1
|
Buchta M, Griessenauer CJ. Commentary: Impact of Race on Outcomes in the Endovascular and Microsurgical Treatment in Patients With Intracranial Aneurysms. Neurosurgery 2024:00006123-990000000-01139. [PMID: 38651893 DOI: 10.1227/neu.0000000000002970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/25/2024] Open
Affiliation(s)
- Melanie Buchta
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | | |
Collapse
|
2
|
Hackett AM, Adereti CO, Walker AP, Nico E, Scherschinski L, Rhodenhiser EG, Eberle AT, Naik A, Giraldo JP, Hartke JN, Rahmani R, Winkler EA, Catapano JS, Lawton MT. Racial and Socioeconomic Status among a Patient Population Presenting with Aneurysmal Subarachnoid Hemorrhage versus Unruptured Intracranial Aneurysm: A Single-Center Study. Brain Sci 2024; 14:394. [PMID: 38672043 PMCID: PMC11047834 DOI: 10.3390/brainsci14040394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Racial and socioeconomic health disparities are well documented in the literature. This study examined patient demographics, including socioeconomic status (SES), among individuals presenting with aneurysmal subarachnoid hemorrhage (aSAH) and unruptured intracranial aneurysm (UIA) to identify factors associated with aSAH presentation. A retrospective assessment was conducted of all patients with aSAH and UIA who presented to a large-volume cerebrovascular center and underwent microsurgical treatment from January 2014 through July 2019. Race and ethnicity, insurance type, and SES data were collected for each patient. Comparative analysis of the aSAH and UIA groups was conducted. Logistic regression models were also employed to predict the likelihood of aSAH presentation based on demographic and socioeconomic factors. A total of 640 patients were included (aSAH group, 251; UIA group, 389). Significant associations were observed between race and ethnicity, SES, insurance type, and aneurysm rupture. Non-White race or ethnicity, lower SES, and having public or no insurance were associated with increased odds of aSAH presentation. The aSAH group had poorer functional outcomes and higher mortality rates than the UIA group. Patients who are non-White, have low SES, and have public or no insurance were disproportionately affected by aSAH, which is historically associated with poorer functional outcomes.
Collapse
Affiliation(s)
- Ashia M. Hackett
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Christopher O. Adereti
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA;
| | - Ariel P. Walker
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Elsa Nico
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Emmajane G. Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Adam T. Eberle
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Juan P. Giraldo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Joelle N. Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| |
Collapse
|
3
|
Kandregula S, Savardekar A, Beyl R, Caskey J, Terrell D, Adeeb N, Whipple SG, Newman WC, Toms J, Kosty J, Sharma P, Mayeaux EJ, Cuellar H, Guthikonda B. Health inequities and socioeconomic factors predicting the access to treatment for unruptured intracranial aneurysms in the USA in the last 20 years: interaction effect of race, gender, and insurance. J Neurointerv Surg 2023; 15:1251-1256. [PMID: 36863863 DOI: 10.1136/jnis-2022-019767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/12/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND The literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed over time. METHODS A cross-sectional study using the National Inpatient Sample database covering 97% of the USA population was carried out. RESULTS A total of 213 350 treated patients with UIA were included in the final analysis and compared with 173 375 treated patients with aneurysmal subarachnoid hemorrhage (aSAH) over the years 2000-2019. The mean (SD) age of the UIA and aSAH groups was 56.8 (12.6) years and 54.3 (14.1) years, respectively. In the UIA group, 60.7% were white patients, 10.2% were black patients, 8.6% were Hispanic, 2% were Asian or Pacific Islander, 0.5% were Native Americans, and 2.8% were others. The aSAH group comprised 48.5% white patients, 13.6% black patients, 11.2% Hispanics, 3.6% Asian or Pacific Islanders, 0.4% Native Americans, and 3.7% others. After adjusting for covariates, black patients (OR 0.637, 95% CI 0.625 to 0.648) and Hispanic patients (OR 0.654, 95% CI 0.641 to 0.667) had lower odds of treatment compared with white patients. Medicare patients had higher odds of treatment than private patients, while Medicaid and uninsured patients had lower odds. Interaction analysis showed that non-white/Hispanic patients with any insurance/no insurance had lower treatment odds than white patients. Multivariable regression analysis showed that the treatment odds of black patients has improved slightly over time, while the odds for Hispanic patients and other minorities have remained the same over time. CONCLUSION This study from 2000 to 2019 shows that disparities in the treatment of UIA have persisted but have slightly improved over time for black patients while remaining constant for Hispanic patients and other minority groups.
Collapse
Affiliation(s)
| | - Amey Savardekar
- Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Robbie Beyl
- Biostatistics, Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Joshua Caskey
- Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
| | | | - Nimer Adeeb
- Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
| | | | | | - Jamie Toms
- Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Jennifer Kosty
- Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Pankaj Sharma
- Neurology, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Edward J Mayeaux
- Family Medicine, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Hugo Cuellar
- Radiology, LSU Health Shreveport, Shreveport, Louisiana, USA
| | | |
Collapse
|
4
|
Koester S, Zeoli T, Yengo-Kahn A, Feldman M, Lan M, Sweeting R, Chitale R. Race as a factor in adverse outcomes following unruptured aneurysm surgery. J Clin Neurosci 2023; 107:34-39. [PMID: 36495724 DOI: 10.1016/j.jocn.2022.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Strong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States. METHODS Data from the 2012-2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type. RESULTS 7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07-1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients. CONCLUSION Our nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.
Collapse
Affiliation(s)
- Stefan Koester
- Vanderbilt School of Medicine, Nashville, TN, United States
| | - Tyler Zeoli
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Aaron Yengo-Kahn
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Matt Lan
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Raeshell Sweeting
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States.
| |
Collapse
|
5
|
Cardinal T, Strickland BA, Bonney PA, Lechtholz-Zey E, Mendoza J, Pangal DJ, Mack W, Giannotta S, Zada G. Disparities in the Surgical Treatment of Cerebrovascular Pathologies: A Contemporary Systematic Review. World Neurosurg 2021; 158:244-257.e1. [PMID: 34856403 DOI: 10.1016/j.wneu.2021.11.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This systematic review analyzes contemporary literature on racial/ethnic, insurance, and socioeconomic disparities within cerebrovascular surgery in the United States to determine areas for improvement. METHODS We conducted an electronic database search of literature published between January 1990 and July 2020 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies analyzing a racial/ethnic, insurance, or socioeconomic disparity within adult cerebrovascular surgery. RESULTS Of 2873 articles screened for eligibility by title and abstract, 970 underwent full-text independent review by 3 authors. Twenty-seven additional articles were identified through references to generate a final list of 47 included studies for analysis. Forty-six were retrospective reviews and 1 was a prospective observational cohort study, thereby comprising Levels III and IV of evidence. Studies investigated carotid artery stenting (11/47, 23%), carotid endarterectomy (22/47, 46.8%), mechanical thrombectomy (8/47, 17%), and endovascular aneurysm coiling or surgical aneurysm clipping (20/47, 42.6%). Minority and underinsured patients were less likely to receive surgical treatment. Non-White patients were more likely to experience a postoperative complication, although this significance was lost in some studies using multivariate analyses to account for complication risk factors. White and privately insured patients generally experienced shorter length of hospital stay, had lower rates of in-hospital mortality, and underwent routine discharge. Twenty-five papers (53%) reported no disparities within at least one examined metric. CONCLUSIONS This comprehensive contemporary systematic review demonstrates the existence of disparity gaps within the field of adult cerebrovascular surgery. It highlights the importance of continued investigation into sources of disparity and efforts to promote equity within the field.
Collapse
Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| |
Collapse
|
6
|
Dharia A, Lacci JV, Mascitelli J, Seifi A. Impact of Ruptured Aneurysm Circulation on Mortality: A Nationwide Inpatient Sample Analysis. J Stroke Cerebrovasc Dis 2020; 29:105124. [PMID: 32912535 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE This study investigates the effect of aneurysm circulation on mortality and patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) within the United States. METHODS A retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization Project (HCUP), with ICD-10 codes for non-traumatic SAH between 2015-2016. Aneurysms were stratified as either anterior or posterior circulation. Multivariate logistic regression was used to find the impact of selected variables on the odds of mortality. RESULTS The NIS reported 1,892 cases of non-traumatic SAH within the study period that were predominantly anterior circulation (82.6%), female (68.6%), white (57.7%), with mean age of 59.07 years, and in-hospital mortality of 21.4%. Anterior circulation aneurysms were associated with lower severity of initial illness (p = 0.014) but higher likelihood of vasospasm (p = 0.0006) than those of the posterior circulation. In a multivariate logistic regression analysis, mortality was associated with posterior circulation aneurysms (OR: 1.42; CI 95% 1.005-20.10, p = 0.047), increasing age (OR: 1.035; 95% CI 1.022-1.049; p < 0.0001), and shorter hospital stays (OR: 0.7838; 95% CI 0.758-0.811; p < 0.0001). Smoking history (OR: 0.825; 95% CI 0.573-1.187, p > 0.05) and vasospasm (OR: 1.005; 95% CI 0.648-1.558; p > 0.05) were not significantly associated with higher odds of mortality. CONCLUSIONS Mortality following aneurysmal SAH is associated with posterior circulation aneurysms, and increasing age, but not smoking history or vasospasm. These findings may be useful for prognostication and counseling patients and families.
Collapse
Affiliation(s)
- Anand Dharia
- Long School of Medicine, University of Texas Health at San Antonio, Texas, USA.
| | - John V Lacci
- Long School of Medicine, University of Texas Health at San Antonio, Texas, USA.
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health at San Antonio, Texas, USA.
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, Texas, USA.
| |
Collapse
|
7
|
Rinaldo L, Rabinstein AA, Cloft HJ, Knudsen JM, Lanzino G, Rangel Castilla L, Brinjikji W. Racial and economic disparities in the access to treatment of unruptured intracranial aneurysms are persistent problems. J Neurointerv Surg 2019; 11:833-836. [DOI: 10.1136/neurintsurg-2018-014626] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/28/2018] [Accepted: 01/01/2019] [Indexed: 11/04/2022]
Abstract
Background and purposePrevious studies have documented disparate access to cerebrovascular neurosurgery for patients of different racial and socioeconomic backgrounds. We further investigated the effect of race and insurance status on access to treatment of unruptured intracranial aneurysms (UIAs) and compared it with data on patients with aneurysmal subarachnoid hemorrhage (aSAH).MethodsThrough the use of a national database, admissions for clipping or coiling of an UIA and for aSAH were identified. Demographic characteristics of patients were characterized according to age, sex, race/ethnicity, and insurance status, and comparisons between patients admitted for treatment of an UIA versus aSAH were performed.ResultsThere were 10 545 admissions for clipping or coiling of an UIA and 33 166 admissions for aSAH between October 2014 and July 2018. White/non-Hispanic patients made up a greater proportion of patients presenting for treatment of an UIA than those presenting with aSAH (64.3% vs 48.2%; P<0.001), whereas black/Hispanic patients presented more frequently with aSAH than for treatment of an UIA (29.3% vs 26.1%; P=0.006). On multivariate linear regression analysis, the proportion of patients admitted for management of an UIA relative to those admitted for aSAH increased with the proportion of patients who were women (P<0.001) and decreased with the proportion of patients with a black/Hispanic background (P=0.010) and those insured with Medicaid or without insurance (P=0.003).ConclusionFor patients with UIAs, racial, ethnic, and socioeconomic backgrounds appear to continue to influence access to treatment.
Collapse
|