaid insurance was associated with a decreased risk of conversion to arthroplasty compared with Medicare patients (OR: 0.6887; P < .001). Medicaid insurance was associated with higher 1-year cost of care compared with patients with both Medicare (P < .001) and commercial insurance (P < .001).

DISCUSSION

Medicaid insurance is associated with increased rates of medical complications, health care utilization, and reoperation after rotator cuff surgery, despite controlling for covariates. Medicaid insurance is also associated with a higher 1-year cost of care. Understanding the complex relationship between sociodemographic factors, such as insurance status, medical comorbidities, and outcomes, is necessary to ensure optimal health care access for all patients and to allow for appropriate risk stratification.

Payor Type is Associated With Increased Rates of Reoperation and Health-care Utilization Following Unicompartmental Knee Arthroplasty: A National Database Study

Background

Unicompartmental knee arthroplasty (UKA) is a common orthopedic procedure with overall good clinical outcomes; however, more recent literature has identified disparities in treatment access and outcomes based on sociodemographic factors. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation following a UKA.

Methods

Patients with Medicare, Medicaid, or commercial payor type who underwent primary medial or lateral UKA between 2010 and 2019 were identified using a large national database. Ninety-day incidence of emergency department visit and 1-year incidence of revision, revision to arthroplasty, reimbursement, and cost of care were evaluated. Propensity score matching was used to control for patient demographic factors and comorbidities as covariates.

Results

Medicaid insurance was associated with an increased risk of emergency room visit (odds ratio [OR] 2.77; P < .001), revision surgery (OR 1.85; P < .001), and conversion to total knee arthroplasty (OR 1.50; P = .0292) compared to commercially insured patients. Medicaid insurance was associated with an increased risk of emergency room visit (OR 3.58; P < .001), revision surgery (OR 1.97; P < .001), and conversion to total knee arthroplasty (OR 1.80; P = .003). Medicaid patients were associated with a higher overall cost of care and lower reimbursement than commercial and Medicare patients (P < .001 and P < .001, respectively).

Conclusions

These findings demonstrate that payor type is associated with increased rates of reoperation and health-care utilization following UKA despite controlling for covariates. Additional work is required to understand the complex relationship between socioeconomic status and outcomes to ensure appropriate health-care access for all patients and pursue appropriate risk stratification.

Level of Evidence

III, retrospective chart review.