Examining delays in diagnosis for slipped capital femoral epiphysis from a health disparities perspective

Abstract

Slipped Capital Femoral Epiphysis (SCFE) is a skeletal pathology affecting adolescents which requires timely surgery to prevent progression. Delays in diagnosis and treatment of SCFE can negatively affect patient prognosis, and few studies have examined how health disparities and barriers to care may influence these delays. In particular, only a handful of studies have included a Hispanic patient sample, despite this ethnic group’s increased risk for the disease and unique barriers to care. A retrospective chart review was conducted for 124 patients surgically treated for idiopathic SCFE from January 2010 to September 2017. Patient data included age, facility and date of diagnosis, sex, BMI, race and ethnicity, Southwick slip angle, and insurance type. Results indicated that patients with private insurance were more likely to present with a mild slip than patients who were insured by Medicaid or uninsured, while patients without insurance were more likely to have severe slips. Patients without insurance also had a significantly higher mean slip than patients with insurance. The relationship between insurance status and slip angle degree was significant independent of race, even though Hispanic individuals were significantly more likely to have Medicaid or be uninsured. All patients without insurance, and a majority of those with Medicaid, were diagnosed in the emergency department. Time to diagnosis and slip angle were positively correlated, which suggests that longer delays led to increase of the slip angle, consistent with previous findings. Time to diagnosis and BMI were also correlated, which may be tied to socioeconomic factors, but the possibility of weight bias should not be dismissed. These results suggest that socioeconomic status and other factors may have contributed to barriers to care which led to delays in diagnosis and thus more severe slips. Future SCFE research should include health disparities variables to better inform treatment and prognosis.

Surgeon Preference for Prophylactic Contralateral Fixation in Slipped Capital Femoral Epiphysis (SCFE) Patients: A Nationwide POSNA Survey Study

“…19 Surgeons may have been concerned about losing patients to follow-up, as a more extended time to diagnosis correlates with more severe slips. 20 However, as suggested by Guzek et al in 2022, implicit bias among surgeons may also play a role. 21 Future research should determine if race is a risk factor for contralateral SCFE and examine the role of implicit bias in this subjective surgical decision-making.…”

“…Many studies have determined that racially minoritized patients were at the greatest risk of losing access to medical care due to COVID-19 19 . Surgeons may have been concerned about losing patients to follow-up, as a more extended time to diagnosis correlates with more severe slips 20 . However, as suggested by Guzek et al in 2022, implicit bias among surgeons may also play a role 21 .…”

Decade-long Trends in Incidence of Slipped Capital Femoral Epiphysis in the United States: A Nationwide Database Analysis of Over 33 Million Patients

“…Furthermore, patients of lower SES may fare worse, with reports of early loss to follow-up, delayed diagnosis, and greater slip severity in this demographic. 14,15 Aside from this association, the increasing incidence of SCFE is cause for concern independently. SCFE is a frequently missed diagnosis, due to its various presentations and similarity to more common and relatively benign conditions leading to delays in treatment.…”

What’s New in Pediatric Orthopaedics

“…A prospective cohort of 486 children with SCFE found that diagnostic delays were common and radiographic severity worsened with increased time to diagnosis 36 . A retrospective review of patients treated surgically for SCFE found that patients with private insurance were more likely to present with a mild slip (23%) than those who were uninsured (0%) or had Medicaid (15%), emphasizing that these diagnostic delays are associated with increased slip angles 37 .…”