Disparities in fetal surgery access: Association with twin-twin transfusion syndrome stage at initial consultation

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Among individuals with twin-twin transfusion syndrome (TTTS), we sought to determine if insurance type was associated with advanced TTTS disease at the time of surgical consultation. This was a retrospective cohort study of individuals with Quintero stage I-IV TTTS undergoing laser surgery at a single center, 2015-2021. Excluded individuals had out-of-state residency, higher order multiples, surrogate or monoamniotic gestations. Primary exposure was insurance type, defined as private/commercial insurance (Commercial), public fee for service (FFS) or traditional Medi-Cal (e.g., California Medicaid), and public Medi-Cal/Covered California Group Plans including self-pay (Group). Primary outcome was Quintero stage III/IV (high TTTS stage), as determined during initial surgical consultation. Secondary outcomes included gestational age and fetal growth restriction (FGR). We compared sociodemographic and obstetric variables at initial consultation across insurance type. Outcomes with p< 0.10 in bivariate analyses were tested using multiple logistic regression models; demographic data were tested for relevance as covariates. Of 362 individuals in this contemporary cohort, 243 met study criteria. The Table provides cohort demographics. Non-Hispanic White individuals were more likely to have Commercial insurance (44.2% vs. FFS 12.8% vs. Group 19.3%, p< 0.0001). In bivariate analyses, high TTTS stage and FGR were associated with insurance type. In adjusted logistic regression, Group insurance was associated with increased odds of presenting with high TTTS stages (OR 2.33, 95%CI 1.16-4.70) and FGR (OR = 2.02, 95%CI 1.06-3.86) (Figure). FFS insurance was not associated with any of these outcomes. Individuals with public Group plans were more likely than those with Commercial plans to present with higher stage TTTS and FGR at initial surgical evaluation, suggesting there may be gaps or delays in access to fetal surgical care for individuals with public insurance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)