Inequalities in Pediatric Fracture Care Timeline Based on Insurance Type

Kitchen, Brock T; Ornell, Samuel S.; Shah, Kush; Pipkin, William; Tips, Natalie L; Hogue, Grant

doi:10.5435/jaaosglobal-d-20-00111

Cited by 16 publications

(30 citation statements)

References 25 publications

(65 reference statements)

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“…Delays in diagnosis and subsequent treatment may be related to the rarity of TSFs, as they account for only 3 per 100,000 children’s fractures. 3 , 13 , 19 At initial presentation, patients may have nonspecific physical examination findings such as an effusion, decreased range of motion, and difficulties with weightbearing. 3 While most fractures can be identified on radiographs, a small or incompletely ossified fragment may be difficult to visualize.…”

Section: Discussionmentioning

confidence: 99%

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study

Smith

Cruz

Mistovich

et al. 2022

Orthopaedic Journal of Sports Medicine

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Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay ( P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.

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Section: Discussionmentioning

confidence: 99%

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study

Smith

Cruz

Mistovich

et al. 2022

Orthopaedic Journal of Sports Medicine

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“…6,14,16,24,26 Despite these consistent findings in the literature and changes to health care in the United States, children with public insurance continue to experience disparities in orthopaedic care 20 years later. Kitchen et al 17 recently analyzed the care timeline in 21 of the most common pediatric fractures, noting that delay between injury and referral is the primary reason for the late orthopaedic evaluation experienced by patients with public insurance. Those with government-funded insurance had a wait time 2.8 times longer than patients with private insurance.…”

Section: Discussionmentioning

confidence: 99%

“…The American Journal of Sports Medicine 2021;49 (14):3842-3849 DOI: 10.1177/03635465211046928 Ó 2021 The Author(s) specialized orthopaedic care often exist and may be related to socioeconomic and demographic factors, including insurance status. 6,14,16,17,24,26,28 Given the rare nature of TSFs and the limitations of the current literature, there is the potential for a resultant delay in diagnosis, referral to a subspecialist, and variations in the approach to treatment. Furthermore, as insurance status has been demonstrated to affect care after other pediatric injuries, it may similarly compound the issues that stem from the uncommon nature of TSFs.…”

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confidence: 99%

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Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

et al. 2021

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Background: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. Purpose: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). Conclusion: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

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“…Children with public health insurance face limited access to orthopaedic surgical care leading to documented delays in fracture diagnosis and fixation, orthotic treatment, and diagnosis and treatment of meniscal tears. [21][22][23][24][25]…”

Section: Insurance Typementioning

confidence: 99%

A Health Equity Primer: Understanding and Addressing Inequities in Pediatric Orthopaedics

Montoya¹,

Gill-Sealy²,

Sabatini³

2022

Journal of the Pediatric Orthopaedic Society of North America

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Sociopolitical events in recent years including ongoing killings of Black Americans, violence against immigrants, and the COVID-19 pandemic have all shone a spotlight on the reality that we live in a society where an individual’s safety, health, and ability to access and receive quality medical care are contingent upon their socioeconomic circumstances and personal identities. These events have inspired both increased civic engagement addressing structural inequities in healthcare, as well as changes within modalities of care delivery, making this an opportune time to examine health inequities in pediatric orthopaedics and re-commit to working towards their reduction. In order to ensure that orthopaedic surgeons are best positioned to engage in such work, this paper will discuss health equity in pediatric orthopaedics to serve as a foundational primer to inform future equity-focused efforts. We will define health equity, equality, and intersectionality, and clarify the differences between these terms and their roles as lenses to better understand patients’ unique backgrounds and personal circumstances. Existing research on health disparities in orthopaedics will be reviewed with a focus on the ways in which race, ethnicity, insurance status, gender and sexuality, health literacy, language, nutrition and food availability, physical ability, and environmental and personal safety all impact the accessibility and quality of orthopaedic care. Beyond discussing existing disparities, the paper will detail tangible actions that clinicians can take to improve inclusivity and accessibility in clinical environments and patient encounters. By centering an intersectional approach to patient care and integrating equity-focused changes within clinical settings, surgeons can ultimately improve their interpersonal interactions with marginalized patients and increase both the quality of the care that they provide and patient trust in that care.

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Inequalities in Pediatric Fracture Care Timeline Based on Insurance Type

Cited by 16 publications

References 25 publications

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

A Health Equity Primer: Understanding and Addressing Inequities in Pediatric Orthopaedics

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