Minority and Lower Socioeconomic Status Patients Receive Ankle Fracture Care at Higher Cost Sites

Abstract

Category: Ankle; Trauma Introduction/ Purpose: Socioeconomic disparities exist in the delivery of orthopedic care. Inequitable outcomes based on socioeconomic status (SES), including income, race, and geography, have been studied in association with outcomes following lower extremity trauma care. As orthopedic surgical care shifts increasingly towards providing care in hospital outpatient departments (HOPD) and freestanding ambulatory surgery centers (ASC), there is an opportunity to address socioeconomic disparities. We aimed to assess the association between patient SES and the outpatient facility type (HOPD versus ASC) where ankle fracture care was performed. We hypothesize: (1) White patients are more likely to receive care at ASCs, (2) Minority and lower income patients are more likely to receive care at HOPDs, and (3) Total charges for care are higher for minority and lower income patients. Methods: Data in patients ≥16 years old was sourced from the State Inpatient Database and Healthcare Utilization Project State Ambulatory Surgery Database (SASD) (for Florida, North Carolina, and Wisconsin) from 2016-2019. These 3 states were selected because their SASDs include a variable defining the location of service as a hospital outpatient department (HOPD) or ASC. Cases were identified using CPT codes converted to ICD-10 procedural codes for ankle fracture open reduction and internal fixation (ORIF). 85,749 cases were included: 50,411 (59%) inpatient, 28,536 (33%) HOPD, and 6,802 (8%) ASC, representing approximately 20% of inpatient and 11.5% of outpatient cases performed in the United States. Patient and facility characteristics were abstracted. Appropriate statistical analyses were conducted to describe and compare differences between facility type and patient characteristics. Results: Significant race and income disparities exist in outpatient ankle fracture care by facility type. Most patients receiving care were White (71%). Of the patients who received care at an HOPD, 32% were Black compared to 6% at ASCs (OR 0.795, CI 0.728-0.869). Of patients receiving care at an HOPD, 27% were other minorities compared to 9% at ASC (OR 1.213, CI 1.213- 1.309). More patients at HOPDs were in the lowest income level (26%) compared to ASC (18%). Factors found to associated with higher charges for surgery included patient being of minority race, patient of lower income level, and surgery performed at HOPD versus ASC. Conclusion: Ankle fractures treated at ASCs were more likely to be White and of higher income. These socioeconomic and racial/ethnic disparities are also associated with receiving care with higher total charges. These data indicate inequitable access to ankle fracture care performed at ASC facilities. More attention to social determinants of health is critical in the context of ankle fracture care to address potential inequitable outcomes and higher cost of care.