# Association Between Public Insurance and Quality of Life Outcomes in Surgically Treated Adolescent Idiopathic Scoliosis

## TL;DR

Publicly insured patients with adolescent idiopathic scoliosis report lower quality of life before and after surgery compared to those with private insurance.

## Contribution

This study identifies disparities in quality of life outcomes between public and private insurance holders undergoing scoliosis surgery.

## Key findings

- Publicly insured patients had worse preoperative scores in function, pain, self-image, mental health, and total QOL.
- Postoperatively, publicly insured patients still reported lower pain and mental health scores at multiple follow-up points.
- Function, self-image, and total QOL improved similarly post-surgery across insurance types.

## Abstract

Background: The role of social determinants of health is becoming increasingly studied in orthopedic diseases. In adolescent idiopathic scoliosis (AIS), patients with public insurance have been shown to have larger Cobb angles, longer waits for surgery, and longer hospitalizations, although the literature is conflicting. We do not yet know how insurance type is associated with patient quality of life (QOL) in AIS patients who require surgical management.

Methods: This retrospective cohort study was conducted among AIS patients surgically managed with posterior spinal fusion (PSF). The primary independent variable was insurance type, classified as public or private. For patient-reported outcomes, we used the Scoliosis Research Society Patient Outcome Questionnaires, which synthesizes patient responses into scores for pain, mental health, self-image, functioning, satisfaction, and total QOL. Patients completed surveys throughout the preoperative and postoperative periods.

Results: Among 263 patients who underwent PSF, 188 (71%) were publicly insured and 75 (29%) were privately insured. Between groups, significant differences were noted for race (P<0.001) and ethnicity (P = 0.01), but no other demographic or preoperative characteristics. Publicly insured patients reported significantly worse preoperative scores for function (3.85 vs 4.11, P = 0.008), pain (3.88 vs 4.31, P = 0.001), self-image (3.18 vs 3.51, P = 0.003), mental health (3.81 vs 4.21, P = 0.002), and total QOL (3.63 vs 3.97, P<0.001). Postoperatively, publicly insured patients continued to report worse scores for pain at six weeks (3.73 vs 3.98, P = 0.03) and six months (4.16 vs 4.40, P = 0.04), and worse mental health scores at six weeks (3.97 vs 4.23, P = 0.03), six months (4.06 vs 4.30, P = 0.05), and one year (4.04 vs 4.36, P = 0.03).

Conclusions: Publicly insured patients were found to have worse QOL metrics in nearly all domains prior to surgery and for pain and mental health after surgery. Equalization of function, self-image, and total QOL metrics postoperatively suggests that access to appropriate surgical interventions may help mitigate some, but not all, of these preoperative differences.

This study provides Level III evidence, based on a retrospective cohort design.