Pediatric and Adolescent Shoulder Instability: Does Insurance Status Predict Delays in Care, Outcomes, and Complication Rate?

Abstract

Background: Recurrent shoulder instability results from overuse injuries that are often associated with athletic activity. Timely diagnosis and treatment are necessary to prevent further dislocations and secondary joint damage. In pediatric and adolescent patients, insurance status is a potential barrier to accessing timely care that has not yet been explored. Purpose: To examine the effect of insurance status on access to clinical consultation, surgical intervention, and surgical outcome of pediatric and adolescent patients with recurrent shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: We conducted a retrospective review of pediatric and adolescent patients who were treated at a single tertiary children’s hospital for recurrent shoulder instability between 2011 and 2017. Patients were sorted into private and public insurance cohorts. Dates of injury, consultation, and surgery were recorded. Number of previous dislocations, magnetic resonance imaging (MRI) results, surgical findings, and postoperative complications were also noted. Delays in care were compared between the cohorts. The presence of isolated anterior versus complex labral pathology as well as bony involvement at the time of surgery was recorded. The incidences of labral pathology and secondary bony injury were then compared between the 2 cohorts. Postoperative notes were reviewed to compare rates of repeat dislocation and repeat surgery. Results: A total of 37 patients had public insurance, while 18 patients had private insurance. Privately insured patients were evaluated nearly 5 times faster than were publicly insured patients ( P < .001), and they obtained MRI scans over 4 times faster than did publicly insured patients ( P < .001). Publicly insured patients were twice as likely to have secondary bony injuries ( P = .016). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced redislocation versus the complete absence of redislocation in the privately insured patients ( P = .022). Conclusion: Public insurance status affected access to care and was correlated with the development of secondary bony injury and a higher rate of postoperative dislocations. Clinicians should practice with increased awareness of how public insurance status can significantly affect patient outcomes by delaying access to care—particularly if delays lead to increased patient morbidity and health care costs.

Association of Insurance Status With Treatment Delays for Pediatric and Adolescent Patients Undergoing Surgery for Patellar Instability

“… 15 , 18 Similarly, adolescents with shoulder instability have higher rates of bony pathology and anterior labral pathology, in addition to higher incidence of recurrent dislocation. 7 In this study, we evaluated the influence of anatomic risk factors. Data are abundant on the impact of findings such as younger age, skeletal immaturity, increased patellar height, and trochlear dysplasia on increasing risk of recurrent instability.…”

“…Recent studies have investigated the role of socioeconomic and characteristic factors in delays in care in pediatric and adolescent orthopaedic sports medicine. 5 , 7 , 12 , 15 , 16 , 18 Much of the literature demonstrates longer time to treatment in those with public or government-based insurance. To date, there is no evidence of similar trends in patients with patellar instability.…”

Epidemiology and Revision Rates of Pediatric ACL Reconstruction in New York State

“…Patel et al 34 retrospectively examined pediatric patients undergoing ACLR at a tertiary care children's hospital and found that government-assisted insurance status was associated with significant delays in definitive management of their injuries. Other studies have shown disparities in access to care for other sports-related conditions in pediatric and adolescent patients, including access to care for meniscal pathology 25,32 and shoulder instability, 22 as well as access to advanced diagnostic imaging modalities. 7 This study was not without limitations.…”

Disparities in Youth Sports and Barriers to Participation

“…Shoulder instability also falls within this trend. Hung et al examined a series of pediatric and adolescent patients with shoulder instability and found that patients with public insurance had to wait 5 times longer for initial evaluation, 4 times longer for MRIs, were twice as likely to have bony pathology, and had post-operative dislocation at higher rates (24.3%) [42].…”