Public Insurance Status Negatively Affects Access to Care in Pediatric Patients With Meniscal Injury

Background: Non- and underinsured individuals experience poor access to care and treatment delays. Meniscal injury is a common reason for surgical intervention in the pediatric population, and delays in care can lead to progression of the tear and other associated problems. Purpose: To investigate the impact of insurance status on access to care and severity of meniscal injury in the pediatric population. Study Design: Cohort study; Level of evidence, 3. Methods: Enrolled in this study were 49 patients receiving care for a meniscal injury between 2016 and 2018 from a safety-net medical system that does not prioritize patients based on insurance status. The patients were stratified into those publicly insured and those privately insured. Access to care was measured as wait time to various points of care: initial injury to clinic, injury to magnetic resonance imaging (MRI), injury to surgery, clinic to MRI, clinic to surgery, and MRI to surgery. The severity of the meniscal tear was measured by findings at the time of arthroscopy, including the type of tear identified, surgery performed, and cartilage injury. Results: Publicly insured patients waited a mean 230 days longer (347 vs 117 days; P < .01) to undergo surgery after injury compared with privately insured patients. The mean wait times in all categories except time from MRI to surgery were significantly longer for publicly insured patients, including injury to clinic (212 vs 73 days; P < .01), injury to MRI (260 vs 28 days; P < .001), injury to surgery (347 vs 117 days; P < .01), clinic to MRI (36 vs 3.9 days; P < .001), and clinic to surgery (136 vs 44 days; P < .01). Neither increased wait times nor insurance status were associated with greater surgical repair rate, severe tear type, or cartilage injury. Conclusion: Publicly insured pediatric patients waited significantly longer for a diagnosis of meniscal tear compared with privately insured patients, even in a safety-net setting. These delays were not associated with greater tear severity or cartilage changes. Providers in all models of care should recognize that insurance status and the socioeconomic factors it represents prevent publicly insured patients from timely diagnostic points of care and strive to minimize the resulting delayed return to normal activity as well as the potential long-term clinical effects thereof.

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Constructing Matched Groups in Dental Observational Health Disparity Studies for Causal Effects

JDR Clinical & Translational Research ◽

10.1177/2380084419830655 ◽

2019 ◽

Vol 5 (1) ◽

pp. 82-91 ◽

Cited By ~ 2

Author(s):

J. Cheng ◽

S.E. Gregorich ◽

S.A. Gansky ◽

S.A. Fisher-Owens ◽

A.M. Kottek ◽

...

Keyword(s):

Oral Health ◽

Electronic Health Record ◽

Pediatric Patients ◽

Health Record ◽

Policy Makers ◽

Average Ratio ◽

Tooth Surfaces ◽

Publicly Insured ◽

Insured Patients ◽

Privately Insured

Introduction: Electronic health record (EHR) systems provide investigators with rich data from which to examine actual impacts of care delivery in real-world settings. However, confounding is a major concern when comparison groups are not randomized. Objectives: This article introduced a step-by-step strategy to construct comparable matched groups in a dental study based on the EHR of the Willamette Dental Group. This strategy was employed in preparation for a longitudinal study evaluating the impact of a standardized risk-based caries prevention and management program across patients with public versus private dental insurance in Oregon. Methods: This study constructed comparable dental patient groups through a process of 1) evaluating the need for and feasibility of matching, 2) considering different matching methods, and 3) evaluating matching quality. The matched groups were then compared for their average ratio in the number of decayed, missing, and filled tooth surfaces (DMFS + dmfs) at baseline. Results: This systematic process resulted in comparably matched groups in baseline covariates but with a clear baseline disparity in caries experience between them. The weighted average ratio in our study showed that, at baseline, publicly insured patients had 1.21-times (95% CI: 1.08 to 1.32) and 1.21-times (95% CI: 1.08 to 1.37) greater number of DMFS + dmfs and number of decayed tooth surfaces (DS + ds) than privately insured patients, respectively. Conclusion: Matching is a useful tool to create comparable groups with EHR data to resemble randomized studies, as demonstrated by our study where even with similar demographics, neighborhood and clinic characteristics, publicly insured pediatric patients had greater numbers of DMFS + dmfs and DS + ds than privately insured pediatric patients. Knowledge Transfer Statement: This article provides a systematic, step-by-step strategy for investigators to follow when matching groups in a study—in this case, a study based on electronic health record data. The results from this study will provide patients, clinicians, and policy makers with information to better understand the disparities in oral health between comparable publicly and privately insured pediatric patients who have similar values in individual, clinic, and community covariates. Such understanding will help clinicians and policy makers modify oral health care and relevant policies to improve oral health and reduce disparities between publicly and privately insured patients.

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Impact of Insurance Status on Time to Evaluation and Treatment of Meniscal Tears in Children, Adolescents, and College-Aged Patients in the United States

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119875079 ◽

2019 ◽

Vol 7 (10) ◽

pp. 232596711987507 ◽

Cited By ~ 2

Author(s):

Taylor R. Johnson ◽

Alexander Nguyen ◽

Kush Shah ◽

Grant D. Hogue

Keyword(s):

Meniscal Tear ◽

The United States ◽

Insurance Status ◽

Meniscal Tears ◽

Aged Patients ◽

Surgical Interventions ◽

Orthopaedic Care ◽

Children And Young Adults ◽

Publicly Insured ◽

Insured Patients

Background: The meniscus is vital for load bearing, knee stabilization, and shock absorption, making a meniscal tear a well-recognized sport-related injury in children and young adults. An inverse relationship between the quality and value of orthopaedic care provided and the overall treatment cycle exists in which delayed meniscal tear treatment increases the likelihood of unfavorable outcomes. Although a majority of children and young adults have health insurance, many athletes within this demographic still face significant barriers in accessing orthopaedic services because of insurance type and household income. Purpose: To determine the impact of insurance status and socioeconomic markers on the time to orthopaedic evaluation and treatment as well as the rate of surgical interventions for meniscal tears in children and young adult athletes in the United States. Study Design: Cohort study; Level of evidence, 3. Methods: We conducted a retrospective review of all patients ≤22 years of age who presented to our institution between 2008 and 2016 and who were diagnosed with meniscal tears. Patients were categorized based on insurance and socioeconomic status. Dates of injury, referral, evaluation by an orthopaedic surgeon, and surgery were also recorded. Chi-square and regression analyses were utilized to determine the significance and correlation between the influencing factors and time to referral, evaluation, and surgery. Results: Publicly insured, commercially insured, and uninsured patients comprised 49.4%, 26.6%, and 24.1%, respectively, of the 237 patients included in this study. Insurance status was predictive of time to orthopaedic referral, initial evaluation, and surgery ( P < .01). Uninsured and publicly insured patients experienced significant delays during their orthopaedic care compared with commercially insured patients. However, no correlation was found between insurance status or household income and the rate of surgical interventions. Conclusion: Publicly insured and uninsured pediatric and college-aged patients faced significant barriers in accessing orthopaedic services, as demonstrated by substantially longer times between the initial injury and referral to an orthopaedic evaluation and surgery; however, these socioeconomic factors did not affect the rate of surgical management. Clinical competency regarding the effects of socioeconomic factors on the time to orthopaedic care and efforts to expedite care among underinsured and underserved children are vital for improving patient outcomes.

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Stalled at the Intersection: Insurance Status and Disparities in Post Mastectomy Breast Reconstruction

10.21203/rs.3.rs-813168/v1 ◽

2021 ◽

Author(s):

Orli Friedman-Eldar ◽

Jonathan Burke ◽

Iago de Castro Silva ◽

Camille C Baumrucker ◽

Fernando Valle ◽

...

Keyword(s):

Breast Cancer ◽

Logistic Regression ◽

Breast Reconstruction ◽

Private Insurance ◽

Safety Net ◽

Insurance Status ◽

Multivariable Logistic Regression ◽

Safety Net Hospital ◽

Insured Patients ◽

Privately Insured

Abstract PurposePost-mastectomy breast reconstruction (PMBR) is an important component of breast cancer treatment, but disparities relative to insurance status persist despite legislation targeting the issue. We aimed to study this relationship in a large health system combining a safety net hospital and a private academic center.MethodsData were collected on all patients who underwent mastectomy for breast cancer from 2011-2019 in a private academic center and an adjacent public safety-net hospital served by same surgical teams. Multivariable logistic regression was used to assess the effect of insurance status on PMBR, controlling for covariates that included socioeconomic, demographic, and clinical factors.ResultsOf 1,554 patients undergoing mastectomy for breast cancer, 753 (48.5%) underwent PMBR. Out of them, 741 had insurance type recorded, with 592 (79.9%) privately insured patients, 50 (6.7%) Medicare, 68 (9.2%) Medicaid, and 31 (4.2%) uninsured patients. Multivariable logistic regression showed a significantly lower likelihood of undergoing PMBR for uninsured (OR 6.9, 95% CI: 4.1-11.7; p<0.0001), Medicare (OR 2.0, (5% CI: 1.2-3.3; p=0.004), and Medicaid (OR 1.7, 95% CI:1.1-2.7; p=0.02) patients, compared with privately insured patients. Age, stage, race, and hospital type confounded this relationship.ConclusionPatients without health insurance have dramatically reduced access to PMBR compared to those with private insurance. Expanding access to this important procedure is essential to achieve greater health equity for breast cancer patients.

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Disparities in survival by insurance status in follicular lymphoma

Blood ◽

10.1182/blood-2018-03-839035 ◽

2018 ◽

Vol 132 (11) ◽

pp. 1159-1166 ◽

Cited By ~ 6

Author(s):

Jordan S. Goldstein ◽

Loretta J. Nastoupil ◽

Xuesong Han ◽

Ahmedin Jemal ◽

Elizabeth Ward ◽

...

Keyword(s):

Follicular Lymphoma ◽

Access To Care ◽

Insurance Status ◽

Key Points ◽

Insured Patients ◽

Privately Insured

Key Points Privately insured patients have improved OS among patients of all ages with FL. Expanding access to care through insurance has the potential to improve FL outcomes.

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

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120959330 ◽

2020 ◽

Vol 8 (10) ◽

pp. 232596712095933

Author(s):

Nicole J. Hung ◽

David M. Darevsky ◽

Nirav K. Pandya

Keyword(s):

Access To Care ◽

Shoulder Instability ◽

Insurance Status ◽

Public Insurance ◽

Recurrent Shoulder Instability ◽

Adolescent Patients ◽

Bony Injury ◽

Labral Pathology ◽

Publicly Insured ◽

Insured Patients

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.

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Association between health insurance status and malignant glioma

Neuro-Oncology Practice ◽

10.1093/nop/npaa030 ◽

2020 ◽

Vol 7 (5) ◽

pp. 531-540

Author(s):

Igor Fischer ◽

Hendrik-Jan Mijderwijk ◽

Ulf D Kahlert ◽

Marion Rapp ◽

Michael Sabel ◽

...

Keyword(s):

Socioeconomic Status ◽

Health Insurance ◽

Brain Tumors ◽

Malignant Neoplasms ◽

German Population ◽

Insurance Status ◽

Health Insurance Status ◽

Neurosurgical Patients ◽

Insured Patients ◽

Privately Insured

Abstract Background Prior studies have suggested an association between patient socioeconomic status and brain tumors. In the present study we attempt to indirectly validate the findings, using health insurance status as a proxy for socioeconomic status. Methods There are 2 types of health insurance in Germany: statutory and private. Owing to regulations, low- and middle-income residents are typically statutory insured, whereas high-income residents have the option of choosing a private insurance. We compared the frequencies of privately insured patients suffering from malignant neoplasms of the brain with the corresponding frequencies among other neurosurgical patients at our hospital and among the German population. To correct for age, sex, and distance from the hospital, we included these variables as predictors in logistic and binomial regression. Results A significant association (odds ratio [OR] = 1.59, CI = 1.45-1.74, P < .001) between health insurance status and brain tumors was found. The association is independent of patients’ sex or age. Whereas privately insured patients generally tend to come from farther away, such a relationship was not observed for patients suffering from brain tumors. Comparing the out of house and in-house brain tumor patients showed no selection bias on our side. Conclusion Previous studies have found that people with a higher income, level of education, or socioeconomic status are more likely to suffer from malignant brain tumors. Our findings are in line with these studies. Although the reason behind the association remains unclear, the probability that our results are due to some random effect in the data is extremely low.

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Does the insurance status influence in-hospital outcome? A retrospective assessment in 30,175 surgical trauma patients in Switzerland

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-021-01689-x ◽

2021 ◽

Author(s):

Lukas Funke ◽

Claudio Canal ◽

Franziska Ziegenhain ◽

Hans-Christoph Pape ◽

Valentin Neuhaus

Keyword(s):

Exclusion Criterion ◽

Surgical Trauma ◽

Insurance Status ◽

Trauma Patients ◽

Complication Rates ◽

Physical Status ◽

Public Insurance ◽

National Quality ◽

Publicly Insured ◽

Insured Patients

Abstract Introduction There has been growing evidence in trauma literature that differences in insurance status lead to inequality in treatment and outcome. Most studies comparing uninsured to insured patients were done in the USA. We sought to gain further insights into differences in the outcomes of trauma patients in a healthcare system with mandatory public health coverage by comparing publicly versus privately insured patients. Methods We used a prospective national quality assessment database from the Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie (AQC). More than 80 surgical departments in Switzerland are part of this quality program. We included all patients in the AQC database with any S- or T-code diagnosis according to the International Classification of Diseases ICD-10 (any injuries) who were treated during the 11-year period of 2004–2014. Missing insurance status information was an exclusion criterion. In total, 30,175 patients were included for analysis. The primary outcome was in-hospital mortality. Secondary outcomes included overall and intra- and postoperative complications. Bi- and multivariate analyses were performed, adjusted for insurance status, age, sex, American Society of Anesthesiologists (ASA) physical status category, type of injury, and surgeon’s level of experience. Results In total, 76.8% (n = 23,196) of the patients were publicly insured. Patients with public insurance were significantly younger (p < 0.001), more often male (p < 0.001), and in better general health according to the ASA physical status category (p < 0.001). Length of pre- and postoperative stay and the number of operations per case were similar in the two groups. Patients with public insurance had a lower mortality rate (1.3% vs. 1.9%, p < 0.001), but after adjusting for confounders, insurance status was not a predictor of mortality. Overall complication rates were significantly higher for publicly insured patients (8.4% vs. 6.2%, p < 0.001), and after adjusting for confounders, insurance status was identified as an independent risk factor for overall complications (p < 0.001). Conclusion Differences exist with respect to patient and procedural characteristics: publicly insured patients were younger, more often male, and scored better on ASA physical status. Insurance status seems not to be a predictor for fatal outcome after trauma, although it is associated with complications.

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Acute Myelogenous Leukemia: Insurance Status, Race and Comorbidities, but Not Distance from Treatment Center Determine Outcome

Blood ◽

10.1182/blood.v126.23.3283.3283 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3283-3283

Author(s):

Samip Master ◽

Zhenzhen Shi ◽

Srinivas S. Devarakonda ◽

Reinhold Munker ◽

Runhua Shi

Keyword(s):

Overall Survival ◽

Treatment Outcomes ◽

Treatment Delay ◽

Myelogenous Leukemia ◽

Insurance Status ◽

Increased Risk ◽

Facility Type ◽

The Mean ◽

Insured Patients ◽

Privately Insured

Abstract Background: The treatment of acute myeloid leukemia (AML) has made major progress in the last 30 years. Well-known risk factors are age, cytogenetics and treatment intensity. Many other factors including access to healthcare modify treatment outcomes. According to smaller studies, the type of insurance (payer status) may or may not influence treatment outcomes. In the wake of the Affordable Care Act and its impact on insurance coverage, evaluating the effect of insurance status on health outcomes is urgently necessary. This study characterizes the relationship between payer status and overall survival for AML patients by analyzing data from the large National Cancer Data Base (NCDB). Methods: Data was analyzed from 67,443 men and women (≥ 18 years of age) registered in the NCDB who were diagnosed with AML between 1998 and 2011 and had follow-ups to end of 2012. The primary predictor variable was payer status and the outcome variable was overall survival. Additional variables addressed and adjusted for included sex, age, race, Charleson Comorbidity index, level of education, income, distance traveled, facility type, diagnosing/treating facility, treatment delay, and chemotherapy. Results: Among these 67,433 patients, the mean age at diagnosis was 61 years (median, 64 years) with a median survival of 7.98 months. The mean ages at diagnosis were 46.8, 51.8, 44.6, 73.6, and 57.9 years old for uninsured, private, Medicaid, Medicare and unknown payer status, respectively. In multivariate analysis, after adjusting for secondary predictor variables, payer status was a statistically significant predictor of overall survival from AML. Relative to privately insured patients, patients with Medicaid had a 17% increased risk, no insurance had a 21% increased risk, Medicare had a 19% increased risk, and unknown insurance had a 22% increased risk of mortality from AML. The percentage of patients surviving from AML after 24 months was 37.6%, 31.4%, 32.3%, 31.8%, and 33.1% for private, unknown, Medicare, uninsured, and Medicaid payer status, respectively. All factors investigated were found to be significant predictors of AML survival except distance travelled. Patients aged 65-74 were 2.9 times more likely to die compared to those aged 19-49. Patients who received chemotherapy were 22% less likely to die compared to those who did not. In the more recent time period (2005-2011 versus 1998- 2004, the prognosis of AML has improved, however the imbalance as per payer status did not change significantly. Conclusion: We observed that payer status has a statistically significant relationship with overall survival from AML. This remained true after adjusting for other predictive factors. Medicaid and uninsured patients had the highest mortality while privately insured patients had the lowest mortality. Further research is necessary how the disparities associated with different types of insurance result in inferior treatment outcomes and how they can be addressed. Multivariate Cox regression, hazard ratio of death by factorsTable 1.FactorLevelHR*LowerUpperAge18-491.0050-641.961.902.0265-742.862.752.9875+4.143.964.32InsurancePrivate1.00Uninsured1.211.141.28Medicaid1.161.111.21Medicare1.191.161.23Unknown1.231.151.31Year of diagnosis98-04105-110.850.820.87RaceWhite1.00Black1.081.041.12Asian0.920.860.98Charleson Comorbidity index01.0011.221.181.2621.491.421.56Unknown1.3521.3211.384ChemotherapyNo Chemo1Single Agent0.780.740.83Multiple Agent0.620.580.65*Adjusted for sex, income, education, distance traveled, facility type, diagnosing/treating facility, and treatment delay. Disclosures No relevant conflicts of interest to declare.

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Impact of Insurance Coverage on Outcomes in Primary Breast Sarcoma

Sarcoma ◽

10.1155/2018/4626174 ◽

2018 ◽

Vol 2018 ◽

pp. 1-11 ◽

Cited By ~ 5

Author(s):

Julie L. Koenig ◽

C. Jillian Tsai ◽

Katherine Sborov ◽

Kathleen C. Horst ◽

Erqi L. Pollom

Keyword(s):

Overall Survival ◽

Private Insurance ◽

Insurance Coverage ◽

Disease Stage ◽

Insurance Status ◽

Rare Cancer ◽

Breast Sarcoma ◽

Specialized Care ◽

Insured Patients ◽

Privately Insured

Private insurance is associated with better outcomes in multiple common cancers. We hypothesized that insurance status would significantly impact outcomes in primary breast sarcoma (PBS) due to the additional challenges of diagnosing and coordinating specialized care for a rare cancer. Using the National Cancer Database, we identified adult females diagnosed with PBS between 2004 and 2013. The influence of insurance status on overall survival (OS) was evaluated using the Kaplan–Meier estimator with log-rank tests and Cox proportional hazard models. Among a cohort of 607 patients, 67 (11.0%) had Medicaid, 217 (35.7%) had Medicare, and 323 (53.2%) had private insurance. Compared to privately insured patients, Medicaid patients were more likely to present with larger tumors and have their first surgical procedure further after diagnosis. Treatment was similar between patients with comparable disease stage. In multivariate analysis, Medicaid (hazard ratio (HR), 2.47; 95% confidence interval (CI), 1.62–3.77; p<0.001) and Medicare (HR, 1.68; 95% CI, 1.10–2.57; p=0.017) were independently associated with worse OS. Medicaid insurance coverage negatively impacted survival compared to private insurance more in breast sarcoma than in breast carcinoma (interaction p<0.001). In conclusion, patients with Medicaid insurance present with later stage disease and have worse overall survival than privately insured patients with PBS. Worse outcomes for Medicaid patients are exacerbated in this rare cancer.

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Treatment trends for stage III non-small cell lung cancer for noninsured patients compared with other types of insurances: A National Cancer Database analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.262 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 262-262

Author(s):

Khaled Abou El Ezz ◽

David Charles Olson ◽

Peter T. Silberstein

Keyword(s):

Stage Iii ◽

Insurance Status ◽

National Cancer Database ◽

Database Analysis ◽

Medicare Patients ◽

Stage Iii Nsclc ◽

Insured Patients ◽

Treatment Trends ◽

To Receive ◽

Privately Insured

262 Background: This study investigated trends in management of stage III NSCLC in patients with no insurance versus other insurance types using the National Cancer Database (NCDB). Methods: 281,277 patients with Stage III NSCLC were identified from 2000 to 2009 using the NCDB. Reported use of surgery, radiation, chemotherapy, or no treatment were analyzed by insurance status. Results: Radiation/chemotherapy was most often used to treat stage III NSCLC among non-insured (41.7%), Medicare (31.3%), Medicaid (42.3%), and private insured patients (43.9%). Non-insured were just as likely to receive radiation/chemotherapy as Medicaid (41.7% vs. 42.3%, p=0.36) but less likely than privately insured (41.7% vs. 43.9%, p<0.001). Non-insured were more likely to receive no treatment than privately insured (20.8% vs. 11.7%, p<0.001) and Medicaid (20.8% vs. 16.8%, p <0.001) but less likely than Medicare (20. 8% vs. 24.6%, p<0.001). Tri-modality treatment was given less often to non-insured patients than privately insured (4.6% vs. 10.2%, p<0.001) and Medicaid (4.6% vs. 6.2%, p<0.001) but more often than Medicare patients (4.6% vs. 3.7%, p<0.001). Conclusions: Stage III NSCLC was most often given chemotherapy/radiation regardless of insurance status. Non-insured patients received this treatment as often as Medicaid but less often than privately insured. Non-insured patients also received no treatment more often than Medicaid and privately insured and less often than Medicare. Future studies could examine if average age among the populations impacted these findings. [Table: see text]

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