SLR - May 2019 - Matthew M. Knabel
Evaluating Patients for Elective
Outpatient Foot and Ankle Surgery: Insurance as a Predictor of Patient
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.
Residency Program: Mount Auburn
Hospital, Cambridge MA
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