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The Impact of Socioeconomic Factors on Operative Management of Acute Distal Radius Fractures
Emma Smolev, BA; Rafa Rahman, MD, MPH; Amy Lu, BS; Rosie Mc Colgan, MD; Troy Amen, MD, MBA; Sanjum Singh, MD; Jeremy Abolade, MD; Isabel Wofle, MD; Joseph Nguyen, MPH; Duretti T. Fufa, MD
Hospital for Special Surgery, New York, NY
Introduction:
Distal radius fractures (DRF) are the most common fractures in adults. Surgical indications often vary and there is variability in treatment strategies. Disparities continue to impact patient care in orthopaedics, and specifically within hand and upper extremity surgery. The primary objective of this study was to determine whether race/ethnicity, geographic socioeconomic deprivation, and insurance status impact treatment recommendation for distal radius fracture.
Methods:
This retrospective cohort study used institutional data between 2016-2021. Unadjusted univariate and adjusted multivariate analyses assessed associations between patient demographics of interest and likelihood of being recommended surgery. Multivariate analysis corrected for potential confounders including fracture severity based on volar angulation (severe: ?-20° or ?10°, non-severe: -20° to +10°), radial inclination, ulnar variance, presence of an ulnar styloid fracture, sex, age, employment status, and Elixhauser Comorbidity score. Geographic socioeconomic deprivation was assessed using Area Deprivation Index (ADI) with patients categorized by ADI quintile, with the highest quintile representing the worst socioeconomic disadvantage.
Results:
1,663 patients were included, with mean age of 54 years (range 18-80), 76% female (n=1,269), and 82% White (n=1,361). The mean value for radiographic parameters were: radial inclination 18.7° ± 6.9°, volar angulation -5.4° ± 17.5°, and ulnar variance 1.7 ± 3.0 mm. Surgery was recommended in 59% (n=984) of patients with severe DRF and 41% (n=678) of patients with non-severe DRF, and overall, 62% (n=1025) of all patients were treated operatively.
In unadjusted analysis, worse ADI quintile (OR:1.14, 95%CI 1.06-1.23, p<0.001), and Asian race compared to White (OR:1.69, 95%CI 1.06-2.71, p=0.029) were associated with a greater likelihood of being recommended surgery, whereas public insurance compared to commercial insurance (OR:0.66, 95%CI 0.51-0.85, p=0.001) was associated with decreased likelihood of being recommended surgery. When adjusted for radiographic fracture severity in addition to other confounding variables, worse ADI quintile (OR:1.36, 95%CI 1.05-1.76, p=0.020) was still associated with higher likelihood of being recommended surgery, and public insurance was still associated with lower likelihood of recommendation for surgery (OR:0.56, 95%CI 0.36-0.88, p=0.012). Race was no longer significantly associated with surgical recommendation after adjusting for confounders.
Discussion and Conclusion:
Insurance status played a significant role in recommendation for surgery when adjusted for fracture severity and other confounders, with patients with public insurance being recommended surgery less frequently. On the other hand, patients with worse geographic socioeconomic disadvantage were more likely to be recommended surgery. Further investigation into factors influencing surgeon indication for DRF surgery is warranted.
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