Financial Burden of Pediatric Anterior Cruciate Ligament Reconstruction

Abstract

Background: High costs and lack of price transparency for common pediatric orthopaedic procedures create financial burden for patients. We assessed (1) how patient medical debt after anterior cruciate ligament reconstruction (ACLR) correlates with health insurance type; and (2) factors associated with patient financial burden and worry after ACLR. Methods: We reviewed records of 122 patients aged below 18 years who underwent ACLR at our US academic hospital from 2016 to 2020. Patients were grouped by health insurance type: private (n=80) or public (n=42). A telephone survey about ACLR-related financial burden and worry was administered to patients’ parents (45% response rate). Primary outcomes were patient medical debt and patient-reported financial burden measured by the financial burden composite score (0 to 6, with 6 representing highest burden) and dichotomized worry score (1 to 3, low worry; 4 to 5, high worry). We used univariate analyses to compare financial outcomes and multivariable regressions to determine factors associated with reported financial burden (alpha=0.05). Results: Debt after ACLR was reported by 10 of 122 patients (8%), all of whom had private insurance (P=0.045). Of 55 survey respondents, treatment-related financial burden was reported by 32 (58%). Mean±SD financial burden composite scores were higher for privately insured (1.8±2.0) versus publicly insured patients (0.74±1.2) (P=0.02), but rates of high financial worry were similar (private, 8% vs. public, 21%) (P=0.22). A higher proportion of patients with private insurance (31%) reported having to use savings after ACLR compared with publicly insured patients (5%) (P=0.04). The most frequently cited reason for financial burden was the cost of postoperative physical therapy (PT) (n=21). Number of PT visits was independently associated with financial burden composite scores (P=0.02). Insurance type was not independently associated with financial burden (P>0.05). Conclusion: Although a small proportion of patients generated medical debt after ACLR (greater for those privately vs. publicly insured), the majority reported treatment-related financial burden primarily driven by PT costs. Level of Evidence: Level III.