Patterson Joseph T, Reddy Akhil S, Becerra Jacob A, Alluri R Kiran, Hernandez Fergui, Duong Andrew M, Ross Ryan C
Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
JB JS Open Access. 2024 Dec 2;9(4). doi: 10.2106/JBJS.OA.23.00152. eCollection 2024 Oct-Dec.
Closed, unstable AO/OTA 44B2 ankle fractures are common injuries with similar distributions by age, sex, and race. The purpose of this study was to identify disparities in access to and utilization of surgical care for these injuries.
Ambulatory patients ≥18 years of age with capitated Medicaid health insurance who presented from January 2016 to February 2020 with an isolated, closed AO/OTA 44B2 ankle fracture with radiographic evidence of instability were retrospectively identified at 1 Level-I safety-net trauma center. Associations between patient characteristics (age, sex, preferred language, race, ethnicity, housing status, employment, and substance use) and measures of access to and utilization of ankle fracture surgery (days from injury to evaluation, being offered surgery, undergoing surgery, and days from evaluation to surgery) were investigated on bivariable and multivariable analysis.
Of the 1,116 patients who were screened, 323 met the inclusion criteria. The included patients had a median age of 41 years; 207 patients (64%) were male and 255 (79%) were Hispanic. Patients presented at a mean of 4.6 ± 7.0 days from injury. Delayed presentation was associated with self-identification as Hispanic (rate ratio [RR], 1.93; 95% confidence interval [CI]: 1.17, 3.12]) and with marijuana use (RR, 1.59; 95% CI: 1.08, 2.36), whereas significantly earlier presentation was associated with a non-English language preference (RR, 0.64; 95% CI: 0.46, 0.89), alcohol abuse (RR, 0.74; 95% CI: 0.55, 0.99), and illicit drug use (RR, 0.30; 95% CI: 0.14, 0.67). Ankle fracture surgery was offered to 274 patients (85%). Experiencing homelessness was associated with a decreased likelihood of being offered surgery (odds ratio [OR], 0.15; 95% CI: 0.03, 0.69). Of patients who were offered surgery, 216 (79%) underwent surgery. Black patients underwent surgery significantly less frequently than patients who identified as White (OR, 0.14; 95% CI: 0.01, 0.77). The median time from evaluation to surgery was 11 days (interquartile range, 7 to 14 days). Patients who used illicit drugs experienced a mean delay to surgery of 6.0 days relative to those who did not use illicit drugs (mean time to surgery, 16.8 ± 7.1 and 10.8 ± 5.1 days, respectively).
We identified disparities in access to and utilization of surgical care for unstable AO/OTA 44B2 ankle fractures that negatively affected patients with Medicaid insurance who identified as Hispanic or Black, were experiencing homelessness, or used illicit drugs. These disparities may negatively affect outcomes for patients receiving care in similar environments, such as capitated health-care networks and public safety-net health systems.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
闭合性、不稳定型AO/OTA 44B2踝关节骨折是常见损伤，在年龄、性别和种族分布上相似。本研究的目的是确定这些损伤在获得和接受手术治疗方面的差异。
回顾性确定2016年1月至2020年2月期间在1家一级安全网创伤中心就诊的年龄≥18岁、参加按人头付费医疗补助医疗保险的门诊患者，这些患者患有孤立性、闭合性AO/OTA 44B2踝关节骨折且有影像学证据显示骨折不稳定。在双变量和多变量分析中，研究患者特征（年龄、性别、首选语言、种族、族裔、住房状况、就业和物质使用情况）与踝关节骨折手术的获得和利用指标（从受伤到评估的天数、被提供手术、接受手术以及从评估到手术的天数）之间的关联。
在筛查的1116例患者中，323例符合纳入标准。纳入患者的中位年龄为41岁；207例患者（64%）为男性，255例（79%）为西班牙裔。患者受伤后平均4.6±7.0天就诊。就诊延迟与自我认定为西班牙裔有关（率比[RR]，1.93；95%置信区间[CI]：1.17，3.12）以及与使用大麻有关（RR，1.59；95%CI：1.08，2.36），而就诊明显较早与偏好非英语语言有关（RR，0.64；95%CI：0.46，0.89）、酗酒（RR，0.74；95%CI：0.55，0.99）和使用非法药物有关（RR，0.30；95%CI：0.14，0.67）。274例患者（85%）被提供踝关节骨折手术。无家可归与被提供手术的可能性降低有关（比值比[OR]，0.15；95%CI：0.03，0.69）。在被提供手术的患者中，216例（79%）接受了手术。黑人患者接受手术的频率明显低于自我认定为白人的患者（OR，0.14；95%CI：0.01，0.77）。从评估到手术的中位时间为11天（四分位间距，7至14天）。与未使用非法药物的患者相比，使用非法药物的患者手术平均延迟6.0天（手术平均时间分别为16.8±7.1天和10.8±5.1天）。
我们确定了不稳定型AO/OTA 44B2踝关节骨折在获得和接受手术治疗方面的差异，这些差异对自我认定为西班牙裔或黑人、无家可归或使用非法药物的医疗补助保险患者产生了负面影响。这些差异可能对在类似环境（如按人头付费的医疗保健网络和公共安全网卫生系统）接受治疗的患者的治疗结果产生负面影响。
预后性III级。有关证据水平的完整描述，请参阅作者须知。
