# Insurance Status and Income Proxies Are the Most Consistent Predictors of Disparities in Access to Care and Outcomes After Medial Patellofemoral Ligament Reconstruction in the United States: A Systematic Review

## TL;DR

This study finds that insurance status and income are the biggest factors affecting access to care and outcomes after a specific knee surgery in the U.S.

## Contribution

The study systematically identifies socioeconomic and insurance-related disparities in access and outcomes after medial patellofemoral ligament reconstruction.

## Key findings

- Insurance status and income proxies consistently predict disparities in care access and outcomes after MPFLR.
- Privately insured patients had better evaluation, treatment, and outcomes compared to publicly insured patients.
- Minority race or ethnicity was linked to delayed evaluation and lower surgical intervention rates.

## Abstract

To evaluate the influence of health care access, insurance coverage, racial and ethnic identity, income-related proxies, employment status, preventive care use, and geographic location on the diagnosis, treatment, and outcomes after medial patellofemoral ligament reconstruction (MPFLR).

A systematic review of electronic databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify Level II-IV clinical studies related to patellar instability that were published between January 2010 and January 2025. Studies were included if they were peer-reviewed English-language studies detailing the socioeconomic and demographic factors of outcomes after MPFLR. Case reports, systematic reviews, animal and cadaver studies, and publication formats other than peer-reviewed journal studies were excluded.

Seven studies met inclusion criteria, which resulted in a total 983,985 patients (983,658 female, 99.97%, and 327 male, 0.03%). Three studies (42.9%) found that insurance status affected the evaluation and treatment of patients with patellar instability, and subsequent outcomes after MPFLR, with those who were privately insured experiencing a better clinical course with regards to evaluation, treatment, and outcomes. Four (57.1%) studies identified race or ethnicity as a factor that influenced the prevalence of patellar instability, treatment, cost, and outcomes. One study (12.5%) found certain markers of high income such as home ownership, full-time employment, and having a recent health check-up positively affected the evaluation, treatment, and postoperative outcomes of patients with patellar instability.

This systematic review found that lower socioeconomic status, public insurance coverage (as opposed to private coverage), and minority racial or ethnic identity were associated with delayed evaluation, lower likelihood of surgical intervention, and reduced postoperative compliance or satisfaction among patients undergoing MPFLR. Patients with these characteristics experience longer wait times from injury to clinic evaluation and have reduced odds in selection as a candidate for surgery. Postoperative satisfaction was also markedly worse for surgical patients with these characteristics.

Level IV, systematic review of Level III and IV studies.