The influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations

Site of Service Disparities Exist for Total Joint Arthroplasty

BACKGROUND

The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes.

MATERIALS AND METHODS

We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models.

RESULTS

We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures.

CONCLUSION

Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].

Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer

BACKGROUND

The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases.

METHODS

This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals.

RESULTS

A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients.

DISCUSSION

Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND

Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.

METHODS

Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.

RESULTS

Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial).

CONCLUSIONS

Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review

PURPOSE

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery.

METHODS

A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities.

RESULTS

The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods.

CONCLUSIONS

Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation.

CLINICAL RELEVANCE

Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level III, retrospective cohort study.

Medicaid Patients Undergo Total Joint Arthroplasty at Lower-Volume Hospitals by Lower-Volume Surgeons and Have Poorer Outcomes

BACKGROUND

Medicaid insurance coverage among patients undergoing total hip arthroplasty (THA) or those undergoing total knee arthroplasty (TKA) has been associated with worse postoperative outcomes compared with patients without Medicaid. Surgeons and hospitals with lower annual total joint arthroplasty (TJA) volume have also been associated with worse outcomes. This study sought to characterize the associations between Medicaid insurance status, surgeon case volume, and hospital case volume and to assess the rates of postoperative complications compared with other payer types.

METHODS

The Premier Healthcare Database was queried for all adult patients who underwent primary TJA from 2016 to 2019. Patients were divided on the basis of their insurance status: Medicaid compared with non-Medicaid. The distribution of annual hospital and surgeon case volume was assessed for each cohort. Multivariable analyses were performed accounting for patient demographic characteristics, comorbidities, surgeon volume, and hospital volume to assess the 90-day risk of postoperative complications by insurance status.

RESULTS

Overall, 986,230 patients who underwent TJA were identified. Of these, 44,370 (4.5%) had Medicaid. Of the patients undergoing TJA, 46.4% of those with Medicaid were treated by surgeons performing ≤100 TJA cases annually compared with 34.3% of those without Medicaid. Furthermore, a higher percentage of patients with Medicaid underwent TJA at lower-volume hospitals performing ≤500 cases annually, 50.8% compared with 35.5% for patients without Medicaid. After accounting for differences among the 2 cohorts, patients with Medicaid remained at increased risk for postoperative deep vein thrombosis (adjusted odds ratio [OR], 1.16; p = 0.031), pulmonary embolism (adjusted OR, 1.39; p < 0.001), periprosthetic joint infection (adjusted OR, 1.35; p < 0.001), and 90-day readmission (adjusted OR, 1.25; p < 0.001).

CONCLUSIONS

Patients with Medicaid were more likely to undergo TJA performed by lower-volume surgeons at lower-volume hospitals and had higher rates of postoperative complications compared with patients without Medicaid. Future research should assess socioeconomic status, insurance, and postoperative outcomes in this vulnerable patient population seeking arthroplasty care.

LEVEL OF EVIDENCE

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

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

STUDY DESIGN

Systematic review.

OBJECTIVES

We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF).

METHODS

Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes.

RESULTS

A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories.

CONCLUSIONS

In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.

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

Objectives

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

Design

A retrospective cohort study.

Setting

Large public level 1 trauma center.

Patients

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

Intervention

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

Main Outcome Measurements

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

Results

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

Conclusions

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

Level of Evidence

Prognostic Level III.

Access to Reconstructive Hand Surgery in the United States-Investigating the Obstacles: A Scoping Review

BACKGROUND

Mechanisms that affect access to surgical hand care appear to be complex and multifaceted. This scoping review aims to investigate the available literature describing such mechanisms and provide direction for future investigation.

METHODS

The methodological framework outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews was used to guide this review. In November 2021, MEDLINE and EMBASE databases were searched. A narrative summary of the characteristics and key findings of each paper is used to present the data to facilitate the integration of diverse evidence.

RESULTS

Of 471 initial studies, 49 were included in our final analysis. Of these, 33% were cohort studies; 27% reported that underinsured patients are less likely to get an appointment with a hand specialist or to receive treatment. Overburdened emergency departments accounted for the second-most reported reason (16%) for diminished access to surgical hand care. Elective procedure financial incentives, poor emergency surgical hand coverage, distance to treatment, race, and policy were also notably reported across the literature.

CONCLUSIONS

This study describes the vast mechanisms that hinder access to surgical hand care and highlights their complexity. Possible solutions and policy changes that may help improve access have been described.

An Analysis of Procedural Medicare Reimbursement Rates in Hand Surgery: 2000 to 2019

BACKGROUND

Medicare reimbursement trends across multiple surgical subspecialties have been analyzed; however, little has been reported regarding the long-term trends in reimbursement of hand surgery procedures. The aim of this study is to analyze trends in Medicare reimbursement for commonly performed hand surgeries.

METHODS

Using the Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File, we determined the 20 hand surgery procedure codes most commonly billed to Medicare in 2016. Reimbursement rates were collected and analyzed for each code from The Physician Fee Schedule Look-Up Tool for years 2000 to 2019. We compared the change in reimbursement rate for each procedure to the rate of inflation in US dollars, using the Consumer Price Index (CPI) over the same time period.

RESULTS

The reimbursement rate for each procedure increased on average by 13.9% during the study period while the United States CPI increased significantly more by 46.7% (P < .0001). When all reimbursement data were adjusted for inflation to 2019 dollars, the average reimbursement for all included procedures in this study decreased by 22.6% from 2000 to 2019. The average adjusted reimbursement rate for all procedures decreased by 21.92% from 2000 to 2009 and decreased by 0.86% on average from 2009 to 2019 (P < .0001).

CONCLUSION

When adjusted for inflation, Medicare reimbursement for hand surgery has steadily decreased over the past 20 years. It will be important to consider the implications of these trends when evaluating healthcare policies and the impact this has on access to hand surgery.

Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery

The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program.

Providing Orthopaedic Care to Vulnerably Underserved Patients: AOA Critical Issues

Implementation of the Affordable Care Act has increased the number of Americans with health insurance. However, a substantial portion of the population is still considered underserved, including those who are uninsured, underinsured, and those who are enrolled in Medicaid. The patients frequently face substantial access-to-care issues. Many underlying social determinants of health impact this vulnerable, underserved population, and surgeons must understand the nuances of caring for the underserved. There are numerous opportunities to engage with this population, and providing care to the indigent can be rewarding for both the vulnerably underserved patient and their surgeon.

Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care

BACKGROUND

Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant.

METHODS

Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state's physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types.

RESULTS

Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures.

CONCLUSIONS

These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability

Purpose

To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors.

Methods

Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type.

Results

In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker’s compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery.

Conclusions

Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation.

Clinical Relevance

Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.

Patient Demographic and Socioeconomic Factors Associated With Physical Therapy Utilization After Uncomplicated Meniscectomy

INTRODUCTION

The extent to which physical therapy (PT) is used after meniscectomy is unknown. The objective of this study was to estimate the extent to which PT is implemented after meniscectomy and to identify factors associated with its utilization.

METHODS

The Mariner PearlDiver database was queried to identify patients who underwent uncomplicated meniscectomy. The number of PT visits for each patient was tabulated. Logistic regressions were used to compare demographic factors associated with no use of PT and use of nine or more PT visits.

RESULTS

In total, 92,291 patients met inclusion criteria. Of these patients, 72.21% did not use PT and 27.8% used 1 or more PT visits. Of the patients who used PT, 19.76% had 1 to 8 PT visits and 8.03% had 9 or more PT visits. Older age and noncommercial insurance types were associated with no PT use. Male sex, Medicaid, and Medicare were associated with markedly lower odds of increased PT utilization.

CONCLUSION

PT is used in the minority of the time after meniscectomy. Among patients who do use PT, however, notable variation exists in the amount of PT visits used. Patient age, sex, insurance status, and geographic variables were independently associated with PT utilization.

Factors Associated with Timing of Syndactyly Release in the United States

Background: Syndactyly is one of the commonly encountered congenital hand anomalies. However, there are no strict guidelines regarding the timing of surgical release. The aim of this study was to investigate the age and factors associated with syndactyly release in the United States. Methods: A retrospective analysis of the California and Florida State Ambulatory Surgery and Services Databases for patients aged 18 years or younger who underwent syndactyly release surgery between 2005 and 2011 was performed. Demographic data that included the age at release, gender, race and primary payor (insurance) was collected. A sub-analysis was performed to compare the demographic characteristics between those patients undergoing syndactyly release before 5 years of age ('Early Release') and at (of after) 5 years ('Late Release'). Results: A total of 2,280 children (68% male, 43% Caucasian) were identified. The mean age of syndactyly release was 3.6 years, and 72.9% of patients underwent release before the age of 5 years. A significantly larger proportion of females (p = 0.002), and Hispanics and African Americans (p = 0.024), underwent late release compared to early release. Additionally, a significantly higher percentage of patients undergoing late release utilised private insurance (p = 0.005). However, the actual differences in gender, race and primary payor were small. Conclusion: The majority of syndactyly releases were performed before school age, which is the primary goal in the management of syndactyly. While gender and racial disparities in the surgical treatment of syndactyly may exist, the differences in the present study were relatively small. Level of Evidence: Level III (Therapeutic).

Socioeconomic Status Impacts Access to Orthopaedic Specialty Care

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

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

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

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

Low socioeconomic status worsens access to care and outcomes for rotator cuff repair: a scoping review

Background

Poor socioeconomic status (SES) is consistently associated with poor quality of health care, particularly in the field of orthopedics. Expanding insurance coverage has created a larger patient population by specifically making health care more accessible, translating to greater demand for care in the low-SES population. The purpose of this article is to provide a scoping review of literature observing access and outcomes of rotator cuff repair surgery among low-SES populations.

Methods

We performed a systematic review of articles using PubMed, Embase, and EBSCO (May 2021) from 2010 onward. Peer-reviewed articles that recorded at least one SES measure specific to patients who underwent rotator cuff repair from the United States were included. SES measures were methodically defined as income, occupation, employment, education, and race. All data that aligned with these SES measures were extracted.

Results

Of the 1009 titles reviewed, 109 studies were screened by abstract, 23 were reviewed in full, and 7 studies met criteria for inclusion. Of the 5 studies investigating access, all 5 found disparities among postoperative physical therapy, orthopedic consult, and surgery, using Medicaid status as a proxy for income in addition to other income measures. Of the 3 studies analyzing outcomes, 2 found that low-SES patients had worse pain and function, again based on Medicaid status and other income measures. Education did not have a significant impact on outcomes, as per the 1 study that included it. No studies included measures of occupation or employment.

Conclusion

Patients of low SES face reduced access to cuff repair care and worse associated outcomes, despite federal and state government efforts to reduce health care disparity through health care reform. The small nature of this review reflects how measures of SES are often not examined in rotator cuff repair studies.

Effect of Institution and COVID-19 on Access to Adult Arthroplasty Surgery

Background

Although insurance status is important to patients’ ability to access care, it varies significantly by race, age, and socioeconomic status. Novel coronavirus disease 2019 (COVID-19) negatively impacted access to care, while simultaneously widening pre-existing health-care disparities. The purpose of the present study was to document this phenomena within orthopedics.

Methods

Patients undergoing hip or knee arthroplasty at two medical centers in San Francisco, California, were evaluated. One cohort came from the University of California San Francisco (UCSF), a tertiary center, and the other from Zuckerberg San Francisco General Hospital (ZSFGH), a safety-net hospital. Patients who underwent arthroplasty before the pandemic (March 2020) and those after pandemic declaration were evaluated. Patient demographics, surgical wait times, and operative volumes were compared.

Results

Two-hundred sixty-nine (pre-COVID, 184; post-COVID, 85) cases at UCSF and 63 (pre-COVID, 47; post-COVID, 16) cases at ZSFGH met inclusion criteria. Patients at ZSFGH had a significantly higher body mass index, were more often racial minorities, and were less likely to speak English. Patients at ZSFGH were less likely to have private insurance. A comparison of case volumes showed a larger decrease at ZSFGH than at UCSF after COVID. Wait times between the two sites before and after COVID showed a larger increase in wait times at ZSFGH. Notably, wait times at ZSFGH before COVID were more than double the wait times at UCSF after COVID.

Conclusions

COVID-19 worsened access to primary hip and knee arthroplasties at two academic medical centers in San Francisco. The pandemic also worsened pre-existing disparities. Racial minorities, non-English speakers, and those with nonprivate insurance were affected the most.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Delayed Referral for Adult Traumatic Brachial Plexus Injuries

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Insurance Status and Disparities in Outpatient Care after Traumatic Injuries of the Hand: A Retrospective Cohort Study

BACKGROUND

Hand-injured patients seen in the emergency department can often be followed as outpatients for definitive care and rehabilitation. Many face barriers to continuing care in the outpatient setting that impact quality of care delivery. The authors aimed to evaluate patterns of outpatient follow-up after initial emergency department evaluation of traumatic hand injuries, identify factors associated with poor follow-up, and suggest areas for improvement.

METHODS

In this retrospective cohort study, the authors reviewed records of adult patients with acute hand injuries referred for outpatient follow-up after initial plastic surgery consultation in the emergency department of a single urban Level I trauma center over a 12-month period (n = 300). Patients were grouped by insurance (i.e., no insurance, Medicaid, Medicare, or private). Outcomes included completion of outpatient follow-up, hand therapy participation, and emergency department return visits.

RESULTS

Factors significantly associated with failure to follow up included male sex (OR, 3.58; 95 percent CI, 1.57 to 8.16), uninsured status (OR, 3.47; 95 percent CI, 1.48 to 8.16), Medicaid insurance (OR, 4.46; 95 percent CI, 1.31 to 15.25), and lack of a driver's license (OR, 3.35; 95 percent CI, 1.53 to 7.34). Hand therapy attendance and unexpected emergency department return visits also varied significantly by insurance type (p < 0.001).

CONCLUSIONS

There is a significant disparity in the use of outpatient care after emergency department visits for acute hand injuries. Uninsured and Medicaid-insured patients are significantly less likely to initiate recommended hand specialty follow-up, and significantly less likely to complete follow-up even when established with an outpatient clinic. Future research should evaluate targeted interventions for at-risk patients.

Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions

Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

Editorial Commentary: Fixing Health Care Requires Us to Evaluate Policy Through an Ethical and Societal (And Not Just a Financial) Lens

Health care systems globally, including in the United States, continue to undergo a much-needed transformation focused on optimizing value-or health outcomes per dollar spent across a full cycle of care-for patients. Given the traditionally high cost and use of orthopaedic surgery services, the field is ripe for in-depth assessment and comparison of interventions to ensure that evidence-based, high-value care is prioritized. Cost-effectiveness analyses (CEAs) provide an important framework from which to begin effective policy discussions, and a recent study suggests that current orthopaedic economic literature is of high quality. However, the same study demonstrated that no authors published CEAs that also provided commentary on how their work can actually guide policy decisions. Furthermore, the ethical implications of their research or insight into the larger consequences of their findings within and outside the health care sector was not discussed. We must be better at "connecting the dots" between CEAs and value-based health care research and practical policy initiatives while also considering how such proposals promote health equity and address systemic injustices currently found in our health care system.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Fate of the Uninsured Ankle Fracture: Significant Delays in Treatment Result in an Increased Risk of Surgical Site Infection

OBJECTIVE

To examine the impact of insurance status on access to orthopaedic care and incidence of surgical site complications in patients with closed unstable ankle fractures.

DESIGN

Retrospective chart review.

SETTING

Certified Level-1 urban trauma center and county facility.

PARTICIPANTS

Four hundred eighty-nine patients with closed unstable ankle fractures undergoing open reduction and internal fixation between 2014 and 2016.

INTERVENTION

Open reduction and internal fixation of unstable ankle fracture.

MAIN OUTCOME MEASURES

Time from injury to presentation, time from injury to surgery, rate of surgical site infections, and loss to follow-up.

RESULTS

A total of 489 patients (70.5% uninsured vs. 29.5% insured) were enrolled. Uninsured patients were more likely to be present to an outside hospital first (P = 0.004). Time from injury to presentation at our hospital was significantly longer in uninsured patients (4.5 ± 7.6 days vs. 2.3 ± 5.5 days, P < 0.001). Time from injury to surgery was significantly longer in uninsured patient (9.4 ± 8.5 days vs. 7.3 ± 9.1 days, P < 0.001). Uninsured patients were more likely to be lost to postoperative follow-up care (P = 0.002). A logistic regression analysis demonstrated that delayed surgical timing was directly associated with an increased risk of postoperative surgical site infection (P = 0.002).

CONCLUSIONS

Uninsured patients with ankle fractures requiring surgery experience significant barriers regarding access to health care. Delay of surgical management significantly increases the risk of surgical site infections in closed unstable ankle fractures.

LEVEL OF EVIDENCE

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

Pediatric and Adolescent Shoulder Instability: Does Insurance Status Predict Delays in Care, Outcomes, and Complication Rate?

Background:

Recurrent shoulder instability results from overuse injuries that are often associated with athletic activity. Timely diagnosis and treatment are necessary to prevent further dislocations and secondary joint damage. In pediatric and adolescent patients, insurance status is a potential barrier to accessing timely care that has not yet been explored.

Purpose:

To examine the effect of insurance status on access to clinical consultation, surgical intervention, and surgical outcome of pediatric and adolescent patients with recurrent shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We conducted a retrospective review of pediatric and adolescent patients who were treated at a single tertiary children’s hospital for recurrent shoulder instability between 2011 and 2017. Patients were sorted into private and public insurance cohorts. Dates of injury, consultation, and surgery were recorded. Number of previous dislocations, magnetic resonance imaging (MRI) results, surgical findings, and postoperative complications were also noted. Delays in care were compared between the cohorts. The presence of isolated anterior versus complex labral pathology as well as bony involvement at the time of surgery was recorded. The incidences of labral pathology and secondary bony injury were then compared between the 2 cohorts. Postoperative notes were reviewed to compare rates of repeat dislocation and repeat surgery.

Results:

A total of 37 patients had public insurance, while 18 patients had private insurance. Privately insured patients were evaluated nearly 5 times faster than were publicly insured patients (P < .001), and they obtained MRI scans over 4 times faster than did publicly insured patients (P < .001). Publicly insured patients were twice as likely to have secondary bony injuries (P = .016). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced redislocation versus the complete absence of redislocation in the privately insured patients (P = .022).

Conclusion:

Public insurance status affected access to care and was correlated with the development of secondary bony injury and a higher rate of postoperative dislocations. Clinicians should practice with increased awareness of how public insurance status can significantly affect patient outcomes by delaying access to care—particularly if delays lead to increased patient morbidity and health care costs.

Improvement in Outpatient Follow-up With a Postdischarge Phone Call Intervention

INTRODUCTION

Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit.

METHODS

This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit.

RESULTS

Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001).

DISCUSSION

Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.

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

PURPOSE

To assess the effect of type of insurance coverage on the ability of a pediatric patient to obtain an outpatient orthopedic appointment for trigger thumb.

METHODS

A list of 200 orthopedic practices in 4 states were contacted and presented with a fictitious 3-year-old patient with trigger thumb. The patient was presented as having Blue Cross Blue Shield Insurance during the first call and Medicaid during the second call. Data regarding whether an appointment was offered or denied were recorded.

RESULTS

Of the 200 practices, 81 were excluded, 22 because they did not answer the calls, 25 needed the patient's social security number, 19 needed medical records, 5 had no hand surgeon in the practice, and 10 would not see any children at all. Of the 119 practices included in the analysis, the private insurance patient was able to get an appointment 51.3% of the time whereas the Medicaid patient was able to get an appointment in 26.9% of instances.

CONCLUSIONS

There is a significant effect of insurance status on the ability of pediatric patients with trigger thumb to obtain outpatient orthopedic appointments.

CLINICAL RELEVANCE

Pediatric patients with Medicaid face greater barriers to accessing proper care for trigger thumb than patients with private insurance.

Predictors of Insurance Claim Rejection in Hand and Upper Extremity Surgery

INTRODUCTION

Insurance claim rejections represent a challenge for healthcare providers because of the potential for lost revenue and administrative costs of reworking claims.

METHODS

The billing records of five hand and upper extremity surgeons at a tertiary academic center were queried for all patient billing activity over a 1-year period yielding a total of 14,421 unique patient encounters.

RESULTS

A total of 11,839 unique patient encounters were included, and the overall claim rejection rate was 19.3%. Claim rejection rate varied significantly by payer (P < 0.0001) and was lowest in private insurance (14.0%) and highest in Medicare (31.2%). The use of multiple Current Procedure Terminology codes for an encounter was independently associated with an increased risk of claim rejection for both office (25.6%, relative risk [RR] 1.27, 95% confidence interval [CI] 1.03 to 1.49, P = 0.0032) and surgical (25.6%, RR 1.67, 95% CI 1.28 to 2.18, P = 0.0002) settings. After multivariate regression adjustment, modifier 25 was associated with a decreased risk of claim rejection (23.3%, RR 0.72, 95% CI 0.61 to 0.85, P < 0.0001).

DISCUSSION

Insurance claim rejection occurs frequently (19.3%) in hand/upper extremity surgery and varies by insurance type, with the highest rejection rate occurring in Medicare (31.2%). For a given encounter, the use of multiple Current Procedure Terminology codes and specific modifiers are predictive of rejection risk.

LEVEL OF EVIDENCE

Level III, prognostic.

Lending a Hand to Health Care Disparities: A Cross-sectional Study of Variations in Reimbursement for Common Hand Procedures

Background: Despite the role of one's hands in human function and quality of life, financial disincentives to perform common hand procedures in patients with government-sponsored insurance plans may lead to longer wait times and decreased access to care. Here, we identify the variations in reimbursement for 4 common hand procedures as a step toward understanding these financial implications to develop safeguards to minimize effects on access to care. Methods: Billing data were collected over a 10-year period for patients undergoing carpal tunnel release (open, Current Procedural Terminology 64721; endoscopic, 29848), cubital tunnel release (64718), ganglion cyst excision (25111), and interposition arthroplasty (25447). Patients were placed into cohorts according to insurance type-private insurance, Medicare, Medicaid, or worker's compensation-and these were directly compared. Results: A total of 3489 procedures between 2005 and 2015 were identified in this study (carpal tunnel 65.8%, cubital tunnel 28.7%, ganglion cyst excision 4.1%, and interposition arthroplasty 13.8%). In all, 54.7% of patients had private insurance; 26.3%, Medicare; 10.5%, worker's compensation; and 8.5%, Medicaid. Reimbursement, as a percentage of charge, differed significantly by payor type for all cases and by procedure. On average, worker's compensation plans reimbursed 65.5% of submitted charges; private insurance, 50.6%; Medicare, 25.1%; and Medicaid, 24.6%. Conclusions: We found that wide variations in reimbursement for common hand procedures exist and may preclude some surgeons from offering certain procedures to a subset of patients. Understanding these discrepancies is a key first step in minimizing a potential care delivery disparity for this patient population.

Providing Hand Surgery Care to Vulnerably Uninsured Patients

Economically vulnerable US patients are at risk for undertreatment of hand-related conditions as well as poorer outcomes. The cost of indigent care can be substantial to both the patients and their communities. Caring for these patients in a system that depends on inconsistent coverage requires a network of safety-net hospitals. To ensure that patients have access to care, the protection of safety-net hospitals should be prioritized when discussing federal and state funding allocation. On an individual scale, surgeons can also make changes in their practices to help find sustainable ways to care for indigent patients.

Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-tissue Sarcomas? A SEER Database Study

BACKGROUND

Several recently published population-based studies have highlighted the association between insurance status and survival in patients with various cancers such as breast, head and neck, testicular, and lymphoma [22, 24, 38, 41]. Generally, these studies demonstrate that uninsured patients or those with Medicaid insurance had poorer survival than did those who had non-Medicaid insurance. However, this discrepancy has not been studied in patients with primary bone and extremity soft-tissue sarcomas, a unique oncological population that typically presents late in the disease course and often requires referral and complex treatment at tertiary care centers-issues that health insurance coverage disparities could aggravate.

QUESTIONS/PURPOSES

(1) What is the relationship between insurance status and cause-specific mortality? (2) What is the relationship between insurance status and the prevalence of distant metastases? (3) What is the relationship between insurance status and the proportion of limb salvage surgery versus amputation?

METHODS

The Surveillance, Epidemiology, and End Results database (SEER) was used to identify a total of 12,008 patients: 4257 patients with primary bone sarcomas and 7751 patients with extremity soft-tissue sarcomas, who were diagnosed and treated between 2007 and 2014. Patients were categorized into one of three insurance groups: insured with non-Medicaid insurance, insured with Medicaid, and uninsured. Patients without information available regarding insurance status were excluded (2.7% [113 patients] with primary bone sarcomas and 3.1% [243 patients] with extremity soft-tissue sarcomas.) The association between insurance status and survival was assessed using a Cox proportional hazards regression analysis adjusted for patient age, sex, race, ethnicity, extent of disease (lymph node and metastatic involvement), tumor grade, tumor size, histology, and primary tumor site.

RESULTS

Patients with primary bone sarcomas with Medicaid insurance had reduced disease-specific survival than did patients with non-Medicaid insurance (hazard ratio 1.3 [95% confidence interval 1.1 to 1.6]; p = 0.003). Patients with extremity soft-tissue sarcomas with Medicaid insurance also had reduced disease-specific survival compared with those with non-Medicaid insurance (HR 1.2 [95% CI 1.0 to 1.5]; p = 0.019). Patients with primary bone sarcomas (relative risk 1.8 [95% CI 1.3 to 2.4]; p < 0.001) and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.1]; p < 0.001) who had Medicaid insurance were more likely to have distant metastases at the time of diagnosis than those with non-Medicaid insurance. Patients with primary bone sarcomas (RR 1.8 [95% CI 1.4 to 2.1]; p < 0.001), and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.0]; p < 0.001) that had Medicaid insurance were more likely to undergo amputation than patients with non-Medicaid insurance. Patients with primary bone and extremity soft-tissue sarcomas who were uninsured were not more likely to have distant metastases at the time of diagnosis and did not have a higher proportion of amputation surgery as compared with patients with non-Medicaid insurance. However, uninsured patients with extremity soft-tissue sarcomas still displayed reduction in disease-specific survival (HR 1.6 [95% CI 1.2 to 2.1]; p = 0.001).

CONCLUSIONS

Disparities manifested by differences in insurance status were correlated with an increased risk of metastasis at the time of diagnosis, reduced likelihood of treatment with limb salvage procedures, and reduced disease-specific survival in patients with primary bone or extremity soft-tissue sarcomas. Although several potentially confounding variables were controlled for, unmeasured confounding played a role in these results. Future studies should seek to identify what factors drive the finding that substandard insurance status is associated with poorer survival after a cancer diagnosis. Candidate variables might include medical comorbidities, treatment delays, time to first presentation to medical care and time to diagnosis, type of treatment received, distance travelled to treatments and transportation barriers, out-of-pocket payment burden, as well as educational and literacy status. These variables are almost certainly associated with socioeconomic deprivation in a vulnerable patient population, and once identified, treatment can become targeted to address these systemic inequities.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Improving Incidental Finding Documentation in Trauma Patients Amidst Poor Access to Follow-up Care

BACKGROUND

Incidental findings (IFs) are common among injured patients and create a complex problem with no standardized solution.

MATERIALS AND METHODS

This is a retrospective review of adult trauma patients admitted to a level I trauma center from January to May 2017. IFs from abdominal, chest, and neck imaging were categorized based on previously published guidelines focused on clinically significant IFs. Patient demographics related to access to care were collected. Outcome measures included documentation and patient notification of IFs. A univariate analysis was performed to identify characteristics that were associated with these outcomes.

RESULTS

Of 1671 patients, 682 met inclusion criteria, and 418 (61.3%) had any IF based on the a priori categorization scheme. In total, 67 (9.8%) were homeless, 58 (8.5%) had no health insurance, and 115 (16.9%) had no established primary care provider prior to admission. Documentation of IFs was included in discharge summaries and instructions 76.5% and 40.2% of the time, respectively. Physicians were statistically more likely to appropriately document IFs when radiologists provided specific recommendations. Transfer to another hospital service prior to discharge and discharge to another acute care facility were associated with reduced rates of successful documentation. No factors significantly affected documentation of patient notification.

CONCLUSIONS

Trauma patients are at risk for poor access to follow-up care of IFs. Expanding IF-specific guidelines, collaborating with radiologists to facilitate their inclusion in reports, and ensuring that IFs are part of patient hand-offs could provide systematic methods of improving their documentation.

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

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.

Breast Reconstruction for Medicaid Beneficiaries: A Systematic Review of the Current Evidence

Introduction: Medicaid beneficiaries are a generally disadvantaged population with access to elective specialty services. We sought to better understand utilization of breast reconstruction by Medicaid beneficiaries.Methods: We systematically searched PubMed, Scopus, Web of Science, and CINAHL databases for studies comparing breast reconstruction rates by insurance type. We extracted the information of interest to qualitatively and quantitatively synthesize the results of the studies.Results: We identified seven eligible studies. Overall, the rates of breast reconstruction have increased across insurance groups. However, our results show that Medicaid beneficiaries were on average less likely to receive breast reconstruction in comparison to patients with private insurance. Although, Medicaid patients again were more likely to receive breast reconstruction in comparison to Medicare beneficiaries.Conclusion: There is wide disparity in reconstruction rates by insurance status. However, with continued increase in the adult Medicaid population due to widening eligibility expansion, disparities involving this vulnerable population should be examined for causes and solutions.

Medicaid Reimbursement for Common Spine Procedures: Are Compensation Rates Consistent?

STUDY DESIGN

Health Services Research.

OBJECTIVE

The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery.

SUMMARY OF BACKGROUND DATA

The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively.

METHODS

MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement.

RESULTS

The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR.

CONCLUSION

Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care.

LEVEL OF EVIDENCE

4.

Variation in the Delivery of Inpatient Orthopaedic Care to Medicaid Beneficiaries within a Single Metropolitan Region

BACKGROUND

There is variability in access to and utilization of orthopaedic care, particularly for those with Medicaid insurance. One potential contributor is perceived unwillingness of surgeons and hospitals to accept underinsured patients. We used administrative data to examine the payer mix for select inpatient orthopaedic surgical procedures at all hospitals within a single region, hypothesizing that the delivery of orthopaedic surgery to Medicaid beneficiaries varies highly at the hospital level.

METHODS

Using administrative data, we analyzed inpatient hospitalizations for elective cases (total knee or hip arthroplasty; spinal decompression or fusion) and trauma cases (hip hemiarthroplasty; femoral or tibial and fibular fracture repair) among 22 hospitals in a single region from 2011 to 2016 for patients who were 18 to 64 years of age. The primary outcome was the percentage of each hospital's caseload with Medicaid listed as the primary payer. The secondary outcome measured each hospital's Medicaid percentage against the percentage of Medicaid-insured individuals within 10 miles of the hospital (Medicaid share ratio), using a ratio of 1 as a benchmark. To quantify variation, we calculated a weighted coefficient of variation of the Medicaid share ratio for all cases combined, elective cases only, and trauma cases only.

RESULTS

For all cases (n = 19,204), the mean percentage of Medicaid-funded surgical procedures was 7.6% (range, 0.2% to 57.3%). The mean Medicaid share ratio was 1.0 (range, 0.05 to 4.20). Across 22 hospitals, the weighted coefficient of variation for Medicaid share was 69, indicating very high variation. For elective cases alone, the mean percentage of Medicaid-funded surgical procedures was 5.5% (range, 0.2% to 64.6%). The mean Medicaid share ratio was 0.71 (range, 0.05 to 4.73), and the weighted coefficient of variation was 93. For trauma cases alone, Medicaid-funded surgical procedures were 14.7% (range, 0.0% to 35.7%). The mean Medicaid share ratio was 2.0 (range, 0 to 3.93), and the weighted coefficient of variation was 34.

CONCLUSIONS

Delivery of care was highly variable when benchmarking against the insurance composition of each hospital's surrounding community. Although generalizability to other regions is limited, our findings support previously asserted notions that delivery of orthopaedic care may differ on the basis of socioeconomic markers (such as insurance status). If not addressed, these inequities may exacerbate existing racially and socioeconomically based disparities in care.

Medicaid Patients Have Greater Difficulty Scheduling Health Care Appointments Compared With Private Insurance Patients: A Meta-Analysis

Medicaid patients are known to have reduced access to care compared with privately insured patients; however, quantifying this disparity with large controlled studies remains a challenge. This meta-analysis evaluates the disparity in health services accessibility of appointments between Medicaid and privately insured patients through audit studies of health care appointments and schedules. Audit studies evaluating different types of outpatient physician practices were selected. Studies were categorized based on the characteristics of the simulated patient scenario. The relative risk of appointment availability was calculated for all different types of audit scenario characteristics. As a secondary analysis, appointment availability was compared pre- versus post-Medicaid expansion. Overall, 34 audit studies were identified, which demonstrated that Medicaid insurance is associated with a 1.6-fold lower likelihood in successfully scheduling a primary care appointment and a 3.3-fold lower likelihood in successfully scheduling a specialty appointment when compared with private insurance. In this first meta-analysis comparing appointment availability between Medicaid and privately insured patients, we demonstrate Medicaid patients have greater difficulty obtaining appointments compared with privately insured patients across a variety of medical scenarios.

Early Hip Arthroscopy for Femoroacetabular Impingement Syndrome Provides Superior Outcomes When Compared With Delaying Surgical Treatment Beyond 6 Months

BACKGROUND

There is literature on the association between chronic preoperative pain and worse outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). However, there are few data on whether there is an optimum window that provides the best midterm surgical outcomes.

PURPOSE

To assess the outcomes of hip arthroscopy for FAIS according to timing of surgical intervention.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing arthroscopic intervention for FAIS with a minimum 2-year follow-up were included. All patients completed the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scales for pain and satisfaction. Patients were stratified by preoperative symptom duration. We compared 3 to 6 months of symptoms with other subsequent time frames (>6-12, >12-24, and >24 months). Clinically significant outcome was determined with the minimal clinically important difference and patient acceptable symptomatic state.

RESULTS

A total of 1049 patients were included (mean ± SD: age, 32.3 ± 12.4 years; follow-up, 30.8 ± 6.7 months). Patients undergoing surgery at 3 to 6 months of symptoms had no significant differences in outcome when compared with those in the >6- to 12-month group except for the iHOT-12 (P = .028). Patients with symptom duration of >12 to 24 months and >24 months had worse outcomes across all measures (P < .001). Surgery within 3 to 6 months of symptoms was predictive for achieving the minimal clinically important difference on the HOS-ADL (odds ratio [OR], 1.81; 95% CI, 1.20-2.73) and HOS-SS (OR, 1.90; 95% CI, 1.11-3.17), as well as the patient acceptable symptomatic state on the HOS-ADL (OR, 1.85; 95% CI, 1.34-2.56) and HOS-SS (OR, 1.58; 95% CI, 1.14-2.18), when compared with the other groups. In multivariate regression analysis, symptom duration was predictive of visual analog scale for pain (β = 3.10; 95% CI, 1.56-4.63; P < .001) and satisfaction (β = -4.16; 95% CI, -6.14 to -2.18; P < .001).

CONCLUSION

Among patients with FAIS, surgical intervention early after the onset of symptoms (3-6 months) was associated with superior postoperative outcomes when compared with patients who underwent surgical intervention beyond this time frame. This information may help guide preoperative decision making regarding delay of surgery. These findings should be confirmed in a prospective study.

Fewer Hospitals Provide Operative Fracture Care to Medicaid Patients Than Otherwise-Insured Patients in 4 Large States

OBJECTIVE

To determine whether Medicaid patients receive operative fracture care at an equal number of hospitals as otherwise-insured patients and to compare travel distances between Medicaid and otherwise-insured patients.

DESIGN

Retrospective, population-based cohort study of administrative health data.

SETTING

One thousand seventy-five hospitals in California, Florida, New York, and Texas.

PARTICIPANTS

Two hundred forty thousand three hundred seventy-six patients who underwent open reduction and internal fixation of a fracture of the radius/ulna, tibia/fibula, or humerus between 2006 and 2010 in Texas or New York, or between 2010 and 2014 in California or Florida.

INTERVENTION

Open reduction and internal fixation of the radius/ulna, tibia/fibula, or humerus.

MAIN OUTCOME MEASUREMENTS

The number of unique hospitals visited and the distance traveled for care were compared by payer status and admission acuity. The distance traveled was also stratified by urban versus rural geographic area.

RESULTS

In nonemergent settings, 7%-16% fewer hospitals saw Medicaid patients than otherwise-insured patients. In emergent settings, the gap between the number of hospitals seeing Medicaid and otherwise-insured patients was less than 5% in every state except Texas, where the gap was 11%-14%. The Medicaid and Medicare groups had longer travel distances in the nonemergent setting than in the emergent setting. Medicaid patients did not travel longer distances than otherwise-insured patients except in Texas, where they traveled 3-5 miles further than otherwise-insured patients in the nonemergent, urban setting.

CONCLUSIONS

Fewer hospitals provide operative fracture care to Medicaid patients than otherwise-insured patients, but Medicaid patients do not travel longer distances to the hospital on a population level.

LEVEL OF EVIDENCE

Prognostic Level III.

Insurance status affects access to physical therapy following rotator cuff repair surgery: A comparison of privately insured and Medicaid patients

Rotator cuff repair (RCR) is an effective procedure to relieve shoulder pain and dysfunction. Postoperative physical therapy (PT) plays an integral role in the overall success of RCR. Insurance status has been shown to be an important predictor of postoperative PT utilization. This study evaluated the effect of insurance status on access to PT services following RCR. One hundred thirty-eight PT clinics were contacted in the Greater Boston metropolitan area. Clinics were contacted on two separate occasions and presented with a fictitious acutely postoperative RCR patient in need of PT. Insurance status was reported as Medicaid or private insurance. Overall, 133 (96.4%) accepted private insurance, whereas only 71 (51.4%) accepted Medicaid (P=0.019). Medicaid patients were offered a first available appointment at a mean of 8.3 days (95% CI: 7.13-9.38, range: 0-31) versus a mean of 6.3 days (95% CI: 5.3-7.22, range: 0-19, P=0.001) for private patients. Clinic location was not associated with access to PT or time to first appointment. Insurance status affects access to PT services and time to first available appointment in patients following RCR surgery in a major metropolitan area.

Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion

BACKGROUND

Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid).

METHODS

Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014).

RESULTS

The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012).

CONCLUSION

Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.

Variations in Utilization of Carpal Tunnel Release Among Medicaid Beneficiaries

PURPOSE

To evaluate the null hypothesis that Medicaid patients receive carpal tunnel release (CTR) at the same time interval from diagnosis as do patients with Medicare Advantage or private insurance.

METHODS

We conducted a retrospective review using a database containing claims records from 2007 to 2016. The cohort consisted of patient records with a diagnosis code of carpal tunnel syndrome (CTS) and a procedural code for CTR within 3 years of diagnosis. We stratified patients into 3 groups by insurance type (Medicaid managed care, Medicare Advantage, and private) for an analysis of the time from diagnosis until surgery and use of preoperative electrodiagnostic testing.

RESULTS

Of all patients who received CTR within 3 years of diagnosis, Medicaid patients experienced longer intervals from CTS diagnosis to CTR compared with Medicare Advantage and privately insured patients (median, 99 days vs 65 and 62 days, respectively). The Medicaid cohort was significantly less likely to receive CTR within 1 year of diagnosis compared with the Medicare Advantage cohort (adjusted odds ratio [OR] = 0.54) or within 6 months of diagnosis compared with the privately insured cohort (adjusted OR = 0.61). Those in the Medicaid cohort were less likely to receive electromyography and nerve conduction studies within 9 months before surgery compared with their Medicare Advantage (adjusted OR = 0.43) and privately insured (adjusted OR = 0.41) counterparts. These effects were statistically significant after accounting for age, sex, region, and Charlson comorbidity index.

CONCLUSIONS

Medicaid managed care patients experience longer times from diagnosis to surgery compared with Medicare Advantage or privately insured patients in this large administrative claims database. Similar variation exists in the use of electrodiagnostic testing based on insurance type.

CLINICAL RELEVANCE

Medicaid patients may experience barriers to CTS care, such as delays from diagnosis to surgery and reduced use of electrodiagnostic testing.

Current Concepts in Orthopaedic Care Disparities

Healthcare delivery is profoundly affected by race/ethnicity, sex, and socioeconomic status. The effect of these factors on patient health and the quality of care received is being studied in more detail. Orthopaedic surgery over the past several years has paid increasing attention to these disparities as well. Not only do these disparities exist with regard to accessing care but also with regard to the quality of care received and postoperative outcomes. Total joint arthroplasty, hip fractures, and spine surgery represent areas where the effect of these factors has been reported. Not only is it essential for the clinician to understand the extent of care disparities but also the manner in which these disparities affect patient health and outcomes within the orthopaedic surgery setting. Strategies should be devised to minimize the effect of these factors on clinical care and patient health.

The Impact of Insurance Status on the Development of Nonunion following Scaphoid Fracture

Purpose  Certain factors have been associated with the development of scaphoid nonunion, including delayed diagnosis, smoking, inadequate initial management, proximal location, and carpal instability. We hypothesized that insurance status would also be a risk factor for the development of scaphoid nonunion. Methods  A case-control study was performed on patients who presented to a single surgeon at a tertiary referral center during 2006 to 2015. Cases were patients presenting with nonunions, controls, and patients with acute fractures. Patients were characterized as underinsured if they lacked any type of insurance or if they were on Medicaid. Results  Patients (39 nonunions [cases] and 32 primary fractures [controls]) presenting with nonunions were more likely than controls to have had displaced fractures (72 vs. 41%) and fractures located at the proximal aspect of the scaphoid (18 vs. 0%), and to be underinsured (46 vs. 19%). Conclusion  Patients presenting with nonunions were more likely to be underinsured than patients presenting with primary fractures. This finding suggests that underinsurance is a risk factor for the development of nonunion. Assuming delay between fracture and intervention is a known risk factor for the development of nonunion, and it is likely that the association between nonunion and underinsurance is mediated through this delay. Level of Evidence  Prognostic, level III, case-control study.