SLR - May 2019 - Matthew M. Knabel

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

Reference: Bakhsh, Wajeeh, et al. Evaluating Patients for Elective Outpatient Foot and Ankle Surgery: Insurance as a Predictor of Patient Outcomes. Foot & Ankle Specialist, Jan. 2019.

Scientific Literature Review

Reviewed By: Matthew M. Knabel, DPM 
Residency Program: Mount Auburn Hospital, Cambridge MA

Podiatric Relevance: Socioeconomic status has been demonstrated to have a significant relationship with patient access to healthcare, utilization of outpatient primary medical services and morbidity.  Medicare coverage has been found to be associated with a higher socioeconomic status than Medicaid patients. To aid in patient selection, this study aims to evaluate whether outcomes from 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: Inclusion criteria for this retrospective chart review involved patients between the ages of 18 and 80 years of age who underwent elective surgery at a single center from January 1, 2015 to January 1, 2016 with one-year follow-up. Patients were excluded if they had ipsilateral lower-extremity trauma or surgery, preexisting neuropathy, they sought follow-up care elsewhere or were covered under workers' compensation. Patients were classified by insurance: under-/uninsured (Medicaid, Option plans) versus fully insured. Outcomes they evaluated included narcotic refills, patient-reported outcomes (PROMIS) of pain, function and mood and compliance with follow-up visits. All surgeons used similar postop pain regimen and protocols. Follow-up visits were scheduled for week 2, week 6 and at the three-month mark. A pre hoc power analysis determined the following with regard to the primary outcomes: 46 patients required to detect a difference of 0.6 in narcotic refills, and 23 patients required to detect the minimum clinically important difference (MCID) of PROMIS scores. Statistical analysis involved mean comparison and multivariate regression modeling, with significance P < .05.

Results: Twenty-six patients were excluded for subsequent trauma or surgery to the ipsilateral limb. Two patients were lost to follow-up out of state and 42 patients were excluded for workers' compensation coverage. Three hundred sixty-seven were successfully followed for a minimum of one year. Cohort groups included 220 insured and 47 under-/uninsured. Outcomes between the insured and under-/uninsured groups differed significantly in narcotic refills (0.72 vs. 1.74 respectively, P < .01), missed appointments (0.13 vs. 0.62, P < .01) and PROMIS results (pain 54.5 vs. 60.2; function 44.3 vs. 39.5; mood 44.6 vs. 51.3; P < .01). The change in PROMIS scores from preoperative to one-year postoperative were different in pain (−7.3 vs −2.5, P = .03) and function (+6.3 vs +1.3, P = .04). Regression results confirmed insurance as a significant factor (coefficient 0.27, P < .01).

Conclusions: Their results demonstrate that under-/uninsured patients perform worse postoperatively with regard to pain, function and mood and are a costlier healthcare burden than their insured counterparts. This may alter surgical candidacy and inform patient selection, but more importantly, this study brings to light means of preoperative intervention to improve these outcomes for the under-/uninsured cohort. 

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