O2061: How Do Neighborhood Conditions Impact Children and Adolescents Undergoing Anterior Cruciate Ligament Reconstruction?

Background: Markers of socioeconomic status (SES), including insurance status and median household income based on zip code, have been associated with time between injury and anterior cruciate ligament (ACL) reconstruction as well as the presence of concomitant meniscus pathology in children and adolescents. However, these surrogate indicators of SES may not reflect all of the socioeconomic and healthcare resources affecting the care of ACL injuries in this population. The purpose of this study was to investigate the impact of the neighborhood conditions on treatment of ACL injuries in children and adolescents via the Child Opportunity Index (COI).

Methods: This retrospective cohort study included patients aged 18 years or younger who underwent primary ACL reconstruction at an urban tertiary children’s hospital. Medical records were reviewed for demographic, pre-operative, and intra-operative data. Patient addresses at the time of surgery were used to determine COI score. The COI is a summative measure of 29 indicators that reflect neighborhood opportunities across three domains: education, health and environment, and social and economic. COI scores are categorized as “very low,” “low,” “moderate,” “high,” or “very high” based on quintile rankings. Univariate analysis was followed by multivariate regression to adjust for confounding factors.

Results: 415 patients with COI scores in either the top or bottom two quintiles were included. The mean age was 15.8 ± 1.8 years and 210 (50.6%) patients were female. The median time between injury and surgery was 52.8 days (IQR 52.6) for patients with a high/very high COI score compared to 96.6 days (IQR 104) for those with a low/very low score (p < 0.001). After adjusting for insurance and race/ethnicity in multivariate analysis, those with a low or very low COI score had 2.1 times higher odds of surgery later than 60 days after injury (95% CI 1.1 to 4.0; p=0.02) and 1.8 times higher odds of surgery later than 90 days after surgery (95% CI 1.1 to 3.4; p=0.04) than patients with high or very high COI. Furthermore, patients with low or very low COI scores had 1.6 times higher odds of concomitant meniscus pathology (95% CI 1.1 to 2.5; p=0.04). COI did not maintain a statistically significant relationship with meniscectomy or presence of a chondral injury in multivariate analysis.

Conclusion: Even when controlling for insurance status, race/ethnicity, and other factors in multivariate analysis, lower COI scores predicted longer time between injury and surgery as well as increased frequency of concomitant meniscus tears. These findings suggest that COI provides a more granular assessment of a child’s social determinants of health than previously used markers of SES, like insurance status alone. Furthermore, as COI utilizes neighborhood-level data, neighborhood-level interventions may be impactful in providing equitable care to all children and adolescents with ACL injuries.