Does Universal Insurance and Access to Care Influence Disparities in Outcomes for Pediatric Patients With Osteomyelitis?

Abstract

Purpose: Although insurance expansion efforts may mitigate racial disparities in surgical outcomes, prior studies have not examined these effects on differences in pediatric orthopaedic care. To assess for racial disparities in pediatric orthopaedic care that may persist despite insurance expansion, we asked whether (1) the rates of surgical intervention and (2) 90-day outcomes were different among pediatric patients with osteomyelitis insured through TRICARE, the healthcare program of the United States Department of Defense and a model of universal insurance and healthcare access. Methods: We analyzed TRICARE claims from 2005 to 2016. We identified 2906 pediatric patients, of whom 62% (1810) were white and 18% (520) were black. A surgical intervention was performed in 9% of the patients (253 of 2906 patients). The primary outcome was receipt of surgical intervention for osteomyelitis. Secondary outcomes included 90-day complications, readmissions, and returns to the emergency department. The primary predictor variables were race and sponsor rank. Patient demographic (age, sex, race, sponsor rank, beneficiary category, and geographic region) and clinical information (prior comorbidities, environment of care, treatment setting, and length of stay) were used as covariates in multivariable logistic regression analyses. Results: After controlling for demographic and clinical factors including age, sex, sponsor rank, beneficiary category, geographic region, Charlson comorbidity index, environment of care, and treatment setting, black children were more likely to undergo surgical interventions for osteomyelitis than white children (odds ratio 1.78; 95% confidence interval, 1.26-2.50; p = 0.001). When stratified by environment of care, this finding persisted only in the civilian healthcare setting (OR 1.85; 95% CI, 1.26-2.74; p = 0.002). Additionally, after controlling for demographic and clinical factors, lower socioeconomic status (junior enlisted personnel) was associated with a higher likelihood of 90-day emergency department use overall (OR 1.60; 95% CI, 1.02-2.51; p = 0.040). Conclusions: We found that for pediatric patients with osteomyelitis in the universally insured TRICARE system, many of the historically reported disparities in care were absent, suggesting they benefitted from improved access to healthcare. However, despite universal coverage, racial disparities persisted in the civilian care environment, suggesting that no single intervention such as universal insurance sufficiently addresses differences in racial disparities in care.