Insurance Status Correlates With Patient-reported Baseline Symptoms of Adult Spinal Deformity

Close up of doctor pointing to clipboard paper, sitting at table explaining something to patient

Standardized patient-reported outcome measures (PROMs) are increasingly used to determine institutional and provider performance and are linked to reimbursement. Therefore, it’s important to determine what factors influence patient-reported symptoms before and after treatment.

This is particularly true for conditions such as adult spinal deformity (ASD), where there is wide variation in treatment approaches and an increasing prevalence of highly invasive surgical interventions.

In a study of patients with lumbar spinal stenosis, researchers at Brigham and Women’s Hospital previously demonstrated that patients insured by Medicaid have worse baseline PROMs than those commercially insured or insured by Medicare. Now, they’ve found the same is true in the setting of ASD.

Their report in the Journal of Clinical Neuroscience is authored by Ikechukwu C. Amakiri, MD, of the Harvard Combined Orthopaedic Residency Program, and Andrew K. Simpson, MD, MBA, MHS, director of minimally invasive spine surgery in the Department of Orthopaedic Surgery at the Brigham, and colleagues.


The researchers retrospectively studied 207 adults with ASD, mean age 62, who presented to the Brigham, Massachusetts General Hospital or one of two affiliated community-based hospitals between 2015 and 2019.

Within six months of presentation, patients completed the Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function Form 10a (PF10a), the PROMIS Global–Physical scale, the PROMIS Global–Mental scale, and visual analog scales (VAS) for low back pain and leg pain. The back pain VAS was selected as the primary outcome given the dominance of axial symptoms in patients with spinal deformity.

Unadjusted Analyses

Unadjusted analyses showed that compared with patients in other insurance groups, those receiving Medicaid benefits had significantly worse baseline scores on the:

  • PROMIS Physical Function scale
  • PROMIS 10 Physical scale
  • PROMIS Pain Intensity scale
  • Low back pain VAS

Scores on the PROMIS Pain Intensity scale and the low back pain VAS exceeded the minimal clinically important differences previously established for those scales.

Multivariable Analyses

Many of the disparities in PROMs persisted after adjustment for race, age, and other demographic variables, even though the Medicaid cohort was significantly younger and healthier than the other insurance groups. Compared with commercially insured patients, the Medicaid group scored significantly higher on the:

  • Low back pain VAS—Incidence rate ratio (IRR), 1.535; 95% CI, 1.122–2.101 (P=0.007)
  • PROMIS Pain Intensity scale—IRR, 1.174; 95% CI, 1.079–1.276 (P<0.001)
  • PROMIS Anxiety scale—IRR, 1.088; 95% CI, 1.022–1.159 (P=0.008)

Interpreting the Findings

Several groups have proposed that delays in access or suboptimal access to musculoskeletal care for marginalized patient populations may result in greater severity of disease at the time of presentation.

As more healthcare systems move toward value-based care and reimbursement incentives, a tendency may arise for surgeons to make systematically different treatment decisions for more symptomatic patients. Decision-makers who establish standards for performance and compensation must protect the equity of care for musculoskeletal pathologies.

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