Disparities in Pediatric Scoliosis: The Impact of Race and Insurance Type on Access to Nonoperative Treatment for Adolescent Idiopathic Scoliosis

Abstract

Background: Adolescent idiopathic scoliosis (AIS) has evidencebased, nonoperative treatments proven to be effective with early diagnosis and prompt treatment. The purpose of this study was to identify potential disparities in access to nonoperative treatment for AIS. Specifically, we sought to determine the interaction of socioeconomic factors on a major curve magnitude and recommend treatment at the initial presentation. Methods: A retrospective review of AIS patients who underwent surgery at a single tertiary pediatric hospital between January 1, 2013 and December 31, 2018 was conducted. Patients were divided into 2 groups for comparison: patients with public insurance (PUB) and those with private insurance (PRV). Primary variables analyzed were patient race, Area Deprivation Index (ADI), major curve magnitude, and treatment recommendation at the initial presentation. Univariate and multivariate analyses were conducted to identify the predictors of the major curve magnitude at presentation. Results: A total of 341 patients met the inclusion criteria; PUB and PRV groups consisted of 182 (53.4%) and 159 (46.6%) children, respectively. Overall, the major curve magnitude at presentation was significantly higher in PUB compared with PRV patients (50.0°vs. 45.1°; P = 0.004) and higher in Black patients compared to White patients (51.8 vs. 47.0, P = 0.042). Surgery was recommended for 49.7% of the PUB group and 43.7% of the PRV group. A lesser number of PUB patients had curve magnitudes within the range of brace indications ( ≤ 40°) compared to PRV patients (22.5% vs. 35.2%, respectively; P = 0.010). The odds of having an initial major curve magnitude <40 degrees were 67% lower among Black patients with public insurance compared to Black patients with private insurance (OR = 0.33; 95% CI: 0.13-0.83; P = 0.019). Conclusion:This study demonstrated disparity in access to nonoperative treatment for pediatric scoliosis. Black patients with public insurance were the most at-risk to present with curve magnitudes exceeding brace indications. Future work focused on understanding the reasons for this significant disparity may help to promote more equitable access to effective nonoperative treatment for adolescent idiopathic scoliosis. Level of Evidence: III.

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

“…In the United States, Medicaid insurance is often a proxy for racial and ethnic disparities in health care, which are not just limited to surgical interventions. Recently Heffernan et al 3 reviewed access to nonoperative scoliosis care in patients with AIS compared by insurance status and race/ethnicity. They found that at first presentation to their clinic for scoliosis, AIS patients with public insurance were more likely to have curves that were too big to treat in a brace and were more likely to be Black.…”

“…More than a decade later, Nguyen et al 2 implemented a similar telephone call strategy and were able to successfully to schedule a fracture clinic visit for a hypothetical Medicaid-insured child in <40% of clinics compared with a success rate exceeding 80% if that hypothetical child were privately insured. Another study by Heffernan et al 3 observed that children with adolescent idiopathic scoliosis (AIS) insured by public insurances (like Medicaid) present with larger curves and are more likely to be recommended surgical intervention at the initial first presentation. However; no studies have investigated whether Medicaid-insured patients with AIS experience higher postoperative complications or revisions.…”

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

“…[1][2][3][4][5][6][7] There is increasing interest regarding the effect of health care disparities on the accessibility and delivery of pediatric orthopaedic care in the United States. [1][2][3][8][9][10][11][12] It is known that children with publicly funded insurance wait longer to access general pediatric orthopaedic care, including scoliosis care. [13][14][15] A recent significant emphasis on understanding the root causes of such disparities as they pertain to adolescent idiopathic scoliosis (AIS) care exists.…”

“…2,8,12,13,17 At-risk patients in disadvantaged inner-city neighborhoods where in-school screenings are not statemandated are potentially vulnerable to poorer nonoperative scoliosis health care access as they may experience delayed initial referral and missed nonoperative treatments. 12,21 In states where in-school scoliosis screenings are mandated, such as Massachusetts and Texas, SES factors and public versus private insurance have failed to exhibit a clinically meaningful difference in major coronal curve severity at initial orthopaedic presentation. 2,17 However, Heffernan et al 12 recently demonstrated patients with public insurance, lower SES by Area Deprivation Index (ADI), and African American race were at greatest risk of presenting with curve magnitudes outside of acceptable bracing parameters.…”

“…19,20 Most of the current literature surrounding health care disparities in AIS focuses on the effect of SES, insurance type, race/ethnicity, and obesity on major coronal curve magnitude and access to and delivery of nonoperative treatment. 2,8,12,16,17,21 However, although obesity has been correlated with larger curves at initial presentation, 16,17 mixed conclusions regarding the effects of SES, race, and insurance on AIS care and curve magnitude exist. 2,8,12,13,17 At-risk patients in disadvantaged inner-city neighborhoods where in-school screenings are not statemandated are potentially vulnerable to poorer nonoperative scoliosis health care access as they may experience delayed initial referral and missed nonoperative treatments.…”