After ACL Injury in Children and Adolescents, Where in the Preoperative Timeline do Disparities in Timing and Clinical Course Originate?

backgroundDisparities in the timing of pediatric ACL reconstruction (ACLR) have been described along the lines of insurance and race. However, it is unclear where exactly in the preoperative timeline these inequities originate. Effective interventions to mitigate disparities cannot be designed without understanding this. This study aims to identify differences in the course and timing at each stage of the pre-ACLR process with respect to insurance and race or ethnicity. Such data can be used in the development of strategies to reduce delays for pediatric patients with ACL injuries. QUESTIONS/PURPOSES: (1) When considering insurance and race or ethnicity, where in the preoperative timeline do disparate delays occur? (2) Do patients who are publicly insured or those in racially or ethnically minoritized groups experience differences in the type and number of clinicians seen before surgery?

methodsIn this retrospective, comparative study, we identified 591 patients treated surgically for ACL injuries between 2011 and 2023. Of those, patients aged 18 years or younger who underwent primary ACLR were included. Fifty-seven were excluded due to intentionally delayed surgery, staged procedures, multiligamentous reconstruction, or prior surgery in either knee, leaving 534 for analysis. The mean ± SD age was 16 ± 2 years, and 51% (271) of participants were boys. Demographic data were collected, as well as the time elapsed between various preoperative timepoints, including injury, initial evaluation, MRI, evaluation by the treating surgeon, and surgery. We also documented the number and types of clinicians seen before surgery. Race and ethnicity data were selected by the patient in the medical record based on the available categorizations in the system, which did not allow for more nuanced identification of nationality, immigration status, generationality, and other characteristics that may be unique for individuals selecting the umbrella term "Hispanic." Additionally, although confounding social determinants besides insurance and race can play a role in access to care, race may be associated with unique factors like cultural perspectives, trust, and others that are not directly tied to other social influences. Furthermore, some of these other social determinants may be the consequence of historic discrimination along the lines of race. Univariable analysis was followed by purposeful entry multivariable regression to adjust for confounders. Insurance as well as race and ethnicity were included in all multivariable models to determine whether they were associated with outcome variables (time between various clinical events or visits, types of clinicians seen, and number of clinicians seen). All findings pertaining to race and ethnicity accounted for insurance type in regression analysis. Multivariable results are reported with odds ratios (ORs) and 95% confidence intervals (CIs).

resultsAfter controlling for race and ethnicity as well as other variables (number of clinicians seen, multiple surgeons seen, misdiagnosis before MRI) when relevant, children with public insurance had higher odds of initial evaluation more than 14 days after injury (OR 4.2 [95% CI 1.2 to 15.3]; p = 0.03), MRI more than 60 days after injury (OR 7.4 [95% CI 2.1 to 25.5]; p = 0.002), evaluation by the treating surgeon more than 60 days after initial evaluation (OR 4.4 [95% CI 1.3 to 14.7]; p = 0.02), and more than 90 days between injury and surgery (OR 4.6 [95% CI 1.9 to 11.0]; p < 0.001). Independent of insurance, non-White Hispanic patients had higher odds of MRI more than 60 days after injury (OR 6.7 [95% CI 1.9 to 24.6]; p = 0.004), evaluation by the treating surgeon more than 60 days after initial evaluation (OR 4.4 [95% CI 1.2 to 16.1]; p = 0.03), and more than 90 days between injury and surgery (OR 3.7 [95% CI 1.5 to 9.3]; p = 0.006). When adjusting for covariance between race or ethnicity and insurance, children with public insurance had higher odds of initial evaluation in an emergency department or urgent care (OR 2.1 [95% CI 1.1 to 4.1]; p = 0.03), evaluation by three or more clinicians before surgery (OR 1.8 [95% CI 1.2 to 2.8]; p = 0.004), and misdiagnosis before MRI (OR 1.7 [95% CI 1.1 to 2.7]; p = 0.03). Independent of insurance, non-White Hispanic patients were more likely to visit an emergency department or urgent care for their initial evaluation (OR 2.6 [95% CI 1.3 to 5.4]; p = 0.008) and be misdiagnosed before MRI (OR 1.7 [95% CI 1.1 to 3.0]; p = 0.04) than White patients.

conclusionEven when accounting for covariation between insurance and race or ethnicity in children with ACL injuries, these factors are associated with disparities in the course and timing of care and exist at every step of the preoperative timeline. Although most of these disparities originate before orthopaedic evaluation, surgeons may consider strengthening relationships with local primary care, emergency medicine, and urgent care clinicians as well as other community stakeholders to facilitate communication and referrals when needed. Community-engaged and mixed-methods research approaches are required to better understand the mechanisms underlying disparities and to codesign multilevel interventions. The present data can be used in conjunction with future research to provide targets for interventions. LEVEL OF EVIDENCE: Level III, therapeutic study.