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Nacier CM, Vutescu ES, Bergen MA, Quinn MS, Albright JA, Cruz AI. Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics. PHYSICIAN SPORTSMED 2024:1-6. [PMID: 38618689 DOI: 10.1080/00913847.2024.2342235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES This study aims to characterize the association between the timing of MRI ordering and completion for pediatric knee injuries and Social Deprivation Index (SDI), which is a comprehensive, validated, county-level, measure of socioeconomic variation in health outcomes based upon combining geography, income, education, employment, housing, household characteristics, and access to transportation. METHODS A retrospective chart review was completed of patients 21 years old and younger from our institution with a history of knee sports injury (ligamentous/soft tissue injury, structural abnormality, instability, inflammation) evaluated with MRI between 5/26/2017 and 12/28/2020. Patients were from three states and attended to by physicians associated with an urban academic institution. Patients were assigned SDI scores based on their ZIP code. Excluded from the study were patients with a non-knee related diagnosis (hip, foot, or ankle), patients from ZIP codes with unknown SDI, and non-sports medicine diagnoses (tumor, infection, fracture). RESULTS In a multivariate regression analysis of 355 patients, increased SDI was independently associated with increased time from clinic visit to MRI order (p = 0.044) and from clinic visit to MRI completion (p = 0.047). Each 10-point increase in SDI (0-100) was associated with a delay of 7.2 days on average. SDI itself was found to be associated with a patient's race (p < 0.001), ethnicity (p < 0.001), and insurance category (p < 0.001). CONCLUSION Increased SDI is independently associated with longer time from clinic visit to knee MRI order and longer time from clinic visit to knee MRI completion in our pediatric population. Recognizing potential barriers to orthopedic care can help create the change necessary to provide the best possible care for all individual patients.
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Affiliation(s)
| | - Emil Stefan Vutescu
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael A Bergen
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Matthew S Quinn
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - J Alex Albright
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Benes G, Ghanem D, Badin D, Greenberg M, Honcharuk E. The Effect of Socioeconomic Deprivation on Radiographic Deformities in Children With Blount Disease. J Pediatr Orthop 2024; 44:254-259. [PMID: 38158726 DOI: 10.1097/bpo.0000000000002608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Blount disease can occur at any time during the growth process, primarily with a bimodal distribution in children younger than 4 years old and adolescents. The disease process most commonly presents in Black adolescents, with disease severity positively correlated with obesity. Given the known associations among race, obesity, and socioeconomic status, we investigated the relationship between the degree of social deprivation and severity of lower extremity deformities among a community-based cohort with Blount disease. METHODS A retrospective review of hospital records and radiographs of patients with previously untreated Blount disease was conducted. Patients were classified as having early-onset or late-onset Blount disease based on whether the lower limb deformity was noted before or after the age of 4 years. The area deprivation index (ADI), a nationally validated measure that assesses socioeconomic deprivation by residential neighborhood, was calculated for each patient as a surrogate for socioeconomic status. Higher state (range: 1 to 10) or national (range: 1 to 100) ADI corresponds to increased social deprivation. Full-length standing radiographs from index clinic visits were evaluated by 2 reviewers to measure frontal plane deformity. The association of ADI with various demographic and radiographic parameters was then analyzed. RESULTS Of the 65 patients with Blount disease, 48 (74%) children were Black and 17 (26%) were non-black children. Nineteen children (32 limbs) had early-onset and 46 children (62 limbs) had late-onset disease. Black patients had significantly higher mean state (7.6 vs. 5.4, P =0.009) and national (55.1 vs. 37.4, P =0.002) ADI values than non-black patients. Patients with severe socioeconomic deprivation had significantly greater mechanical axis deviation (66 mm vs. 51 mm, P =0.008). After controlling demographic and socioeconomic factors, the results of multivariate linear regression showed that only increased body mass index (β=0.19, 95% CI: 0.12-0.26, P <.001) and state ADI (β=0.021, 95% CI: 0.01-0.53, P =.043) were independently associated with greater varus deformity. CONCLUSIONS Socioeconomic deprivation was strongly associated with increased severity of varus deformity in children with late-onset Blount disease. Our analysis suggests that obesity and socioeconomic factors are the most influential with regard to disease progression. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Gregory Benes
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
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Culbert AA, Ren BO, Maheshwer B, Curtis A, Ajayakumar J, Gilmore A, Hardesty C, Mistovich RJ, Son-Hing J, Liu RW, Glotzbecker MP. Disparities in Pediatric Orthopedic Surgery Care During the COVID-19 Pandemic Pre-vaccine and Post-Vaccine Availability. J Pediatr Orthop 2023; 43:529-535. [PMID: 37442779 PMCID: PMC10627400 DOI: 10.1097/bpo.0000000000002469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND The COVID-19 pandemic has led to significant disruptions in medical care, resulting in an estimated 40% of US adults avoiding care. However, the return to baseline health care utilization following COVID-19 restrictions within the pediatric orthopedic population remains unexplored. We sought to analyze the visit volume and demographics of pediatric orthopedic patients at 3 timepoints: prepandemic (2019), pandemic (2020), and pandemic post-vaccine availability (2021), to determine the impact of COVID-19 restrictions on our single-center, multisite institution. METHODS We performed a retrospective cohort study of 6318 patients seeking treatment at our institution from May through August in 2019, 2020, and 2021. Patient age, sex, address, encounter date, and ICD-10 codes were obtained. Diagnoses were classified into fractures and dislocations, non-fracture-related trauma, sports, elective, and other categories. Geospatial analysis comparing incidence and geospatial distribution of diagnoses across the time periods was performed and compared with the Centers for Disease Control (CDC) social vulnerability index (SVI). RESULTS The total number of pediatric orthopedic visits decreased by 22.2% during the pandemic ( P <0.001) and remained 11.6% lower post-vaccine availability compared with prepandemic numbers ( P <0.001). There was no significant difference in age ( P =0.097) or sex ( P =0.248) of the patients across all 3 timepoints; however, patients seen during the pandemic were more often White race (67.7% vs. 59.3%, P <0.001). Post-vaccine availability, trauma visits increased by 18.2% ( P <0.001) and total fractures remained 13.4% lower than prepandemic volume ( P <0.001). Sports volume decreased during the pandemic but returned to prepandemic volume in the post-vaccine availability period ( P =0.298). Elective visits did not recover to prepandemic volume and remained 13.0% lower compared with baseline ( P <0.001). Geospatial analysis of patient distribution illustrated neighborhood trends in access to care during the COVID-19 pandemic, with fewer patients from high SVI and low socioeconomic status neighborhoods seeking fracture care during the pandemic than prepandemic. Post-vaccine availability, fracture population distribution resembled prepandemic levels, suggesting a return to baseline health care utilization. CONCLUSION Pediatric orthopedic surgery visit volume broadly decreased during the COVID-19 pandemic and did not return to prepandemic levels. All categories increased in the post-vaccine availability time point except elective visits. Geospatial analysis revealed that neighborhoods with a high social vulnerability index (SVI) were associated with decreased fracture visits during the pandemic, whereas low SVI neighborhoods did not experience as much of a decline. Future research is needed to study these neighborhood trends and more completely characterize factors preventing equitable access to care in the pediatric orthopedic population. LEVEL OF EVIDENCE Retrospective Study, Level III.
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Affiliation(s)
- August A. Culbert
- Cleveland Clinic Lerner College of Medicine
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Bryan O. Ren
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI
| | - Bhargavi Maheshwer
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Andrew Curtis
- Department of Population and Quantitative Health Sciences, Case Western Reserve University
| | | | - Allison Gilmore
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Christina Hardesty
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - R. Justin Mistovich
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Jochen Son-Hing
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Raymond W. Liu
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Michael P. Glotzbecker
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
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Smith HE, Cruz AI, Mistovich RJ, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes JT, Sachleben BC, Schmale GA, Patel NM. What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study. Orthop J Sports Med 2022; 10:23259671221078333. [PMID: 35284586 PMCID: PMC8905066 DOI: 10.1177/23259671221078333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.
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Affiliation(s)
- Haley E. Smith
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I. Cruz
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - R. Justin Mistovich
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M. Leska
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J. Ganley
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T. Aoyama
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B. Ellis
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J. Lee
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D. McKay
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Todd A. Milbrandt
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T. Rhodes
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C. Sachleben
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A. Schmale
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M. Patel
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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5
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Smith HE, Mistovich RJ, Cruz AI, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Fabricant PD, Green DW, Jagodzinski J, Johnson B, Kushare I, Lee RJ, McKay SD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Yen YM, Patel NM. Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures? Am J Sports Med 2021; 49:3842-3849. [PMID: 34652247 DOI: 10.1177/03635465211046928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.
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Affiliation(s)
- Haley E Smith
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - R Justin Mistovich
- Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I Cruz
- School of Medicine, Brown University, Providence, Rhode Island, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M Leska
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J Ganley
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T Aoyama
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Peter D Fabricant
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Daniel W Green
- Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason Jagodzinski
- UCSF Benioff Children's Hospital, San Francisco, California, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Benjamin Johnson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J Lee
- Johns Hopkins Children's Center, Baltimore, Maryland, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D McKay
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T Rhodes
- Children's Hospital Colorado, Aurora, Colorado, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C Sachleben
- Arkansas Children's Hospital, Little Rock, Arkansas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - M Catherine Sargent
- Central Texas Pediatric Orthopaedics, Austin, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A Schmale
- Seattle Children's Hospital, Seattle, Washington, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA].,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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