Do Race, Insurance Status, and Income Factors Impact Pathologic Fracture Presentation and Management?

Introduction

Metastatic bone disease (MBD) and pathologic fractures (PF) can impact quality of life, functionality, and survival. Understanding the management of PF and access to care and treatment in the U.S. healthcare system can improve patient outcomes, directly impacting treatment eligibility and overall survival. We ask: (1) Do race, income, and insurance status differ between prophylactic stabilization of impending and acute fixation of overt PF, respectively? (2) Are race, income, and insurance status associated with complications in patients with metastatic bone disease? (3) Are race, income, and insurance associated with length of stay and insurance type in patients with MBD?

Methods

The NIS HCUP database was queried from 2016 to 2020 for pathological fractures. We then identified patients with associated cancer ICD-10 diagnostic codes for the hospitalization (breast, prostate, renal, lung, thyroid, bone, and other). General linear models (GLMs) were used to answer each clinical question. We conducted a post hoc analysis of the other malignancies associated with osseous metastasis and performed the same studies as above.

Results

We found 2050 prophylactically stabilized impending and 4181 acute fractures. There were no differences among races, income, or insurance status and the prevalence of impending versus acute fractures. We found that Black patients were more likely to have complications, while Hispanic patients were the least likely, compared to other races. Black patients had higher hospital costs, while both Black and Hispanic patients had more extended hospitalizations and were more likely to have Medicaid or no insurance compared to other races. Our post hoc analyses found that the rate of impending and acute fractures differed among race, income, and insurance status, depending on the metastatic cause.

Conclusions

We identified healthcare disparities in patients with impending and overt PF due to MBD despite minimal to no differences in patient comorbidities, fracture management, or hospitalization complications.