Examining Health Disparities in Orthopedic Care During COVID-19

Abstract

Background

Demographics and socioeconomic status affect the delivery of medical care resulting in healthcare disparities. The purpose of this study was to investigate the impact of COVID-19 on existing healthcare disparities, including access to healthcare in the outpatient orthopedic surgery clinic.

Methods

The medical records of 3006 patients treated at the University of Kentucky Orthopedic Surgery Department prior to COVID-19 (April 2018, 2019), and during the COVID-19 pandemic (2020) were retrospectively reviewed for demographic data, distance to clinic, and type of visit. We then compared the total number of patient visits, new patient visits, telehealth visits, and the patient’s insurance provider (public or private) between the time period prior to and during the pandemic.

Results

During the COVID-19 pandemic, there were significant declines in the number of patients seen, new patient presentations, and publicly insured patients. Thirty-three percent of visits were telemedicine visits in 2020 compared to 0% pre-COVID (P < .0001). There was a lower proportion of initial visits in 2020 (P < .0001). The majority of patients paid via private/commercial insurance (1798, 59.8%), with a greater proportion paying via private/commercial insurance in 2020 (P < .001). The median average household income was increased in 2020 (P < .001).

Discussion

While COVID-19 resulted in a significant decline in overall access to care, there were negative ramifications particularly on patients with new complaints and those of lower socioeconomic status. Future endeavors should be focused on correcting the obstacles to accessing care, exacerbated by the pandemic, that these vulnerable populations face.

Key Takeaways

• • The COVID-19 pandemic placed additional strain on the healthcare system, exacerbating gaps in healthcare in already vulnerable populations.

• • In particular, the decline in access to care negatively impacted patients with new complaints, low socioeconomic status, and medical comorbidities.

• • Future studies and quality improvement projects should be aimed at correcting obstacles to accessing care, analyzing special population outlooks on accessing care, and pathways to accessing clinics.

Introduction

The COVID-19 pandemic has placed widespread strain on global economic and healthcare systems, disrupting the daily lives of people all around the globe. In addition, COVID-19 has had a disproportionately greater impact on minority and low-income populations. COVID-19 infection and mortality rates are significantly higher among African American individuals compared to Latino and white individuals.^1–4 The disproportionate burden of medical comorbidities and factors that prevent effective social distancing recommendations are two major contributors to the increased impact of COVID-19 on minority populations; but the concurrent presence of other disparities such as access to health insurance, lower quality of care, inability to obtain testing and healthcare resources, inadequate diet and lifestyle factors, and housing situations also likely contribute.^2,5,6 Aside from increased morbidity and mortality of vulnerable populations caused directly by COVID-19, adverse effects caused by the pandemic permeate into morbidity and mortality in other areas of medicine on these vulnerable populations as well due to disparities in underlying healthcare infrastructure and resource allocation. ⁷ In addition, many people experienced increased socioeconomic risks during the COVID-19 pandemic, including food insecurity, housing instability, transportation difficulties, and utilities difficulties. ⁸

Similar to the multifactorial nature of disparities related to COVID-19, multifactorial healthcare disparities in orthopedic care also exist. In addition to disparities due to race/ethnicity and sex, differences in a patient’s insurance status affect their ability to schedule appointments with an orthopedic provider and access to elective surgery. ⁹ Disparities in healthcare outcomes have also been noted. Specifically, uninsured patients, patients with public insurance, and patients of minority race or ethnicity experience poorer outcomes in orthopedic care. ⁹

Since its onset, the COVID-19 pandemic has had unprecedented effects and disruption of the delivery of healthcare in the United States, and subsequent solutions are associated with their own host of disparities. However, the impact of the COVID-19 pandemic on existing disparities in orthopedic care has not yet been extensively studied. The present study is a retrospective analysis to determine the impact of COVID-19 on existing healthcare disparities, including access to healthcare, in the orthopedic setting at the University of Kentucky Medical Center. We hypothesized that there will be a difference in patient characteristics presenting to the orthopedic clinic before the impact of COVID-19 compared to after COVID-19. This is an important step in identifying health disparities for musculoskeletal complaints in order to ensure equal care is provided for all patients.

Methods

Appropriate approval by the University of Kentucky Institutional Review Board was obtained prior to study initiation. Medical records for patients presenting to the University of Kentucky Medical Center orthopedic clinic during the month of April in 2018, 2019, and 2020 were reviewed retrospectively for data including demographics, type of visit (in-person or telehealth, initial visit or follow-up), insurance status, and distance to clinic. Income data was collected via UnitedStatesZipCodes.org Enterprise dataset to determine average household income based on the patient’s ZIP code of residence as documented in the patient medical record. All patients aged 18 years or older being seen by 5 orthopedic surgeons at the University of Kentucky Orthopedic Clinic were included in the study. The University of Kentucky Medical Center is a large, academic, tertiary referral center that receives patients from over half the state, including both urban and rural regions, providing a diverse patient population. There were no exclusion criteria.

April 2020 was selected as the pandemic time period analyzed because this is the month in which the hospital largely shutdown for elective procedures and maximum COVID restrictions were put in place. All elective cases were canceled and operating rooms were only open for emergent cases during this time. April of 2018 and 2019 were selected to compare as pre-COVID controls and two years were used in order to lower variability. This data was also used as the demographic control given the hospital’s wide catchment area and how hospital-wide data may be misleading due to inpatient versus outpatient nature of inquiry. The five surgeons selected for analysis areas of interest are as follows: hip and knee total replacement; arthroscopic shoulder and knee sports medicine; arthroscopic knee sports medicine; arthroscopic and open hip surgery; musculoskeletal oncology. No surgeons who specialized in trauma were included in this study, as the focus was on patients presenting as an outpatient for elective and semi-elective cases.

All statistical analyses were performed using Microsoft Excel data analysis package. For the purposes of statistical analyses, data from years 2018 and 2019 were combined to form a pre-COVID dataset, and 2020 data was considered post-COVID data. Statistical significance was set at P < .05. For categorical variables, frequencies and column percentages were reported and P-values were calculated using Chi-squared test. For all quantitative variables, mean and standard deviation (SD) or median and inter-quartile range were reported as appropriate, and P-values were calculated using independent t-tests. There were no variables that exceeded more than 5% missing values; however, n is reported as appropriate for variables with missing values.

Results

A total of 3006 patients presented to the 5 physicians in the University of Kentucky Orthopedic Clinic. There were 1292 patients seen in April 2018, 1250 patients seen in April 2019, and 464 patients seen in April 2020.

Across the 3 years included in these analyses, the mean age of patients was 48.5 years. There were 1495 (49.7%) male patients and 1511 (50.2%) female patients. There were 2629 (87.5%) Caucasian patients, 324 (10.8%) African–American patients, and 23 (.77%) Hispanic patients. The average distance traveled to clinic was 54.3 miles. The average age of patients seen decreased in 2020 (P = .018), (Table 1). Average body mass index (BMI) of patients was 30.5 kg/m², and average BMI was decreased in 2020 (P = .023), (Table 1).

Table 1.

Population Characteristics of Orthopedic Patients (n = 3006).

	Pre-COVID (n = 2542)	COVID (n = 464)	P-value
Demographics, n (%)
Male	1256 (49.4)	238 (51.3)	.460
Female	1285 (50.6)	226 (48.7)
Median [Q1, Q3]
Age(years)	53 [33, 64]	51 [28, 61]	.018
Weight (kg)	87.5 [72.6, 104.0]	86.0 [70.8, 103.2]	.229
Height(cm)	170.2 [162.6, 179.9]	172.7 [163.9, 180.3]	.094
BMI(kg/m2)	29.5 [25.3, 34.9]	28.9 [24.3, 34.4]	.023
Distance to clinic (mi)	25.2 [6.3, 68.9]	21.8 [6.5, 61.6]	.087
Race, n (%)	N = 2515	N = 461	.869
Caucasian	2225 (88.5)	404 (87.6)
African American	271 (10.8)	53 (11.5)
Hispanic	19 (.8)	4 (.9)
Type of visit, n (%)	N = 2542	N = 464	<.0001
In person	2542 (100.0)	311 (67.0)
Telehealth	0	153 (33.0)
Initial visit	616 (24.2)	59 (12.7)	<.0001
Follow-up	1926 (75.8)	405 (87.3)
Primary payment method, n (%)	N = 2537	N = 464
Private/commercial	1491 (58.8)	307 (66.2)	<.001
Medicare	701 (27.6)	84 (18.1)
Medicaid	293 (11.5)	63 (13.6)
Self-pay	25 (1.0)	3 (.7)
Other	27 (1.1)	7 (1.5)
Smoking status, n (%)	N = 2520	N = 458	.012
Nonsmoker	1689 (67.0)	339 (74.0)
Smoker	387 (15.4)	57 (12.4)
Previous smoker	444 (17.6)	62 (13.5)
Employment status, n (%)	N = 2485	N = 443	.470
Employed	1110 (44.7)	204 (46.0)
Unemployed	1127 (45.4)	203 (45.8)
Retired	248 (10.0)	36 (8.1)
Marital status, n (%)	N = 2501	N = 453	.661
Single	870 (34.8)	169 (37.3)
Married	1189 (47.5)	207 (45.7)
Divorced	297 (11.9)	55 (12.1)
Widowed	145 (5.8)	22 (4.9)
First language, n (%)	N = 2536	N = 464	.498
English	2518 (99.3)	462 (99.6)
Spanish	18 (.7)	2 (.4)
Average household income for ZIP code of residence (USD), median [Q1, Q3]	N = 2413	N = 451	<.001
	55726 [42929, 67834]	56644 [44377, 67834]

Legend: Miles (mi)

There were 153 (5.1%) telemedicine visits overall, all of which were in 2020. Thirty-three percent of visits were telemedicine visits in 2020 compared to 0% in 2018 and 2019 (P < .0001), (Table 1). There were 675 (22.5%) initial new patient visits overall. There was a lower proportion of initial visits in 2020 compared to 2018 and 2019 (P < .0001), (Table 1).

The majority of patients paid via private/commercial insurance (1798, 59.8%), with a greater proportion paying via private/commercial insurance in 2020 (P < .001). Medicare and self-pay were decreased in 2020 compared to 2018 and 2019 (P < .001), (Table 1).

The median average household income for all patients was $55,726. The median average household income in 2018 and 2019 was $55,726. The median average household income in 2020 was $56,644 (P < .001), (Table 1).

The majority of patients were reported non-smokers (2028, 67.5%). There was a decreased proportion of smokers and former smokers presenting in 2020 (P = .012), (Table 1).

There was no significant difference in weight, height, race, employment status, marital status, first language, or distance traveled to clinic between presenting patients during the two time periods (Table 1).

Discussion

Overall, patients seen in the orthopedic clinic during the COVID-19 pandemic were less likely to present for in-person initial visits, have risk factors for disease/complication, and have public insurance than patients seen prior to the COVID-19 pandemic. However, the overall number of patients seen in clinic also decreased.

The decrease in proportion of overall visits, and particularly initial visits, seen in the orthopedic clinic during the COVID-19 pandemic is consistent with other settings, in which evidence showed patients delayed seeking healthcare during the COVID-19 pandemic. There was a significant decrease in hospital admissions for heart attacks and strokes after the onset of the pandemic. Ambulatory care visits decreased nearly 60% after the onset of the pandemic. ⁴

This delay of care was even more prevalent in Medicaid-insured and non-insured patients, even despite outreach campaigns to engage patients in seeking healthcare during the COVID-19 pandemic. ⁴ The orthopedic clinic in the present study experienced a significant decrease in the proportion of patients with Medicare or no insurance during the COVID-19 pandemic compared to previous years, consistent with previous studies. ⁴ While not a direct measurement of socioeconomic status, patients with commercial insurance are more likely to have higher income than publicly insured patients. ⁴ In addition, most private insurance plans are obtained through employment or employment of a family member and those with lower socioeconomic status are more likely to be uninsured. ¹⁰ One reason to explain the significant decrease in the proportion of patients with Medicare or no insurance during the pandemic could be related to overall lower income and barriers to receiving care. ¹⁰ Potential barriers to care include access to technological devices, difficulty scheduling appointments, low health literacy, and difficulty accessing transportation. Patients who presented to the orthopedic clinic during the COVID-19 pandemic were significantly more likely to be residents in a ZIP code with a higher average household income level. Notably, the median household income for this study population is higher than the Kentucky median income reported as $52,238 in the 2020 census, while the United States median household income is reported as $64,994. ¹¹ This large difference between median incomes between the US national average and our study population, demonstrates the extensive presence of socioeconomically disadvantaged patient populations within our catchment area. The increase in median average household income of patients seen during 2020 demonstrates the increased socioeconomic risks within our catchment area that were worsened by the pandemic. These risks include food insecurity, housing instability, transportation difficulties, and utility difficulties. ⁸

These findings are consistent with other studies during the COVID-19 pandemic. Preventative healthcare and screening, such as breast cancer screening, declined during the COVID-19 pandemic, and this decline was even more pronounced among patients of underserved racial/ethnic groups and lower socioeconomic status. ¹² The number of patients seeking care for chronic conditions, including cancer, also decreased during the first year of the COVID-19 pandemic, with a significant decline in the proportion of low-income patients compared to years prior to the pandemic. ¹³ This delay of care is particularly detrimental to minority and low socioeconomic populations, which have an increased prevalence of comorbid medical conditions, that complicates medical care and affects outcomes. ⁴

The orthopedic clinic saw a decreased proportion of patients with risk factors for disease (older age, high BMI, and former smokers) present for care during the COVID-19 pandemic than years prior to the pandemic. These findings could be due in part to increased risk of severe infection and mortality of COVID-19 in patients with these risk factors, ¹⁴ and subsequent hesitation among patients to seek healthcare. However, there is an increased prevalence of these comorbidities among minority and low socioeconomic patient populations, which were less likely to access care as discussed previously. ⁴ While the decrease in BMI among patients presenting during the COVID-19 pandemic was statistically significant, the median BMI in the pre-COVID group (29.5 kg/m²) versus the COVID group (28.9 kg/m²) both fall within the overweight category, making this difference less clinically significant.

The significant increase in telehealth appointments seen in the orthopedic clinic during the COVID-19 pandemic is similar to responses to social distancing recommendations in other healthcare facilities across the country. In response to widespread stay-at-home orders during the COVID-19 pandemic, the use of telehealth drastically increased, with increases in telehealth use as high as 700% from early March to mid-April 2020 in New York City. ⁴ The Center for Medicare and Medicaid Services (CMS) and other insurance providers expanded coverage to include telehealth as well. ¹⁵

However, despite its utility in providing a means to access healthcare in concordance with social distancing guidelines, telehealth has its own issues in terms of healthcare disparities. During the COVID-19 pandemic specifically, Blacks and Hispanics had significantly higher odds of seeking care via in-person ER or office visits versus telehealth compared to Caucasians. Additionally, patients aged 65 or older were significantly more likely to seek care via in-person ER and office visits versus telehealth compared to other age groups. ¹⁵ Access to broadband internet connection is required for access to telehealth services. However, nearly one-third of rural Americans lack broadband connection access, and this disparity is even more prevalent among older adults and those of lower socioeconomic status.^16,17 For instance, the state of Kentucky has a lower proportion of residents with a household computer or broadband internet subscription (88.5% and 81.6%, respectively) compared to the overall United States population (91.9% and 85.2%, respectively). ¹¹ In addition to lack of adequate access, lack of familiarity and comfort with the required technology as well as cognitive and sensory impairments (especially in older patients) can impair the delivery of care via telehealth. ¹⁶ Therefore, while telehealth has its benefits, the impact on already disadvantaged patient populations should be considered so as not to exacerbate pre-existing healthcare disparities. ¹⁸

This study has several limitations. The present study was conducted at the University of Kentucky Medical Center, which is a large academic medical center that serves over half of the state, including a large population of rural, minority, underserved, and low socioeconomic patients. While the sample in this study comes from a diverse patient population, generalizability to larger patient populations nationwide is limited since the present study was conducted at a single institution. In addition, direct measurements of socioeconomic status such as individual annual household income, level of education, or occupation, were not reliably included in patient records and thus could not be included in study analysis. However, an approximation of patients’ average household income was derived from their zip code of residence to minimize this limitation. Future studies may be directed at analyzing possible prolonged changes resulting from the pandemic to see if the changes identified in the current study have continued after the acute shutdown phase. Prolonged effects of the pandemic are ongoing and constantly changing as more time passes, and as more data becomes readily available, new research evaluating the healthcare environment changes will be needed to guide the population needs for accessing healthcare. The vulnerable populations identified in this study should help direct public health campaigns to strengthen outreach programs and resources to assist these patients in accessing healthcare.

Overall, we found that patients with less risk factors for disease, patients with established orthopedic conditions, access to telehealth, private insurance, and residence in a zip code with higher average household income level was associated with increased access to care during the COVID-19 pandemic. In conclusion, the COVID-19 pandemic placed widespread strain on the healthcare system, exacerbating pre-existing healthcare disparities. These effects also permeate into orthopedic care, particularly among patients with new complaints, low socioeconomic status, and medical comorbidities. Future endeavors and healthcare delivery strategies should pay special consideration to these vulnerable populations in order to improve healthcare disparities in orthopedic care.