Insurance type associated with differing patient-reported outcomes in those with lumbar spinal stenosis

Andrew Simpson

Patients with lumbar spinal stenosis (LSS) who are insured in the USA through Medicaid have systematically worse baseline patient-reported outcome measures (PROMs) across almost all domains as compared to those with commercial insurance and Medicare, even after adjusting for confounders, new research has found.

Published in the journal Spine by Andrew Simpson (Brigham and Women’s Hospital, Boston, USA) et al, the retrospective cohort study sought to determine if insurance type is associated with differences in baseline PROMs among patients with LSS.

The researchers note that the study findings “have broad ranging implications for research and healthcare policy, especially when using PROMs as measures of value”.

A total of 688 patients with LSS were identified within a major academic health system and their baseline Patient-Reported Outcomes Measurement Information System for physical function, pain, anxiety and depression, and visual analogue scale for low back and leg pain analysed.

Wilcoxon rank-sum testing and chi-squared testing were utilised for descriptive non-adjusted comparisons. Negative binomial regression modelling was performed with PROMs considered as dependent variables, insurance type as the primary predictor, and all other factors (e.g. Charlson Comorbidity Index, age, gender, race, ethnicity, language spoken, and median geospatial household income) considered as covariates.

The mean age of the study cohort was 62.6 ± 14years with a slight female majority (50.7%). Patients with Medicaid insurance were younger, more likely to be Hispanic, and less likely to be English-speaking than those with commercial insurance or Medicare.

Overall, patients with Medicaid insurance were found to have worse baseline PROMs across almost all domains, with the worst performance in Patient-Reported Outcomes Measurement Information System 10 physical global (incidence rate ratio 0.88; 95% confidence interval [CI], 0.82–0.95) and mental function (incidence rate ratio 0.85; 95% CI, 0.80–0.92).

Speaking to Spinal News International, Simpson said: “This study contributes to the growing body of literature across various medical specialties highlighting that factors beyond the patient’s clinical scenario affect the manifestation of disease.

“In the United States, medical insurance type serves as a proxy for sociodemographic factors and patient resources. Approximately 18% of the US population is insured by Medicaid, which typically represents lower-income households. We found that, in patients with lumbar stenosis, those insured by Medicaid had worse patient-reported outcome measures across several domains as compared to patients with Medicare or private health insurance. In additional subsequent work, we also demonstrated similar findings in patients with disc herniations.

“As orthopaedic and spine specialists continue to leverage PROMs as measures of value in care delivery and potentially as decision aids for therapeutic guidance, it is imperative that health care stakeholders recognise and account for these systematic disparities in PROMs by insurance type. Our findings highlight the pervasive differences in how different populations experience similar disease states, and serve as a reminder that there is work to be done to ensure that all patients, including disadvantaged populations, get access to high quality spine care.

“I would like to thank the talented group of Harvard orthopaedic surgery residents, Alexander Crawford, Grace Xiong, Harry Lightsey, and Brian Goh, and my faculty colleagues, Andrew Schoenfeld, Stuart Hershman, and Jeremy Smith, that made this important work possible.”


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