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Abstract Number: 1027

Single-Payer Health Insurance May Not Mitigate Income-Based Differences in Total Hip Arthroplasty Utilization: A Transnational Analysis

Bella Mehta1, Kaylee Ho2, J. Alex Gibbons3, Vicki Ling4, Susan Goodman5, Michael Parks5, Bheeshma Ravi6, Fei Wang2, Said Ibrahim7 and Peter cram8, 1Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, 2Weill Cornell Medicine, New York, NY, 3Columbia University Vagelos College of Physicians & Surgeons, New York, NY, 4Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, 5Hospital for Special Surgery, New York, NY, 6Sunnybrook Health Sciences Centre, Toronto, ON, Canada, 7Northwell Health, New York, NY, 8The University of Texas Medical Branch, Galveston, TX

Meeting: ACR Convergence 2023

Keywords: Access to care, Administrative Data, Arthroplasty, Disparities, socioeconomic factors

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Session Information

Date: Monday, November 13, 2023

Title: (1013–1032) Healthcare Disparities in Rheumatology Poster II: Socioeconomic Determinants

Session Type: Poster Session B

Session Time: 9:00AM-11:00AM

Background/Purpose: Access to care varies across health systems. Countries with universal health insurance are thought to have less wealth-based health disparities, but it is unclear if this applies to total hip arthroplasty (THA) utilization and outcomes. The purpose of this study was to determine whether a single-payer healthcare system would mitigate income-based disparities in THA utilization and outcomes.

Methods: We retrospectively compared all patients undergoing THA from 1/2012 to 9/2018 in Ontario (ON), Canada and Pennsylvania (PA), United States. We obtained PA patient data from Pennsylvania Health Care Cost Containment Council and ON patient data from Ontario’s Institute for Clinical Evaluative Sciences. Patient-level data were linked to Census data of median household income of the ZIP code or postal code of patients’ residence. We then analyzed whether community income-based differences in THA utilization were reduced in Ontario compared to Pennsylvania due to Canada’s single-payer healthcare system. We used logistic regression to examine the relative risks for lowest community income of outcomes such as rates of 1-year revision, 90-day mortality, and 90-day readmission in the two regions.

Results: Among all THAs, 13,280 patients (15.8%) and 16,850 patients (16.0%) lived in communities within the lowest income quintile in Ontario and Pennsylvania, respectively (Table 1). Overall THA utilization was lower in Ontario compared to Pennsylvania across income groups (Figure 1). In Ontario, patients in the highest income quintile utilized THA 43.2% more than those in the lowest income quintile (12.6 vs 8.8); this difference in utilization was slightly greater than the difference in Pennsylvania, where patients in the highest income quintile utilized THA 41.7% more than patients in the lowest income quintile (21.4 vs. 15.1) (p < 0.001). Patients in the lowest community income quintile in Pennsylvania had a greater rate of 1-year revision, 90-day mortality, and 90-day readmission compared to patients in the lowest income quintile of Ontario. However, after adjusting for age, sex, hospital volume, and rural vs. urban hospital, the odds for patients in the lower-income group compared to the higher-income group of 1-year revision (ON: OR 1.70, 95% CI: [1.34, 2.15]. PA: 1.30 [1.12, 1.52]), 90-day mortality (ON: 1.92 [1.24, 2.98]. PA: 1.66 [1.18, 2.33]), and 90-day readmission (ON: 1.48 [1.34, 1.62]. PA: 1.43 [1.34, 1.54] were greater in Ontario compared to Pennsylvania (Figure 2).

Conclusion: Income-based differences in THA utilization were greater in Ontario than in Pennsylvania. Additionally, patients in low-income communities in Ontario were at greater risk relative to higher community income patients for adverse outcomes. These findings suggest that a single-payer insurance system may not be sufficient to eliminate income-based differences in utilization and complications of THA.

Supporting image 1

Table 1: Characteristics of patients who underwent total hip arthroplasty in Ontario and Pennsylvania by community income level

Supporting image 2

Figure 1: Utilization rate of total hip arthroplasty for patients in Ontario and Pennsylvania by community income level

Supporting image 3

Figure 2: Adjusted odds ratios and 95% confidence intervals for risk of adverse outcomes in lowest community income group compared to highest community income group.

Note: Model 1 adjusts for income group, age, sex, hospital volume, rural / urban hospital. Model 2 adjusts for income group, age, sex, hospital volume, rural / urban hospital, and Elixhauser index.


Disclosures: B. Mehta: Janssen, 1, Novartis, 5; K. Ho: None; J. Gibbons: None; V. Ling: None; S. Goodman: NIH, 5, Novartis, 5; M. Parks: None; B. Ravi: None; F. Wang: None; S. Ibrahim: None; P. cram: None.

To cite this abstract in AMA style:

Mehta B, Ho K, Gibbons J, Ling V, Goodman S, Parks M, Ravi B, Wang F, Ibrahim S, cram P. Single-Payer Health Insurance May Not Mitigate Income-Based Differences in Total Hip Arthroplasty Utilization: A Transnational Analysis [abstract]. Arthritis Rheumatol. 2023; 75 (suppl 9). https://acrabstracts.org/abstract/single-payer-health-insurance-may-not-mitigate-income-based-differences-in-total-hip-arthroplasty-utilization-a-transnational-analysis/. Accessed .
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