Socioeconomic Factors Are Associated With Trends in Treatment of Pediatric Femoral Shaft Fractures, and Subsequent Implant Removal in New York State.
BACKGROUND
Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment.


METHODS
Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal).


RESULTS
Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal.


CONCLUSIONS
There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here.


METHODS
Level III-retrospective cohort study.
*Hospital for Special Surgery and Weill Cornell Medical College, New York, NY ‡Rutgers New Jersey Medical School, Newark, NJ †Department of Orthopaedic Surgery, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
Emily
E
Dodwell
James
J
Wright
Roger
R
Widmann
Flo
F
Edobor-Osula
Ting-Jung
TJ
Pan
Stephen
S
Lyman
D000293:Adolescent; D001741:Black or African American / Q000706:statistics & numerical data; D001860:Bone Plates; D002648:Child; D000070628:Closed Fracture Reduction / Q000706:statistics & numerical data; D020878:Device Removal / Q000706:statistics & numerical data*; D005006:Ethnicity / Q000706:statistics & numerical data*; D005260:Female; D005264:Femoral Fractures / Q000628:therapy*; D005269:Femur / Q000601:surgery*; D005592:Fracture Fixation / Q000379:methods; D005593:Fracture Fixation, Internal / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000208:ethnology / Q000706:statistics & numerical data; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D015999:Multivariate Analysis; D009518:New York; D000070799:Open Fracture Reduction / Q000706:statistics & numerical data; D011203:Poverty / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D012044:Regression Analysis; D012189:Retrospective Studies; D012923:Social Class; D012959:Socioeconomic Factors; D044465:White People / Q000706:statistics & numerical data