Patients with government insurance had longer wait times for ACL reconstruction

SAN DIEGO — Pediatric patients with an ACL injury who had commercial health insurance underwent reconstruction surgery sooner than patients with government health insurance, according to results presented at the American Orthopaedic Society for Sports Medicine Annual Meeting.

Perspective from Lynn Snyder-Mackler, PT, SCS, ATC, ScD, FAPTA

Curtis Vandenberg

Curtis Vandenberg, MD, and colleagues measured socioeconomic status by health insurance type and household income among 127 pediatric patients with ACL injury to assess the impact of socioeconomic status on the time to surgical intervention after ACL injury and outcomes following primary ACL reconstruction.

“Regarding insurance type, we had 69 [patients] with commercial insurance and 58 with government-assisted insurance,” Vandenberg said in his presentation here.

Results also showed an average household median income of $87,767 among patients with commercial insurance vs. $51,366 among patients with government insurance.

Vandenberg noted time from injury to first appointment, injury to MRI, injury to surgery, first appointment to surgery and injury to return to play were twice as long among the government insurance group vs. the commercial insurance group.

“We also tried to correlate surgical factors looking at specifically meniscal and chondral injury,” Vandenberg said. “In the commercially insured patient, there was approximately [a] 65% rate of associated meniscal pathology at the time of surgery vs. 81% in the government-insured patients.”

During the postoperative period, patients in the government-assisted insurance group experienced decreased range of motion, according to Vandenberg. However, he added there was no statistically significant difference with graft failure, reoperation and infection between groups.

“In looking at injury to return to play, it was 11 vs. 13 months longer in the government-insured group,” Vandenberg said. – by Casey Tingle

Reference:

Patel AR, et al. Abstract 149. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 5-8, 2018; San Diego.

Disclosure: Vandenberg reports no relevant financial disclosures.

Perspective

Lynn Snyder-Mackler, PT, SCS, ATC, ScD, FAPTA

Access to care is hot topic in orthopedic research and health policy. Vandenberg and colleagues’ work adds to a growing body of published research that an association exists between socioeconomic (SE) and demographic status and access to surgery. Those with government insurance (surrogate for lower SE status) were diagnosed (first orthopedic visit) 3.5 months after injury vs. 6 weeks after injury for those with commercial insurance. Delay in diagnosis was just the beginning. Those with commercial insurance went to surgery a month later, while those with government insurance waited almost 3 months. While this can be interpreted by some as bias against government insurance, navigating the diagnostic, operative and postsurgical appointments associated with the surgical management of an ACL rupture places substantial burden on patients and families, only some of which are economic or related to insurance. Travel to appointments, time off from work and managing childcare for other children are often larger obstacles to access to care than insurance type. Imagine being a single mother of three, without a car, working as a home health aide, trying to get one kid’s knee injury taken care of.

Vandenberg’s work also adds to the story that some prognostic factors for outcome are worse at the time of surgery (more meniscal pathology) and after (more postoperative stiffness). It is unlikely that 2 months delay causes more meniscal tears, maybe only those with worse pathology persist to seek care at all. The burdens also likely also contribute to lack of access to postoperative care (eg, PT) and the higher postoperative stiffness rate. Those of us who care for children and adolescents with ACL injury should acknowledge that families with government insurance or lower household incomes may not be able to navigate the system as successfully as families with more resources and work to develop strategies to assist them.

Lynn Snyder-Mackler, PT, SCS, ATC, ScD, FAPTA

Orthopedics Today Editorial Board member

Alumni Distinguished Professor

Department of Physical Therapy

Francis Alison Professor

University of Delaware

Newark, Delaware

Disclosures: Snyder-Mackler reports she receives NIH grants to study the ACL.