Purpose
Prior studies evaluated the impact of insurance type on access to hand care. However, there is limited literature quantifying whether patient symptoms are worse at the time of intervention. Our primary null hypothesis was that insurance type would not be associated with Patient-Reported Outcomes Measure Information System (PROMIS) Upper-Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores at the preoperative visit before carpal tunnel release (CTR).
Methods
Between December 2016 and November 2018, patients with known carpal tunnel syndrome presenting to a tertiary academic hand clinic for the preoperative visit within 3 months of CTR, completed PROMIS UE, PF, PI, and Depression computer adaptive tests. Patient characteristics were recorded, including insurance type as commercial, Medicare, Medicaid, or workers’ compensation. Multivariable linear regression was used to determine which variables were associated with PROMIS scores at the preoperative visit before CTR.
Results
A total of 301 patients were included in the analysis. All PROMIS domains were significantly different by insurance type; Medicaid patients had the worst preoperative score for all domains in bivariate analysis. In multivariable linear regression modeling, commercial insurance was associated with better preoperative PROMIS UE, PF, PI, and Depression scores.
Conclusions
Commercial insurance is associated with significantly better preoperative PROMIS PF, PI, and Depression scores compared with other insurance types (ie, Medicaid, Medicare, and Workers’ compensation). This may be the result of a number of factors, including differences in access to hand care or life circumstances that allow for only certain individuals to seek hand care early on in the disease process. However, further research is warranted to determine more definitively why this association exists.
Type of study/level of evidence
Prognostic II.
Key words
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in the upper extremity.
1
One successful definitive treatment for CTS is a carpal tunnel release (CTR), a surgical intervention with a lifetime prevalence of 3.1%.National Institute of Neurological Disorders and Stroke
Carpal Tunnel Syndrome Fact Sheet.
Carpal Tunnel Syndrome Fact Sheet.
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Carpal-Tunnel-Syndrome-Fact-Sheet
Date accessed: November 30, 2019
2
Given the pathophysiology of CTS, performing a CTR before permanent neurologic damage is often recommended to maximize the chance for recovery. Therefore, it is crucial for hand surgeons to recognize patient and societal factors that lead to patients seeking care for CTS.The impact of insurance type on access to health care is well-established in the literature. Prior research demonstrated that patients with commercial insurance are more likely to have access to physician appointments and gain timely access to care compared with those with Medicaid insurance.
3
,4
When evaluating the hand surgery literature specifically, similar findings were reported. For example, Draeger et al5
that found fictitious patients with acute flexor tendon lacerations who had Medicaid insurance had notably more barriers with access to care in North Carolina than did those with private insurance. In addition, Ayoade and Fowler6
found that pediatric patients with a diagnosis of trigger thumb and covered by Medicaid faced greater obstacles to accessing appropriate care. These findings were further corroborated by Calfee et al,7
who found that economically disadvantaged patients with Medicaid or no insurance faced substantial barriers accessing hand surgery care. In addition, Cheng and Rodner8
demonstrated that publicly insured patients seeking care for cubital tunnel syndrome were delayed in seeing an orthopedic surgeon for evaluation, and when such patients did present, they had notably worse symptoms.The literature consistently demonstrates that insurance type has an impact on access to orthopedic surgery care. However, aside from Cheng and Rodner’s
8
study assessing the association of insurance type and cubital tunnel syndrome presentation, there appears to be a paucity of research examining whether the downstream impact of access inequity leads to patients with lesser insurances who have worse symptoms when presenting or preparing to undergo common hand surgery procedures, such as CTR. We thought that a study along the same lines of Cheng and Rodner's work for patients with CTS undergoing CTR was warranted. If CTS symptoms were worse at the final preoperative visit for patients with lesser insurance types when accounting for other factors (eg, age, sex, and/or self-reported race), this would suggest that many patients who needed assistance faced accessibility barriers in receiving appropriate CTS-related hand surgery care.The primary null hypothesis of this study was that insurance type would not be associated with Patient-Reported Outcomes Measure Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores at the preoperative visit before CTR.
Materials and Methods
Our institutional review board approved this study. Patients presenting to a single academic hand clinic for the preoperative visit before CTR were identified in the patient-reported outcomes measure database. Patients who presented between December 2016 and November 2018 were considered for inclusion. The database included PROMIS domain scores as well as a number of patient characteristics. The PROMIS UE, PF, PI, and Depression computer adaptive tests (CATs) are completed as part of routine clinical care at our institution.
9
The PROMIS is a patient-reported outcome measure that uses item response theory as part of a CAT and is designed to be normed to the population with a mean score of 50 and SD of 10.10
, 11
, 12
, HealthMeasures. PROMIS. Available at: http://www.healthmeasures.net/score-and-interpret/interpret-scores/promis. Accessed November 1, 2019.
13
However, PROMIS Depression has been shown to have a notable floor effect in many clinical orthopedic scenarios.14
,15
A higher score indicates more of the construct being evaluated. For PROMIS UE and PF, high scores represent better functional status. In contrast, for PROMIS PI and Depression, lower scores represent less difficulty with function owing to pain and better mental health status.Only patients with a diagnosis of CTS who had a preoperative visit within 90 days of CTR were included in the current study. Patients with incomplete PROMIS UE, PF, PI, or Depression CATs were excluded. In addition to PROMIS scores, we recorded patient characteristics from our institutional database: age (in years), sex, self-reported race (white, black, or other), days from preoperative visit to CTR, and insurance status (commercial, Medicare, Medicaid, or workers’ compensation). All of our hand surgeons saw and treated patients with all of the described insurance types.
Descriptive patient characteristics were determined. Chi-square analysis was used to compare categorical patient variables by insurance status, whereas one-way analyses of variance were used to compare continuous patient variables by insurance status. We conducted multivariable linear regression analyses to determine which patient variables were associated with PROMIS UE, PF, PI, and Depression scores at the preoperative visit before CTR. Four separate models were built with a different PROMIS domain as the dependent variable for each. For each model, we included age, sex, self-reported race, and insurance in the multivariable linear regression analysis. We included these variables because they have been shown to be potential factors influencing delay or avoidance of health care services, or access to them.
5
,7
,16
, 17
, 18
In addition, we used the variance inflation factor (VIF) to ensure the included independent variables did not display excessive levels of multicollinearity. Generally, VIF values of greater than 5 to 10 suggest concerning levels of multicollinearity.19
,20
For the study, all variables had a VIF of 2.15 or below.It is important for our regression coefficient estimate results to be viewed in terms of both statistical significance and clinical importance. We believe that clinical relevance relates to a difference in PROMIS domain score at or above the minimal clinically important difference (MCID), which is commonly estimated using a distribution-based or anchor-based approach.
21
,22
The distribution-based approach estimates MCID at about one-half of 1 SD,23
or about 5 for PROMIS domains. Within hand surgery, PROMIS UE, PF, and PI MCID anchor-based estimates have ranged from 4.2 to 8.0, 2.7 to 4.6, and 4.1 to 9.7, respectively.21
,24
For all statistical analyses, significance was set at .05.
Results
A total of 301 patients were included in the analysis. Most patients were white (242; 80%) and female (187; 62%), average age 57 years (range, 22–89 years) (Table 1). Average PROMIS UE, PF, PI, and Depression scores were 37.2 (SD, 10.4), 42.6 (SD, 9.3), 59.0 (SD, 8.7), and 50.2 (SD, 11.0), respectively (Table 1).
Table 1Patient Characteristics (n = 301)
| Characteristic | Value |
|---|---|
| Age, y (mean [range]) | 57 (22–89) |
| Sex, n (%) | |
| Female | 187 (62) |
| Male | 114 (38) |
| Race, n (%) | |
| White | 242 (80) |
| Black | 38 (13) |
| Other | 21 (7.0) |
| Insurance, n (%) | |
| Commercial | 102 (34) |
| Medicaid | 59 (20) |
| Medicare | 91 (30) |
| Workers' compensation | 49 (16) |
| Final preoperative visit, d (mean [range]) | 37 (1–89) |
| PROMIS score (mean [SD]) | |
| UE | 37.2 (10.4) |
| PF | 42.6 (9.3) |
| PI | 59.0 (8.7) |
| Depression | 50.25 (11.0) |
In bivariate analysis, there was no difference in the number of days between the preoperative visit and CTR by insurance type (P = .49) (Table 2). There was a significant difference across insurance types for sex; significantly greater percentage of women were enrolled in Medicaid (P < .05). Furthermore, there was significant difference in age across insurance types; the age of those covered by Medicare was higher than for other insurance types (P < .05). All PROMIS domains were significantly different by insurance type; Medicaid patients had the worst preoperative score for all domains and commercial patients had the best (P < .05) (Table 2).
Table 2Comparison of Patient Characteristics by Insurance Type (n = 301)
| Characteristic | Commercial (n = 102) | Medicare (n = 91) | Medicaid (n = 59) | Workers' Compensation (n = 49) | P Value |
|---|---|---|---|---|---|
| Age, y (mean [SD]) | 55 (9) | 69 (10) | 47 (9) | 52 (10) | <.05 |
| Sex, n (%) | <.05 | ||||
| Female | 68 (67) | 50 (55) | 45 (76) | 24 (49) | |
| Male | 34 (33) | 41 (45) | 14 (24) | 25 (51) | |
| Race, n (%) | <.05 | ||||
| White | 90 (88) | 78 (86) | 37 (63) | 37 (76) | |
| Black | 8 (8) | 12 (13) | 12 (20) | 6 (12) | |
| Other | 4 (5) | 1 (1) | 10 (17) | 6 (12) | |
| Final preoperative visit, d (mean [SD]) | 36 (22) | 37 (24) | 36 (23) | 42 (22) | .49 |
| PROMIS domain (mean [SD]) | |||||
| UE | 40.1 (10.0) | 38.5 (10.4) | 31.9 (8.8) | 35.0 (10.1) | <.05 |
| PF | 45.8 (9.7) | 41.7 (8.5) | 38.9 (8.1) | 42.1 (9.0) | <.05 |
| PI | 57.2 (8.0) | 58.3 (9.3) | 62.7 (8.2) | 59.6 (8.2) | <.05 |
| Depression | 47.2 (9.5) | 49.4 (10.2) | 57.3 (11.2) | 49.0 (11.7) | <.05 |
In multivariable linear regression analysis, age (β = 0.13; 95% confidence interval [CI], 0.02–0.25; P < .05), female sex (β = –2.82; 95% CI, –5.16 to –0.47; P < .05), and commercial insurance (β = 6.20; 95% CI, 2.89–9.51; P < .05) were associated with final preoperative PROMIS UE scores (Table 3). When considering MCID estimates, the commercial insurance regression coefficient estimate may be both statistically and clinically relevant. Indeed, the regression coefficient for commercial insurance in this analysis indicated that patients enrolled in commercial insurance had PROMIS UE scores that were 6.20 points better, when accounting for other patient factors, than patients covered by Medicaid (ie, the insurance type reference group in the multivariable linear regression).
Table 3Patient Characteristics Independently Associated With PROMIS UE Score (n = 301)
| Patient Characteristics | Adjusted R2 Regression Coefficient (95% CI) | P Value |
|---|---|---|
| Age, y | 0.13 (0.02 to 0.25) | <.05 |
| Sex | ||
| Male | Reference | |
| Female | –2.82 (–5.16 to –0.47) | <.05 |
| Race | ||
| White | Reference | |
| Black | –2.44 (–5.86 to 0.99) | .16 |
| Other | –2.97 (–7.52 to 1.57) | .20 |
| Insurance | ||
| Medicaid | Reference | |
| Medicare | 2.52 (–1.54 to 6.58) | .22 |
| Commercial | 6.20 (2.89 to 9.51) | <.05 |
| Workers' compensation | 1.41 (–2.37 to 5.19) | .46 |
For PROMIS PF, female sex (β = –2.16; 95% CI, –4.30 to –0.02; P < .05) and commercial insurance (β = 5.52; 95% CI, 2.50–8.54; P < .05) were associated with the final preoperative scores (Table 4). Similar to PROMIS UE, the commercial insurance regression coefficient estimate may be both statistically and clinically relevant based on both distribution-based and anchor-based MCID estimates.
Table 4Patient Characteristics Independently Associated With PROMIS PF Score (n = 301)
| Patient Characteristics | Adjusted R2 Regression Coefficient (95% CI) | .09 P Value |
|---|---|---|
| Age, y | 0.07 (–0.03 to 0.18) | .17 |
| Sex | ||
| Male | Reference | |
| Female | –2.16 (–4.30 to –0.02) | <.05 |
| Race | ||
| White | Reference | |
| Black | –1.13 (–4.25 to 1.99) | .47 |
| Other | –3.35 (–7.50 to 0.79) | .11 |
| Insurance | ||
| Medicaid | Reference | |
| Medicare | 0.08 (–3.62 to 3.80) | .97 |
| Commercial | 5.52 (2.50 to 8.54) | <.05 |
| Workers' compensation | 2.00 (–1.44 to 5.45) | .25 |
For PROMIS PI, age (β = –0.14; 95% CI, –0.25 to –0.04; P < .05) and commercial insurance (β = –4.07; 95% CI, –6.93 to –1.21; P < .05) were associated with the final preoperative scores (Table 5). Based on MCID estimates, the commercial insurance regression coefficient was close to both the distribution-based and anchor-based MCID estimates; thus, the strength of the association between commercial insurance and final preoperative PROMIS PI scores may not be clinically relevant.
Table 5Patient Characteristics Independently Associated With PROMIS PI Score (n = 301)
| Patient Characteristics | Adjusted R2 Regression Coefficient (95% CI) | .07 P Value |
|---|---|---|
| Age, y | –0.14 (–0.25 to –0.04) | <.05 |
| Sex | ||
| Male | Reference | |
| Female | 0.86 (–1.17 to 2.88) | .41 |
| Race | ||
| White | Reference | |
| Black | 0.95 (–2.00 to 3.91) | .53 |
| Other | 1.52 (–2.40 to 5.44) | .45 |
| Insurance | ||
| Medicaid | Reference | |
| Medicare | –0.92 (–4.42 to 2.59) | .61 |
| Commercial | –4.07 (–6.93 to –1.21) | <.05 |
| Workers' compensation | –2.16 (–5.42 to 1.10) | .19 |
For PROMIS Depression, age (β = –0.16; 95% CI, –0.28 to –0.03; P < .05), commercial insurance (β = –8.41; 95% CI, –11.93 to –4.89; P < .05), and workers’ compensation (β = –7.33; 95% CI, –11.35 to –3.31; P < .05) were associated with the final preoperative PROMIS Depression score (Table 6). The regression coefficient estimates for commercial insurance and workers’ compensation were clinically relevant based on the distribution-based MCID estimate. The regression coefficient estimates may also be clinically relevant based on an anchor-based MCID estimate, but we unaware of such an estimate in the hand literature to date.
Table 6Patient Characteristics Independently Associated With PROMIS Depression Score (n = 301)
| Patient Characteristics | Adjusted R2 Regression Coefficient (95% CI) | .12 P Value |
|---|---|---|
| Age, y | –0.16 (–0.28 to –0.03) | <.05 |
| Sex | ||
| Male | Reference | |
| Female | 0.33 (–2.17 to 2.83) | .80 |
| Race | ||
| White | Reference | |
| Black | –0.43 (–4.08 to 3.21) | .82 |
| Other | 3.76 (–1.08 to 8.59) | .13 |
| Insurance | ||
| Medicaid | Reference | |
| Medicare | –3.95 (–8.27 to 0.37) | .07 |
| Commercial | –8.41 (–11.93 to –4.89) | <.05 |
| Workers' compensation | –7.33 (–11.35 to –3.31) | <.05 |
Discussion
Prior hand surgery research demonstrated that insurance status can have an impact on access to care, and that patients enrolled in Medicaid potentially faced notably more barriers.
5
, 6
, 7
,25
In addition, a prior study demonstrated that publicly insured patients seeking care for cubital tunnel syndrome had substantially worse symptoms than their privately insured counterparts. This was most likely explained by a delay in receiving appropriate evaluation and treatment.8
Overall, however, there is a paucity of literature quantifying whether patient symptoms are worse once patients receive care and prepare for surgical intervention for common hand conditions, such as those undergoing a CTR for CTS, on the basis of insurance type. In the current study, we found that commercial insurance was associated with better PROMIS UE, PF, PI, and Depression scores at the final preoperative visit when we accounted for patient age, sex, self-reported race, and other insurance types. For all PROMIS domains except PROMIS PI, the regression coefficient estimates were large enough (ie, at or above the level of MCID estimates) that the difference in symptoms between those with commercial insurance and those covered by Medicaid (ie, the insurance type reference group in the multivariable linear regression) were likely clinically relevant.One hypothesis for our findings is that patients with commercial insurance may have better access to care, which allows them to be seen and treated when symptoms are less advanced. As previously noted, insurance status has been shown to have an impact on access to orthopedic care; this is true for both pediatric
26
,27
and adult patients.28
,29
Importantly, Kim et al30
found that for patients with Medicaid who sought surgical care for CTS, similar barriers and delays were present despite the passage of the Patient Protection and Affordable Care Act. Symptoms of CTS typically progress over time, and patients with private insurance have been shown to receive earlier appointments and intervention. Therefore, we believe that the current findings, in which patients with commercial insurance undergoing CTR had better self-reported symptom severity using a validated patient-reported outcomes measure at the preoperative clinic visit, were to be expected.Another hypothesis is that patients with commercial insurance have higher expectations when it comes to care. In a study of patients seeking foot and ankle care, the wealthiest patients based on Area Deprivation Index values were satisfied with the quality of life given the symptom severity if the symptoms were near the population norm, whereas the poorest patients based on Area Deprivation Index values were satisfied with the quality of life given the symptom severity if the symptoms were about 1 SD below the population norm.
31
Therefore, our findings may indicate that patients with commercial insurance, which may be a proxy for wealth, or better jobs that provide insurance, undergo CTR when the self-reported symptoms are less severe than those enrolled in Medicaid or other insurance because of higher expectations.A final hypothesis is that patients enrolled in Medicaid may have circumstances that preclude them from seeking care when symptoms first arise. This may be because insurance type could be a proxy for wealth, socioeconomic status, or both. Wealthier patients may have more flexibility to seek care when needed, with fewer personal or financial repercussions. However, patients with Medicaid may think that they cannot miss work to seek medical care because of concerns regarding losing income or their job. Hamad et al
32
found that job insecurity was associated with decreased health care use; however, future research is warranted to determine whether this is the case for patients with CTS.This work had limitations. First, although there was no difference in the average number of days between the preoperative visit and the time when patients ultimately underwent CTR based on insurance type, we included patients who completed the questionnaires anytime within 90 days of surgery. Therefore, some patients reported symptoms nearly 3 months before surgery, whereas others did so a few weeks before surgery. Although patients with PROMIS scores from a range of dates (e.g., within 60 or 90 days of surgery) were defined as the preoperative data point in previous studies evaluating CTR outcomes,
21
,33
future research may confirm our findings using PROMIS scores from a more narrow window before surgery or even on the day of surgery. Second, our database did not include employment information for patients. Thus, we were unable to determine whether job type (eg, manual laborer vs not manual laborer) had an impact on findings or whether it differed by insurance status. Nonetheless, we believe the findings are important because policy proposals to ensure equal access to care can address equity more practically based on insurance type than job type owing to a clearer definition of each type of insurance. Third, because the data were pulled from the database in aggregate and deidentified, we were unable to consider objective measures of CTS severity in this study; therefore, it was not possible to compare a patient’s self-reported symptom severity with objective measures. We believe future research can assess the impact of insurance on objective measures such as electrodiagnostic testing, 2-point discrimination, and/or thenar atrophy or weakness. Fourth, the findings were based on data from a single institution from one state; thus, results may not be generalizable. Because insurance coverage and eligibility, including for Medicaid, differ from state to state, future work should seek to confirm our findings within our state as well as in other states, although the literature is consistent in showing the impact of insurance type on access to hand surgery care.This study builds on previous research demonstrating that patients with Medicaid who seek hand surgery care face barriers to receiving timely intervention. Our findings suggest that unequal access to care by insurance type, which was confirmed in previous studies,
3
, 4
, 5
,7
may ultimately lead patients with Medicaid to undergo CTR when symptoms are more advanced. Another potential explanation is that patients with commercial insurance, who likely are wealthier than those with Medicaid, have higher care expectations and undergo CTR when self-reported symptoms are less advanced. Our work sets the groundwork for future work ultimately to determine the underlying cause of the difference in self-reported symptoms at the preoperative visit before patients undergo CTR and may lead to improved policy to ensure improved hand care access for all.References
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- Carpal tunnel release: lifetime prevalence, annual incidence, and risk factors.Muscle Nerve. 2018; 58: 497-502
- Does Medicaid insurance confer adequate access to adult orthopaedic care in the era of the Patient Protection and Affordable Care Act?.Clin Orthop Relat Res. 2017; 475: 1527-1536
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- Minimal clinically important differences for PROMIS Physical Function, Upper Extremity, and Pain Interference in carpal tunnel release using region- and condition-specific PROM tools.J Hand Surg Am. 2019; 44: 635-640
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- Minimal clinically important difference for PROMIS Physical Function in patients with distal radius fractures.J Hand Surg Am. 2019; 44 (454.e451–459.e451)
- Variations in utilization of carpal tunnel release among medicaid beneficiaries.J Hand Surg Am. 2019; 44: 192-200
- Pediatric orthopaedic patients presenting to a university emergency department after visiting another emergency department: demographics and health insurance status.J Pediatr Orthop. 2007; 27: 690-694
- Impact of insurance status on time to evaluation and treatment of meniscal tears in children, adolescents, and college-aged patients in the United States.Orthop J Sports Med. 2019; 72325967119875079
- The influence of medical insurance on patient access to orthopaedic surgery sports medicine appointments under the Affordable Care Act.Orthop J Sports Med. 2017; 52325967117714140
- Survey of patient insurance status on access to specialty foot and ankle care under the Affordable Care Act.Foot Ankle Int. 2016; 37: 776-781
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- Do patient sociodemographic factors impact the PROMIS scores meeting the patient-acceptable symptom state at the initial point of care in orthopaedic foot and ankle patients?.Clin Orthop Relat Res. 2019; 477: 2555-2565
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Article info
Publication history
Published online: January 07, 2021
Accepted:
October 26,
2020
Received:
December 15,
2019
Footnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2021 by the American Society for Surgery of the Hand. All rights reserved.
