SLR - March 2019 - Nicole Spalj

Evaluating Patients for Elective Outpatient Foot and Ankle Surgery: Insurance as a Predictor of Patient Outcomes

Reference: Bakhsh W, Childs S, Oh I, Flemister S, Baumhauer J, Ketz J. Evaluating Patients for Elective Outpatient Foot and Ankle Surgery: Insurance as a Predictor of Patient Outcomes. Foot and Ankle Specialists. 2019 Jan [Epub ahead of print].

Scientific Literature Review

Reviewed By: Nicole Spalj, DPM

Residency Program: Detroit Medical Center, Detroit, MI

Podiatric Relevance: Numerous factors result in a successful outcome following surgery. In elective foot and ankle surgery, proper patient selection, appropriate procedure choice, compliance, postoperative management and follow-up all play a role in determining the outcome of each procedure. Although these are all important aspects to achieve a successful outcome, a patient’s socioeconomic status, and similarly his or her health insurance, has not been studied extensively in the field of foot and ankle surgery. The goal of this study is to evaluate whether outcomes in elective foot and ankle surgery are correlated with socioeconomic status via insurance level and to identify what preoperative steps can be taken to address these issues and improve postoperative results.

Methods: Patients were evaluated and treated at a single surgical center between January 1, 2015 and January 1, 2016. They were identified by CPT codes used for elective foot and ankle procedures. Inclusion criteria involved patients between 18 and 80 years old who had a minimum of one-year follow-up. Exclusion criteria included patients with subsequent ipsilateral lower-extremity trauma or surgery, preexisting neuropathy, patients who sought follow-up care elsewhere, worker’s compensation cases and those with insufficient follow-up or incomplete data. Retrospective chart review was performed on all patients. Postoperative outcomes included the number of narcotic prescriptions refills, office visits, missed appointments, surgical complications, PROMIS (patient-reported outcomes measurement information system) survey and the VAS pain scores at last clinic appointment. Patients were separated into two groups: a) standard coverage insurance (private and Medicare) and b) underinsured (uninsured and Medicaid).

Results: Two hundred sixty-seven patients met criteria for the study with 82 percent in the insured group and 18 percent in the underinsured group. Average age, comorbidities, incidence of diabetes and English comprehension were all similar between groups. BMI was significantly different, as was smoking and employment status. There was no difference in postoperative complications, clinic appointments scheduled or ancillary services utilized. However, the underinsured group had a significantly higher amount of narcotic refills, missed appointments and VAS pain scores. There was also a statistically significant difference between groups in function scores, pain control and depressed mood (PROMIS survey). Similarly, when compared to preoperative evaluations individually, the insured group showed a greater improvement in function, pain and mood. Furthermore, smoking, BMI, diabetes and comorbidities were not significant dependent variables in determining outcomes of narcotic refills, clinic visits or PROMIS score.

Conclusions: In elective foot and ankle surgery, patient selection is extremely important. Although this study is limited in its data and length of follow-up, the authors concluded that underinsured patients have increased postoperative pain, worse function and mood and are a costlier healthcare burden than insured patients. This article does help provide assistance with patient selection; however, moving forward, surgeons will need to find a way to determine preoperative measures to ensure that underinsured patients achieve as successful of outcomes as their insured counterparts.

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