University of Michigan Medical School, Ann Arbor.
Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor.
JAMA Netw Open. 2023 Dec 1;6(12):e2349621. doi: 10.1001/jamanetworkopen.2023.49621.
Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood.
To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF).
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023.
Eligibility for Medicare coverage at age 65 years.
Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years.
A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage.
Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.
医疗保险为美国 65 岁及以上的居民提供了近乎普遍的健康保险。对于 Medicare 覆盖范围如何影响骨科创伤后手术管理的种族和民族差异，人们知之甚少。
评估 Medicare 资格与桡骨远端骨折 (DRF) 后开放性复位内固定术 (ORIF) 的种族和民族差异之间的关联。
设计、地点和参与者：这项回顾性队列研究采用回归不连续性设计，从佛罗里达州、马里兰州和纽约的医疗保健成本和利用项目全州支付者数据库中获取数据。这些数据库包含急诊科、门诊手术中心和医院的纵向随访的患者识别码和遭遇水平数据。队列包括年龄在 57 至 72 岁之间的患者，他们在 2016 年 1 月 1 日至 2019 年 11 月 30 日期间发生了 DRF。数据分析于 2023 年 3 月 1 日至 10 月 15 日进行。
65 岁时获得 Medicare 保险的资格。
DRF 的管理类型（闭合治疗、外固定、经皮钉固定和 ORIF）。接受 ORIF 的患者的手术时间在接受 ORIF 的患者中确定。多变量逻辑回归和回归不连续性设计用于比较在 65 岁之前或之后接受 ORIF 的患者之间的种族和民族差异。
共纳入 26874 例 DRF 患者（平均[SD]年龄 64.6[4.6]岁；22359 例女性[83.2%]）。其中，2805 例为西班牙裔或拉丁裔（10.4%；以下简称西班牙裔），1492 例为非西班牙裔黑人（5.6%；以下简称黑人），20548 例为非西班牙裔白人（76.5%；以下简称白人），2029 例（7.6%）为其他种族和民族（包括亚洲或太平洋岛民、美国原住民和其他种族）。总体而言，32.6%的患者接受 ORIF，但黑人（20.2%比 35.4%；P<0.001）和西班牙裔（25.8%比 35.4%；P<0.001）患者的使用率明显较低。在调整潜在混杂因素后，多变量逻辑回归分析证实了黑人（比值比[OR]，0.60；95%置信区间[CI]，0.50-0.72）和西班牙裔（OR，0.82；95%CI，0.72-0.94）患者与白人患者相比，ORIF 使用率存在差异。在 65 岁时，在没有 Medicare 保险的情况下，白人和黑人群体之间 ORIF 使用的差异没有统计学意义。在没有 Medicare 保险的情况下，白人患者和黑人患者之间 ORIF 使用的预期差异为 12.6 个百分点；然而，实际差异为 22.0 个百分点，高于预期 9.4 个百分点（95%CI，0.3-18.4 个百分点），增加了 75%（P=0.04）。在没有 Medicare 保险的情况下，白人和西班牙裔患者之间 ORIF 使用的预期差异为 8.3 个百分点，而在有 Medicare 保险的情况下，这一结果持续存在，没有明显变化。
这项研究的结果表明，DRF 的手术治疗在 57 至 72 岁的成年人中很常见，但少数民族患者的 ORIF 使用率较低。65 岁时获得 Medicare 资格并不能减轻 DRF 手术管理中基于种族和民族的差异。
