What's New in Pediatric Orthopaedic Health Care Disparities?

Greater socioeconomic deprivation predicts worse functional status two years after orthopaedic surgery, but not magnitude of change from baseline

Background

The purpose of this study was to analyze if Area Deprivation Index (ADI), as a geography-based proxy for socioeconomic status (SES), is associated with differences in patient-reported outcomes (PROs) 2 years after outpatient orthopaedic surgery.

Methods

Patients undergoing outpatient orthopaedic surgery from June 2015 to November 2018 were administered Patient-Reported Outcomes Measurement Information System (PROMIS) and joint-specific surveys at baseline and 2 years postoperatively. ADI was computed from home address. Tests of association were used to characterize 2-year PROs dependence on ADI. This informed covariate selection for multivariable linear regression examined PRO change over 2 years with ADI in the context of other self-reported socioeconomic covariates.

Results

Enrollment was 2117 patients, 1483 (70 %) completed follow-up. Lower SES as measured by home address was associated with lower function and less improvement from baseline at 2 years postoperatively. This trend was most apparent in PROMIS instruments.

Conclusion

SES as approximated by ADI is associated with PROs at 2 years after outpatient orthopaedic surgery for a subset of PROs. ADI should be considered for inclusion in statistical models using an SES-sensitive PRO as an outcome, understanding that model performance may also depend on if a single value or change over time is being estimated.

Social Disadvantage and Transportation Insecurity in Clubfoot Clinic

OBJECTIVES

This study aims to evaluate the association of missing clubfoot clinic visits with transportation barriers and measures of socioeconomic status including the child opportunity index (COI).

METHODS

An 11-question survey was administered to caregivers of patients with clubfoot seen at a single pediatric tertiary hospital between August 2020 and September 2023. A chart review was conducted to obtain zip codes used to determine COI 2.0 scores. The impact of race/ethnicity, income, persons per household, COI, and transportation methods on missing at least one clinic visit was analyzed using descriptive and nonparametric statistics.

RESULTS

The transportation survey was completed by a total of 99 caregivers. The median travel time to the clinic was 45 minutes (IQR: 33, range: 1 to 180). Most participants reported use of a personal car (108/128, 83%), and 72% took time off work to attend the appointment. Those with lower COI had longer travel time ( P =0.02) and were less likely to use personal cars ( P =0.05). Missed clubfoot clinic visits were more common for families reliant on transportation other than a personal vehicle ( P =0.01) and those with annual income under $30,000 ( P =0.02).

CONCLUSIONS

Transportation insecurity was associated with greater social disadvantage as indicated by COI and more missed clinic visits.

LEVEL OF EVIDENCE

Level III.

The Lack of Reporting Social Determinants of Health in Pediatric Orthopaedic Randomized Controlled Trials

BACKGROUND

Social determinants of health (SDOHs) affect health outcomes outside the hospital, and understanding them can enhance postoperative outcomes in orthopaedic surgery patients. This study aimed to describe the prevalence of randomized controlled trials (RCTs) in pediatric orthopaedic journals reporting on the SDOHs of their patient cohorts. We hypothesize that many SDOHs will be underreported in RCTs investigating pediatric orthopaedic surgery.

METHODS

Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, the authors queried the PubMed database to examine SDOHs from 2 pediatric orthopaedic journals: Journal of Pediatric Orthopaedics and Journal of Pediatric Orthopaedics: Part B. The inclusion criteria incorporated RCTs published between 2005 and April 2024. The exclusion criteria included any articles that were not RCTs published in this period.

RESULTS

One hundred thirteen articles met the search criteria, with 31 excluded because they did not fall from 2005 to 2024. Eighty-two were published from 2005 to 2024, but 6 RCTs were excluded, as 3 were non-RCTs, and 3 examined cadavers. Seventy-six RCTs were included for analysis, with 65 articles from the Journal of Pediatric Orthopaedics and 11 articles from the Journal of Pediatric Orthopaedics: Part B . Articles originated from 17 countries, with the United States producing 61.8% (47) of the included studies. Of all 76 included studies, 96.1% (73) reported age, 88.2% (67) reported sex/gender, 30.3% (23) reported BMI, 21.1% (16) reported race/ethnicity, 5.3% (4) reported educational level, 2.6% (2) reported stress, and 2.6% (2) reported insurance. Smoking status, socioeconomic status, income levels, and employment status were each reported by only 1 study.

CONCLUSIONS

The RCTs examining pediatric orthopaedic surgery tend to scarcely report SDOHs. Future RCTs should expand beyond demographic characteristics such as age, race/ethnicity, sex/gender, and BMI and incorporate other relevant SDOHs. This will allow us to develop a more comprehensive understanding of health outcomes in the pediatric orthopaedic population.

LEVEL OF EVIDENCE

I; Therapeutic Studies.

A systematic review of racial health disparities among children and youth with physical disabilities

PURPOSE

Children and youth who belong to a racially minoritized group commonly experience multiple and complex forms of discrimination and health disparities. The purpose of this review was to explore racial disparities in health care and health outcomes among children and youth with physical disabilities.

METHODS

Six international databases (Ovid Medline, Healthstar, Embase, PsycINFO, Scopus, and Web of Science) were searched and screened for inclusion. A narrative synthesis was used to identify the common trends.

RESULTS

Thirty-seven articles met the inclusion criteria, which involved 218 555 children and youth with various types of physical disabilities spanning over 29 years. We noted the following trends: (1) racial disparities in accessing or receiving care; (2) racial disparities in health outcomes and mortality rates; and (3) factors affecting racial disparities. Most studies reported at least one finding indicating that racially minoritized youth had differential access to care and/or disparities in health outcomes compared to white youth.

CONCLUSIONS

Our findings highlight the concerning racial disparities among children and youth with physical disabilities within health care. There is an urgent need for advocacy and interventions at multiple levels to address the perpetual racism and racial disparities that racially minoritized youth with physical disabilities experience.Implications for rehabilitationThere is an urgent need for health care leaders and health care providers to address the systemic health inequalities in rehabilitation for racially minoritized children and youth with physical disabilities.Health care leaders and clinicians should recognize the racial disparities that racially minoritized youth with physical disabilities encounter in accessing or receiving care in addition to health outcomes.Health care leaders and decision-makers should advocate for policy change to optimize equitable and inclusive health care to enhance the well-being of racially minoritized children with disabilities.Health care providers should engage in training to understand how to recognize and address how intersectional forms of a child's identity such as disability, race, and socio-economic status can influence health care experiences and health outcomes.

Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics

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.

Associations Between Race and Socioeconomic Status, Lower Extremity Strength, and Patient-Reported Outcomes Following Anterior Cruciate Ligament Reconstruction

CONTEXT

There are significant disparities in access to health care, but there are limited data about the impact of race and socioeconomic status on postoperative outcomes following anterior cruciate ligament reconstruction (ACLR) surgery.

OBJECTIVE

To identify associations between the Area Deprivation Index (ADI), strength measures, and patient-reported outcomes following ACLR and examine differences in outcomes between race, sex, and socioeconomic status.

DESIGN

Case-control study in a single hospital setting.

SETTING

Database secondary analysis.

PATIENTS OR OTHER PARTICIPANTS

Data were collected from 340 patients who underwent primary, isolated, unilateral ACLR.

MAIN OUTCOME MEASURE(S)

Strength measures and patient-reported outcomes were obtained at patients' postoperative assessments at approximately 6 months postsurgery. Area Deprivation Index values were calculated on each patient's census tract, as determined through medical records review. Correlations were conducted to determine the relationship between the ADI and Knee Injury and Osteoarthritis Outcome Score measures, International Knee Documentation Committee, and limb symmetry on strength measurements. The racial composition of the sample was heavily skewed and was excluded from statistical analyses.

RESULTS

The ADI was weakly correlated with International Knee Documentation Committee (ρ = 0.11, P = .04) outcomes, with more disadvantaged patients reporting better quality of life and knee function. The ADI was not correlated with other outcomes of interest. The median ADI value of the sample was 32 (range, 1-86 [interquartile range, 19-47]).

CONCLUSIONS

Our study revealed a weak correlation between higher levels of socioeconomic disadvantage as measured by the ADI and improved subjective assessment of knee function and quality of life as measured by International Knee Documentation Committee. These findings are contrary to what other studies on this subject have found and highlight the importance of further research into the impact of socioeconomic status and other social determinants of health on post-ACLR outcomes.

Disparities in Musculoskeletal Oncology

PURPOSE OF REVIEW

Disparities within the healthcare system serve as barriers to care that lead to poor outcomes for patients. These healthcare disparities are present in all facets of medicine and extend to musculoskeletal oncology care. There are various tenets to health disparities with some factors being modifiable and non-modifiable. The factors play a direct role in a patient's access to care, time of presentation, poor social determinants of health, outcomes and survival.

RECENT FINDINGS

In musculoskeletal oncologic care, factors such as race, socioeconomic factors and insurance status are correlated to advanced disease upon presentation and poor survival for patients with a sarcoma diagnosis. These factors complicate the proper delivery of coordinated care that is required for optimizing patient outcomes. Healthcare disparities lead to suboptimal outcomes for patients who require musculoskeletal oncologic care in the short and long term. More research is required to identify ways to address the known modifiable and non-modifiable factors to improve patient outcome.

Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature

CONTEXT

Neighborhood and built environment encompass one key area of the Social Determinants of Health (SDOH) and is frequently assessed using area-level indices.

OBJECTIVE

We sought to systematically review the pediatric surgery literature for use of commonly applied area-level indices and to compare their utility for prediction of outcomes.

DATA SOURCES

A literature search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence search tool (1/2013-2/2023).

STUDY SELECTION

Inclusion required pediatric surgical patients in the US, surgical intervention performed, and use of an area-level metric.

DATA EXTRACTION

Extraction domains included study, patient, and procedure characteristics.

RESULTS

Area Deprivation Index is the most consistent and commonly accepted index. It is also the most granular, as it uses Census Block Groups. Child Opportunity Index is less granular (Census Tract), but incorporates pediatric-specific predictors of risk. Results with Social Vulnerability Index, Neighborhood Deprivation Index, and Neighborhood Socioeconomic Status were less consistent.

LIMITATIONS

All studies were retrospective and quality varied from good to fair.

CONCLUSIONS

While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role of SDOH to building meaningful interventions towards equity in care.

TYPE OF STUDY

Systematic Review.

LEVEL OF EVIDENCE

Level III.

Investigating the Relationship Between Neighborhood Social Deprivation and Time to Specialty Orthopedic Care for Pediatric Trigger Thumb

Purpose

Pediatric trigger thumb is a common condition resulting in referral from primary care to specialty care. Access to pediatric hand specialty care is a complex issue influenced by a multitude of social factors, including socioeconomic status. The aim of this study is to investigate the relationship between area deprivation and the time from primary care referral to presentation to specialty care for pediatric trigger thumb.

Methods

Participants were pediatric patients with trigger thumb. Patient-level area deprivation was reflected by the area deprivation index (ADI). We analyzed the relationship of the ADI to patient demographics (age and sex), trigger thumb treatment (surgical vs nonsurgical), and time to initial hand surgical visit after referral and surgical management when indicated.

Results

Among 163 patients with trigger thumb, 52% were men. Mean age at referral for trigger thumb was 2.9 ± 1.7 years. Mean ADI for patients diagnosed with trigger thumb was 57.8 ± 23.4 for the 2018 data set and 57.3 ± 23.6 for the 2021 data set, on a scale of 1 (low) to 100 (high). The median time from referral from primary care to presentation to orthopedic care for trigger thumb was 34 days. Upon presentation to treating hand surgeon, 118 patients (72.4%) underwent surgical release. We found no difference in ADI between men and women nor between patients treated operatively or with nonsurgical management. We found a weak positive correlation between ADI and time from initial referral to presentation to the treating hand surgeon. There was no correlation between ADI and time from initial hand surgical evaluation and surgical management in patients indicated for surgery.

Conclusions

Pediatric trigger thumb patients from areas with higher ADI have a slightly longer delay between initial referral and their initial visit with an orthopedic hand specialist. Although we found a delay in initial evaluation by the treating hand surgeon in patients with higher ADI, ADI status was not different between patients managed with surgical and nonsurgical treatment nor between men and women.

Clinical relevance

Neighborhood ADI weakly correlated with increased time from referral to accessing specialty orthopedic care for trigger thumb. This may suggest a need for more equitable access to specialty care for patients with pediatric trigger thumb from high ADI areas.

Understanding Pediatric Surge in the United States

The concepts of pediatric surge in the United States continue to evolve from a theoretic framework to practical implementation. As disasters become more frequent, ranging from natural to human-caused, children remain a vulnerable population. The coronavirus disease 2019 pandemic and the 2022 to 2023 tripledemic respiratory surge revealed advances and continued challenges in our ability to care for a large influx of pediatric patients. Understanding pediatric surge through the framework of the 4 S's (space, staff, stuff, and systems/structures) can identify gaps at multiple levels.

A Framework for Studying Healthcare Equity in Adolescent Idiopathic Scoliosis: Scoping Review and Meta-Analysis of Existing Literature

INTRODUCTION

Health inequities remain a notable barrier for pediatric patients, especially in conditions such as adolescent idiopathic scoliosis (AIS), where the efficacy of nonsurgical treatment is dependent on early diagnosis and referral to a specialist. Social determinants of health (SDOH) are nonmedical factors that affect health outcomes, such as economic stability, neighborhood environment, and discrimination. Although these factors have been studied throughout the AIS literature, considerable inconsistencies remain across studies regarding the investigation of SDOH for this population. Through a scoping review, we analyze the existing literature to propose a comprehensive framework to consider when designing future prospective and retrospective studies of healthcare equity in AIS.

METHODS

A systematic review was executed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. A meta-analysis was performed for each reported SDOH (race, ethnicity, insurance provider, and socioeconomic status) including only studies with complete and consistent variables and outcomes. Cobb angle measurements were aggregated and summarized as the weighted mean difference with 95% confidence interval using a fixed or random-effects model (substantial heterogeneity identified).

RESULTS

Of 7,539 studies reviewed, nine studies met all the inclusion criteria. As expected, considerable inconsistencies were found across the nine studies making it difficult to aggregate data. Within the meta-analyses, the mean difference between White non-Hispanic and Hispanic patients was statistically significant (1.71; 95% confidence interval 0.78 to 2.65; P < 0.001). No other statistically significant differences were identified among the SDOH and presenting main Cobb angle magnitude.

CONCLUSION

These studies provide insight into healthcare inequities in AIS, although notable inconsistencies make it difficult to aggregate data and draw the conclusions needed to drive necessary public health changes. However, our proposed framework can provide a guideline for future prospective and retrospective studies to standardize data reporting and allow for improved collaboration, study design, and future systematic reviews and meta-analyses.

Impact of Insurance Type on Access to Pediatric Surgical Care

Background

This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance.

Methods

This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex.

Results

A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007).

Conclusions

No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.

Socioeconomic status is associated with greater hazard of post-discharge mortality than race, gender, and ballistic injury mechanism in a young, healthy, orthopedic trauma population

OBJECTIVES

To explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries.

METHODS

A retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period.

RESULTS

We identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2-4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1-4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3-3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8-2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20).

CONCLUSION

Low SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

Socioeconomic, Racial, and Insurance Disparities in Clinical Outcomes After Surgery Among Patients With Idiopathic Scoliosis

BACKGROUND

Socioeconomic status (SES), race, and insurance type correlate with initial curve severity for patients with idiopathic scoliosis, but less is known regarding how these variables impact surgical outcomes. The objectives of this study were to determine the influence of SES, race, and insurance on preoperative appointment attendance, likelihood of obtaining a preoperative second opinion, brace prescription, missed 6 or 12-month postsurgical appointments, incidence of emergency department visits 0 to 90 days after surgery, and major complications within a year of surgery.

METHODS

A review of 421 patients diagnosed with idiopathic scoliosis who underwent surgery at a single high-volume pediatric spinal deformity institution between May 2015 and October 2021 was conducted. Area Deprivation Index, a quantitative measure of SES, was collected. Scores were stratified by quartile; higher scores indicated a lower SES. χ 2 tests for correlation were performed to determine whether clinical outcomes were dependent upon Area Deprivation Index, race, or insurance type; P ≤0.05 was significant.

RESULTS

The sample was 313 Caucasian (74%), 69 (16%) black, and 39 (9.3%) other patients. More patients had private versus public insurance (80% vs 20%) and were of higher SES. The likelihood of missing preoperative appointments was higher for black patients ( P = 0.037). Those with lower SES missed more postoperative appointments and received less bracing and second opinions ( P = 0.038, P = 0.017, P = 0.008, respectively). Being black and publicly insured correlated with fewer brace prescriptions ( P < 0.001, P = 0.050) and decreased rates of obtaining second opinions ( P = 0.004,  P = 0.001).

CONCLUSION

Patients with idiopathic scoliosis surgery who were Caucasian, privately insured, and of higher SES were more likely to seek preoperative second opinions, be prescribed a brace, and attend postoperative appointments. Recognition of the inherent health care disparities prevalent within each pediatric spine surgery referral region is imperative to better inform local and national institutional level programs to educate and assist patients and families most at risk for disparate access to scoliosis care.

LEVEL OF EVIDENCE

Level III; retrospective case-control study.

Applying machine learning to consumer wearable data for the early detection of complications after pediatric appendectomy

When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3-17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events.

Health Inequities in Pediatric Trauma

This review article highlights the disparities evident in pediatric trauma care in the United States. Social determinants of health play a significant role in key aspects of trauma care including access to care, gun violence, child abuse, head trauma, burn injuries, and orthopedic trauma. We review the recent literature as it relates to these topics. The findings from these recent studies emphasize the important principle that trauma care for children should be designed with a focus on equity for all children.