Impact of Socioeconomic Status on Concomitant Injuries and Access to Care Following ACL Injury

Abstract

Time to ACL reconstruction has been shown to vary greatly in diverse patient populations, and delay has been associated with additional knee pathology. However, there is a paucity of literature examining the correlation between lower socioeconomic status, delay in treatment and increased concomitant pathologies following ACL injury. The purpose of this study was to identify socioeconomic factors in patients sustaining an ACL tear that may influence a delay in seeking treatment or lead to concomitant pathology at the time of surgery. All patients undergoing ACL reconstruction at our institution between November 2015 and August 2018 were identified. Patients were emailed a survey asking about income, highest level of education, primary language spoken at home and the number of re-injuries prior to surgery. Insurance status, date of injury, number of weeks from the initial injury to the first visit with orthopaedic surgery, and date of surgery were recorded from the patient’s medical record. Multiple linear regression with backwards elimination was used to determine statistically significant independent predictors for each outcome. A standard least squares model was used for continuous variables and a nominal regression model for nominal variables. Standard summary statistics are reported for demographic information. The predictive value of the time between the injury and seeing an orthopaedic surgeon on meniscus tears was assessed by establishing a cutoff value that maximized sensitivity and specificity. Then, the group that saw a surgeon faster was compared to the slower group by Chi-Square analysis or Fisher’s Exact Test, depending on the number of patients in each cell. P < .05 was considered significant. Of the 241 patients who met the inclusion criteria, 126 responded to the survey, with an average age of 26.5 ± 9.88 years. Insurance information from all 241 patients was used. Patients with commercial insurance visited an orthopaedic surgeon 39.4 weeks earlier (P=.012) and underwent surgery after being seen by an orthopaedic surgeon 5 weeks sooner (P=.016) as compared to patients with government insurance. English speaking patients independently predicted an earlier visit with an orthopaedic surgeon by 55.86 weeks compared to non-English-speaking patients (P=.027). Speaking English predicted earlier surgery after seeing an orthopaedic surgeon by 21 weeks compared to non-English speakers (P=.019). Additionally, non-English speakers had an odds ratio of 4.62 for having a bucket handle medial meniscus tear at the time of ACL reconstruction (P=.01; CI=1.67-21.3) compared to English speakers. With respect to education, having a college degree predicted earlier initial visit to an orthopaedic surgeon by 36 weeks (P=.023) and predicted earlier surgery by 32 weeks (P=.036) compared to those without a college degree. The level of education completed was not an independent predictor of a bucket handle meniscus tear at the time of surgery. Income level was not a significant independent predictor of number of weeks from initial injury to seeing an orthopaedic surgeon, or time between the initial visit with orthopaedics and surgery. However, having a household income less than $100,000/year independently predicted 0.25 more episodes of instability (P=.039), and an odds ratio of 7.37 (CI=1.20-53.39) for having a bucket handle medial meniscus tears at the time of surgery. Time from injury to seeing an orthopaedic surgeon longer than 13 weeks significantly increased the chance of any type of meniscus tear (P=.007) and specifically non-bucket tears (P=.022). Times longer than 30 weeks, 4 days significantly increased the chance of a bucket handle meniscus tear at the time of surgery compared to both no meniscus tear (P < .001) and a non-bucket type meniscus tear (P < .001). Patients with government insurance and who were non-English-speaking experienced later access to care and later surgery after orthopaedic surgery evaluation. Non-English-speaking patients also experienced higher rates of re-injury, instability, and bucket handle medial meniscus tears. Patients without a college degree also experienced later access to care. Patients with a household income less than $100,000/year experienced higher rates of instability and bucket handle medial meniscus tears. Delayed access to orthopaedic care longer than 13 weeks was associated with higher rates of meniscus tears, and after 30 weeks bucket handle meniscus tears were significantly increased. These data may inform the orthopaedic and broader medical communities of the impact of lower socioeconomic status on patients' access to care and higher rates of concomitant injuries.