O2063: Role of Race and Insurance in Anterior Cruciate Ligament Surgery Timing and Postoperative Testing

Background: The anterior cruciate ligament (ACL) injury and reconstruction (ACLR) have become increasingly common in the pediatric and adolescent populations, with some studies showing as high as 25% repeat injury thus careful attention should be paid not only to surgical technique, but the rehabilitation after surgery and criteria for return to sport. Health disparities are sparsely researched in orthopedics but are essential in providing adequate care. We were interested in evaluating barriers to a successful return to sport after ACLR. Our study evaluated race and insurance as separate metrics against time between injury to MRI and MRI to surgery. We hypothesized that there would be an increase in the time between MRI and surgery for uninsured patients and minorities.

Methods: After IRB approval we performed a retrospective chart review of patients treated with ACLR who were >=24 weeks postoperative, had completed a postoperative ACL therapy protocol, and met inclusion and exclusion criteria. We examined patient characteristics as predictors of days from injury to MRI and days from MRI to surgery, using linear regression to model each (log-transformed) outcome as a function of patient sex, race and ethnicity, age, and insurance status. Bootstrapping was used to obtain 95% confidence intervals and p-values.

Results: Controlling for other model variables, including insurance status, the average time from injury to MRI for black and other/mixed patients is estimated to be 178% and 85% greater, respectively, than for white patients. The average time from MRI to surgery is estimated to be 36% longer for black patients than for white patients. The remaining effects were mostly small and not estimated with sufficient precision to rule out an effect in either direction.

Conclusion: The time between injury and MRI represents the initial access of a patient to the healthcare system after injury. After adjustment for other variables, we did not see a large difference in time between patients with private insurance vs. those who were publicly insured or self-pay. When controlling for insurance status, the average time from injury to MRI for black and other/mixed patients was greater than for white patients. We suspect that barriers such as knowledge of injury, access to orthopaedic care and fear of losing ability to participate in sport likely play a role in this increase in time to diagnosis in minority patients; further investigation is needed. In conclusion, there is a disparity between black and white patients with early access to care after ACL injury and it may lead to a delayed return to sport for these patients.