Dodwell Emily, Wright James, Widmann Roger, Edobor-Osula Flo, Pan Ting-Jung, Lyman Stephen
*Hospital for Special Surgery and Weill Cornell Medical College, New York, NY ‡Rutgers New Jersey Medical School, Newark, NJ †Department of Orthopaedic Surgery, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
J Pediatr Orthop. 2016 Jul-Aug;36(5):459-64. doi: 10.1097/BPO.0000000000000494.
Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment.
Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal).
Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal.
There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here.
Level III-retrospective cohort study.
小儿骨科门诊服务的可及性存在差异。本研究旨在评估在诸如取出内固定装置等择期小儿骨科手术中是否也存在差异，并确定哪些人口统计学和社会经济因素可能与治疗差异相关。
在纽约州SPARCS数据库中识别出1997年至2010年间发生股骨干骨折的7至18岁（含）儿童。确定患者的年龄、性别、种族/族裔、保险状况、教育程度和贫困情况。通过多变量回归分析评估与骨折治疗方法相关的因素。对接受内固定治疗的患者亚组随访至2011年（含）以了解内固定装置取出情况。使用Cox比例风险生存分析（至内固定装置取出的时间）评估与内固定装置取出相关的因素。
在识别出的3220例闭合性股骨干骨折中，2609例（81%）接受了内固定治疗，9例（0.3%）接受了无植入物的开放治疗，203例（6.3%）接受了外固定治疗，399例（12.4%）接受了闭合治疗方法。与有私人保险的患者相比，有非工伤/意外保险的患者更有可能接受内固定治疗（P<0.001）。在3220例患者中，2572例纳入了内固定装置取出亚分析。725例（28.2%）患者进行了内固定装置取出。在多变量模型中，年龄较小（P<0.001）、白人[与黑人相比（P<0.001）、与西班牙裔相比（P=0.035）、与其他种族相比（P=0.001）]以及生活在贫困程度较低社区的患者（P=0.016）更有可能接受内固定装置取出。保险状况不是内固定装置取出的统计学显著预测因素。
儿童内固定装置取出与年龄较小、白人种族和较高的社会经济地位之间存在关联。认识到这些差异应促使对其原因进行进一步评估，无论是由于缺乏关于内固定装置取出的循证指南、外科医生的偏见、报销差异还是医疗服务可及性的差异。建议进一步研究以更好地阐明儿童内固定装置取出的指征以及此处所确定差异的原因。
III级——回顾性队列研究。
