So, we all know that lower socioeconomic status and public insurance are both associated with barriers to care following an ACL injury, and those include lower likelihood to receive surgical management, a longer delay from initial injury to surgery, and a higher likelihood of concomitant pathologies before undergoing an ACL reconstruction. And prior studies have mostly focused on self-reported indicators of socioeconomic factors and may have overlooked the influence that the community has on deprivation on interactions of health care system. So, the ADI, or the Area of Deprivation Index, is a quantitative measure of social deprivation consisting of 17 measures of deprivation that you can see here on the table on your right. That's measured on the census block level, so basically using the patient's address. Greater ADI indicates a greater social deprivation, and the ADI has been shown to influence health outcomes, even independently of other common socioeconomic measures. This data is free and publicly available. So, Dr. Sheng, in 2022, evaluated how we should be measuring social deprivation in orthopedic patients, and after evaluating almost 80,000 orthopedic encounters, he concluded that the insurance classification was the most consistent association for orthopedic patient-reported physical health, and also that the ADI stratified patients across a wider range of values. So, if we combine these two measures, the national ADI and the insurance classification, this has been shown to predict the most variability in orthopedic patient-reported physical health. And over the past several decades, there has been an increased interest in ADI. In 2020, Dr. Sheth evaluated and found that the ADI was predictive of a worse preoperative function, pain, and increased opiate use in patients undergoing a primary shoulder replacement. In 2021, Dr. Glogovac evaluated the ADI and also found it to be predictive of more opiate requirement after an arthroscopic knee surgery. And more recently, in hand surgery in patients with carpal tunnel syndrome, Dr. Bernstein and Dr. Wright found that the ADI has been related to the patient's severity at the beginning of presentation. However, none of these studies have evaluated, at least to our knowledge, and have evaluated ADI with care characteristics and ACL re-injury rate after reconstruction. So the purpose of this study was to investigate how the ADI or the area of deprivation index and insurance type actually affects timing of care and re-injury rate after an ACL reconstruction. And we hypothesized that a greater national ADI percentile and Medicaid insurance status will be associated with delays in care and an increased risk of re-injury. So we retrospectively evaluated 205 patients aged from 12 to 40 years old with a minimum follow-up of two years that underwent a primary unilateral ACL reconstruction with autograph from 2016 to 2019. And in terms of demographics, we obtained the ADI from the Neighborhood Atlas. This is a website from the University of Wisconsin. And we also subdivided the patient's insurance between commercial and Medicaid. Our outcomes of interest were time from injury to specialized care and time from injury to surgery and also if the patient sustained a second ACL injury defined as a graft failure or a contralateral ACL injury. So we ended up with 205 total patients with demographics of an average age of 23 years old. 46% were female, 43% white with an average national ADI of 16. In terms of access to care, the mean time from injury to specialized care was 103 days. The mean time from injury to surgery was 142 days. In terms of graft source, 55% had bone patella tendon, 43% hamstring. And in terms of insurance type, 82% were commercial insurance, 18% Medicaid insurance. When we evaluated the access to care, we found that a greater national ADI, meaning patients with lower socioeconomic status, was associated with a longer time from injury to specialized care and a longer time from injury to surgery. However, when we evaluated insurance status, this was not associated with delays in care. When we evaluated the second ACL injury group, we found that almost 15.6% of patients experienced a second ACL injury, meaning a contralateral injury or an extralateral ACL injury. And this group had a higher national ADI, and that was statistically significant. And they also had a higher proportion of Medicaid patients as well. You can see that in the table here. So we conclude that a lower socioeconomic status adversely affects timing of care and re-injury rates following an ACL injury. Patients with a greater national ADI percentile, meaning a lower socioeconomic status, took significantly longer to reach specialized care and to obtain surgery following an ACL injury. However, patients with Medicare insurance status were not associated with a delay of care. And patients utilizing Medicaid insurance and those with a greater national ADI percentile were more likely to sustain a re-injury following an ACL reconstruction. Thank you very much.

socioeconomic factors

orthopedic care

ACL injuries

Area of Deprivation Index

health outcomes