O2098: Public Insurance Is Strongly Associated with Worse Pre-operative and Post-operative Quality of Life for Surgically Managed Adolescent Idiopathic Scoliosis

Background: In recent years, stronger emphasis has been placed on the social determinants of health in orthopaedic diseases. In adolescent idiopathic scoliosis (AIS), patients with public insurance are more likely to have more severe disease at initial presentation and, thus, are less likely to be indicated for non-operative management than patients with private insurance. We do not yet know, however, how insurance type is associated with patient quality of life, including in patients who require surgical management.

Methods: This retrospective cohort study was conducted among AIS patients who were surgically managed with posterior spinal fusion (PSF) at a large, urban tertiary children’s hospital. The primary independent variable of interest was insurance type, which we classified as public or private depending on the insurance plan at the time of PSF. For patient-reported outcomes, we used the results of the Scoliosis Research Society’s SRS-30 and SRS-22, which synthesize patient responses into composite scores for pain, mental health, self-image, functioning, satisfaction, and overall quality of life. Patients are asked to complete these surveys throughout pre- and post-operative periods. Composite scores are out of 5.0, with lower values indicating worse scores.

Results: Among 263 patients who underwent PSF between 2017 and 2022 at our hospital, 187 were publicly insured and 76 were privately insured (71% and 29%, respectively). There were no significant differences between these cohorts in demographics (age, sex, BMI, race, ethnicity), initial recommendation (observation, brace, or surgery), Cobb angle (at initial visit and at surgery), or time to surgery (Table 1). Pre-operatively, publicly insured patients were significantly more likely to report worse scores in total and for each individual domain except satisfaction. In the post-operative period, publicly insured patients were significantly more likely to report worse scores for pain and mental health at six weeks, six months, and one year post-operatively (Table 2).

Conclusion: At our tertiary children’s hospital, we found that publicly insured patients had worse quality of life metrics prior to surgery and, notably, in the mental health and pain domains at all measured timepoints after surgery up to one year. These findings were despite no differences in demographics, pre-operative Cobb angle, or time to surgery, suggesting that factors beyond delay in treatment may play a role. While difference in insurance type could directly contribute to these differences, insurance type may also serve as a proxy for other differences between groups such as social determinants of health that are more difficult to measure. Future work should continue to parse out the factors that contribute to decreased quality of life metrics both before and after surgery, so that intentional interventions can be designed to help mitigate these disparities.