Disparities in Access to and Utilization of Surgical Care for Patients with Closed Unstable AO/OTA 44B2 Ankle Fractures and Medicaid

Background: Closed, unstable AO/OTA 44B2 ankle fractures are common injuries with similar distributions by age, sex, and race. The purpose of this study was to identify disparities in access to and utilization of surgical care for these injuries.

Methods: Ambulatory patients ≥18 years of age with capitated Medicaid health insurance who presented from January 2016 to February 2020 with an isolated, closed AO/OTA 44B2 ankle fracture with radiographic evidence of instability were retrospectively identified at 1 Level-I safety-net trauma center. Associations between patient characteristics (age, sex, preferred language, race, ethnicity, housing status, employment, and substance use) and measures of access to and utilization of ankle fracture surgery (days from injury to evaluation, being offered surgery, undergoing surgery, and days from evaluation to surgery) were investigated on bivariable and multivariable analysis.

Results: Of the 1,116 patients who were screened, 323 met the inclusion criteria. The included patients had a median age of 41 years; 207 patients (64%) were male and 255 (79%) were Hispanic. Patients presented at a mean of 4.6 ± 7.0 days from injury. Delayed presentation was associated with self-identification as Hispanic (rate ratio [RR], 1.93; 95% confidence interval [CI]: 1.17, 3.12]) and with marijuana use (RR, 1.59; 95% CI: 1.08, 2.36), whereas significantly earlier presentation was associated with a non-English language preference (RR, 0.64; 95% CI: 0.46, 0.89), alcohol abuse (RR, 0.74; 95% CI: 0.55, 0.99), and illicit drug use (RR, 0.30; 95% CI: 0.14, 0.67). Ankle fracture surgery was offered to 274 patients (85%). Experiencing homelessness was associated with a decreased likelihood of being offered surgery (odds ratio [OR], 0.15; 95% CI: 0.03, 0.69). Of patients who were offered surgery, 216 (79%) underwent surgery. Black patients underwent surgery significantly less frequently than patients who identified as White (OR, 0.14; 95% CI: 0.01, 0.77). The median time from evaluation to surgery was 11 days (interquartile range, 7 to 14 days). Patients who used illicit drugs experienced a mean delay to surgery of 6.0 days relative to those who did not use illicit drugs (mean time to surgery, 16.8 ± 7.1 and 10.8 ± 5.1 days, respectively).

Conclusions: We identified disparities in access to and utilization of surgical care for unstable AO/OTA 44B2 ankle fractures that negatively affected patients with Medicaid insurance who identified as Hispanic or Black, were experiencing homelessness, or used illicit drugs. These disparities may negatively affect outcomes for patients receiving care in similar environments, such as capitated health-care networks and public safety-net health systems.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.