The association between patient education level and economic status on outcomes following surgical management of (fracture) non-union.

Background: Socioeconomic disparities are an inherent and currently unavoidable aspect of medicine. Knowledge of these disparities is an essential component towards medical decision making, particularly among an increasingly diverse population. While healthcare disparities have been elucidated in a wide variety of orthopaedic conditions and management options, they have not been established among patients who present for treatment of an ununited fracture. The purpose of this study is to answer the following questions: 1) Following surgical management of (fracture) non-unions, are there differences in outcomes between differing ethnic groups? 2) Following surgical management of (fracture) non-unions, are there differences in outcomes between patients with differing education levels? 3) Following surgical management of (fracture) non-unions, are there differences in outcome between patients with differing incomes?
Methods: Between September 2004 and December 2017, operatively treated patients who presented with a long bone fracture non-union were prospectively followed. These patients presented with a variety of fracture non-unions that underwent surgical intervention. Sociodemographic factors were recorded at presentation. Long-term outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, post-operative complications and physical exam at latest follow up. The SMFA is a 46-item questionnaire, assessing patient functional and emotional response to musculoskeletal ailments.
Results: Three-hundred-twenty-nine patients met inclusion criteria. Patients with a lower education had worse long-term functional outcomes (P < 0.001) and increased pain scores (P = 0.002) at latest follow-up. Patients who made less than $50,000 annually had worse long-term functional outcomes (P = 0.002) and reported higher pain scores (P = 0.003) following surgical management of (fracture) non-unions. Multiple linear regression demonstrated education level to be an independent predictor of long-term functional outcomes following surgical management of (fracture) non-unions (B= -0.154, 95% Confidence Interval [CI]=-10.96 to -1.26, P = 0.014). No differences existed in outcomes or pain scores between those of different ethnic groups. No differences existed regarding post-operative complications and time to union between patients of different ethnic groups, educational levels and income status.
Conclusion: Patients with lower education levels and individuals who make less than $50,000 annually have worse functional outcomes following surgical management of (fracture) non-unions. Orthopaedic trauma surgeons should therefore be aware of these disparities, and consider early interventions aimed at optimizing patient recovery in these subsets.
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