title: Impact of insurance status on ability to return for outpatient management of pediatric supracondylar humerus fractures.
abstract: OBJECTIVE
  Outcomes are excellent following surgical management of displaced supracondylar humerus fractures. Short delays until surgical fixation have been shown to be equivalent to immediate fixation with regards to complications. We hypothesized that insurance coverage may impact access to care and the patient's ability to return to the operating room for outpatient surgery.
  
  
  METHODS
  A retrospective review of supracondylar humerus fractures treated at a large urban pediatric hospital from 2008 to 2012 was performed. Fractures were classified by the modified Gartland classification and baseline demographics were collected. Time from discharge to office visits and subsequent surgical fixation was calculated for all type II fractures discharged from the emergency department. Insurance status and primary carrier were collected for all patients.
  
  
  RESULTS
  2584 supracondylar humerus fractures were reviewed, of which 584 were type II fractures. Of the 577 type II fractures with complete records, 383 patients (61 %) were admitted for surgery and the remaining 194 were discharged with plans for outpatient follow-up. There was no difference in insurance status between patients admitted for immediate surgery. Of the 194 patients who were discharged with type 2 fractures after gentle reduction, 59 patients (30.4 %) ultimately underwent surgical fixation. Of these, 42 patients were privately insured (58.3 % of patients with private insurance), 16 had governmental insurance (15.1 %), and 1 was uninsured (6.3 %). Patients with private insurance were 2.46 times more likely to have surgery than patients with public or no insurance (p = 0.005). Of the 135 patients who did not eventually have surgery, 92 (68.1 %) were seen in the clinic. Patients with private insurance were 2.78 times more likely to be seen back in the clinic when compared to publicly insured or uninsured patients (p = 0.0152).
  
  
  CONCLUSIONS
  Despite an equivalent number of privately insured and publicly insured patients undergoing immediate surgery for type II fractures, those with public or no insurance who were discharged were 2.46 times less likely to obtain outpatient surgery when compared to privately insured patients. Patient insurance status and the ability to follow up in a timely manner should be assessed at the time of initial evaluation in the emergency department. Level of evidence Level 3.
authors: Department of Orthopaedics, Emory University, 59 Executive Park South NE, Atlanta, GA, 30329, USA. Nicholas.d.fletcher@emory.edu.
authors: Nicholas D
authors: ND
authors: Fletcher
authors: Department of Orthopaedics, Emory University, 59 Executive Park South NE, Atlanta, GA, 30329, USA.
authors: Bryan J
authors: BJ
authors: Sirmon
authors: Department of Orthopaedics, Emory University, 59 Executive Park South NE, Atlanta, GA, 30329, USA.
authors: Ashton S
authors: AS
authors: Mansour
authors: Department of Orthopaedics, Emory University, 59 Executive Park South NE, Atlanta, GA, 30329, USA.
authors: William E
authors: WE
authors: Carpenter
authors: Department of Biostatistics, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA.
authors: Laura A
authors: LA
authors: Ward
keywords: Access to care; Insurance; Medicaid; Supracondylar humerus fracture