Correlation Between Patient-Reported Outcome Measures and Health Insurance Provider Types in Patients with Hip Osteoarthritis

The Minimal Clinically Important Difference for the Oswestry Disability Index Substantially Varies Based on Calculation Method: Implications to Value-Based Care

STUDY DESIGN

Retrospective study.

OBJECTIVE

Evaluate differences in the minimal clinically important difference (MCID) threshold value based on various acceptable statistical methods and how these differences may influence the interpretation of surgical benefit following elective 1- and 2-level lumbar fusion.

SUMMARY OF BACKGROUND DATA

The MCID is a statistically determined threshold value to evaluate if a patient has received benefit from a medical procedure. In the era of value-based medicine, the MCID has become increasingly important. However, there is substantial ambiguity surrounding the interpretation of this value, given that it can be influenced by both demographic and methodological factors.

METHODS

A total of 371 patients who underwent 1- or 2-level elective lumbar fusions between June 2021 and June 2023 were included in this study. All patients completed both their preoperative and 6-month postoperative Oswestry Disability Index (ODI), as well as 2 anchor questions concerning satisfaction with their surgical procedure. The MCID values were calculated using 16 accepted statistical methods, and the resulting MCID values were applied to the cohort to determine how many patients reached MCID by 6 months postfusion.

RESULTS

Results demonstrated significant variability in the MCID value. The average MCID value for all 16 methods was 10.5±7.0 points in the in the range (0.8 to 25). Distribution methods provided lower threshold MCID values but had greater variability while the Anchor methods resulted in higher threshold values but had lower variability. Depending on the method used 30% to 83% of the cohort reached MCID by 6 months.

CONCLUSION

The statistical method used to calculate the MCID resulted in significantly different threshold values and greatly affected the number of patients meeting MCID. The results demonstrates the complexity surrounding the interpretation of MCID values and calls into question the utility of a single statistically determined value to assess surgical success.

The Minimal Clinically Important Difference (MCID) for Total Joint Arthroplasty Outcome Measures Varies Substantially by Calculation Method

BACKGROUND

As the United States health-care system transitions to a value-based model, the minimal clinically important difference (MCID) has become an important metric for assessing perceived benefit in clinical settings. However, there is substantial ambiguity surrounding the MCID value because the calculation method used can lead to substantial changes in the clinical interpretation of surgical success.

METHODS

A total of 1,113 patients who underwent either total knee arthroplasty (TKA) or total hip arthroplasty (THA) between June 2021 and June 2023 and completed their patient-reported outcomes (the KOOS JR [Knee injury and Osteoarthritis Outcome Score for Joint Replacement] or HOOS JR [Hip disability and Osteoarthritis Outcome Score for Joint Replacement]) preoperatively and at 1 year postoperatively were reviewed for this study. The MCID values for the HOOS JR and KOOS JR were determined using 16 statistically appropriate methods, and the resulting MCID values were applied to the study group to assess how differences in methods changed the number of patients who met the MCID at 1 year postoperatively.

RESULTS

The study cohort consisted of 570 patients who underwent TKA and 543 who underwent THA. The overall cohort was 62.2% female, had a mean age of 69.3 ± 8.3 years, and was 92.3% Caucasian, 2.9% African American, and 4.8% other race (i.e., Asian, multiracial, or "other"). The MCID values varied substantially among the methods evaluated. The mean MCID was 11.5 ± 9.2 (range, 0.5 to 36.6) for the KOOS JR and 12.2 ± 8.9 (range, 0.6 to 34.3) for the HOOS JR. Distribution-based methods led to smaller but more variable MCID values, whereas anchor-based methods were noted to have larger but more consistent MCID values.

CONCLUSIONS

Different statistical approaches resulted in substantial variation in the MCID threshold value, which affected the number of patients who reached the MCID. This study demonstrates the ambiguity of the MCID and casts some doubt regarding its utility for assessing the surgical benefit of total joint arthroplasty.

LEVEL OF EVIDENCE

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

Disparities in access but not outcomes: Medicaid versus non-Medicaid patients in multidisciplinary chronic pain rehabilitation

Purpose: There are known disparities in chronic pain severity, treatment, and opioid-related risks amongst individuals from lower socioeconomic status, including Medicaid beneficiaries, but little is known about whether Medicaid beneficiaries benefit in a similar way from multidisciplinary chronic pain rehabilitation. This study investigated differences in clinical outcomes between Medicaid and non-Medicaid beneficiaries who completed a 3-week multidisciplinary chronic pain rehabilitation program.Methods: Participants (N = 131) completed a broad range of clinical measures pre- and post-treatment including pain severity, pain interference, depression, anxiety, objective physical functioning, and opioid misuse risk. Patients with Medicaid were compared with non-Medicaid patients in terms of baseline characteristics and rate of change, utilizing two-factor repeated measures analyses of variance.Results: There were baseline characteristic differences, with Medicaid beneficiaries being more likely to be African American, have higher rates of pain, worse physical functioning, and lower rates of opioid use. Despite baseline differences, both groups demonstrated significantly improved outcomes across all measures (p<.001) and no significant difference in rate of improvement.Conclusions: Results suggest that pain rehabilitation is as effective for Medicaid recipients as non-Medicaid recipients. Patients with Medicaid are particularly vulnerable to disparities in treatment, so efforts to expand access to multidisciplinary pain treatments are warranted.

Correlation between the optimal screening for prediction of referral and outcome yellow flag tool and patient-reported legacy outcome measures in patients undergoing shoulder surgery

Background

The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) Tool is a 10-item multidimensional screening tool utilized to evaluate pain-related psychological traits in individuals with musculoskeletal pain conditions. The validity of postoperatively collected OSPRO-YF is unclear. This study sought to assess validity of the OSPRO-YF by comparing it to patient-reported outcome scores in both preoperative and postoperative settings.

Hypothesis

The authors hypothesized that OSPRO-YF overall score would correlate with shoulder and global function PROs at preoperative and postoperative timepoints.

Methods

A review of 101 patients undergoing shoulder surgery by one sports medicine orthopedic surgeon at a large academic institution was conducted. 90 and 54 patients had complete preoperative and postoperative patient-reported outcome responses. OSPRO-YF, American Shoulder and Elbow Surgeons (ASES) Evaluation Form, and Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) were routinely administered before and after surgery at the senior author's clinic visits. Concurrent validity of OSPRO-YF at either timepoint was assessed by comparing scores with PROs cross-sectionally using Pearson correlations and multiple comparison corrections.

Results

Preoperatively, higher OSPRO-YF total score was associated with greater concurrent PROMIS-CAT Pain Interference (r = 0.43; P < .01) and Depression (r = 0.36; P = .05) and lower ASES (r = -0.34; P < .01). Higher postoperative OSPRO-YF was also associated with greater concurrent PROMIS-CAT Pain Interference (r = 0.43; P < .01) and Depression (r = 0.36; P < .01) and lower ASES (r = -0.34; P = .01). ASES had strong correlation with Single Assessment Numeric Evaluation and Pain scores at both preoperative and postoperative timepoints. Single Assessment Numeric Evaluation was not significantly associated with OSPRO-YF total score or number of yellow flags at either timepoints.

Conclusion

The study findings support the clinical validity of the 10-item OSPRO-YF tool when administered before or after shoulder surgery. For patients exhibiting suboptimal recovery or those identified as high risk at initial screening, assessment of pain-related psychological distress postoperatively may be particularly beneficial in guiding rehabilitation.

Worker's compensation and no-fault insurance are associated with decreased patient reported outcomes and higher rates of revision at 2 and 5 years follow-up compared to patients with commercial insurance undergoing hip arthroscopy for femoroacetabular impingement

PURPOSE

To investigate the patient reported outcomes (PROs) of patients undergoing hip arthroscopy (HA) for femeroacetabular impingement syndrome (FAIS), a condition where irregular bone growth in the hip joint leads to friction and pain during movement, who have worker's compensation (WC) or no-fault insurance (NF) versus commercial insurance (CI) at both 2 year and 5 year follow-up.

METHODS

This was a single center, single surgeon, retrospective analysis performed between August 2007 and May 2023 of consecutive patients that underwent HA, a minimally invasive surgical procedure used to diagnose and treat problems inside the hip joint through small incisions, for FAIS. Patients were divided into two cohorts-those with WC/NF and those with commercial insurance (CI). Patient reported outcomes (PROs), which included modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS), were collected preoperatively, as well as at least 2-year postoperatively. Additionally, other clinically relevant outcomes variables including prevalence of revision surgery and conversion to total hip arthroplasty were recorded.

RESULTS

Three hundred and forty three patients met inclusion criteria. There were 32 patients in the WC/NF cohort and 311 patients in the commercial cohort. When controlling for age, sex, and Body Mass Index (BMI), WC/NF status was associated with lower mHHS at both 2 year (β = - 8.190, p < 0.01, R2 = 0.092) and 5 year follow-up (β = - 16.60, p < 0.01, R2 = 0.179) and NAHS at 5 year follow up (β = - 13.462, p = 0.03, R2 = 0.148). The WC/NF cohort had a lower rate of achieving Substantial Clinical Benefit (SCB) for mHHS at 2-years follow-up (66.7% vs. 84.1%, p = 0.02).The rate of revision hip arthroscopy was significantly higher in the worker's compensation/no fault cohort than the commercial insurance cohort (15.6% vs. 3.5%, p < 0.01). The rate of conversion to total hip arthroplasty (THA) in the WC/NF cohort was not significantly different than the rate of conversion to THA in the commercial insurance cohort (0.0% vs. 3.2%, p = 0.30).

CONCLUSION

Patients with WC/NF insurance may expect a significant improvement from baseline mHHS and NAHS following HA for FAIS at short-term follow-up. However, this improvement may not be as durable as those experienced by patients with CI. Additionally, WC/NF patients should be counseled that they have a higher risk of undergoing revision hip arthroscopy than similar CI patients.

LEVEL OF EVIDENCE

III, Retrospective Comparative Prognostic Investigation.

Automating Patient-reported Data Collection: Does it Work?

OBJECTIVE

There are several electronic patient-reported outcomes (ePROs) vendors that are being used at institutions to automate data collection. However, there is little known about their success in collecting patient-reported outcomes (PROs) and it is unknown which patients are more likely to complete these surveys. In this study, we assessed rates of PRO completion, as well as determined factors that contributed to the completion of baseline and follow-up surveys.

METHODS

We queried our ePRO platform to assess rates of completion for baseline and follow-up surveys for patients from October 2019 to June 2022. All baseline surveys were administered before pediatric orthopaedic procedures, and follow-up surveys were sent at 3 months, 6 months, 1 year, and 2 years after surgery to patients with baseline data. Descriptive statistics were used to summarize the data. Univariate and multivariate analyses were performed to assess differences in patients who did and did not complete surveys.

RESULTS

This study included 1313 patients during the study period. Baseline surveys were completed by 66% of the cohort (n = 873 patients). There was a significant difference in race/ethnicity and language spoken in the patients who did and did not complete baseline surveys ( P < 0.01) with lower rates of completion in African American, Hispanic, and Spanish-speaking patients. At least one follow-up was obtained for 68% of patients with baseline surveys (n = 597 patients). There were significant differences in completion rates based on race/ethnicity ( P = 0.03) and language spoken ( P = 0.01). There were lower rates of baseline completion for patients with government insurance in our multivariate analysis (odds ratio: 0.6, P < 0.01).

CONCLUSION

Baseline and follow-up PRO data can be obtained from the majority of patients using automated ePRO platforms. However, additional focus is needed on collecting data from traditionally underrepresented patient groups to better understand outcomes in these patient populations.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND

Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS).

METHODS

A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05.

RESULTS

A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223).

CONCLUSION

Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

The Effects of Sociodemographic Factors on Baseline Patient-Reported Outcome Measures in Patients with Foot and Ankle Conditions

BACKGROUND

Racial and ethnic care disparities persist within orthopaedics in the United States. This study aimed to deepen our understanding of which sociodemographic factors most impact patient-reported outcome measure (PROM) score variation and may explain racial and ethnic disparities in PROM scores.

METHODS

We retrospectively reviewed baseline PROMIS (Patient-Reported Outcomes Measurement Information System) Global-Physical (PGP) and PROMIS Global-Mental (PGM) scores of 23,171 foot and ankle patients who completed the instrument from 2016 to 2021. A series of regression models was used to evaluate scores by race and ethnicity after adjusting in a stepwise fashion for household income, education level, primary language, Charlson Comorbidity Index (CCI), sex, and age. Full models were utilized to compare independent effects of predictors.

RESULTS

For the PGP and PGM, adjusting for income, education level, and CCI reduced racial disparity by 61% and 54%, respectively, and adjusting for education level, language, and income reduced ethnic disparity by 67% and 65%, respectively. Full models revealed that an education level of high school or less and a severe CCI had the largest negative effects on scores.

CONCLUSIONS

Education level, primary language, income, and CCI explained the majority (but not all) of the racial and ethnic disparities in our cohort. Among the explored factors, education level and CCI were predominant drivers of PROM score variation.

LEVEL OF EVIDENCE

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

Are Detailed, Patient-level Social Determinant of Health Factors Associated With Physical Function and Mental Health at Presentation Among New Patients With Orthopaedic Conditions?

BACKGROUND

It is well documented that routinely collected patient sociodemographic characteristics (such as race and insurance type) and geography-based social determinants of health (SDoH) measures (for example, the Area Deprivation Index) are associated with health disparities, including symptom severity at presentation. However, the association of patient-level SDoH factors (such as housing status) on musculoskeletal health disparities is not as well documented. Such insight might help with the development of more-targeted interventions to help address health disparities in orthopaedic surgery.

QUESTIONS/PURPOSES

(1) What percentage of patients presenting for new patient visits in an orthopaedic surgery clinic who were unemployed but seeking work reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, reported trouble paying for medications, and/or had no current housing? (2) Accounting for traditional sociodemographic factors and patient-level SDoH measures, what factors are associated with poorer patient-reported outcome physical health scores at presentation? (3) Accounting for traditional sociodemographic factor patient-level SDoH measures, what factors are associated with poorer patient-reported outcome mental health scores at presentation?

METHODS

New patient encounters at one Level 1 trauma center clinic visit from March 2018 to December 2020 were identified. Included patients had to meet two criteria: they had completed the Patient-Reported Outcome Measure Information System (PROMIS) Global-10 at their new orthopaedic surgery clinic encounter as part of routine clinical care, and they had visited their primary care physician and completed a series of specific SDoH questions. The SDoH questionnaire was developed in our institution to improve data that drive interventions to address health disparities as part of our accountable care organization work. Over the study period, the SDoH questionnaire was only distributed at primary care provider visits. The SDoH questions focused on transportation, housing, employment, and ability to pay for medications. Because we do not have a way to determine how many patients had both primary care provider office visits and new orthopaedic surgery clinic visits over the study period, we were unable to determine how many patients could have been included; however, 9057 patients were evaluated in this cross-sectional study. The mean age was 61 ± 15 years, and most patients self-reported being of White race (83% [7561 of 9057]). Approximately half the patient sample had commercial insurance (46% [4167 of 9057]). To get a better sense of how this study cohort compared with the overall patient population seen at the participating center during the time in question, we reviewed all new patient clinic encounters (n = 135,223). The demographic information between the full patient sample and our study subgroup appeared similar. Using our study cohort, two multivariable linear regression models were created to determine which traditional metrics (for example, self-reported race or insurance type) and patient-specific SDoH factors (for example, lack of reliable transportation) were associated with worse physical and mental health symptoms (that is, lower PROMIS scores) at new patient encounters. The variance inflation factor was used to assess for multicollinearity. For all analyses, p values < 0.05 designated statistical significance. The concept of minimum clinically important difference (MCID) was used to assess clinical importance. Regression coefficients represent the projected change in PROMIS physical or mental health symptom scores (that is, the dependent variable in our regression analyses) accounting for the other included variables. Thus, a regression coefficient for a given variable at or above a known MCID value suggests a clinical difference between those patients with and without the presence of that given characteristic. In this manuscript, regression coefficients at or above 4.2 (or at and below -4.2) for PROMIS Global Physical Health and at or above 5.1 (or at and below -5.1) for PROMIS Global Mental Health were considered clinically relevant.

RESULTS

Among the included patients, 8% (685 of 9057) were unemployed but seeking work, 4% (399 of 9057) reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, 4% (328 of 9057) reported trouble paying for medications, and 2% (181 of 9057) had no current housing. Lack of reliable transportation to attend doctor visits or pick up medications (β = -4.52 [95% CI -5.45 to -3.59]; p < 0.001), trouble paying for medications (β = -4.55 [95% CI -5.55 to -3.54]; p < 0.001), Medicaid insurance (β = -5.81 [95% CI -6.41 to -5.20]; p < 0.001), and workers compensation insurance (β = -5.99 [95% CI -7.65 to -4.34]; p < 0.001) were associated with clinically worse function at presentation. Trouble paying for medications (β = -6.01 [95% CI -7.10 to -4.92]; p < 0.001), Medicaid insurance (β = -5.35 [95% CI -6.00 to -4.69]; p < 0.001), and workers compensation (β = -6.07 [95% CI -7.86 to -4.28]; p < 0.001) were associated with clinically worse mental health at presentation.

CONCLUSION

Although transportation issues and financial hardship were found to be associated with worse presenting physical function and mental health, Medicaid and workers compensation insurance remained associated with worse presenting physical function and mental health as well even after controlling for these more detailed, patient-level SDoH factors. Because of that, interventions to decrease health disparities should focus on not only sociodemographic variables (for example, insurance type) but also tangible patient-specific SDoH characteristics. For example, this may include giving patients taxi vouchers or ride-sharing credits to attend clinic visits for patients demonstrating such a need, initiating financial assistance programs for necessary medications, and/or identifying and connecting certain patient groups with social support services early on in the care cycle.

LEVEL OF EVIDENCE

Level III, prognostic study.

The Relationship Between the Timing of Knee Osteoarthritis Diagnoses and Arthroscopic Partial Meniscectomy

BACKGROUND

There is ongoing debate regarding the efficacy of arthroscopic partial meniscectomy (APM) for meniscus tears in patients with knee osteoarthritis (OA). Some insurance payers will not authorize APM in patients with knee OA. The purpose of this study was to assess the timing of knee OA diagnoses in patients undergoing APM.

METHODS

A large commercial national claims data set containing deidentified information from October 2016 to December 2020 was used to identify patients undergoing arthroscopic partial meniscectomy. Data were analyzed to determine whether patients in this group had a diagnosis of knee OA within 12 months before surgery and for the presence of a new diagnosis of knee OA at 3, 6, and 12 months after APM.

RESULTS

Five lakhs thousand nine hundred twenty-two patients with a mean age of 54.0 ± 8.52 years, with the majority female (52.0%), were included. A total of 197,871 patients underwent APM without a diagnosis of knee OA at the time of the procedure. Of these patients, 109,427 (55.3%) had a previous diagnosis of knee OA within 12 months preceding surgery, and 24,536 (12.4%), 15,596 (7.9%), and 13,301 (6.7%) patients were diagnosed with knee OA at 3, 6, and 12 months after surgery, respectively.

CONCLUSION

Despite evidence against APM in patients with knee OA, more than half of the patients (55.3%) had a previous diagnosis of OA within 12 months of surgery and 27.0% received a new diagnosis of knee OA within one year of surgery. A notable number of patients had a diagnosis of knee OA either before or shortly after APM.

The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures

BACKGROUND

Social deprivation is a state marked by limited access to resources due to poverty, discrimination, or other marginalizing factors. We investigated the links between social deprivation and orthopaedic trauma, including patient-reported outcomes, radiographic healing, and complication rates following intramedullary nailing of tibial shaft fractures.

METHODS

We retrospectively reviewed 229 patients who underwent intramedullary nailing of tibial shaft fractures at our Level-I trauma center. The Area Deprivation Index (ADI), a validated proxy for social deprivation, was used to group patients into the most deprived tercile (MDT), the intermediate deprived tercile (IDT), and the least deprived tercile (LDT) for outcome comparison. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the domains of Physical Function (PF), Pain Interference (PI), Anxiety, and Depression, and radiographic healing was assessed with the Radiographic Union Scale in Tibial fractures (RUST) system.

RESULTS

On univariate analyses, patients from the MDT reported worse PF, PI, Anxiety, and Depression scores than those from the LDT within the first year of postoperative follow-up. On multivariable regression analysis, PROMIS score outcomes were influenced by age, race, and smoking status, but not by social deprivation tercile. Furthermore, residing in the MDT was associated with a 31% increase in time to radiographic union compared with the LDT (β = 0.27; p = 0.01).

CONCLUSIONS

Following intramedullary nailing of tibial shaft fractures, social deprivation is associated with slower fracture-healing and potentially influences short-term PROMIS scores. These results warrant further investigation in additional patient populations with orthopaedic trauma and highlight the importance of developing interventions to reduce inequities faced by patients from low-resource settings.

LEVEL OF EVIDENCE

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

Impact of insurance type on patient-reported outcome measures in patients with lumbar disc herniation

BACKGROUND

Lumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined.

PURPOSE

To elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations.

STUDY DESIGN/SETTING

Retrospective cohort study PATIENT SAMPLE: Baseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015-2020).

OUTCOME MEASURES

The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed.

METHODS

PROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income.

RESULTS

We included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85-0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82-0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04-1.40) when compared to the commercially insured.

CONCLUSIONS

We encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers.

Insurance types are correlated with baseline patient-reported outcome measures in patients with adult spinal deformity

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly recognized as a key component of healthcare value, allowing comparison of therapeutic impact across different specialties. Prior literature suggests that insurance type may be associated with differing baseline PROMs among patients with degenerative conditions, including lumbar stenosis and hip arthritis. This association, however, has not been investigated for adult spinal deformity (ASD).

METHODS

Baseline PROMs were reviewed from 207 patients with ASD presenting for treatment between 2015 and 2019. The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed. Negative binomial regression was used to determine the impact of sociodemographic factors, including insurance type, on severity of symptoms and degree of disability at baseline.

RESULTS

Mean age of the study population was 62.2 +/- 15 years, with 61.8 % male prevalence. The Medicaid population had a greater proportion of Hispanic and non-English speaking patients, compared to commercially insured patients. Medicaid insured patients had significantly greater VAS low back pain scores compared with commercially insured individuals (IRR 1.535, 95 % CI 1.122-2.101, p = 0.007).

CONCLUSIONS

Medicaid insured patients demonstrated worse baseline PROMs at presentation with ASD, as compared to commercially insured or Medicare patients. Stakeholders across spine care delivery should elucidate the etiology of baseline disparities in ASD patients, as they may result from health system asymmetries. In an ecosystem moving toward value-driven treatment algorithms, accounting for and addressing these differences will be necessary to provide equitable care for ASD populations.

Sociodemographic Factors Are Associated with Patient-Reported Outcome Measure Completion in Orthopaedic Surgery: An Analysis of Completion Rates and Determinants Among New Patients

Patient-reported outcome measures (PROMs) and, specifically, the Patient-Reported Outcomes Measurement Information System (PROMIS), are increasingly utilized for clinical research, clinical care, and health-care policy. However, completion of these outcome measures can be inconsistent and challenging. We hypothesized that sociodemographic variables are associated with the completion of PROM questionnaires. The purposes of the present study were to calculate the completion rate of assigned PROM forms and to identify sociodemographic and other variables associated with completion to help guide improved collection efforts.

Methods

All new orthopaedic patients at a single academic medical center were identified from 2016 to 2020. On the basis of subspecialty and presenting condition, patients were assigned certain PROMIS forms and legacy PROMs. Demographic and clinical information was abstracted from the electronic medical record. Bivariate analyses were performed to compare characteristics among those who completed assigned PROMs and those who did not. A multivariable logistic regression model was created to determine which variables were associated with successful completion of assigned PROMs.

Results

Of the 219,891 new patients, 88,052 (40%) completed all assigned PROMs. Patients who did not activate their internet-based patient portal had a 62% increased likelihood of not completing assigned PROMs (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.58 to 1.66; p < 0.001). Non-English-speaking patients had a 90% (OR, 1.90; 95% CI, 1.82 to 2.00; p < 0.001) increased likelihood of not completing assigned PROMs at presentation. Older patients (≥65 years of age) and patients of Black race had a 23% (OR, 1.23; 95% CI, 1.19 to 1.27; p < 0.001) and 24% (OR, 1.24; 95% CI, 1.19 to 1.30; p < 0.001) increased likelihood of not completing assigned PROMs, respectively.

Conclusions

The rate of completion of PROMs varies according to sociodemographic variables. This variability could bias clinical outcomes research in orthopaedic surgery. The present study highlights the need to uniformly increase completion rates so that outcomes research incorporates truly representative cohorts of patients treated. Furthermore, the use of these PROMs to guide health-care policy decisions necessitates a representative patient distribution to avoid bias in the health-care system.

Level of Evidence

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

Insurance Type is Associated with Baseline Patient-Reported Outcome Measures in Patients with Lumbar Stenosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine if insurance type is associated with differences in baseline patient-reported outcome measures (PROMs) among patients with lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

PROMs are increasingly used as means to convey value. Prior research suggests that sociodemographic factors, including insurance type may influence these metrics, with patients who are more socioeconomi-cally disadvantaged reporting poorer baseline PROMs. Nonetheless, this association is yet to be evaluated among patients with spinal stenosis.

METHODS

Six-hundred-eight patients with LSS were identified within a major academic health system. Their baseline Patient-Reported Outcomes Measurement Information System for physical function, pain, anxiety and depression, and visual analogue scale for low back and leg pain were analyzed. Wilcoxon rank-sum testing and chi-squared testing were utilized for descriptive nonadjusted comparisons. Negative binomial regression modeling was performed with PROMs considered as dependent variables, insurance type as the primary predictor, and all other factors (e.g., Charlson Comorbidity Index, age, gender, race, ethnicity, language spoken, and median geospatial household income) considered as covariates.

RESULTS

The mean age of the cohort was 62.6 ± 14years with a female majority (50.7%). Patients with Medicaid insurance were younger, more likely to be Hispanic, and less likely to be English-speaking than those with commercial insurance or Medicare. Overall, patients with Medicaid insurance were found to have worse baseline PROMs across almost all domains, with the worst performance in Patient-Reported Outcomes Measurement Information System 10 physical global (incidence rate ration 0.88, 95% confidence interval 0.82-0.95) and mental function (incidence rate ration 0.85, 95% confidence interval 0.80-0.92).

CONCLUSION

LSS patients insured through Medicaid have systematically worse baseline PROMs across almost all domains as compared to those with commercial insurance and Medicare, even after adjusting for confounders. These findings have broad ranging implications for research and healthcare policy, especially when using PROMs as measures of value.