Are There Nationwide Socioeconomic and Demographic Disparities in the Use of Outpatient Orthopaedic Services?
Authors: Rabah Nicholas M. , Knusel Konrad D. , Khan Hammad A. , Marcus Randall E. 
Published: March 2020

Abstract

Background
Although disparities in the use of healthcare services in the United States have been well-documented, information examining sociodemographic disparities in the use of healthcare services (for example, office-based and emergency department [ED] care) for nonemergent musculoskeletal conditions is limited.

Questions/purposes
This study was designed to answer two important questions: (1) Are there identifiable nationwide sociodemographic disparities in the use of either office-based orthopaedic care or ED care for common, nonemergent musculoskeletal conditions? (2) Is there a meaningful difference in expenditures associated with these same conditions when care is provided in the office rather than the ED?

Methods
This study analyzed data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS). The MEPS is a nationally representative database administered by the Agency for Healthcare Research and Quality that tracks patient interactions with the healthcare system and expenditures associated with each visit, making it an ideal data source for our study. Differences in the use of office-based and ED care were assessed across different socioeconomic and demographic groups. Healthcare expenditures associated with office-based and ED care were tabulated for each of the musculoskeletal conditions included in this study. The MEPS database defines expenditures as direct payments, including out-of-pocket payments and payments from insurances. In all, 63,514 participants were included in our study. Fifty-one percent (32,177 of 63,514) of patients were aged 35 to 64 years and 29% were older than 65 years (18,445 of 63,514). Women comprised 58% (37,031 of 63,514) of our population, while men comprised 42% (26,483 of 63,514). Our study was limited to the following eight categories of common, nonemergent musculoskeletal conditions: osteoarthritis (40%, 25,200 of 63,514), joint derangement (0.5%, 285 of 63,514), other joint conditions (43%, 27,499 of 63,514), muscle or ligament conditions (6%, 3726 of 63,514), bone or cartilage conditions (8%, 5035 of 63,514), foot conditions (1%, 585 of 63,514), fractures (7%, 4189 of 63,514), and sprains or strains (18%, 11,387 of 63,514). Multivariable logistic regression was used to ascertain which demographic, socioeconomic, and health-related factors were independently associated with differences in the use of office-based orthopaedic services and ED care for musculoskeletal conditions. Furthermore, expenditures over the course of our study period for each of our musculoskeletal categories were calculated per visit in both the outpatient and the ED settings, and adjusted for inflation.

Results
After controlling for covariates like age, gender, region, insurance status, income, education level, and self-reported health status, we found substantially lower use of outpatient musculoskeletal care among patients who were Hispanic (odds ratio 0.79 [95% confidence interval 0.72 to 0.86]; p < 0.001), non-Hispanic black (OR 0.77 [95% CI 0.70 to 0.84]; p < 0.001), lesser-educated (OR 0.72 [95% CI 0.65 to 0.81]; p < 0.001), lower-income (OR 0.80 [95% CI 0.73 to 0.88]; p < 0.001), and nonprivately-insured (OR 0.85 [95% CI 0.79 to 0.91]; p < 0.001). Public insurance status (OR 1.30 [95% CI 1.17 to 1.44]; p < 0.001), lower income (OR 1.53 [95% CI 1.28 to 1.82]; p < 0.001), and lesser education status (OR 1.35 [95% CI 1.14 to 1.60]; p = 0.001) were also associated with greater use of musculoskeletal care in the ED. Healthcare expenditures associated with care for musculoskeletal conditions was substantially greater in the ED than in the office-based orthopaedic setting.

Conclusions
There are substantial sociodemographic disparities in the use of office-based orthopaedic care and ED care for common, nonemergent musculoskeletal conditions. Because of the lower expenditures associated with office-based orthopaedic care, orthopaedic surgeons should make a concerted effort to improve access to outpatient care for these populations. This may be achieved through collaboration with policymakers, greater initiatives to provide care specific to minority populations, and targeted efforts to improve healthcare literacy.

Level of Evidence
Level III, therapeutic study.