O1079: Efficiency and Outcomes of Idiopathic Clubfoot Treatment in Varying Healthcare Settings

Background: The Ponseti method is the gold standard treatment for clubfoot, involving successive casts followed most commonly by an Achilles tendon lengthening and subsequent bracing for full correction. Patients with less financial and social resources may have more difficulty accessing and adhering to highly regimented interventions, such as Ponseti casting. This study focuses on 2 treatment settings; teaching clinic (TC) and private office (PO). In the TC setting, resident physicians deliver care, with fellowship-trained pediatric orthopedist supervision, to patients utilizing public insurance. In the PO, fellowship-trained pediatric orthopedists directly deliver care to patients with commercial insurance. We compared timeline and outcomes of clubfoot management in these two settings within the same institution to identify disparities in care and better understand how to optimize health outcomes for underserved patients.

Methods: After IRB approval, a retrospective chart review was performed for patients with idiopathic clubfoot treated via Ponseti method from 2008 to present. Patients were divided based on treatment setting. Data on demographics, treatment timeline, and treatment outcomes were collected for each patient. Inferential statistics were used to analyze data.

Results: The TC (n=40) and PO cohorts (n=32) had similar distributions of sex (p=0.26) and primary language (p=0.12), but TC patients were more likely to belong to a minority racial group (85.0% vs. 53.1%; p< 0.01). For treatment timeline, more TC patients began treatment after 3 months of age (p < 0.01) and were older upon initiating bracing (p < 0.01). Additionally, the time from 1st cast to brace initiation (p < 0.01) was longer for TC patients. More TC patients spent at least 2 weeks out of their casts (p < 0.01) and missed at least 1 casting appointment (p < 0.01). TC patients were also less likely to be compliant to brace requirements (p < 0.01) and more likely to be lost to follow-up before their post-tenotomy appointment or never returned for their brace check-in (p < 0.01). (Table 1) For treatment outcomes, no difference was noted between cohorts for initial clubfoot correction (p=1.00), but TC patients were more likely to experience recurrent deformity (p=0.01). TC patients were also more likely to encounter a casting complication, such as ulcers or loose casts (p=0.05). (Table 2)

Conclusion: Patients treated for clubfoot in a TC setting began treatment later, spent more time being treated, and had higher recurrence rates. These patients were more likely to be lost to follow up and not adhere to bracing specifications. As initial deformity correction rates are similar between cohorts, it is likely that bracing non-compliance and premature termination of care were primary drivers for unsuccessful treatment. Therefore, efforts to enhance patient and family education and improve social and financial supportive care may help minimize barriers to care and improve outcomes for patients with unmet socioeconomic needs.