O2104: Different Roads Traveled: Disparities in the Preoperative Timeline Result in Delays to Pediatric Anterior Cruciate Ligament Reconstruction

Background: Inequities in the timing of pediatric ACL reconstruction (ACLR) are well established, but it is unclear exactly where in the preoperative timeline these disparate delays originate. This study aims to identify differences in the course and timing of preoperative care for pediatric ACL injuries with respect to insurance and race/ethnicity. Such data can guide intervention design.

Methods: Patients aged ≤18 years that underwent primary ACLR at a single tertiary children’s hospital were included in this retrospective cohort study. Exclusion criteria included multiligament reconstructions, previous knee surgery, or intentionally delayed ACLR. We calculated the time elapsed between various timepoints, including injury, first evaluation, magnetic resonance imaging (MRI), evaluation by the treating surgeon, and ACLR. Also noted were the number and types of clinicians seen before surgery. Multivariate regressions were used to calculate odds ratios (OR) and 95% confidence intervals (CI) while controlling for confounders.

Results: A total of 534 patients were included (mean age 15.8±1.8 years, 51% male). Children with public insurance and Latinx/Hispanic and Black patients had increased odds of surgery ≥90 days after injury (Table 1). Seeking opinions from multiple surgeons (more common for privately insured and white patients) was not associated with this delay, but seeing ≥3 total clinicians (more common for publicly insured patients) was. Publicly insured (OR 1.7, 95% CI 1.1-2.7; p=0.03) and Latinx/Hispanic patients (OR 1.7, 95% CI 1.1-3.0; p=0.04) were more likely to be misdiagnosed prior to MRI than privately insured and white patients, respectively. Children with public insurance had 1.7 times higher odds of initial evaluation in an emergency department (ED) or urgent care (UC) than those with private insurance (95% CI 1.1-2.5, p=0.009). Latinx/Hispanic (OR 2.1, 95% CI 1.3-3.3; p< 0.002) and Black patients (OR 2.1, 95% CI 1.2-3.7; p=0.009) were also more likely to visit an ED/UC initially. Finally, insurance or race/ethnicity were associated with delays at every point in the preoperative timeline, even when controlling for confounders (Table 1).

Conclusion: When considering insurance and race/ethnicity, inequities in timing of ACLR result from disparate delays in each step of the preoperative timeline. Additionally, publicly insured or racially minoritized patients are more likely to be misdiagnosed initially, first seek care at an ED/UC (rather than with a pediatrician or surgeon), and see ≥3 clinicians before surgery.