Uneven Playing Field: Insurance Status Adversely Affects Children with Tibial Spine Fractures (181)

Objectives: Previous studies have reported disparities in medical and surgical care resulting from demographic factors, including insurance status. Tibial spine fractures are uncommon injuries, which may exacerbate potential disparities in care. The purpose of this study is to assess the impact of insurance status on the treatment of tibial spine fractures in children and adolescents. Methods: We performed a retrospective cohort study of tibial spine fractures treated at 10 institutions between 2000 and 2019. Polytraumas and patients older than 18 years were excluded. Demographic data was collected as was information regarding pre-operative, intra-operative, and post-operative treatment, with attention to delays in management and differences in care. Both surgical and non-surgical fractures were included, but a separate analysis of operative patients was performed subsequently. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data was collected on a total of 434 subjects with a mean age of 11.7±3.0. Of these, 61.1% had commercial insurance and 38.9% had public insurance. Publicly insured children were more likely to be injured in a motor vehicle accident. Among athletes, those with public insurance were injured more frequently during football while commercially insured patients were more likely to be injured while skiing. When analyzing the overall cohort of surgical and non-surgical fractures in multivariate analysis, those with magnetic resonance imaging (MRI) performed 21 or more days after injury were 5.3 times more likely to have public insurance (95% CI 1.3-21.7, p=0.02). Similar results were found with the 365 patients that required surgery. In this cohort, those with MRI delayed ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI 1.2-19.6, p=0.03). Children that underwent surgery ≥21 days after injury were 2.2 times more likely to have public insurance (95% CI 1.1-4.1, p=0.02). Those that were publicly insured had 2.5 times higher odds of undergoing open surgery rather than arthroscopic (95% CI 1.1-6.1, p=0.04). These children also had 4.5 times lower odds of receiving a continuous passive motion machine (CPM) after surgery (95% CI 1.7-11.7, p=0.002) and were 4.0 times more likely to be immobilized in a cast rather than a brace post-operatively (95% CI 2.0-8.2, p<0.001). Conclusions: Children with public insurance and a tibial spine fracture were more likely to experience delays with MRI and surgical treatment than those with commercial insurance. Additionally, these patients were more likely to undergo open surgery and post-operative casting and less likely to receive a CPM machine.

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UNEVEN PLAYING FIELD: INSURANCE STATUS ADVERSELY AFFECTS CHILDREN WITH TIBIAL SPINE FRACTURES

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00123 ◽

2021 ◽

Vol 9 (7_suppl3) ◽

pp. 2325967121S0012

Author(s):

Neeraj M. Patel ◽

Tomasina M. Leska ◽

Theodore J. Ganley ◽

Julien T. Aoyama ◽

Aristides I. Cruz ◽

...

Keyword(s):

Open Surgery ◽

Continuous Passive Motion ◽

Separate Analysis ◽

Insurance Status ◽

Spine Fractures ◽

Public Insurance ◽

Commercial Insurance ◽

Tibial Spine ◽

Publicly Insured ◽

The Impact

Background: Previous studies have reported disparities in medical and surgical care resulting from demographic factors, including insurance status. Hypothesis/Purpose: The purpose of this study is to assess the impact of insurance status on the treatment of tibial spine fractures in children and adolescents. Methods: We performed a retrospective cohort study of tibial spine fractures treated at 10 institutions between 2000 and 2019. Polytraumas and patients older than 18 years were excluded. Demographic data was collected as was information regarding pre-operative, intra-operative, and post-operative treatment, with attention to delays in management and differences in care. Both surgical and non-surgical fractures were included, but a separate analysis of operative patients was performed subsequently. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data was collected on a total of 434 subjects with a mean age of 11.7±3.0. Of these, 61.1% had commercial insurance and 38.9% had public insurance. Publicly insured children were more likely to be injured in a motor vehicle accident. Among athletes, those with public insurance were injured more frequently during football while commercially insured patients were more likely to be injured while skiing. When analyzing the overall cohort of surgical and non-surgical fractures in multivariate analysis, those with magnetic resonance imaging (MRI) performed 21 or more days after injury were 5.3 times more likely to have public insurance (95% CI 1.3-21.7, p=0.02). Similar results were found with the 365 patients that required surgery. In this cohort, those with MRI delayed ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI 1.2-19.6, p=0.03). Children that underwent surgery ≥21 days after injury were 2.2 times more likely to have public insurance (95% CI 1.1-4.1, p=0.02). Those that were publicly insured had 2.5 times higher odds of undergoing open surgery rather than arthroscopic (95% CI 1.1-6.1, p=0.04). These children also had 4.5 times lower odds of receiving a continuous passive motion machine (CPM) after surgery (95% CI 1.7-11.7, p=0.002) and were 4.0 times more likely to be immobilized in a cast rather than a brace post-operatively (95% CI 2.0-8.2, p<0.001). Conclusion: Children with public insurance and a tibial spine fracture were more likely to experience delays with MRI and surgical treatment than those with commercial insurance. Additionally, these patients were more likely to undergo open surgery and post-operative casting and less likely to receive a CPM machine.

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Impact of health disparities on treatment for single-suture craniosynostosis in an era of multimodal care

Neurosurgical FOCUS ◽

10.3171/2021.1.focus201000 ◽

2021 ◽

Vol 50 (4) ◽

pp. E13

Author(s):

Caitlin Hoffman ◽

Alyssa B. Valenti ◽

Eseosa Odigie ◽

Kwanza Warren ◽

Ishani D. Premaratne ◽

...

Keyword(s):

Open Surgery ◽

Statistical Significance ◽

Demographic Data ◽

Tertiary Care ◽

Insurance Status ◽

Significant Difference ◽

Race Ethnicity ◽

The Impact ◽

Type Of Surgery ◽

Surgical Group

Craniosynostosis is the premature fusion of the skull. There are two forms of treatment: open surgery and minimally invasive endoscope-assisted suturectomy. Candidates for endoscopic treatment are less than 6 months of age. The techniques are equally effective; however, endoscopic surgery is associated with less blood loss, minimal tissue disruption, shorter operative time, and shorter hospitalization. In this study, the authors aimed to evaluate the impact of race/ethnicity and insurance status on age of presentation/surgery in children with craniosynostosis to highlight potential disparities in healthcare access. Charts were reviewed for children with craniosynostosis at two tertiary care hospitals in New York City from January 1, 2014, to August 31, 2020. Clinical and demographic data were collected, including variables pertaining to family socioeconomic status, home address/zip code, insurance status (no insurance, Medicaid, or private), race/ethnicity, age and date of presentation for initial consultation, type of surgery performed, and details of hospitalization. Children with unknown race/ethnicity and those with syndromic craniosynostosis were excluded. The data were analyzed via t-tests and chi-square tests for statistical significance (p < 0.05). A total of 121 children were identified; 62 surgeries were performed open and 59 endoscopically. The mean age at initial presentation of the cohort was 6.68 months, and on the day of surgery it was 8.45 months. Age at presentation for the open surgery cohort compared with the endoscopic cohort achieved statistical significance at 11.33 months (SD 12.41) for the open cohort and 1.86 months (SD 1.1473) for the endoscopic cohort (p < 0.0001). Age on the day of surgery for the open cohort versus the endoscopic cohort demonstrated statistical significance at 14.19 months (SD 15.05) and 2.58 months (SD 1.030), respectively. A statistically significant difference between the two groups was noted with regard to insurance status (p = 0.0044); the open surgical group comprised more patients without insurance and with Medicaid compared with the endoscopic group. The racial composition of the two groups reached statistical significance when comparing proportions of White, Black, Hispanic, Asian, and other (p = 0.000815), with significantly more Black and Hispanic patients treated in the open surgical group. The results demonstrate a relationship between race and lack of insurance or Medicaid status, and type of surgery received; Black and Hispanic children and children with Medicaid were more likely to present later and undergo open surgery.

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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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Socioeconomic and Racial Disparities in Diabetic Ketoacidosis Admissions in Youth With Type 1 Diabetes

Journal of Hospital Medicine ◽

10.12788/jhm.3664 ◽

2021 ◽

Author(s):

Andrea R Maxwell ◽

Nana-Hawa Yayah Jones ◽

Stuart Taylor ◽

Sarah D Corathers ◽

Erika Rasnick ◽

...

Keyword(s):

Type 1 Diabetes ◽

Length Of Stay ◽

Diabetic Ketoacidosis ◽

Census Tract ◽

Population Based ◽

Poverty Rate ◽

Insurance Status ◽

Public Insurance ◽

Publicly Insured

OBJECTIVE: We sought to determine whether census tract poverty, race, and insurance status were associated with the likelihood and severity of diabetic ketoacidosis (DKA) hospitalization among youth with type 1 diabetes (T1D). METHODS: We conducted a retrospective population-based cohort study using Cincinnati Children’s Hospital electronic medical record (EMR) data from January 1, 2011, to December 31, 2017, for T1D patients ≤18 years old. The primary outcome was admission for DKA. Secondary outcomes included DKA severity, defined by initial pH and bicarbonate, and length of stay. Exposures were the poverty rate for the youth’s home census tract, parent-reported race, and insurance status. We used multivariable logistic regression to analyze effects on odds of admission. RESULTS: We identified 439 patients with T1D; 152 were hospitalized. The cohort was 48% female, 25% Black, and 36% publicly insured; the median age was 14 years. For every 10% increase in a youth’s census tract poverty rate, the adjusted odds of admission increased by 22% (95% CI, 1.03-1.47). Public insurance status was associated with DKA admission (adjusted odds ratio [AOR], 2.71, 95% CI, 1.62-4.55) while race was not. There were no clinically meaningful differences in pH or bicarbonate by census tract poverty, race, or insurance status; however, Black patients experienced differences in care (eg, longer length of stay). CONCLUSION: Youth with T1D living in high poverty areas and on public insurance were significantly more likely to be admitted for DKA. Severity upon presentation was similar across exposures. Understanding contextual mechanisms by which disparities emerge will inform changes aimed at equitably improving care.

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Abstract 15778: The Impact of Health Insurance Status on Heart Transplant Recipients

Circulation ◽

10.1161/circ.142.suppl_3.15778 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Mehreen Iqbal ◽

Yulin Zhang ◽

Selena Gonzales ◽

John Dykes ◽

Christopher S Almond

Keyword(s):

Heart Transplant ◽

Private Insurance ◽

Insurance Coverage ◽

Insurance Status ◽

Public Insurance ◽

Post Transplant ◽

Increased Risk ◽

One Year ◽

The Impact

Introduction: Gaps in insurance coverage have been associated with diminished access to health care for children with chronic illness. Continuity of coverage is associated with improved long-term clinical outcomes among adolescent heart transplant (HT) recipients, but the relationship between insurance status and post-transplant outcomes has not been described across all pediatric HT recipients. Hypothesis: HT recipients with changes in insurance status will have worse outcomes as opposed to those with continuous coverage. Methods: We queried the United Network for Organ Sharing (UNOS) registry for patients age 0-18 receiving isolated HT or heart re-transplant between 2006 and 2019 and included them in the analysis if they survived at least one year post-transplant. Patients were categorized by insurance coverage at wait listing, HT, and one year follow-up. Cox proportional hazards models were used to characterize the association between coverage pattern and long-term patient survival. Results: Among the 3,247 patients in the analysis, insurance coverage patterns included continuous private (37%), continuous public (46%), gain of private (6%), and loss of private (11%). Patients who had continuous public insurance were more likely to be Black or Hispanic, adolescent, and require ICU care. In a multivariate Cox model, continuous public insurance was associated with increased mortality risk (HR = 1.46, P = 0.014), while loss of private insurance trended towards increased risk (HR = 1.14, P = 0.014). Figure 1 illustrates Kaplan-Meier conditional survival curves according to insurance trajectory. Multivariate sub-group analysis by Black race demonstrated no differences in outcomes by coverage pattern. Conclusions: In comparison to those with continuous private insurance, having continuous public insurance is associated with higher risk of adverse outcomes in pediatric HT recipients, but it does not account for disparate outcomes in Black patients.

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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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PEDIATRIC AND ADOLESCENT SHOULDER INSTABILITY: DOES INSURANCE STATUS PREDICT THE DEVELOPMENT OF BONY BANKART AND ENGAGING HILL-SACHS LESIONS?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00161 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0016

Author(s):

NJ Hung ◽

DM Darvesky ◽

NK Pandya

Keyword(s):

Shoulder Instability ◽

Private Insurance ◽

Insurance Status ◽

Public Insurance ◽

Repeat Surgery ◽

Public And Private ◽

Bony Injury ◽

Labral Pathology ◽

Publicly Insured ◽

Insured Patients

Background: Pediatric and adolescent patients who undergo shoulder stabilization surgery have higher rates of failure than their adult counterparts. The impact of insurance status on intra-operative findings and outcomes is largely unknown. Hypothesis/Purpose: We hypothesized that patients with public insurance who undergo shoulder stabilization surgery would have greater degrees of bony pathology; leading to poor outcomes after stabilization. Methods: This was a retrospective cohort study of pediatric and adolescent patients with public and private insurance who were treated for recurrent shoulder instability from 2011-2017. Patients were treated at a tertiary care children’s hospital by a single orthopaedic surgeon. Patients 10 to 18 years of age were included in the study if they presented with recurrent shoulder instability and underwent surgical intervention for their injury. Time from injury to clinical consultation, imaging, and surgical intervention; incidences of labral pathology and secondary bony injury; and rates of repeat dislocation and repeat surgery were compared between the public and private insurance cohorts Results: Thirty-seven patients had public insurance while 18 patients had private insurance. Privately insured patients were evaluated by clinicians nearly five times faster than were publicly insured patients (p < 0.001), and they obtained MRIs over four times faster than did public insurance patients (p < 0.001). Publicly insured patients were twice as likely to have secondary bony injuries (p=0.043). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced re-dislocation versus the complete absence of re-dislocation in the privately insured patients (p=0.022). Conclusion: Public insurance status impacts access to care and correlates with both the development of secondary bony injury and an increased rate of clinical failure manifested as repeat post-operative dislocations. [Table: see text] Table 1 shows the summary of results for public and private insurance cohorts for days from injury to clinic, injury to MRI, injury to surgery, clinic to MRI, MRI to surgery as well as number of prior dislocations, incidence of anterior only vs. complex labral pathology, incidence of bony involvement, incidence of repeat dislocations, and incidence of repeat surgery. * denotes that the difference between the two insurance cohorts was not statistically significant.

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Impact of insurance status on overall survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

Pleura and Peritoneum ◽

10.1515/pp-2020-0105 ◽

2020 ◽

Vol 5 (3) ◽

Author(s):

Ravi J. Chokshi ◽

Jin K. Kim ◽

Jimmy Patel ◽

Joseph B. Oliver ◽

Omar Mahmoud

Keyword(s):

Overall Survival ◽

Neoadjuvant Chemotherapy ◽

Abdominal Wall ◽

Intraperitoneal Chemotherapy ◽

Hyperthermic Intraperitoneal Chemotherapy ◽

Safety Net ◽

Insurance Status ◽

Gynecologic Malignancies ◽

Safety Net Hospital ◽

The Impact

AbstractObjectivesThe impact of insurance status on oncological outcome in patients undergoing cytoreduction and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is poorly understood.MethodsRetrospective study on 31 patients having undergone 36 CRS-HIPEC at a single institution (safety-net hospital) between 2012 and 2018. Patients were categorized as insured or underinsured. Demographics and perioperative events were compared. Primary outcome was overall survival (OS).ResultsA total of 20 patients were underinsured and 11 were insured. There were less gynecologic malignancies in the underinsured (p=0.02). On univariate analysis, factors linked to poor survival included gastrointestinal (p=0.01) and gynecologic malignancies (p=0.046), treatment with neoadjuvant chemotherapy (p=0.03), CC1 (p=0.02), abdominal wall resection (p=0.01) and Clavien–Dindo 3-4 (p=0.01). Treatment with neoadjuvant chemotherapy and abdominal wall resections, but not insurance status, were independently associated with OS (p=0.01, p=0.02 respectively). However, at the end of follow-up, six patients were alive in the insured group vs. zero in the underinsured group.ConclusionsIn this small, exploratory study, there was no statistical difference in OS between insured and underinsured patients after CRS-HIPEC. However, long-term survivors were observed only in the insured group.

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Chemotherapy Delays Are Associated with Inferior Outcome in Acute Lymphoblastic Leukemia: A Retrospective Study from a Tertiary Cancer Center in South India

Indian Journal of Medical and Paediatric Oncology ◽

10.1055/s-0041-1729513 ◽

2021 ◽

Vol 42 (01) ◽

pp. 051-060

Author(s):

Vineet Agrawal ◽

Smita Kayal ◽

Prasanth Ganesan ◽

Biswajit Dubashi

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Lymphoblastic Leukemia ◽

Univariate Analysis ◽

Cancer Center ◽

Survival Outcomes ◽

Separate Analysis ◽

Term Survival ◽

Free Survival ◽

Intensive Phase ◽

The Impact

Abstract Background Treatment protocols for acute lymphoblastic leukemia (ALL) have evolved over time to give excellent cure rates in children and moderate outcomes in adults; however, little is known how delays in chemotherapy affect long-term survival. Objectives To find the association of delays during different treatment phases on the survival outcomes. Materials and Methods Data from 149 ALL cases treated between 2009 and 2015 were retrospectively analyzed. Treatment course in commonly used protocols was divided into three phases—induction, consolidation (postremission), maintenance, and also a combined intensive phase (induction plus consolidation) for the purpose of analysis, and delay in each phase was defined based on clinically acceptable breaks. Analysis was done to find the impact of treatment delay in each phase on the survival outcomes. Results The median age was 12 years (range, 1–57). Multi-center Protocol-841 (MCP-841) was used for 72%, German Multicenter Study Group for Adult ALL (GMALL) for 19%, and Berlin, Frankfurt, Muenster, 95 protocol (BFM-95) for 9% of patients. Delay in induction was seen in 52%, consolidation in 66%, and during maintenance in 42% of patients. The median follow-up was 41 months, and 3-year survival outcomes for the entire cohort were event-free survival (EFS)—60%, relapse-free survival (RFS)—72%, and overall survival (OS)—68%. On univariate analysis, delay in induction adversely affected EFS (hazard ratio [HR] = 1.78, p = 0.04), while delay in intensive phase had significantly worse EFS and RFS (HR = 2.41 [p = 0.03] and HR = 2.57 [p = 0.03], respectively). On separate analysis of MCP-841 cohort, delay in intensive phase affected both EFS (HR = 3.85, p = 0.02) and RFS (HR = 3.42, p = 0.04), whereas delay in consolidation significantly affected OS with (HR = 4.74, p = 0.04) independently. Conclusion Treatment delays mostly in intensive phase are associated with worse survival in ALL; attempts should be made to maintain protocol-defined treatment intensity while adequately managing toxicities.

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