Addressing Inequities in Pediatric Orthopedic Care
The division of Orthopedic Surgery and Sports Medicine at Ann and Robert H. Lurie Children's Hospital of Chicago, cares for more than 49,000 patients with bone, joint, muscle ligament, and nerve disorders every year. In this episode, you will hear from three pediatric orthopedic specialists at Lurie Children's, Drs. Cynthia LaBella, Neeraj Patel, and Jill Larson, who are spearheading research to uncover and address inequities, improve treatment options and offer better access to care for all children who need it.
“I think we all share this passion for helping young people and especially promoting physical activity. Knowing that you have the skills to do that and help kids recover from injury or identify injury and get back on the field, but yet these people can't find you or can't get to you, it's really a bit heartbreaking. So, we really want to make an effort to get out to these folks … what we've learned is we can't wait for them to come find us, we have to go find them.”
Cynthia LaBella, MD
Medical Director, Institute for Sports Medicine
- LaBella is the medical director at Lurie Children's Institute for Sports Medicine. Her research focuses on developing strategies to prevent injury in youth sports. And she is also dedicated to advancing advocacy and equity in youth sports. She developed the Knee Injury Prevention Program (KIPP) for girls after research revealed that adolescent females tend to have the highest rates of knee injuries, particularly injuries to the anterior cruciate ligament (ACL).
- She was able to show that the program led to a significant reduction in knee injuries after recruiting 80 Chicago Public High Schools that provide girls soccer and basketball to take part in a study. Half of those schools learned how to use KIPP exercises while the other teams used their usual warm up without these exercises. The research project revealed a significant difference. The teams using KIPP had significantly lower rates of knee injuries, ACL injuries, and lower leg injuries in general, such as ankle sprains.
- Since that time LaBella has deployed KIPP to thousands of people through an free online training program specifically targeting under-resourced high schools like many in Chicago Public Schools.
- By partnering with school nurses, LaBella launched another online program that has improved concussion care in children. She has trained hundreds of school nurses in Illinois to support children with concussions through their symptoms and communicate accommodations that can be put in place to help them learn while they're recovering from their concussion.
Neeraj Patel, MD, MPH, MBS
Attending Physician, Division of Orthopaedic Surgery and Sports Medicine
Assistant Professor of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine
- Patel, an orthopedic surgeon specializing in ACL care, is investigating why some families delay care when their child has an ACL injury.
- Using electronic medical records and the child opportunity index or the COI, a very comprehensive neighborhood level metric, Patel found that patients in under-resourced neighborhoods experience delays in surgery, even when controlling for insurance type.
- Patel says there is a correlation between delayed surgery and worse outcomes for patients and this disparity he found is an opportunity to reach out to under-resourced communities and do some meaningful work to address some of these equity issues.
Jill E. Larson, MD
Attending Physician, Division of Orthopaedic Surgery and Sports Medicine
Assistant Professor of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine
- Larson, a surgeon, physician scientist and hip and spine expert at Lurie Children's, recently published a study on racial disparities in the diagnosis of scoliosis, exposing racial disparities in scoliosis severity.
- Also using COI and electronic medical record data, Larson found the odds of presenting with severe scoliosis were 2.3 times higher for patients who identified as African American or black compared to those who identified as white.
- She is exploring innovative strategies aimed at early identification and accessible care, including school-based screenings and mobile pediatric orthopedic units.
[00:00:00] Erin Spain, MS: This is Precision, Perspectives on Children's Surgery from Ann and Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they're transforming pediatric medicine. The division of Orthopedic Surgery and Sports Medicine at Ann and Robert H. Lurie Children's Hospital of Chicago, cares for more than 49,000 patients with bone, joint, muscle ligament, and nerve disorders every year. To make sure all patients have the opportunity to receive care from this team, physician scientists are spearheading research and running programs to uncover and address inequities and improve treatment options and better access to care for all children who need it. Joining me to discuss some specific initiatives are Drs. Cynthia LaBella, Neeraj Patel, and Jill Larson pediatric orthopedic specialists at Lurie Children's. Starting us off today is Dr. Cynthia LaBella medical director at Lurie Children's Institute for Sports Medicine. Her research focuses on developing strategies to prevent injury in youth sports. And she is also dedicated to advancing advocacy and equity in youth sports. Dr. LaBella, welcome to the show.
[00:01:26] Cynthia LaBella, MD: Oh, thank you. Great to be here.
[00:01:27] Erin Spain, MS: Let's start off by talking about this drive and passion that you and so many of your colleagues have to address inequities and improve treatment options for all children with sports injuries.
[00:01:40] Cynthia LaBella, MD: Well, I think we all share this passion for helping, young people and especially promoting physical activity and knowing that you have the skills to do that and help kids recover from injury or identify injury and get back on the field, but yet these people can't find you or can't get to you. It's really a bit heartbreaking, and so we really want to make an effort to get out to these folks, right? And so, I think what we've learned is we can't wait for them to come find us, we have to go find them. And so connecting with communities has been our goal. And learning and asking questions is the first step. Finding out what are the barriers, what are the questions they have, what would make things easier, what do they perceive are the needs in their community, and starting there. We don't know that until we start asking those questions.
[00:02:30] Erin Spain, MS: And not only have you been doing the research and asking those questions you've been able to implement evidence-based injury prevention programming for young athletes, right into Chicago Public Schools. One of those programs is called KIPP, which stands for knee injury prevention program. This program was designed for girls who are playing sports. Tell me more.
[00:02:50] Cynthia LaBella, MD: We had looked at data that is pretty consistent showing that adolescent females tend to have the highest rates of knee injuries, particularly injuries to the ACL or anterior cruciate ligament. And these injuries can be pretty devastating for teenagers because they often require surgery or months and months of rehabilitation, they can miss whole seasons of play. Some of them never even get back to playing sports. And so our primary goal has always been to promote sports and physical activity for youth because it's just so great for them in all domains, both physical. for their mental health, for their cognitive performance in school. So keeping kids on the court, on the field, has always been our focus. And along with this data showing that girls have a higher rate of these injuries, was also data coming out investigating why that is the case. And what many researchers were finding was that it had to do with the way girls use their muscles when they play sports. They use their muscles differently than boys. And the way they use their muscles puts their knees at higher risk for injury. So we worked with our physical therapists and athletic trainers and based on some research done in other institutions, we designed a neuromuscular training program, which is a series of exercises that are designed to train girls to use their muscles differently when they jump and land in sports. Using their muscles in this way helps protect their knees as opposed to putting them at risk.
[00:04:26] Erin Spain, MS: This program has been very successful and is really a model for how to reach under-resourced communities. Tell me about your collaboration with Chicago Public Schools and the impact that it's had.
[00:04:37] Cynthia LaBella, MD: Yes, we're very thrilled about the reach that this program has had. We started by doing a very large research project within Chicago Public Schools, and we had recruited 80 of the high schools in the area, public schools that provide girls soccer and basketball and researched this program with half of those schools learning how to use these exercises. Coaches were trained how to incorporate them into the warmup for their teams and the other teams used their usual warm up without these exercises. And at the end of the season, we compared injury rates between the teams using KIPP and the teams not using KIPP. And we found a very significant difference where the teams using KIPP had significantly lower rates of knee injuries, ACL injuries, and lower leg injuries in general, such as ankle sprains. And importantly, we wanted to target Chicago Public High Schools because so many of these high schools are in areas that are under-resourced. They do not have athletic trainers, for instance, to help athletes prepare adequately for their season or treat injuries on the spot and rehab those injuries to get them back on the field safely and efficiently. And so we thought, what better place where injury prevention is needed than in these under resourced high schools. And since then, that research project has launched additional outreach efforts where we obtained funding to create an online training course for coaches, that is completely free and accessible from anywhere, where they can learn how to use these exercises. It's equipped with videos and instructions, so that they can learn it on their own and start incorporating it with their teams. And as of this point, we've had thousands of folks from really all over the world log on to this online training program, and learn KIPP, which is really great.
[00:06:33] Erin Spain, MS: I also wanted to talk today about your research and youth concussion. This is an area that you have also been studying for quite some time, and you've been able to implement concussion care in schools with some help from school nurses. Tell me about this effort.
[00:06:48] Cynthia LaBella, MD: Sure, when we see concussions, what we quickly learned was that school nurses are really on the front lines of these injuries. Often they happen at school during sports, training or competition, but then the athlete is showing up in the nurse's office, say the next day or for several weeks, with symptoms, whether it be headaches or difficulty, focusing, problems with their vision, feeling dizzy. And so nurses are in a position to not only have to manage and help these athletes and support them through their symptoms, but also help discuss with the teachers and communicate some of the accommodations that can be put in place to help them learn while they're recovering from their concussion. So we would get numerous phone calls from nurses all around the state really, looking for guidance. And primarily it was in areas where kids had little resource to connect with physicians who were trained and specialized in treating concussions. And so they really didn't have a contact person to answer these questions and the nurses were reaching out to us. We put together an online training program for nurses, specifically targeting school nurses and did a bit of a focus group to find out what would be helpful for them to know and what kind of resources do they need to help them manage these concussions in schools. And so this program has been up and running for many years now and we've had hundreds of nurses be trained through this online training program. And we continue to get inquiries about it and folks looking to learn from our education resource. In addition, we partner with some school based health centers in the Chicago Public Schools, which are specifically there to support students who may not have a primary care provider or do not have access to healthcare but they can get it in the school. And so we've worked side by side with the school nurses in three of these school based health clinics in Chicago to help them learn how to evaluate and manage concussions as well as other sports injuries.
[00:08:50] Erin Spain, MS: Thank you so much, Dr. Cynthia Labella for sharing these insights into the work that you've been doing with Chicago public schools and beyond for the past decade, I appreciate it.
[00:09:00] Cynthia LaBella, MD: It's been my pleasure. This is exciting to know that you're spreading the word.
[00:09:03] Erin Spain, MS: Now I'd like to welcome Dr. Neeraj Patel to the show. He's an orthopedic surgeon whose research shines a light on disparities and ACL care in pediatric patients. Welcome to the show.
[00:09:14] Neeraj Patel, MD: Thank you. Glad to be here.
[00:09:15] Erin Spain, MS: What drives you to investigate health inequities and take on health disparities as part of your research?
[00:09:22] Neeraj Patel, MD: For me personally, I grew up in a very diverse area on the East coast. And then, where I trained also was extremely diverse. We took care of lots and lots of different types of patients from every walk of life. And you really kind of saw firsthand the impact that these health equity issues we're having, on a one person basis with every patient that you saw. So, I was definitely interested in digging further into this stuff in my own little way, right, in my own little niche of pediatric orthopedics and sports medicine to really kind of move the needle forward.
[00:09:50] Erin Spain, MS: We just heard from Dr. Cynthia LaBella about how devastating an ACL injury can be to a young athlete and the importance of preventing such injuries. However, when they do occur, timely care is very important and something that you noticed was that not all children are receiving timely care and you decided to investigate why we're going to talk about the results of that study shortly. But first, tell me about ACL injuries and why timely care is so important.
[00:10:20] Neeraj Patel, MD: The ACL, as many people know, is one of the main ligaments that stabilizes the knee, and we know that ACL injuries in pediatric patients and children and adolescents has been skyrocketing over the last 20 to 30 years, becoming more and more common unfortunately. And typically in this age group, when a child or an adolescent tears their ACL, we are usually recommending surgery for that injury to, in the short term, allow them to return to their activities, sports, etc. that they like to with a stable, functional knee, and hopefully for the long term, again, to provide a stable knee for them to live, work, play, whatever it is that they're going to do into adulthood. And so there's plenty of data that suggests that the time between injury and surgery is important and that the longer time elapses between injury and surgery, the worse the outcomes are in a nutshell. So that means there's a higher risk of residual instability of the knee, of additional meniscus and cartilage injuries at the time of surgery that we can't then repair because they're just kind of a more complex or degenerative pattern by the time we get to it. And that that patient reported outcomes may also be lower if there's a delay to surgery at the end of the day. And that there's potentially a higher risk of needing a revision surgery or getting re injured if there's a delay to surgery. So, for all those factors, we think that timely treatment of these injuries is important in this population.
[00:11:32] Erin Spain, MS: And you've been investigating what is causing delays in surgery for many of these young patients and in a recent study, you published, you found the patients living in under-resourced neighborhood conditions were more likely to experience these delays in surgery, especially beyond 60 and 90 days after the injury. This was even when controlling for other factors, such as type of insurance. So this was a pretty significant finding. Tell me about this study and what you found.
[00:12:00] Neeraj Patel, MD: The impetus for this study was to sort of build upon and hopefully move beyond a little bit some of the research that had already been done in this space.Previously, most of what has been done revolved around insurance. We know pretty well that kids that have Medicaid or government insurance are at higher risk for delayed surgery and other problems. But I think insurance is the most commonly highlighted factor here because it's the easiest to study, frankly, right? And so, our team decided to try to dig a little deeper and go beyond just insurance as a marker of like socioeconomic status or other things. And so one of the things that we used in this study was what's called a child opportunity index or the COI, which is a very comprehensive neighborhood level metric that looks at, I believe, 29 different variables across three different domains, and looks at the child's opportunity or neighborhood resources through that lens. And so, it's very comprehensive. and we found, like you mentioned, that children from neighborhoods with lower COI scores, so they're more disadvantaged neighborhoods, lower resource neighborhoods, did have a longer delay between injury and surgery. And so that included even when you got beyond 90 days between injury and surgery, there was a higher risk in the kids from those neighborhoods. We also found in the same study that those same kids were more likely at the time of surgery to have a meniscus tear and meniscus tears that couldn't be fixed. So we know that those are also things that ultimately result in worse outcomes. And so the idea there was even though we controlled for insurance type when we're doing our analysis the idea was that, well, insurance is important, but it's not the only factor. And that there are other probably more local and neighborhood level factors at play that lead to some of these results.
[00:13:35] Erin Spain, MS: Could you expand on that a little bit? What are some of the ideas you have about some of those factors that may be impacting timely care?
[00:13:42] Neeraj Patel, MD: So in previous studies we've looked at race and ethnicity as being risk factors for delay. And found that to be true. So, black and Latinx patients are at higher risk for delays. Insurance, as we very well know, is a factor. We found in this study that neighborhood resources as measured by the Child Opportunity Index is a risk factor. In another study published around the same time, we found out that the preferred language of the patient is also at risk and we're controlling for multiple variables in each of these studies. And we're finding that each of them does somewhat play a role, which for many reasons makes it challenging to then potentially address the disparities ultimately. But I do think it's important to note that it's not just one thing. So we know then what to actually target when we're trying to do something actionable here.
[00:14:23] Erin Spain, MS: And the studies that you just mentioned, the data has come from patients here in the Chicagoland area from their electronic medical records. Talk to me about Chicago and some of the disparities that we see specifically here in the city.
[00:14:37] Neeraj Patel, MD: I think for many reasons, I'm very happy to be working and living in Chicago. It's a beautiful city. It's a huge city. We also know that unfortunately it's one of the most, if not the most segregated city in America, right? And so, in a lot of the talks I give, I show the map that shows that within the same city, depending on the neighborhood you live in, the life expectancy is up to 20 years different. which is pretty wild, right? it's from 63 to I think 83 in the best and the worst. So, you see there's a lot of room for work there. Our hope certainly is to enter the community and really talk to folks to understand what they're facing, what issues they perceive as being important versus not, what the barriers and facilitators are to timely care and other things. And hopefully partnering with them in an equitable fashion. So, hopefully stay tuned, you know, we'll all be partnering together to do some hopefully meaningful work in the community and address some of these equity issues in the future.
[00:15:25] Erin Spain, MS: Well, thank you so much for your time today.
[00:15:27] Neeraj Patel, MD: I appreciate you having me. Thank you so much.
[00:15:29] Erin Spain, MS: Now let's welcome Dr. Jill Larson. She is a surgeon, physician scientist, as well as a hip and spine expert here at Lurie Children's, who recently published a study on racial disparities in the diagnosis of scoliosis. Welcome to the show.
[00:15:44] Jill Larson, MD: Thanks so much for having me.
[00:15:45] Erin Spain, MS: Talk to me about adolescent idiopathic scoliosis. This is something that is very commonly referred to you and other pediatric orthopedic surgeons. Explain the condition to me, who it impacts and how severe it can be.
[00:15:59] Jill Larson, MD: Well, you're absolutely right. It's probably one of the most common diagnoses that we see as pediatric orthopedic surgeons. Idiopathic scoliosis within the general population is actually quite low, although in the literature it's quoted as about a half to about 5 percent of the general population. But it is what we see the most common in the teenage years, and that's for any child over the age of 10 up to 18 years of age. We kind of categorize the severity of the curve of the spine or scoliosis into three categories: mild, moderate, and severe. And we base this diagnosis off a radiograph. And so briefly, if the curve is less than 25 degrees, but greater than 10 degrees, we call that mild. Between 25 and 40 degrees, we call that moderate. And greater than 45 degrees, 40 to 50 degrees, we call severe. And the importance of this is that it helps not only for diagnosis, but also for treatment. So the mild category, we can just watch these curves. In the moderate category, we treat with bracing because we know that bracing can prevent progression into severe scoliosis, which is recommended for surgical intervention to prevent the long term complications of scoliosis. So we know the earlier we identify scoliosis, the better treatment children can have. In other words, potentially avoiding surgery or the long term consequences of scoliosis, including pain and degenerative issues with the curvature of the spine.
[00:17:38] Erin Spain, MS: Tell me about the screening for this condition. When does that usually happen and how is it working in the communities right now?
[00:17:45] Jill Larson, MD: That's a great question. So, pediatricians, in general, are our frontline providers for screening for scoliosis. And they generally follow the American Academy of Pediatric Guidelines, which is to universally screen females from the ages of 10 to 12 and boys from the ages of 13 to 14. Now, the reality is they're probably looking at the back of the child more frequently than that, but they want to have kind of a close eye on that. And traditionally, this is an Adam's Forward Bend test, or some of them even have the scoliometer device, or you can even do a scoliometer app on the phone. But obviously, to be a primary screener for scoliosis, you actually have to have the child come into clinic on a routine annual basis.
[00:18:32] Erin Spain, MS: You noticed a trend in your own patients that prompted you to investigate the social demographic differences between patients who are initially diagnosed with mild versus moderate or severe scoliosis, you publish the results of this study in the journal of the pediatric orthopedic society of north America. And these results revealed some stark race disparities. What did you find?
[00:18:55] Jill Larson, MD: Traditionally, children who are Black or identify as African American are actually not that at risk for scoliosis. But here in the Chicagoland area, we noticed a higher propensity of those patients that we were operating on. So, the hunch was that they were probably presenting later or not having the ability to be identified as mild or moderate and seek the non surgical treatment options, which led us to consider this study. So, we found that the odds of presenting with severe scoliosis, in other words, a cob angle greater than 40 degrees, were 2.3 times higher for patients who identified as African American or black compared to those who identified as white. And then we further found that that was an independent risk factor, and the other independent risk factor for presenting with severe scoliosis was something called a Child Opportunity Index. So a low Child Opportunity Index was associated with a 17 to 19 percent decrease in the odds of presenting with severe scoliosis.
[00:20:02] Erin Spain, MS: What are some of the reasons that you think this is happening?
[00:20:06] Jill Larson, MD: Well, that's probably the million dollar question, and unfortunately, my paper can't address that. But some of our theories are that children in these underserved areas just don't have access to a pediatrician on a regular basis, or maybe at these ideal times to pick up the scoliosis early so one is access to care. And then the second theory is they maybe have appropriately identified the scoliosis early, but then the access to an upper level provider, so a pediatric orthopedic surgeon to verify the diagnosis and initiate treatment. So again, I think it's two fold. It's the initial access to a pediatrician with routine screening. And then the second step is elevation of care to a pediatric orthopedic surgeon to be able to initiate treatment in a timely fashion.
[00:20:57] Erin Spain, MS: You and your colleagues at Lurie Children's want to tackle this problem, and you're coming about it from some different ways. I'd love for you to share with us some of the ways you're hoping to tackle this.
[00:21:07] Jill Larson, MD: Screening actually is not supported by the Preventative Task Force. So we are a little bit encouraging pediatricians and other family care providers or frontline providers who see kids on a regular basis to be our eyes on the ground, and one of those is school. Kids are going to school on a regular basis, and so school screening is one of those opportunities to potentially identify scoliosis early with appropriate referral to a pediatric orthopedic surgeon, and again, while school screening is not universally performed, it can be a way in these underserved communities to get kids identified early. So we're using education through the school system to identify scoliosis, safe ways to do that, and then providing direct referrals to Lurie Children's. And then the other way that we're looking to tackle this problem is to provide pediatric orthopedic surgeons into the community. So if children have already been identified or we identify kids in at risk neighborhoods, bringing the pediatric orthopedic surgeons to them through mobile units and increased access to care.
[00:22:11] Erin Spain, MS: What would you like to see happen in the next decade? What would your goal be to address this problem?
[00:22:16] Jill Larson, MD: So obviously I think reducing the risk ratios is the statistically way to do it. But I think, you know, seeing just in general an increased awareness of these health disparities, more public health initiatives. And even consideration for the Chicago Public Schools to initiate universal school screenings, especially in these at-risk populations and then Lurie Children supporting more access to care in these different neighborhoods that are at risk.
[00:22:45] Erin Spain, MS: Well, thank you so much, Dr. Jill Larson, for your time today.
[00:22:48] Jill Larson, MD: My pleasure. Thank you so much.
[00:22:50] Erin Spain, MS: For more information, including how to make a referral or an appointment, visit LurieChildrens. org.