Disparity in Access to Orthopedic Surgery between Public and Private Healthcare Insurance: a nationwide population-based study.

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María Jesús Lira, Paula Pino, Catalina Vidal, Pamela Mery, Sebastián Irarrazaval, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4730910/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 May, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 12 You are reading this latest preprint version Abstract Background: The aim of this study was to examine the influence of healthcare coverage in the access to orthopedic surgery in a country with a dual (private/public) healthcare system. We hypothesize that differential access would exist according to the type of healthcare coverage. This difference would accentuate when analyzing access to elective orthopedic surgery. Methods: A cross-sectional, population-based design was used to investigate orthopedic surgery rates in Chile during 2016. The rates of orthopedic surgeries provided under the private and public healthcare systems were calculated per 1,000 beneficiaries, as based on data collected from the Hospital Discharge Registry provided by the Chilean Ministry of Health. ICD-10 diagnoses were classified as urgent or elective, categories into which the public/private surgery rates were also sorted. Results: The overall rate of orthopedic surgery was 7.54 per 1000 inhabitants in 2018. Patients covered under private insurance had an orthopedic surgery rate 2.23 times higher than patients within the public system. This difference became more accentuated when sorting by elective surgeries, with private healthcare having a rate 2.97 times higher than public healthcare. Conclusions: Access disparity to orthopedic surgical care existed between the private and public healthcare systems in Chile. Disparity in access became greater when separately analyzing the rates of elective and urgent orthopedic surgeries. Level of evidence : III Disparity Orthopedic Surgery Healthcare Insurance Figures Figure 1 INTRODUCTION Disparity in healthcare access is a current subject of interest in medicine (1). Health disparities have been defined as systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups(2). When considering access to surgical care, these differences may directly influence the population’s morbidity, mortality, and the country’s global burden of disease (1,3). Studies investigating these differences may help understand the nature of these inequities and contribute to directing resource allocation policies. Weiser et al. reported that worldwide access to surgical care is inequitably distributed across different countries, exposing the disproportionate scarcity of surgical access in low-income settings (3). There is evidence of a wide number of factors that influence the population’s access to primary care, specialist referrals, and optimal treatment of their conditions (4–7). In the field of orthopedic surgery, gender, race, geographic location, and socioeconomic status have established effects on the access to surgical care of selected groups (7–10). Insurance status has also been shown to be determinant in the resolution of specific interventions such as lower extremity fractures and reconstructive and arthroscopic surgery, among others (7,9,11–15). Insurance status may have a greater impact on the treatment of elective surgeries compared to urgent cases. This limits the opportunity to treat elective cases, in a scenario with limited resources. Despite the available literature, population-based studies remain lacking in regard to access to orthopedic surgery. The aim of this study was to establish if access to orthopedic surgery differs by healthcare coverage in a country with a dual healthcare system and to analyze how this impacts the treatment of urgent and elective conditions. We hypothesized that differential access to orthopedic surgery would exist according to the type of healthcare coverage (i.e., private vs. public), having a greater impact on non-urgent conditions. METHODS Design A cross-sectional, population-based study investigated the rate of orthopedic surgery in Chile in 2018. The Institutional Review Board (ID Resolution 16-196) granted approval for this study. Background Chile is a developed country with a population of 18,751,4051 inhabitants (Table 1). Among members of the Organization for Economic Co-operation and Development (OECD), Chile has one of the highest levels of income inequality (16). Healthcare is provided through two separate insurance systems – public and private (17). Public healthcare insurance is funded through taxes paid by workers and pensioners in this system, corresponding to 7% of their income. It also covers unemployed individuals, dependent family members of insured workers, and the poor or indigent. However, enrollment in the public option is not mandatory, and individuals can choose to use the legally mandated 7% or more to purchase health insurance from multiple private companies. Finally, 6.8% of the population receives healthcare through semi-private coverage for the police and armed forces, among other entities (17) (Table 2). I nformation Sources Demographic distribution of Chile’s population was extracted from the Chilean National Institute of Statistics. Information regarding the number of beneficiaries covered by each type of healthcare insurance was obtained from the Chilean Ministry of Health (18). The number of surgeries performed in 2018 was collected from the Hospital Discharge Registry (Department of Statistics, Chilean Ministry of Health). Information is mandatorily entered in this registry when patients are discharged from any healthcare center. This database also provides patients’ demographic data, diagnosis, surgical procedures performed, and information about their healthcare insurance. Musculoskeletal diagnoses were independently defined by two orthopedic surgeons from the ICD-10 (CIE-10) database. In cases of disagreement, a third orthopedic surgeon was consulted to reach a consensus. In all, 1,041 ICD-10 diagnoses were obtained from The National Discharge Registry from the Ministry of Health (13), the most frequent categories of which were M, Q, S, and T (Annex 1). Inclusion criteria considered patients operated and discharged with a musculoskeletal condition during the year 2018. This year was selected as the registry’s most recent full year when the database was obtained before the 2019 Chilean social upheaval and the 2020 COVID-19 pandemic. This year does not show significant differences from subsequent years in relation to health access and macroeconomic variables. The ICD-10 diagnoses defined as musculoskeletal conditions were grouped according to the type of surgical treatment needed into elective (e.g., osteoarthritis) and urgent (e.g., fractures, acute infections), as per the aforementioned procedure. Statistical Analysis The annual rate of orthopedic surgeries per 1,000 inhabitants was calculated. Surgery access by healthcare insurance was compared by calculating the rate of surgeries in the private and public healthcare systems per 1,000 beneficiaries. The annual rates of elective and urgent surgeries were calculated for each insurance type. The obtained rates for each healthcare system were compared through Negative Binomial regression, calculating the Incidence Rate Ratio (IRR). A significant p-value was considered over 5%. Statistical analyses were performed with Stata LLC v.16 software (serial number 401606250896). RESULTS A total of 751,477 hospital discharges occurred during 2018 in Chile. There were 141,374 orthopedic surgeries, which accounted for 18,81% of all surgical procedures. The national rate of orthopedic surgery was 7,54 per 1,000 inhabitants (CI95% 7,50-7,58). Male patients correspond to 56.69% (n=77,977) and the average age was 46.37 years old (± 20.69). The urgent surgeries were 62,900 (44.49%) and the elective 78,474 (55,51%), with a rate per 1,000 inhabitants of 3.35 and 4.18, respectively (Table 3). The rate of orthopedic surgery in the public system was 5.77 per 1,000 beneficiaries (CI95% 5.73-5.81), while the private system had a rate of 12.88 per 1,000 beneficiaries (CI95% 12.76-13.00). When both rates were compared, the private system had an orthopedic surgery rate 2.23 times greater than the public system (CI 95% 2.20-2.26; p <0.001) (Table 4). The difference between insurance types became accentuated when separating analyses based on elective and urgent surgeries. The annual rate of elective surgeries was 2.97 times greater in the private system (CI 95% 2.92-3.01; p <0.001), while urgent surgeries in the private system occurred only at a rate 1.46 times more than in the public system (CI 95% 1.43-1.48; p <0.001). In the multivariate analysis, according to the insurance and type of surgery, the differences observed in orthopedic surgery rates were maintained. The annual rate of orthopedic surgery was 2.08 times greater in the private system (CI 95% 1.46-2.96; p <0.001) and 1.50 times higher in elective surgeries (vs urgent) (CI 95% 1.06-2.13; p <0.024). (Table 5 and Figure 1). DISCUSSION This study evaluated the access to orthopedic surgery according to public and private health insurance in a country with a dual healthcare system. Our results confirmed the hypothesis that there is an important disparity in access to orthopedic surgical care. The population insured by private companies had a 2.23 times higher rate of surgeries than those under public insurance. In elective procedures, this difference is accentuated to 2.97 times higher in private insurance beneficiaries. Recent literature has shown disparities in access to orthopedic care in specific populations. A large number of studies performed in the United States have compared the access to healthcare of groups under Medicaid and private insurance. These studies have found disparities in access to pediatric orthopedic care, differences in the time to surgery of patients with anterior cruciate ligament reconstruction surgery, and treatment of hand flexor tendon lacerations, among others ( 10 – 12 , 15 , 19 , 20 ). Despite the high prevalence of orthopedic surgery, there is limited evidence in Latin America regarding inequities in access. Vidal et al. observed that in Chile, the rotator cuff surgery rates were 3.4 times higher in the private healthcare system compared to the public system ( 7 ). Our study suggests a large unaddressed orthopedic surgery burden in the public insured population, as this system covers 75% of Chile’s population ( 21 ). Even though the aim of this study was not to analyze socioeconomic factors, the population that can opt for private insurances has higher levels of income ( 22 ). This fact suggest that socioeconomic status may play a role in access to surgery in a dual healthcare system. The disparity found is represented mostly by limited access to elective surgeries. This can be explained by barriers in the public system which include limited access to primary care, delayed orthopedic surgeon referrals, and long waiting lists for surgery. Elective conditions are not a priority in a system with limited resources and a high demand to solve urgent cases. Additionally, the elevated rate of elective surgeries observed within the private system warrants careful analysis. It is important to consider that financial incentives may potentially impact surgical decision-making processes. The main strength of this study is that it was a population study, being the first to assess access to orthopedic surgery for an entire country. A two-tier healthcare system was analyzed, which can be extrapolated to other countries with similar healthcare systems. The limitations of this study include a possible information bias. The analyzed data were obtained from national surveys and clinical forms, which are completed by individuals with different degrees of specializations and competencies. For this reason, there could be errors in coding of diagnoses and procedures. Furthermore, the selection of musculoskeletal ICD-10 diagnoses was arbitrary, as was subsequent classification into elective or urgent conditions. Classification of these diagnoses has not been standardized in the literature. More accurate statistics could be obtained by selecting cases based on surgical procedure codes. This information was not available in a standardized manner in our databases. Our study confirms that there is an important disparity in access to orthopedic surgery in Chile according to healthcare insurance system. The limited access of the population under the public system was accentuated when analyzing elective surgeries. Future investigations should study the effect of other factors such as access to primary care physicians, orthopedic surgeon referral, waiting times for orthopedic surgery, and number of orthopedic surgery indications. CONCLUSION Access disparity to orthopedic surgical care existed between the private and public healthcare systems in Chile. Disparity in access became greater when separately analyzing the rates of elective and urgent orthopedic surgeries. Declarations Ethics approval The Institutional Review Board to Pontificia Universidad Católica de Chile (ID Resolution 16-196) granted approval for this study. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding Our research project did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions MJL made substantial contributions to the conception, design, acquisition, analysis, and interpretation of data, drafted the work, approved the submitted version, and agreed to be personally accountable for the author's own contributions. PP made substantial contributions to the conception, drafted the work, approved the submitted version, and agreed to be personally accountable for the author's contributions. CV made substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author's contributions. PM made substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author's contributions. JC made substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author's contributions. SI made substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author's contributions. JV made substantial contributions to the conception, design of the work and the acquisition, analysis and interpretation of data, have approved the submitted version, and have agreed both to be personally accountable for the author's own contributions. Acknowledgments We want to express our sincere gratitude to Macarena Valdés (PhD) for her contribution to this line of research. References McQueen K. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ. 2008;86(8):646–7. Braveman PA, Kumanyika S, Fielding J, LaVeist T, Borrell LN, Manderscheid R, et al. Health Disparities and Health Equity: The Issue Is Justice. Am J Public Health. 2011;101(S1):S149–55. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. The Lancet. 2008;372(9633):139–44. Blanchard J, Ogle K, Thomas O, Lung D, Asplin B, Lurie N. Access to Appointments Based on Insurance Status in Washington, D.C. J Health Care Poor Underserved. 2008;19(3):687–96. Olah ME, Gaisano G, Hwang SW. The effect of socioeconomic status on access to primary care: an audit study. Can Med Assoc J. 2013;185(6):E263–9. Purnell TS, Calhoun EA, Golden SH, Halladay JR, Krok-Schoen JL, Appelhans BM, et al. Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research. Health Aff. 2016;35(8):1410–5. Vidal C, Lira MJ, de Marinis R, Liendo R, Contreras JJ. Increasing incidence of rotator cuff surgery: A nationwide registry study in Chile. BMC Musculoskelet Disord. 2021;22(1):1052. Cannada LK, Ortega G, Mclaurin TM, Tejwani NC, Little MTM, Benson E, et al. Racial, Ethnic, and Socioeconomic Healthcare Disparities in Orthopaedics: What About Orthopaedic Trauma? [Internet]. 2023. Available from: http://journals.lww.com/jorthotrauma Solarczyk JK, Roberts HJ, Wong SE, Ward DT. Healthcare Disparities in Orthopaedic Surgery: A Comparison of Anterior Cruciate Ligament Reconstruction Incidence Proportions With US Census–Derived Demographics. JAAOS: Global Research and Reviews. 2023;7(7). Derman PB, Lampe LP, Hughes AP, Pan TJ, Kueper J, Girardi FP, et al. Demographic, Clinical, and Operative Factors Affecting Long-Term Revision Rates After Cervical Spine Arthrodesis. Journal of Bone and Joint Surgery. 2016;98(18):1533–40. Baraga MG, Smith MK, Tanner JP, Kaplan LD, Lesniak BP. Anterior Cruciate Ligament Injury and Access to Care in South Florida: Does Insurance Status Play a Role? The Journal of Bone and Joint Surgery-American Volume. 2012;94(24):e183-1–6. Gundle KR, McGlaston TJ, Ramappa AJ. Effect of Insurance Status on the Rate of Surgery Following a Meniscal Tear. The Journal of Bone and Joint Surgery-American Volume. 2010;92(14):2452–6. Kim CY, Wiznia DH, Roth AS, Walls RJ, Pelker RR. Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act. Foot Ankle Int. 2016;37(7):776–81. Wolinsky P, Kim S, Quackenbush M. Does Insurance Status Affect Continuity of Care for Ambulatory Patients with Operative Fractures? Journal of Bone and Joint Surgery. 2011;93(7):680–5. Archdeacon MT, Simon PM, Wyrick JD. The Influence of Insurance Status on the Transfer of Femoral Fracture Patients to a Level-I Trauma Center. The Journal of Bone and Joint Surgery-American Volume. 2007;89(12):2625–31. Lecaros I, Cruzat DP, Pommer Muñoz R, Tillan P, Walton M. Working Papers Inequality in Chile: Perceptions and Patterns. 2023. Bastias G, Pantoja T, Leisewitz T, Zarate V. Health care reform in Chile. Can Med Assoc J. 2008;179(12):1289–92. Ministerio de Salud C. https://deis.minsal.cl/?#estadisticas. Bases de datos Egresos Hospitalarios Departamento Estadística e Información en Salud. Patterson BM, Draeger RW, Olsson EC, Spang JT, Lin FC, Kamath G V. A Regional Assessment of Medicaid Access to Outpatient Orthopaedic Care: The Influence of Population Density and Proximity to Academic Medical Centers on Patient Access. Journal of Bone and Joint Surgery. 2014;96(18):e156. Draeger RW, Patterson BM, Olsson EC, Schaffer A, Patterson JMM. The Influence of Patient Insurance Status on Access to Outpatient Orthopedic Care for Flexor Tendon Lacerations. J Hand Surg Am. 2014;39(3):527–33. FONASA. https://www.fonasa.cl/sites/fonasa/institucional/archivos. Bases de datos, Informes, Estudios y Documentos . Mondaca ALN, Chi C. Equity in out-of-pocket payment in Chile. Rev Saude Publica. 2017;51(0). Tables Table 1. Chilean sociodemographic data for 2018. Population a 18,751,4051 Life Expectancy a 80 years Gross Domestic Product b GINI Coefficient b, c 295.4 USD Billion 0,44 Sources: a National Institute of Statistics; b World Bank; 3c OECD average GINI 0,313. Table 2. Beneficiaries covered by each type of health insurance offered in Chile for 2018. Health Insurance 1 Beneficiaries (%) Public 75.2% Private 18.0% Others 6.8% Sources: a Ministry of Health Table 3. Total and orthopedic (urgent/elective) surgeries performed in Chile in 2018, as well as respective rates. n Rate Per 1,000 Inhabitants b Total Surgeries a 751,477 40.08 (39.99-40.16) Orthopedic Surgeries a 141,374 7.54 (7.50-7.58) Urgent 62,900 3.35 (3.33-3.38) Elective 78,874 4.18 (4.16-4.21) Source: a Ministry of Health, b National Institute of Statistics Table 4. Annual rate of orthopedic surgeries, per 1,000 beneficiaries, by healthcare insurance for Chile in 2018. Type of Surgery Public Insurance (CI 95%) Private Insurance (CI 95%) IRR a (CI 95%) p-value Urgent 2.81 (2.79-2.84) 4.10 (4.03-4.17) 1.46 (1.43-1.48) <0.001 Elective 2.96 (2.93-2.99) 8.78 (8.68-8.87) 2.97 (2.92-3.01) <0.001 Total 5.77 (5.73-5.81) 12.88 (12.76-13.00) 2.23 (2.20-2.26) <0.001 Univariate Negative Binomial Regression. Abbreviatures: CI: Confidence interval; IRR: Incidence rate ratio Table 5. Comparison of incidence orthopedic surgery rate between public and private health insurance Variables IRR Std. Err. CI 95% p-value Health insurance Public (reference) Private 2.08 0.37 1.46-2.96 <0.001 Type of surgery Elective (reference) Urgent 1.50 0.27 1.06-2.13 0.024 Multivariate Binomial Negative Regression. Abbreviature: IRR (incidence rate ratio); Std. Err (Standard Error); CI (Confidence Interval) Additional Declarations No competing interests reported. Supplementary Files Annex1.docx Annex2.docx Cite Share Download PDF Status: Published Journal Publication published 10 May, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 10 Oct, 2024 Reviews received at journal 08 Oct, 2024 Reviewers agreed at journal 08 Oct, 2024 Reviews received at journal 06 Oct, 2024 Reviewers agreed at journal 04 Oct, 2024 Reviewers agreed at journal 04 Oct, 2024 Reviewers agreed at journal 04 Oct, 2024 Reviewers invited by journal 08 Aug, 2024 Editor invited by journal 26 Jul, 2024 Editor assigned by journal 26 Jul, 2024 Submission checks completed at journal 22 Jul, 2024 First submitted to journal 12 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4730910","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":340129217,"identity":"ac0140ae-d798-452f-a082-a666ec35c4f0","order_by":0,"name":"María Jesús Lira","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Jesús","lastName":"Lira","suffix":""},{"id":340129218,"identity":"6b44db38-6936-4f7c-a898-54d9c72feca5","order_by":1,"name":"Paula Pino","email":"","orcid":"","institution":"Pontificia Universidad Católica de 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11:33:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22687,"visible":true,"origin":"","legend":"","description":"","filename":"Annex1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4730910/v1/440fa01ef94b5bedbeb6cf70.docx"},{"id":63271333,"identity":"fd84d9a9-4d2a-4b53-9e9d-6fa56c000ebf","added_by":"auto","created_at":"2024-08-26 11:25:47","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20804,"visible":true,"origin":"","legend":"","description":"","filename":"Annex2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4730910/v1/6a92ad68df95f620e4b07dc7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disparity in Access to Orthopedic Surgery between Public and Private Healthcare Insurance: a nationwide population-based study.","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDisparity in healthcare access is a current subject of interest in medicine (1). Health disparities have been defined as systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups(2). When considering access to surgical care, these differences may directly influence the population\u0026rsquo;s morbidity, mortality, and the country\u0026rsquo;s global burden of disease (1,3). Studies investigating these differences may help understand the nature of these inequities and contribute to directing resource allocation policies.\u003c/p\u003e\n\u003cp\u003eWeiser et al. reported that worldwide access to surgical care is inequitably distributed across different countries, exposing the disproportionate scarcity of surgical access in low-income settings (3). There is evidence of a wide number of factors that influence the population\u0026rsquo;s access to primary care, specialist referrals, and optimal treatment of their conditions (4\u0026ndash;7).\u003c/p\u003e\n\u003cp\u003eIn the field of orthopedic surgery, gender, race, geographic location, and socioeconomic status have established effects on the access to surgical care of selected groups (7\u0026ndash;10). Insurance status has also been shown to be determinant in the resolution of specific interventions such as lower extremity fractures and reconstructive and arthroscopic surgery, among others (7,9,11\u0026ndash;15). Insurance status may have a greater impact on the treatment of elective surgeries compared to urgent cases. This limits the opportunity to treat elective cases, in a scenario with limited resources. Despite the available literature, population-based studies remain lacking in regard to access to orthopedic surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to establish if access to orthopedic surgery differs by healthcare coverage in a country with a dual healthcare system and to analyze how this impacts the treatment of urgent and elective conditions. We hypothesized that differential access to orthopedic surgery would exist according to the type of healthcare coverage (i.e., private vs. public), having a greater impact on non-urgent conditions.\u0026nbsp;\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cem\u003eDesign\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional, population-based study investigated the rate of orthopedic surgery in Chile in 2018. The Institutional Review Board (ID Resolution 16-196) granted approval for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eChile is a developed country with a population of 18,751,4051 inhabitants (Table 1). Among members of the Organization for Economic Co-operation and Development (OECD), Chile has one of the highest levels of income inequality (16). Healthcare is provided through two separate insurance systems \u0026ndash; public and private (17). Public healthcare insurance is funded through taxes paid by workers and pensioners in this system, corresponding to 7% of their income. It also covers unemployed individuals, dependent family members of insured workers, and the poor or indigent. However, enrollment in the public option is not mandatory, and individuals can choose to use the legally mandated 7% or more to purchase health insurance from multiple private companies. Finally, 6.8% of the population receives healthcare through semi-private coverage for the police and armed forces, among other entities (17) (Table 2). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u003c/em\u003e\u003cem\u003enformation Sources\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDemographic distribution of Chile\u0026rsquo;s population was extracted from the Chilean National Institute of Statistics. Information regarding the number of beneficiaries covered by each type of healthcare insurance was obtained from the Chilean Ministry of Health (18).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe number of surgeries performed in 2018 was collected from the Hospital Discharge Registry (Department of Statistics, Chilean Ministry of Health). Information is mandatorily entered in this registry when patients are discharged from any healthcare center. This database also provides patients\u0026rsquo; demographic data, diagnosis, surgical procedures performed, and information about their healthcare insurance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMusculoskeletal diagnoses were independently defined by two orthopedic surgeons from the ICD-10 (CIE-10) database. In cases of disagreement, a third orthopedic surgeon was consulted to reach a consensus. In all, 1,041 ICD-10 diagnoses were obtained from The National Discharge Registry from the Ministry of Health\u0026nbsp;(13),\u0026nbsp;the most frequent categories of which were M, Q, S, and T (Annex 1). Inclusion criteria considered patients operated and discharged with a musculoskeletal condition during the year 2018. This year was selected as the registry\u0026rsquo;s most recent full year when the database was obtained before the 2019 Chilean social upheaval and the 2020 COVID-19 pandemic. This year does not show significant differences from subsequent years in relation to health access and macroeconomic variables.\u003c/p\u003e\n\u003cp\u003eThe ICD-10 diagnoses defined as musculoskeletal conditions were grouped according to the type of surgical treatment needed into elective (e.g., osteoarthritis) and urgent (e.g., fractures, acute infections), as per the aforementioned procedure. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analysis\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe annual rate of orthopedic surgeries per 1,000 inhabitants was calculated. Surgery access by healthcare insurance was compared by calculating the rate of surgeries in the private and public healthcare systems per 1,000 beneficiaries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe annual rates of elective and urgent surgeries were calculated for each insurance type. The obtained rates for each healthcare system were compared\u0026nbsp;through Negative Binomial regression, calculating the Incidence Rate Ratio (IRR).\u0026nbsp;A significant p-value was considered over 5%.\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed with Stata LLC v.16 software (serial number 401606250896).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 751,477 hospital discharges occurred during 2018 in Chile. There were 141,374 orthopedic surgeries, which accounted for 18,81% of all surgical procedures. The national rate of orthopedic surgery was 7,54 per 1,000 inhabitants (CI95% 7,50-7,58). Male patients correspond to 56.69% (n=77,977) and the average age was 46.37 years old (\u0026plusmn; 20.69). The urgent surgeries were 62,900 (44.49%) and the elective 78,474 (55,51%), with a rate per 1,000 inhabitants of 3.35 and 4.18, respectively (Table 3).\u003c/p\u003e\n\u003cp\u003eThe rate of orthopedic surgery in the public system was 5.77 per 1,000 beneficiaries (CI95%\u0026nbsp;5.73-5.81), while the private system had a rate of 12.88 per 1,000 beneficiaries\u0026nbsp;(CI95%\u0026nbsp;12.76-13.00). When both rates were compared, the private system had an orthopedic surgery rate 2.23 times greater than the public system (CI 95%\u0026nbsp;2.20-2.26; p \u0026lt;0.001) (Table 4).\u003c/p\u003e\n\u003cp\u003eThe difference between insurance types became accentuated when separating analyses based on elective and urgent surgeries. The annual rate of elective surgeries was 2.97 times greater in the private system (CI 95%\u0026nbsp;2.92-3.01; p \u0026lt;0.001), while urgent surgeries in the private system occurred only at a rate 1.46 times more than in the public system (CI 95%\u0026nbsp;1.43-1.48; p \u0026lt;0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the multivariate analysis, according to the insurance and type of surgery, the differences observed in orthopedic surgery rates were maintained. The annual rate of orthopedic surgery was 2.08 times greater in the private system (CI 95% 1.46-2.96; p \u0026lt;0.001) and 1.50 times higher in elective surgeries (vs urgent) (CI 95% 1.06-2.13; p \u0026lt;0.024). (Table 5 and Figure 1).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study evaluated the access to orthopedic surgery according to public and private health insurance in a country with a dual healthcare system. Our results confirmed the hypothesis that there is an important disparity in access to orthopedic surgical care. The population insured by private companies had a 2.23 times higher rate of surgeries than those under public insurance. In elective procedures, this difference is accentuated to 2.97 times higher in private insurance beneficiaries.\u003c/p\u003e \u003cp\u003eRecent literature has shown disparities in access to orthopedic care in specific populations. A large number of studies performed in the United States have compared the access to healthcare of groups under Medicaid and private insurance. These studies have found disparities in access to pediatric orthopedic care, differences in the time to surgery of patients with anterior cruciate ligament reconstruction surgery, and treatment of hand flexor tendon lacerations, among others (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Despite the high prevalence of orthopedic surgery, there is limited evidence in Latin America regarding inequities in access. Vidal et al. observed that in Chile, the rotator cuff surgery rates were 3.4 times higher in the private healthcare system compared to the public system (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study suggests a large unaddressed orthopedic surgery burden in the public insured population, as this system covers 75% of Chile\u0026rsquo;s population (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Even though the aim of this study was not to analyze socioeconomic factors, the population that can opt for private insurances has higher levels of income (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This fact suggest that socioeconomic status may play a role in access to surgery in a dual healthcare system. The disparity found is represented mostly by limited access to elective surgeries. This can be explained by barriers in the public system which include limited access to primary care, delayed orthopedic surgeon referrals, and long waiting lists for surgery. Elective conditions are not a priority in a system with limited resources and a high demand to solve urgent cases. Additionally, the elevated rate of elective surgeries observed within the private system warrants careful analysis. It is important to consider that financial incentives may potentially impact surgical decision-making processes.\u003c/p\u003e \u003cp\u003eThe main strength of this study is that it was a population study, being the first to assess access to orthopedic surgery for an entire country. A two-tier healthcare system was analyzed, which can be extrapolated to other countries with similar healthcare systems. The limitations of this study include a possible information bias. The analyzed data were obtained from national surveys and clinical forms, which are completed by individuals with different degrees of specializations and competencies. For this reason, there could be errors in coding of diagnoses and procedures. Furthermore, the selection of musculoskeletal ICD-10 diagnoses was arbitrary, as was subsequent classification into elective or urgent conditions. Classification of these diagnoses has not been standardized in the literature. More accurate statistics could be obtained by selecting cases based on surgical procedure codes. This information was not available in a standardized manner in our databases.\u003c/p\u003e \u003cp\u003eOur study confirms that there is an important disparity in access to orthopedic surgery in Chile according to healthcare insurance system. The limited access of the population under the public system was accentuated when analyzing elective surgeries. Future investigations should study the effect of other factors such as access to primary care physicians, orthopedic surgeon referral, waiting times for orthopedic surgery, and number of orthopedic surgery indications.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAccess disparity to orthopedic surgical care existed between the private and public healthcare systems in Chile. Disparity in access became greater when separately analyzing the rates of elective and urgent orthopedic surgeries.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Institutional Review Board to Pontificia Universidad Cat\u0026oacute;lica de Chile (ID Resolution 16-196) granted approval for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur research project did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMJL\u0026nbsp;\u003c/strong\u003emade substantial contributions to the conception, design, acquisition, analysis, and interpretation of data, drafted the work, approved the submitted version, and agreed to be personally accountable for the author\u0026apos;s own contributions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePP\u0026nbsp;\u003c/strong\u003emade substantial contributions to the conception,\u0026nbsp;drafted the work, approved the submitted version, and agreed to be personally accountable for the author\u0026apos;s\u0026nbsp;contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCV\u0026nbsp;\u003c/strong\u003emade substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author\u0026apos;s\u0026nbsp;contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePM\u0026nbsp;\u003c/strong\u003emade substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author\u0026apos;s\u0026nbsp;contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJC\u0026nbsp;\u003c/strong\u003emade substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author\u0026apos;s\u0026nbsp;contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSI\u0026nbsp;\u003c/strong\u003emade substantial contributions to the conception, approved the submitted version, and agreed to be personally accountable for the author\u0026apos;s\u0026nbsp;contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJV\u0026nbsp;\u003c/strong\u003emade substantial contributions to the conception, design of the work and the acquisition, analysis and interpretation of data, have approved the submitted version, and have agreed both to be personally accountable for the author\u0026apos;s own contributions. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to express our sincere gratitude to Macarena Vald\u0026eacute;s (PhD) for her contribution to this line of research.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcQueen K. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ. 2008;86(8):646\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eBraveman PA, Kumanyika S, Fielding J, LaVeist T, Borrell LN, Manderscheid R, et al. Health Disparities and Health Equity: The Issue Is Justice. Am J Public Health. 2011;101(S1):S149\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eWeiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. The Lancet. 2008;372(9633):139\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eBlanchard J, Ogle K, Thomas O, Lung D, Asplin B, Lurie N. Access to Appointments Based on Insurance Status in Washington, D.C. J Health Care Poor Underserved. 2008;19(3):687\u0026ndash;96. \u003c/li\u003e\n\u003cli\u003eOlah ME, Gaisano G, Hwang SW. The effect of socioeconomic status on access to primary care: an audit study. Can Med Assoc J. 2013;185(6):E263\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003ePurnell TS, Calhoun EA, Golden SH, Halladay JR, Krok-Schoen JL, Appelhans BM, et al. Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research. Health Aff. 2016;35(8):1410\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eVidal C, Lira MJ, de Marinis R, Liendo R, Contreras JJ. Increasing incidence of rotator cuff surgery: A nationwide registry study in Chile. BMC Musculoskelet Disord. 2021;22(1):1052. \u003c/li\u003e\n\u003cli\u003eCannada LK, Ortega G, Mclaurin TM, Tejwani NC, Little MTM, Benson E, et al. Racial, Ethnic, and Socioeconomic Healthcare Disparities in Orthopaedics: What About Orthopaedic Trauma? [Internet]. 2023. Available from: http://journals.lww.com/jorthotrauma\u003c/li\u003e\n\u003cli\u003eSolarczyk JK, Roberts HJ, Wong SE, Ward DT. Healthcare Disparities in Orthopaedic Surgery: A Comparison of Anterior Cruciate Ligament Reconstruction Incidence Proportions With US Census\u0026ndash;Derived Demographics. JAAOS: Global Research and Reviews. 2023;7(7). \u003c/li\u003e\n\u003cli\u003eDerman PB, Lampe LP, Hughes AP, Pan TJ, Kueper J, Girardi FP, et al. Demographic, Clinical, and Operative Factors Affecting Long-Term Revision Rates After Cervical Spine Arthrodesis. Journal of Bone and Joint Surgery. 2016;98(18):1533\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eBaraga MG, Smith MK, Tanner JP, Kaplan LD, Lesniak BP. Anterior Cruciate Ligament Injury and Access to Care in South Florida: Does Insurance Status Play a Role? The Journal of Bone and Joint Surgery-American Volume. 2012;94(24):e183-1\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eGundle KR, McGlaston TJ, Ramappa AJ. Effect of Insurance Status on the Rate of Surgery Following a Meniscal Tear. The Journal of Bone and Joint Surgery-American Volume. 2010;92(14):2452\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eKim CY, Wiznia DH, Roth AS, Walls RJ, Pelker RR. Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act. Foot Ankle Int. 2016;37(7):776\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eWolinsky P, Kim S, Quackenbush M. Does Insurance Status Affect Continuity of Care for Ambulatory Patients with Operative Fractures? Journal of Bone and Joint Surgery. 2011;93(7):680\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eArchdeacon MT, Simon PM, Wyrick JD. The Influence of Insurance Status on the Transfer of Femoral Fracture Patients to a Level-I Trauma Center. The Journal of Bone and Joint Surgery-American Volume. 2007;89(12):2625\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eLecaros I, Cruzat DP, Pommer Mu\u0026ntilde;oz R, Tillan P, Walton M. Working Papers Inequality in Chile: Perceptions and Patterns. 2023. \u003c/li\u003e\n\u003cli\u003eBastias G, Pantoja T, Leisewitz T, Zarate V. Health care reform in Chile. Can Med Assoc J. 2008;179(12):1289\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eMinisterio de Salud C. https://deis.minsal.cl/?#estadisticas. Bases de datos Egresos Hospitalarios Departamento Estad\u0026iacute;stica e Informaci\u0026oacute;n en Salud. \u003c/li\u003e\n\u003cli\u003ePatterson BM, Draeger RW, Olsson EC, Spang JT, Lin FC, Kamath G V. A Regional Assessment of Medicaid Access to Outpatient Orthopaedic Care: The Influence of Population Density and Proximity to Academic Medical Centers on Patient Access. Journal of Bone and Joint Surgery. 2014;96(18):e156. \u003c/li\u003e\n\u003cli\u003eDraeger RW, Patterson BM, Olsson EC, Schaffer A, Patterson JMM. The Influence of Patient Insurance Status on Access to Outpatient Orthopedic Care for Flexor Tendon Lacerations. J Hand Surg Am. 2014;39(3):527\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eFONASA. https://www.fonasa.cl/sites/fonasa/institucional/archivos. Bases de datos, Informes, Estudios y Documentos . \u003c/li\u003e\n\u003cli\u003eMondaca ALN, Chi C. Equity in out-of-pocket payment in Chile. Rev Saude Publica. 2017;51(0). \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"350\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eChilean sociodemographic\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003edata for 2018.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.57142857142857%\"\u003e\n \u003cp\u003ePopulation\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.42857142857143%\"\u003e\n \u003cp\u003e18,751,4051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.57142857142857%\"\u003e\n \u003cp\u003eLife Expectancy\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.42857142857143%\"\u003e\n \u003cp\u003e80 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.57142857142857%\"\u003e\n \u003cp\u003eGross Domestic Product\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eGINI Coefficient\u003csup\u003eb, c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.42857142857143%\"\u003e\n \u003cp\u003e295.4 USD Billion\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eSources: \u003csup\u003ea\u003c/sup\u003eNational Institute of Statistics; \u003csup\u003eb\u003c/sup\u003eWorld Bank;\u003csup\u003e3c\u003c/sup\u003eOECD average GINI 0,313.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"369\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eBeneficiaries covered by each\u0026nbsp;type of health insurance offered in Chile\u0026nbsp;for 2018.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.19565217391305%\"\u003e\n \u003cp\u003eHealth Insurance\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.80434782608695%\"\u003e\n \u003cp\u003eBeneficiaries\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.19565217391305%\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.80434782608695%\"\u003e\n \u003cp\u003e75.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.19565217391305%\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.80434782608695%\"\u003e\n \u003cp\u003e18.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.19565217391305%\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.80434782608695%\"\u003e\n \u003cp\u003e6.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eSources: \u003csup\u003ea\u003c/sup\u003eMinistry of Health\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"435\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eTotal and orthopedic (urgent/elective) surgeries performed in Chile in 2018, as well as respective rates.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.632183908045974%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.919540229885058%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.44827586206897%\"\u003e\n \u003cp\u003eRate Per 1,000 Inhabitants\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.632183908045974%\"\u003e\n \u003cp\u003eTotal Surgeries\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.919540229885058%\"\u003e\n \u003cp\u003e751,477\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.44827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e40.08 (39.99-40.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.632183908045974%\"\u003e\n \u003cp\u003eOrthopedic Surgeries\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.919540229885058%\"\u003e\n \u003cp\u003e141,374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.44827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e7.54 (7.50-7.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.632183908045974%\"\u003e\n \u003cp\u003eUrgent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.919540229885058%\"\u003e\n \u003cp\u003e62,900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.44827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e3.35 (3.33-3.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.632183908045974%\"\u003e\n \u003cp\u003eElective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.919540229885058%\"\u003e\n \u003cp\u003e78,874\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.44827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e4.18 (4.16-4.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eSource: \u003csup\u003ea\u003c/sup\u003eMinistry of Health, \u003csup\u003eb\u003c/sup\u003eNational Institute of Statistics\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"86.82842287694974%\" colspan=\"5\" style=\"width: 99.8264%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eAnnual rate of orthopedic surgeries, per 1,000 beneficiaries, by healthcare insurance for Chile in 2018.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.251299826689774%\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.090121317157713%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePublic Insurance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(CI 95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.61005199306759%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrivate Insurance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(CI 95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.87694974003466%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRR\u003csup\u003ea\u003c/sup\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(CI 95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.17157712305026%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.251299826689774%\"\u003e\n \u003cp\u003eUrgent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.090121317157713%\"\u003e\n \u003cp\u003e2.81 (2.79-2.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.61005199306759%\"\u003e\n \u003cp\u003e4.10 (4.03-4.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.87694974003466%\"\u003e\n \u003cp\u003e1.46 (1.43-1.48)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.17157712305026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.251299826689774%\"\u003e\n \u003cp\u003eElective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.090121317157713%\"\u003e\n \u003cp\u003e2.96 (2.93-2.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.61005199306759%\"\u003e\n \u003cp\u003e8.78 (8.68-8.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.87694974003466%\"\u003e\n \u003cp\u003e2.97 (2.92-3.01)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.17157712305026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.251299826689774%\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.090121317157713%\"\u003e\n \u003cp\u003e5.77 (5.73-5.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.61005199306759%\"\u003e\n \u003cp\u003e12.88 (12.76-13.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.87694974003466%\"\u003e\n \u003cp\u003e2.23 (2.20-2.26)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.17157712305026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"86.82842287694974%\" colspan=\"5\" style=\"width: 99.8264%;\"\u003e\n \u003cp\u003e\u003cem\u003eUnivariate Negative Binomial Regression.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAbbreviatures: CI: Confidence interval; IRR: Incidence rate ratio\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u003c/strong\u003e Comparison of incidence orthopedic surgery rate between public and private health insurance\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"444\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.432432432432435%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\n \u003cp\u003eIRR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.243243243243242%\" valign=\"bottom\"\u003e\n \u003cp\u003eStd. Err.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.693693693693692%\" valign=\"bottom\"\u003e\n \u003cp\u003eCI 95%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.432432432432435%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.243243243243242%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.693693693693692%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.432432432432435%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003ePublic (reference)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.243243243243242%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.693693693693692%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.432432432432435%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003ePrivate\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.243243243243242%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.693693693693692%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.46-2.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.432432432432435%\" valign=\"bottom\"\u003e\n \u003cp\u003eType of surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.243243243243242%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.693693693693692%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.432432432432435%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eElective (reference)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.243243243243242%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.693693693693692%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.432432432432435%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eUrgent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.243243243243242%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.693693693693692%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.06-2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.315315315315315%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eMultivariate Binomial Negative Regression.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviature: IRR (incidence rate ratio); Std. Err (Standard Error); CI (Confidence Interval)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"30\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Disparity, Orthopedic Surgery, Healthcare Insurance","lastPublishedDoi":"10.21203/rs.3.rs-4730910/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4730910/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe aim of this study was to examine the influence of healthcare coverage in the access to orthopedic surgery in a country with a dual (private/public) healthcare system. We hypothesize that differential access would exist according to the type of healthcare coverage. This difference would accentuate when analyzing access to elective orthopedic surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA cross-sectional, population-based design was used to investigate orthopedic surgery rates in Chile during 2016. The rates of orthopedic surgeries provided under the private and public healthcare systems were calculated per 1,000 beneficiaries, as based on data collected from the Hospital Discharge Registry provided by the Chilean Ministry of Health. ICD-10 diagnoses were classified as urgent or elective, categories into which the public/private surgery rates were also sorted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe overall rate of orthopedic surgery was 7.54 per 1000 inhabitants in 2018. Patients covered under private insurance had an orthopedic surgery rate 2.23 times higher than patients within the public system. This difference became more accentuated when sorting by elective surgeries, with private healthcare having a rate 2.97 times higher than public healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAccess disparity to orthopedic surgical care existed between the private and public healthcare systems in Chile. Disparity in access became greater when separately analyzing the rates of elective and urgent orthopedic surgeries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence\u003c/strong\u003e: III\u003c/p\u003e","manuscriptTitle":"Disparity in Access to Orthopedic Surgery between Public and Private Healthcare Insurance: a nationwide population-based study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 11:25:42","doi":"10.21203/rs.3.rs-4730910/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-10T08:03:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-09T02:31:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48991664755608456525601070307047789171","date":"2024-10-09T02:05:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-06T17:35:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75746585224181710773671396759891173500","date":"2024-10-04T17:51:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158896819223609180008215906888391206810","date":"2024-10-04T11:50:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225688630523248653753795853944738245410","date":"2024-10-04T10:24:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-08T10:01:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-26T22:57:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-26T22:36:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-23T02:50:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-07-12T14:19:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8e8fb6e7-6e1e-4779-be3b-4ff24d7be98c","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T16:08:55+00:00","versionOfRecord":{"articleIdentity":"rs-4730910","link":"https://doi.org/10.1186/s12891-025-08295-7","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-05-10 15:57:06","publishedOnDateReadable":"May 10th, 2025"},"versionCreatedAt":"2024-08-26 11:25:42","video":"","vorDoi":"10.1186/s12891-025-08295-7","vorDoiUrl":"https://doi.org/10.1186/s12891-025-08295-7","workflowStages":[]},"version":"v1","identity":"rs-4730910","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4730910","identity":"rs-4730910","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}