Abstract

BACKGROUND: Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs.METHODS: We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010-2019 were identified by ICD-9/10 diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, non-infectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications.RESULTS: We included 245,396 patients for analysis. 14% of Medicaid patients (1,789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately-insured patients and 16% (13,305/83,068) of Medicare patients (pairwise p < 0.001). TTS (Medicaid: 11.7 days, private: 10.6 days (p < 0.001), Medicare: 10.7 days (p = 0.003)) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio [OR]: 0.77 [95% confidence interval (CI): 0.63 - 0.93] for private vs Medicaid, and 0.71 [95% CI: 0.59 - 0.88] for Medicare vs Medicaid) and experienced fewer 90-day postoperative complications (adjusted ORs: 0.73 [95% CI: 0.62 - 0.85] for private vs Medicaid, 0.65 [95% CI: 0.55 - 0.77] for Medicare vs Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications.CONCLUSION: There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality-improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers patients face and minimize healthcare inequities seen in the treatment of PHFs based on insurance type.

View details for DOI 10.1016/j.jse.2022.11.016

View details for PubMedID 36581135