Is Insurance Status Associated With Likelihood of Operative ACL Injury Treatment Compared With Nonoperative Treatment?

Abstract

Background: While many factors inform the choice of operative versus nonoperative treatment of injuries to the anterior cruciate ligament (ACL) of the knee, socioeconomic status influences this decision, as has been reported with other procedures. Purpose: To identify any associations between insurance status and likelihood of operative treatment of ACL injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The Nationwide Inpatient Sample database was queried using International Classification of Diseases, 9th Revision codes for ACL injuries and reconstruction from 2001 to 2013. Chi-square analysis was performed to determine significant predictors of operative intervention. Binary logistic regression was used to account for demographic and significant predictor variables. Results were recorded as odds ratios (ORs) and 95% CIs. Significance was defined as P < .05. Results: A total of 32,541 patients with ACL injuries were included in the final analysis. Overall incidence of surgical reconstruction was 85.4% (n = 27,805). Multivariable regression revealed that nonprivate insurance types were associated with lower likelihoods of operative reconstruction compared with private insurance: the lowest likelihood of operation was seen in uninsured patients (OR, 0.31; P < .01), followed by Medicare (OR, 0.33; P < .01) and Medicaid (OR, 0.51; P < .01) patients. There was also a decreased likelihood of surgery for elderly (OR, 0.0 [for age ≥75 years]; P < .01) and Black patients (OR, 0.65; P < .01). An increased likelihood of surgery was seen with female patients (OR, 1.14; P < .01). Patients in the highest median household income quartile were more likely to undergo surgery than those in the lowest (OR, 1.36; P < .01). Conclusion: Compared with privately insured patients, patients with nonprivate insurance had lower likelihood of surgery. Furthermore, patients in higher income quartiles were more likely to undergo operative fixation. These findings may suggest a need for more precise treatment guidelines and studies that investigate causes of such differences.