1
|
Quinn M, Marcaccio SE, Brodeur PG, Testa EJ, Gil JA, Cruz AI. In Patients With Rotator Cuff Tears, Female, Hispanic, African American, Asian, Socially Deprived, Federally Insured, and Uninsured Patients Are Less Commonly Treated Surgically. Arthroscopy 2024:S0749-8063(24)00415-8. [PMID: 38901676 DOI: 10.1016/j.arthro.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/14/2024] [Accepted: 05/24/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE The purpose of the current study was to evaluate socioeconomic factors affecting whether a patient undergoes rotator cuff repair after a diagnosis of a rotator cuff tear. METHODS From 2009 through 2018, claims for adult (≥18 years of age) patients who were diagnosed with a primary rotator cuff injury were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database via International Classification of Diseases (ICD)-9th Revision-Clinical Modification (CM) and ICD-10-CM diagnostic codes. SPARCS is a comprehensive all-payer database collecting all inpatient and outpatient pre-adjudicated claims in New York. ICD-9-CM and ICD-10-CM codes were used to identify the initial diagnosis for each patient. Current Procedural Terminology codes were used to identify subsequent rotator cuff surgery. The procedures identified were linked with the initial diagnosis, and patients were noted as either having or not having rotator cuff surgery. Logistic regression analysis was performed for variables including age, sex, race, Social Deprivation Index (SDI), Charlson Comorbidity Index, and primary insurance type to determine the effect of patient factors on the likelihood of having surgery after a diagnosis of rotator cuff injury. RESULTS Of the 67,584 rotator cuff patients included in the analysis, 19,770 (29.3%) of the patients underwent surgical intervention. From the logistic regression, females relative to males (odds ratio [OR] = 0.798, P < .0001), increased SDI (OR = 0.994, p < .0001), African American compared with White race (OR = 0.694, P < .0001), Asian compared with White (OR = 0.832, P < .0001), Hispanic compared with White (OR = 0.693, P < .0001), other race (OR = 0.58, P < .0001), those with Medicare (OR = 0.601, P < .0001) or Medicaid (OR = 0.614, P < .0001) relative to private insurance, and self-pay relative to private insurance (OR = 0.727, P < .0001) were all associated with decreased odds of undergoing rotator cuff surgery. Older patients (OR = 1.012, P < .0001) and Workers' Compensation relative to private insurance (OR = 1.664, P < .0001) had increased odds of undergoing surgery. CONCLUSIONS The results of the current study identified disparities in the likelihood of undergoing rotator cuff repair after a diagnosis of a rotator cuff tear based on patient demographic and socioeconomic factors. Individuals with higher SDI; African American, Asian, Hispanic, or other non-White races; and those with Medicare, Medicaid, or self-pay insurance had decreased odds of surgery, whereas older age and Workers' Compensation insurance were associated with increased odds of undergoing surgery. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Matthew Quinn
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Stephen E Marcaccio
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Peter G Brodeur
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A..
| | - Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| |
Collapse
|
2
|
Watson RR, Niedziela CJ, Nuzzi LC, Netson RA, McNamara CT, Ayannusi AE, Flanagan S, Massey GG, Labow BI. Impact of Insurance Type on Access to Pediatric Surgical Care. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5831. [PMID: 38798939 PMCID: PMC11124593 DOI: 10.1097/gox.0000000000005831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/01/2024] [Indexed: 05/29/2024]
Abstract
Background This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance. Methods This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex. Results A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007). Conclusions No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.
Collapse
Affiliation(s)
- Rachel R. Watson
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Cassi J. Niedziela
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Laura C. Nuzzi
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Rebecca A. Netson
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Catherine T. McNamara
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Anuoluwa E. Ayannusi
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Sarah Flanagan
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Gabrielle G. Massey
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Brian I. Labow
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| |
Collapse
|
3
|
Tsourmas NF, Bernacki EJ, Hunt DL, Kalia N, Lavin RA, Yuspeh L, Leung N, Green-McKenzie J, Tao XG. Is Arthroscopic Meniscectomy Associated With an Increased Risk of Total Knee Arthroplasty for Claimants in the Workers' Compensation System? A 10-Year Study of Workers' Compensation Claims From a Large Nationwide Workers' Compensation Insurance Carrier. J Occup Environ Med 2024; 66:280-285. [PMID: 38234200 DOI: 10.1097/jom.0000000000003044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a commonly performed knee surgery and prior arthroscopic meniscectomy (AM) has been linked to an increased risk of TKA in the general population. OBJECTIVE To study the relationship between AM and TKA among injured workers whose medical care is paid for under workers' compensation (WC). METHOD A total of 17,247 lost-time claims depicting all arthroscopic knee surgical procedures performed from 2007 to 2017 were followed to the end of 2022 and analyzed. RESULTS The odds ratio of undergoing a TKA for those with a preceding AM is 2.20, controlling for age, sex, and attorney involvement. CONCLUSIONS Undergoing an AM is associated with an increased risk of TKA in WC claimants.
Collapse
Affiliation(s)
- Nicholas F Tsourmas
- From the Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland (N.F.T., E.J.B., R.A.L., N.K., L.Y., N.L., X.T.); AF Group, Lansing, MI (D.L.H.); General Electric, Norwalk, Connecticut (N.K.); Corporate Administration Office, Strategy, Enterprise Risk, and Research, Louisiana Workers' Compensation Corporation, Baton Rouge, Louisiana (L.Y.); Texas Mutual, Workers' Compensation Insurance, Austin, Texas (N.F.T., N.L.). University of Pennsylvania, Philadelphia, Pennsylvania (J.G.-M.)
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Kumar N, Akosman I, Mortenson R, Xu G, Kumar A, Mostafa E, Rivlin J, De La Garza Ramos R, Krystal J, Eleswarapu A, Yassari R, Fourman MS. Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100315. [PMID: 38533185 PMCID: PMC10964016 DOI: 10.1016/j.xnsj.2024.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/13/2024] [Accepted: 02/12/2024] [Indexed: 03/28/2024]
Abstract
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.
Collapse
Affiliation(s)
- Neerav Kumar
- Weill Cornell School of Medicine, New York, NY,
USA
| | | | | | - Grace Xu
- Princeton University, Princeton, NJ, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Bakillah E, Brown D, Syvyk S, Wirtalla C, Kelz RR. Barriers and facilitators to surgical access in underinsured and immigrant populations. Am J Surg 2023; 226:176-185. [PMID: 37156680 DOI: 10.1016/j.amjsurg.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/10/2023] [Accepted: 04/08/2023] [Indexed: 05/10/2023]
Abstract
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.
Collapse
Affiliation(s)
- Emna Bakillah
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Danielle Brown
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Solomiya Syvyk
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Christopher Wirtalla
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
6
|
Derakhshan A, Shaye D, McCarty JC, Nellis J, -Lyford Pike S, Hadlock TA, Gadkaree SK. Surgical Management of Facial Paralysis: Demographic and Socioeconomic Associations. Facial Plast Surg Aesthet Med 2023; 25:165-171. [PMID: 36099197 DOI: 10.1089/fpsam.2021.0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To determine demographic and socioeconomic variables associated with whether surgery is performed for patients with facial paralysis (FP). Background: Management of FP may include elective surgery dependent on patient goals of care and physician experience. Methods: The 2016 State Inpatient Database and State Ambulatory Surgery Services Database for six states were queried to identify patients with FP. These patients were then stratified based on receiving surgery for FP. Demographic and socioeconomic information was collected. Multivariable logistic regression modeling was used to identify predictors of undergoing FP surgery, as well as the hospital setting in which surgery was performed. Results: Of 20,218 patients with FP, 515 underwent surgery. Black patients were significantly less likely to undergo surgery (p < 0.001), as were patients with Medicaid or self-pay insurance (p < 0.001). Those living in rural areas were also less likely to receive surgery (p = 0.001). Individuals receiving surgery in the inpatient setting were more likely to have private insurance, whereas those in the ambulatory setting were more likely to have Medicare (p < 0.001). Conclusion: Several variables are correlated with whether FP is managed surgically, including insurance status, race, and type of residential area.
Collapse
Affiliation(s)
- Adeeb Derakhshan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Shaye
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Justin C McCarty
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Nellis
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sofia -Lyford Pike
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tessa A Hadlock
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Shekhar K Gadkaree
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery, University of Miami, Miami, Florida, USA
| |
Collapse
|
7
|
Testa EJ, Modest JM, Brodeur P, Lemme NJ, Gil JA, Cruz AI. Do Patient Demographic and Socioeconomic Factors Influence Surgical Treatment Rates After ACL Injury? J Racial Ethn Health Disparities 2023; 10:319-324. [PMID: 35006586 DOI: 10.1007/s40615-021-01222-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) injuries may be managed nonoperatively in certain patients and injury patterns; however, complete ACL ruptures are commonly reconstructed to restore anterior and lateral rotatory stability of the knee. While ACL reconstruction is well-studied, the literature is sparse with regard to which socioeconomic patient factors are associated with patients undergoing ACL reconstruction rather than nonoperative management after diagnosis of an ACL injury. The current study seeks to evaluate this relationship between patient demographics as well as socioeconomic factors and the rate of surgery following ACL injuries. METHODS Patients ≤65 years of age with a primary ACL injury between 2011 and 2018 were retrospectively identified in the New York Statewide Planning and Research Cooperative System database. International Classification of Disease 9/10 and Current Procedural Terminology codes were used to identify these patients and their subsequent ACL reconstructions. Logistic regression was performed to determine the effect of patient factors on the likelihood of having surgery after the diagnosis of an ACL injury. RESULTS Compared to White patients, African American patients were significantly less likely to undergo ACL reconstruction following an ACL injury (OR=0.65, 95% CI, 0.573-0.726). Patients older than 35 had decreased odds of undergoing ACL reconstruction compared to younger patients, with patients 55-64 having the lowest odds (OR=0.166, 95% CI, 0.136-0.203). Patients with Medicaid (OR=0.84, 95% CI, 0.757-0.933) or self-pay insurance (OR=0.67, 95% CI, 0.565-0.793), and those with worker's compensation (OR=0.715, 95% CI, 0.621-0.823) had decreased odds of undergoing ACL reconstruction relative to patients with private insurance. Patients with higher Social Deprivation Index (SDI) were significantly more likely to be treated nonoperatively after ACL injuries compared to those with lower SDI (mean nonoperative SDI score, 61, operative SDI, 56, P<0.0001). DISCUSSION In patients with ACL injuries, there are socioeconomic and patient-related factors that are associated with increased odds of undergoing ACL reconstruction. These factors are important to recognize as they represent a source of potential inequality in access to care and an area with potential for improvement.
Collapse
Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI, USA. .,Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI, 02904, USA.
| | - Jacob M Modest
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter Brodeur
- Alpert Medical School of Brown University, Providence, RI, USA
| | - Nicholas J Lemme
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| |
Collapse
|
8
|
Resad Ferati S, Parisien RL, Joslin P, Knapp B, Li X, Curry EJ. Socioeconomic Status Impacts Access to Orthopaedic Specialty Care. JBJS Rev 2022; 10:01874474-202202000-00007. [PMID: 35171876 DOI: 10.2106/jbjs.rvw.21.00139] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
» Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care. » Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States. » Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes. » 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.
Collapse
Affiliation(s)
- Sehar Resad Ferati
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Robert L Parisien
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Patrick Joslin
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Brock Knapp
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Emily J Curry
- Boston University School of Public Health, Boston, Massachusetts
| |
Collapse
|
9
|
Li LT, Bokshan SL, Lemme NJ, Testa EJ, Owens BD, Cruz AI. Predictors of Surgery and Cost of Care Associated with Patellar Instability in the Pediatric and Young Adult Population. Arthrosc Sports Med Rehabil 2021; 3:e1279-e1286. [PMID: 34712964 PMCID: PMC8527270 DOI: 10.1016/j.asmr.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/31/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose To determine how patient demographics, socioeconomic status, history of recurrence, and initial point of presentation for health care influenced the decision for surgical treatment following a patellar instability episode. Methods The New York SPARCS database from 2016 to 2018 was queried for patients aged 21 and younger who were diagnosed with a patellar instability episode. These were linked to later surgeries with Current Procedural Terminology (CPT) codes 27405 (MPFL repair), 27418 (tibial tubercle osteotomy), 27420 (dislocating patella reconstruction), 27422 (Campbell/Roux-Goldthwait procedure), and 27427 (extra-articular knee ligamentous reconstruction). χ2-analysis and binary logistic regression were used to assess demographic and injury-specific variables for association with operative management. A generalized linear model was used to estimate charges associated with patellar instability. Results There were 2,557 patients with patellar instability, 134 (5.2%) of whom underwent surgery. Patients with recurrent instability had 1.875 times higher odds of undergoing surgery (P = .017). Compared to white patients, black patients had 0.428 times the odds of surgery (P = .004). None of the patients without insurance had surgery. In the cost model, an initial visit to an outpatient office was associated with $1,994 lower charges compared to an emergency department (ED) visit (P < .001). Black patients had $566 more in charges than White patients (P = .009). Compared with nonoperative treatment, surgeries with CPT 27405 added $13,124, CPT 27418 added $10,749, CPT 27422 added $18,981, CPT 27420 added $23,700, and CPT 27427 added $25,032 (all P < .001). Conclusions Patients with recurrent instability had higher odds of surgery, while Black and uninsured patients had lower odds of surgery. ED visits were associated with significantly higher charges compared to office visits, and Black patients had higher charges than white patients. Minority and uninsured patients may face barriers in access to orthopedic care. Level of Evidence Level III, retrospective cohort study.
Collapse
Affiliation(s)
- Lambert T. Li
- Address correspondence to Lambert T. Li, B.A., Department of Orthopaedic Surgery, Sports Injury Laboratory, Brown University, Warren Alpert School of Medicine, 1 Kettle Point Ave., Providence, RI 02906, U.S.A.
| | | | | | | | | | | |
Collapse
|
10
|
Benton JA, Weiss BT, Mowrey WB, Yassari N, Wang B, Ramos RDLG, Gelfand Y, Castro-Rivas E, Puthenpura V, Yassari R, Yanamadala V. Association of Medicare and Medicaid Insurance Status with Increased Spine Surgery Utilization Rates. Spine (Phila Pa 1976) 2021; 46:E939-E944. [PMID: 33496542 DOI: 10.1097/brs.0000000000003968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective single-institution study. OBJECTIVE The aim of this study was to determine the relationship between patients' insurance status and the likelihood for them to be recommended various spine interventions upon evaluation in our neurosurgical clinics. SUMMARY OF BACKGROUND DATA Socioeconomically disadvantaged populations have worse outcomes after spine surgery. No studies have looked at the differential rates of recommendation for surgery for patients presenting to spine surgeons based on socioeconomic status. METHODS We studied patients initially seeking spine care from spine-fellowship trained neurosurgeons at our institution from July 1, 2018 to June 30, 2019. Multivariable logistic regression was used to assess the association between insurance status and the recommended patient treatment. RESULTS Overall, 663 consecutive outpatients met inclusion criteria. Univariate analysis revealed a statistically significant association between insurance status and treatment recommendations for surgery (P < 0.001). Multivariate logistic regression demonstrated that compared with private insurance, Medicare (odds ratio [OR] 3.54, 95% confidence interval [CI] 1.21-7.53, P = 0.001) and Medicaid patients (OR 2.46, 95% CI 1.21-5.17, P = 0.014) were more likely to be recommended for surgery. Uninsured patients did not receive recommendations for surgery at significantly different rates than patients with private insurance. CONCLUSION Medicare and Medicaid patients are more likely to be recommended for spine surgery when initially seeking spine care from a neurosurgeon. These findings may stem from a number of factors, including differential severity of the patient's condition at presentation, disparities in access to care, and differences in shared decision making between surgeons and patients.Level of Evidence: 3.
Collapse
Affiliation(s)
- Joshua A Benton
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Brandon T Weiss
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Wenzhu B Mowrey
- Department of Epidemiology and Public Health, Albert Einstein College of Medicine, Bronx, NY
| | - Neeky Yassari
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Benjamin Wang
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Rafael De La Garza Ramos
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Yaroslav Gelfand
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Erida Castro-Rivas
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Vidya Puthenpura
- Section of Pediatric Hematology/Oncology, Department of Pediatrics, Yale School of Medicine and Yale-New Haven Hospital, New Haven, CT
| | - Reza Yassari
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Vijay Yanamadala
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| |
Collapse
|
11
|
Janeway MG, Sanchez SE, Rosen AK, Patts G, Allee LC, Lasser KE, Dechert TA. Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States. J Surg Res 2021; 266:373-382. [PMID: 34087621 DOI: 10.1016/j.jss.2021.03.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/18/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy. MATERIALS AND METHODS Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy. RESULTS Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals. CONCLUSIONS Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.
Collapse
Affiliation(s)
- Megan G Janeway
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Amy K Rosen
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Gregory Patts
- Boston University School of Public Health, Boston, Massachusetts
| | - Lisa C Allee
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Karen E Lasser
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Crosstown Center, Boston, Massachusetts
| | - Tracey A Dechert
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
| |
Collapse
|
12
|
Olson M, Pandya N. Public Insurance Status Negatively Affects Access to Care in Pediatric Patients With Meniscal Injury. Orthop J Sports Med 2021; 9:2325967120979989. [PMID: 33553460 PMCID: PMC7841673 DOI: 10.1177/2325967120979989] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/31/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Non- and underinsured individuals experience poor access to care and treatment delays. Meniscal injury is a common reason for surgical intervention in the pediatric population, and delays in care can lead to progression of the tear and other associated problems. Purpose: To investigate the impact of insurance status on access to care and severity of meniscal injury in the pediatric population. Study Design: Cohort study; Level of evidence, 3. Methods: Enrolled in this study were 49 patients receiving care for a meniscal injury between 2016 and 2018 from a safety-net medical system that does not prioritize patients based on insurance status. The patients were stratified into those publicly insured and those privately insured. Access to care was measured as wait time to various points of care: initial injury to clinic, injury to magnetic resonance imaging (MRI), injury to surgery, clinic to MRI, clinic to surgery, and MRI to surgery. The severity of the meniscal tear was measured by findings at the time of arthroscopy, including the type of tear identified, surgery performed, and cartilage injury. Results: Publicly insured patients waited a mean 230 days longer (347 vs 117 days; P < .01) to undergo surgery after injury compared with privately insured patients. The mean wait times in all categories except time from MRI to surgery were significantly longer for publicly insured patients, including injury to clinic (212 vs 73 days; P < .01), injury to MRI (260 vs 28 days; P < .001), injury to surgery (347 vs 117 days; P < .01), clinic to MRI (36 vs 3.9 days; P < .001), and clinic to surgery (136 vs 44 days; P < .01). Neither increased wait times nor insurance status were associated with greater surgical repair rate, severe tear type, or cartilage injury. Conclusion: Publicly insured pediatric patients waited significantly longer for a diagnosis of meniscal tear compared with privately insured patients, even in a safety-net setting. These delays were not associated with greater tear severity or cartilage changes. Providers in all models of care should recognize that insurance status and the socioeconomic factors it represents prevent publicly insured patients from timely diagnostic points of care and strive to minimize the resulting delayed return to normal activity as well as the potential long-term clinical effects thereof.
Collapse
Affiliation(s)
- Mara Olson
- University of California, San Francisco, San Francisco, California, USA
| | - Nirav Pandya
- University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
13
|
Single-Payer Health Care in the United States: Implications for Plastic Surgery. Plast Reconstr Surg 2020; 145:1089e-1096e. [DOI: 10.1097/prs.0000000000006804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
14
|
Discussion: Impact of Insurance Payer on Type of Breast Reconstruction Performed. Plast Reconstr Surg 2019; 145:9e-10e. [PMID: 31881597 DOI: 10.1097/prs.0000000000006316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
15
|
Leopold SS. Editor's Spotlight/Take 5: Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures? Clin Orthop Relat Res 2019; 477:2617-2619. [PMID: 31764321 PMCID: PMC6907304 DOI: 10.1097/corr.0000000000001025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Seth S Leopold
- S. S. Leopold, Editor-In-Chief, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA
| |
Collapse
|
16
|
Abstract
BACKGROUND Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate. QUESTIONS/PURPOSES (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time? METHODS A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios. RESULTS After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001). CONCLUSIONS We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
17
|
Behery OA, Suchman KI, Paoli AR, Luthringer TA, Campbell KA, Bosco JA. What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy? Knee Surg Sports Traumatol Arthrosc 2019; 27:3345-3353. [PMID: 30656373 DOI: 10.1007/s00167-019-05348-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 01/11/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. METHODS The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10 years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. RESULTS A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5 years, and 6.7% at 10 years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. CONCLUSION Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10 years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5 years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10 years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Omar A Behery
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.
| | - Kelly I Suchman
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.,Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Albit R Paoli
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Tyler A Luthringer
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Kirk A Campbell
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Joseph A Bosco
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| |
Collapse
|
18
|
Williams AA, Mancini NS, Kia C, Wolf MR, Gupta S, Cote MP, Arciero RA. Recurrent Shoulder Instability: Do Morbidity and Treatment Differ Based on Insurance? Orthop J Sports Med 2019; 7:2325967119841079. [PMID: 31065553 PMCID: PMC6487768 DOI: 10.1177/2325967119841079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Patients with public insurance often face barriers to obtaining prompt orthopaedic care. For patients with recurrent traumatic anterior shoulder instability, delayed care may be associated with increasing bone loss and subsequently more extensive surgical procedures. Purpose/Hypothesis: The purpose of this study was to evaluate whether differences exist in patients undergoing treatment for shoulder instability between those with Medicaid versus non-Medicaid insurance. We hypothesized that at the time of surgery, Medicaid patients would have experienced greater delays in care, would have a more extensive history of instability, would have more bone loss, and would require more extensive surgical procedures than other patients. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were identified who underwent surgical stabilization for traumatic anterior shoulder instability between January 1, 2011, and December 1, 2015, at a single sports medicine practice. Clinic, billing, and operative records were reviewed for each patient to determine age, sex, insurance type, total number of instability episodes, time from first instability episode to surgery, intraoperative findings, and procedure performed. Glenoid bone loss was quantified by use of preoperative imaging studies. Results: During this time period, 206 patients (55 Medicaid, 131 private insurance, 11 Tricare, 9 workers’ compensation) underwent surgical stabilization for traumatic anterior shoulder instability. Average wait time from initial injury to surgery was 1640 days (95% CI, 1155-2125 days) for Medicaid patients compared with 1237 days (95% CI, 834-1639 days) for others (P = .005). Medicaid patients were more likely to have sustained 5 or more instability events at the time of surgery (OR, 3.3; 95% CI, 1.64-6.69; P = .001), had a higher risk of having 15% or more glenoid bone loss on preoperative imaging (OR, 3.5; 95% CI, 1.3-10.0; P = .01), and had a higher risk of requiring Latarjet or other open stabilization procedures as opposed to an arthroscopic repair (OR, 3.0; 95% CI, 1.5-6.2; P = .002) when compared with other patients. Conclusion: Among patients undergoing surgery for traumatic anterior shoulder instability, patients with Medicaid had significantly more delayed care. Correspondingly, they reported a more extensive history of instability, were more likely to have severe bone loss, and required more invasive stabilization procedures.
Collapse
Affiliation(s)
- Ariel A Williams
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nickolas S Mancini
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Cameron Kia
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Megan R Wolf
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Simran Gupta
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Robert A Arciero
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA
| |
Collapse
|
19
|
Kim D, Do W, Tajmir S, Mahal B, DeAngelis J, Ramappa A. Mandated health insurance increases rates of elective knee surgery. World J Orthop 2019; 10:81-89. [PMID: 30788225 PMCID: PMC6379740 DOI: 10.5312/wjo.v10.i2.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/11/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The recent federal ruling to against Affordable Care Act (ACA), specifically the mandate requiring people to buy insurance, has once again brought the healthcare reform debate to the spotlight. The ACA increased the number of insured Americans through the development of subsidized healthcare plans and health insurance exchanges. Insurance-based differences in the rate of upper extremity elective orthopaedic surgery have been described before and after healthcare reform in Massachusetts, where a similar mandate was put into place years before the ACA was passed. However, no comprehensive study has evaluated insurance-based differences of knee elective surgery before and after reform.
AIM To investigate how an individual mandate to purchase health insurance affects rates of knee surgery.
METHODS A retrospective review was performed within an orthopaedic surgery department at a tertiary-care, academic medical center in Massachusetts. The rate of elective knee surgery performed before and after the healthcare reform (2005-2006 and 2007-2010, respectively) was calculated. The patients were categorized by insurance type (Commonwealth Care, Medicare, Medicaid, private insurance, Workers’ Compensation, TriCare, and Uninsured). Using χ2 testing, differences in rates of surgery between the pre-reform and post-reform period and among insurance subgroups were calculated.
RESULTS Rate of surgery increased in the post-reform period (pre-reform 8.07% (95%CI: 7.03%-9.11%), post-reform 9.38% (95%CI: 8.74%-10.03%) (P = 0.04) and was statistically significant. When the insurance groups and insurance types were compared, the rates of surgery are not significantly different before or after reform.
CONCLUSION The increase in the rate of elective knee surgery in the post-reform period suggests that health care reform in Massachusetts has been successful in decreasing the uninsured population and may increase health care expenditures. This is a hypothesis generating study that suggests further avenues of study on how mandated coverage may change healthcare utilization and cost.
Collapse
Affiliation(s)
- Daniel Kim
- Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Woo Do
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431, United States
| | - Shahein Tajmir
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Brandon Mahal
- Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Joe DeAngelis
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Arun Ramappa
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| |
Collapse
|
20
|
Schairer WW, Nwachukwu BU, Lyman S, Allen AA. Race and Insurance Status Are Associated With Surgical Management of Isolated Meniscus Tears. Arthroscopy 2018; 34:2677-2682. [PMID: 30173808 DOI: 10.1016/j.arthro.2018.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to perform a population-level analysis to evaluate the effect of socioeconomic markers on the use of meniscus surgery in patients with meniscus tears. METHODS We queried all hospital-based clinic visits from 2011 to 2014 in the Statewide Planning and Research Cooperative System database, which also contains all New York inpatient/outpatient visits. Patients with known prior knee surgery, meniscus tear before 2011, or other ligament injuries were excluded. The primary outcome was a meniscus procedure (meniscectomy or meniscus repair). Survival analysis was used to calculate the rate of meniscus surgery within 6 months. A multivariate model identified patient factors (age, sex, race, and payer) associated with surgical intervention. RESULTS There were 32,012 patients identified who met the inclusion criteria. The rate of meniscus procedure within 6 months of diagnosis was 49.6%. Meniscectomy was performed in 98.8% of cases compared with 1.2% for meniscus repair. Rates of meniscus procedures were higher in patients who were older, male, and white, as well as those first diagnosed by a surgeon. The highest rates of meniscus procedures were in those with private, worker's compensation, or other insurance types. Multivariable analysis showed that female sex, non-white race, and public or self-pay insurance were independently associated with lower rates of meniscus surgery. CONCLUSIONS These results suggest both insurance-based and race-based disparities regarding surgical treatment. Additionally, the strongest variable for surgical management was a meniscus tear being first diagnosed by a surgeon. LEVEL OF EVIDENCE Level of Evidence IV, retrospective case-control study.
Collapse
Affiliation(s)
- William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A..
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Stephen Lyman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Answorth A Allen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| |
Collapse
|
21
|
Montgomery SR, Butler PD, Wirtalla CJ, Collier KT, Hoffman RL, Aarons CB, Damrauer SM, Kelz RR. Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease. Am J Surg 2018; 215:1046-1050. [PMID: 29803499 DOI: 10.1016/j.amjsurg.2018.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 04/05/2018] [Accepted: 05/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients. METHODS A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes. RESULTS Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64). CONCLUSIONS Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.
Collapse
Affiliation(s)
- Samuel R Montgomery
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Paris D Butler
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Chris J Wirtalla
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Karole T Collier
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca L Hoffman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Cary B Aarons
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Scott M Damrauer
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
| |
Collapse
|
22
|
Schairer WW, Nwachukwu BU, Warren RF, Dines DM, Gulotta LV. Operative Fixation for Clavicle Fractures-Socioeconomic Differences Persist Despite Overall Population Increases in Utilization. J Orthop Trauma 2017; 31:e167-e172. [PMID: 28538455 DOI: 10.1097/bot.0000000000000820] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Clavicle fractures were traditionally treated conservatively, but recent evidence has shown improved outcomes with surgical management. The purpose of this study was to evaluate the recent trends in operative treatment of clavicle fractures, and to analyze for patient related factors that may affect treatment strategy. METHODS The Healthcare Cost and Utilization Project (HCUP) California and Florida inpatient, outpatient, and the Emergency Department databases were used to identify all patients with clavicle fractures between 2005 and 2010. We evaluated the overall number of procedures over the study period and calculated the rates of operative and nonoperative treatment by tracking a large cohort of emergency department patients with clavicle fractures. Poisson and multivariable regression were used to identify trends and patient factors associated with treatment. RESULTS There was a 290% increase in the annual number clavicle fracture procedures over the study period. The rate of fixation increased from 3.7% to 11.1% (P < 0.001). Significant increases were seen in all patient age groups less than 65 years. Comparatively, higher rates of fixation were found in patients who were white, privately insured, and of high-income status. Lower income status was also associated with delayed surgery. CONCLUSIONS The rates of clavicle fracture fixation have increased. However, there are differences associated with socioeconomic factors including race, insurance type, and income level. In part, this likely representing both underutilization and overutilization but may also show differential access to care. This differential utilization suggests both that further work is needed to more clearly define indications for operative versus nonoperative management and to further evaluate referral systems and access to care to ensure equal and quality treatment is available for all patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- William W Schairer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | | | | | | |
Collapse
|
23
|
Socioeconomic Factors Are Associated With Trends in Treatment of Pediatric Femoral Shaft Fractures, and Subsequent Implant Removal in New York State. J Pediatr Orthop 2017; 36:459-64. [PMID: 25929779 DOI: 10.1097/bpo.0000000000000494] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment. METHODS Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal). RESULTS Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal. CONCLUSIONS There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here. LEVEL OF EVIDENCE Level III-retrospective cohort study.
Collapse
|
24
|
Zheng J, Zhai W, Li Q, Jia Q, Lin D. A Special Tear Pattern of Anterior Horn of the Lateral Meniscus: Macerated Tear. PLoS One 2017; 12:e0170710. [PMID: 28125675 PMCID: PMC5268414 DOI: 10.1371/journal.pone.0170710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 01/09/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND We describe a special, interesting phenomenon found in the anterior horn of the lateral meniscus (AHLM): most tear patterns in the AHLM are distinctive, with loose fibers in injured region and circumferential fiber bundles were separated. We name it as macerated tear. The goal of this study was to bring forward a new type of meniscal tear in the AHLM and investigate its clinical value. MATERIALS AND METHODS AHLM tears underwent arthroscopic surgery from January 2012 to December 2014 were included. Data regarding the integrity of AHLM were prospectively recorded in a data registry. Tear morphology and treatment received were subsequently extracted by 2 independent reviewers from operative notes and arthroscopic surgical photos. RESULTS A total of 60 AHLM tears in 60 patients (mean age 27.1 years) were grouped into horizontal tears (n = 15, 25%), vertical tears (n = 14, 23%), complex tears (n = 6, 10%), and macerated tears (n = 25, 42%). There were 6 patients with AHLM cysts in macerated tear group and one patient in vertical tear group. 60 patients were performed arthroscopic meniscus repairs and were followed-up with averaged 18.7 months. Each group had significant postoperative improvement in Lysholm and IKDC scores (p < 0.05). However, the macerated tear group showed least functional recovery of Lysholm and IKDC scores compared to other groups (p < 0.05). In addition, there were no differences in postoperative range of motion, return to work, or return to sport/other baseline activities between the four groups (p > 0.05). CONCLUSIONS This study demonstrated that the macerated tear is common in the tear pattern of AHLM. However, feasibility of the treatment of this type of meniscal tear, especially the meniscus repairs still requires further study.
Collapse
Affiliation(s)
- Jiapeng Zheng
- Department of Orthopaedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Wenliang Zhai
- Department of Orthopaedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Qiang Li
- Department of Orthopaedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Qianxin Jia
- Department of Radiology, the Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Dasheng Lin
- Department of Orthopaedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
- Experimental Surgery and Regenerative Medicine, Department of Surgery, Ludwig-Maximilians-University (LMU), Munich, Germany
| |
Collapse
|
25
|
Jentzsch T, Neuhaus V, Seifert B, Osterhoff G, Simmen HP, Werner CM, Moos R. The impact of public versus private insurance on trauma patients. J Surg Res 2016; 200:236-41. [DOI: 10.1016/j.jss.2015.06.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 06/17/2015] [Accepted: 06/23/2015] [Indexed: 11/29/2022]
|
26
|
Sood A, Gonzalez-Lomas G, Gehrmann R. Influence of Health Insurance Status on the Timing of Surgery and Treatment of Bucket-Handle Meniscus Tears. Orthop J Sports Med 2015; 3:2325967115584883. [PMID: 26676153 PMCID: PMC4622351 DOI: 10.1177/2325967115584883] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Lack of insurance has been shown to lead to delays in seeking care as well as fewer preventive medicine visits and poorer overall health status. Purpose To investigate the effects of insurance status on the timing and treatment of patients with bucket-handle meniscus tears. Study Design Cohort study; Level of evidence, 3. Methods Charts from 2004 to 2013 were retrospectively reviewed for patients diagnosed with bucket-handle meniscus tears. Patients were divided into 2 groups: insured or underinsured. The insured group included patients with commercial insurance or Medicare. The underinsured group included patients with Medicaid or Charity Care. Time intervals were categorized as <6 weeks or ≥6 weeks. Results A total of 52 patients were included in this study: 15 (29%) insured and 37 (71%) underinsured. Underinsured patients experienced delays in initial presentation to an orthopaedic surgeon (P = .004), time from magnetic resonance imaging to surgery (P = .01), and time from injury to surgery (P = .007). Repair rates were 40% and 38% (P > .999) for the insured and underinsured, respectively. Repair rates for <6 weeks from injury to surgery were 75% for insured (P = .007) and 100% for underinsured patients (P = .001). Repair rates for ≥6 weeks from injury to surgery were 0% for insured and 30% for underinsured patients. Overall, patients with an injury-to-surgery time of <6 weeks had a significantly higher repair rate (87%) than those managed >6 weeks (19%) (P < .001). Conclusion Underinsured patients experience significant delays in time to presentation and overall time to surgery. However, the overall repair rate between the insured and underinsured is similar. Regardless of insurance status, patients undergoing arthroscopy within 6 weeks of injury have a significantly higher repair rate than those after 6 weeks. Clinical Relevance Patients undergoing arthroscopy within 6 weeks of injury have a significantly higher repair rate than those after 6 weeks.
Collapse
Affiliation(s)
- Amit Sood
- Shoulder and Elbow Surgery Fellow, Harvard Boston Shoulder Institute, Boston, Massachusetts, USA
| | - Guillem Gonzalez-Lomas
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| | | |
Collapse
|
27
|
An Evaluation of Trauma Outcomes Related to Insurance Status in Patients Requiring Prehospital Helicopter Transport. Prehosp Disaster Med 2014; 30:62-5. [DOI: 10.1017/s1049023x14001253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AbstractIntroductionDisparities in access to medical care and outcomes of medical treatment related to insurance status are documented. However, little attention has been given to the effect of health care funding status on outcomes in trauma patients.Hypothesis/ProblemThis study evaluated if adult trauma patients who arrived by air transport to a trauma center had different clinical outcomes based on their health insurance status.MethodsA retrospective analysis was performed of all adult trauma patients arriving by prehospital flight services to a Level I Trauma Center over a 5-year period. Patients were classified as unfunded or funded based on health insurance status. Injury severity scores (ISS) were compared, while the end points evaluated in the study included duration of stay in the intensive care unit (ICU), duration of hospitalization, and mortality.ResultsA total of 1,877 adult patients met inclusion criteria for the study, with 14% (n = 259) classified as unfunded and 86% (n = 1,618) classified as funded. Unfunded patients compared to funded patients had a significantly lower average ISS (12.82 vs 15.56; P < .001) but a significantly higher mortality rate (16.6% vs 10.7%; P < .01) and a 1.54 relative risk of death (95% CI, 1.136-2.098). Neither mean ICU stay (3.44 days vs 4.98 days; P = .264) nor duration of hospitalization (11.18 days vs 13.34 days; P = .382) was significantly different when controlling for ISS.ConclusionUnfunded health insurance status is associated with worse outcomes following less significant injury. Further investigation of baseline health disparities for identification and early intervention may improve outcomes. Additionally, these findings may have implications for the health systems of other countries that lack universal health care coverage.GurienLA, ChesireDJ, KoonceSL, BurnsJBJr. An evaluation of trauma outcomes related to insurance status in patients requiring prehospital helicopter transport. Prehosp Disaster Med. 2014;29(6):1-4.
Collapse
|
28
|
Mills AM, Holena DN, Kallan MJ, Carr BG, Reinke CE, Kelz RR. Effect of insurance status on patients admitted for acute diverticulitis. Colorectal Dis 2013; 15:613-20. [PMID: 23078007 DOI: 10.1111/codi.12066] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 08/21/2012] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample. METHOD A retrospective cohort analysis of a nationally representative sample of 1 031 665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project data set. The main outcome measures included state at presentation (complicated/uncomplicated), management (medical/surgical), time to surgical intervention, type of operation and inpatient death. RESULTS In total, 207 838 discharges were identified (including 37.0% with private insurance, 49.3% in Medicare, 5.6% in Medicaid and 5.8% uninsured) representing 1 031 665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared with private insurance patients (23.8% vs 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR = 0.86, 95% CI: 0.82-0.91), while the uninsured were more likely to undergo drainage (OR = 1.30, 95% CI: 1.16-1.46) or a colostomy only (OR = 1.70, 95% CI: 1.24-2.33). All patients without private insurance were more likely to die in hospital (Medicare OR = 1.29, 95% CI: 1.09-1.52; Medicaid OR = 1.55, 95% CI: 1.22-1.97; uninsured OR = 1.41, 95% CI: 1.07-1.87). CONCLUSION In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status, despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome.
Collapse
Affiliation(s)
- A M Mills
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | | | | | | |
Collapse
|
29
|
Bevevino AJ, Lehman RA. Commentary: Access to care affects the rate of spinal deformity surgery. Spine J 2013; 13:124-6. [PMID: 23452568 DOI: 10.1016/j.spinee.2012.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/20/2012] [Indexed: 02/03/2023]
Affiliation(s)
- Adam J Bevevino
- Division of Orthopaedics, Department of Orthopaedic Surgery and Rehabilitation, Uniform Services University of Health Sciences, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | | |
Collapse
|
30
|
Haider AH, Scott VK, Rehman KA, Velopulos C, Bentley JM, Cornwell EE, Al-Refaie W. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg 2013; 216:482-92.e12. [PMID: 23318117 DOI: 10.1016/j.jamcollsurg.2012.11.014] [Citation(s) in RCA: 412] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 11/28/2012] [Accepted: 11/28/2012] [Indexed: 02/06/2023]
Affiliation(s)
- Adil H Haider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | | | | | | | | | | | | |
Collapse
|
31
|
Pickham DM, Callcut RA, Maggio PM, Mell MW, Spain DA, Bech F, Staudenmayer K. Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients. Surgery 2012; 152:232-7. [PMID: 22828145 DOI: 10.1016/j.surg.2012.05.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Accepted: 05/14/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND It is controversial whether patients at high risk for pulmonary embolism (PE) should receive prophylactic inferior vena cava filters (IVC) filters. This lack of clarity creates the potential for variability and disparities in care. We hypothesized there would be differential use of prophylactic IVC filters for patients at high risk for PE on the basis of insurance status. METHODS We performed a retrospective analysis using the National Trauma Databank (2002-2007). We included adult patients at high risk for PE (traumatic brain injury or spinal cord injury) and excluded patients with a diagnosis of deep venous thrombosis (DVT) or PE. Logistic regression was performed to control for confounders and a hierarchical mixed effects model was used to control for center. RESULTS A prophylactic filter was placed in 3,331 (4.3%) patients in the study cohort. Patients without insurance had an IVC filter placed less often compared with those with any form of insurance (2.7% vs 4.9%, respectively). After adjusting for confounders, we found that patients without insurance were less likely to receive a prophylactic IVC filter, even when we controlled for center (OR 5.3, P < .001). CONCLUSION When guidelines lack clarity, unconscious bias has the potential to create a system with different levels of care based on socioeconomic disparities.
Collapse
|
32
|
McGlaston TJ, Kim DW, Schrodel P, DeAngelis JP, Ramappa AJ. Few insurance-based differences in upper extremity elective surgery rates after healthcare reform. Clin Orthop Relat Res 2012; 470:1917-24. [PMID: 22451335 PMCID: PMC3369096 DOI: 10.1007/s11999-012-2305-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 02/22/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Before the US Patient Protection and Affordable Care Act of 2010, there were documented insurance-based disparities in access to orthopaedic surgeons and care of orthopaedic conditions. While Massachusetts passed healthcare reform in 2007 with many similar provisions, it is unknown whether the disparities were present during the period of the law's enactment. QUESTIONS/PURPOSES We asked whether differences in rates of surgery between patients with novel government-subsidized healthcare plans and other forms of insurance, and between uninsured and insured patients, were similar after institution of the Massachusetts reform laws. METHODS We identified 7577 patients diagnosed with upper extremity injuries between January 1, 2007 and October 1, 2010. From an institutional administrative database, we extracted demographics, insurance status, and plan of care. Insurance categories included government-subsidized healthcare plan (Commonwealth Care), private insurance, workers compensation, military-related (TriCare), Medicare, Medicaid (MassHealth), non-Commonwealth Care, and other insured and uninsured. After adjusting for age, gender, and diagnosis, we compared the proportions of patients who underwent elective surgery. RESULTS Of 7577 patients, 1685 (22%) underwent elective upper extremity surgery. The adjusted rates of surgery were similar across most insurance categories, with higher rates in the workers compensation and TriCare categories compared with Commonwealth Care. Uninsured patients were as likely to undergo surgery as insured patients. CONCLUSION In a population with near-universal health insurance, a government-run health insurance exchange, and novel, government-subsidized, managed care plans, we found few insurance-based differences in rates of elective upper extremity orthopaedic surgery in a cohort of patients after healthcare reform.
Collapse
Affiliation(s)
- Timothy J. McGlaston
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Stoneman 10, Boston, MA 02115 USA
| | - Daniel W. Kim
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Stoneman 10, Boston, MA 02115 USA
| | - Philip Schrodel
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Stoneman 10, Boston, MA 02115 USA
| | - Joseph P. DeAngelis
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Stoneman 10, Boston, MA 02115 USA
| | - Arun J. Ramappa
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Stoneman 10, Boston, MA 02115 USA
| |
Collapse
|
33
|
Lin N, Popp AJ. Insurance status and patient outcome after neurosurgery. World Neurosurg 2012; 76:398-400. [PMID: 22152563 DOI: 10.1016/j.wneu.2011.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 05/02/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Ning Lin
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
34
|
Dasenbrock HH, Wolinsky JP, Sciubba DM, Witham TF, Gokaslan ZL, Bydon A. The impact of insurance status on outcomes after surgery for spinal metastases. Cancer 2012; 118:4833-41. [DOI: 10.1002/cncr.27388] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/23/2011] [Indexed: 11/08/2022]
|