Race, Income, and Insurance Status Are Associated with Increased Time to Initial Outpatient Evaluation of Fracture Patients

Abstract

Background: Social determinants of health (SDOH) are conditions in the environments where people are born, live, learn, work, play, and worship that affect a wide range of health and quality of life outcomes. While SDOH have been shown to have a significant effect on outcomes and access to care for many orthopaedic conditions, their effect on pediatric orthopaedic care is less well established. The purpose of this study was to evaluate the effects of race, income, parental employment status and education level, and type of insurance, on time to initial evaluation of pediatric fracture patients in an orthopaedic clinic.

Methods: A retrospective chart review was performed for fracture patients who presented to a children's emergency department (ED) and were followed up at an outpatient pediatric orthopaedic clinic. Socioeconomic and demographic data were collected including patient age at presentation of fracture, type of insurance, patient race and ethnicity, patient ZIP code, primary guardian's employment status and education level, and household annual income. Multivariable negative binomial regression analysis was used to determine the effect of SDOH on time from ED visit to initial orthopaedic follow up.

Results: A total of 516 patients were included in the study (mean follow-up time = 8.54 days; SD = 4.53 days) between the ED visit and initial orthopaedic follow up. After adjusting for all other collected variables, there was a correlation between time to follow up and patient race (White patients had 0.76 days shorter time compared with that of non-White patients, P = .0455), insurance status (self-pay patients had 1.73 days longer time compared with that of insured patients), and mean household income in the patient's ZIP code (decrease of 0.92 days per $10,000 increase in mean household income, P = .0431). Patient age also correlated with increased time to follow up (1.03-day increase per year of age, P = .0051).

Conclusions: The time from ED visit to initial evaluation in an orthopaedic clinic for pediatric fracture patients was correlated with certain SDOH including race, insurance status, mean income in patients' respective ZIP code, and age of the patient.

Key concepts: (1)Social determinants of health may impact access to care and outcomes in pediatric orthopaedics, and this relationship is confounded by multiple factors.(2)Time to follow up for pediatric fracture patients is affected by race, income, and insurance status.(3)Pediatric orthopaedic surgeons must be aware of this disparity and use specific strategies to address potential barriers to care.

Level of evidence: III, Prognostic Study.

Keywords: Follow-up visits; Health disparity; Pediatric fractures; Social determinants of health.

Figure 1

Patient inclusion and eligibility for the study.

Figure 2

Frequency of time to evaluation by an orthopaedic clinician, by aggregated racial category.

Figure 3

Frequency of time to evaluation by an orthopaedic clinician, by insurance status.