Socioeconomic and geographic disparities in pediatric scoliosis surgery

Socioeconomic differences in access to scoliosis care in the pediatric population

PURPOSE

Adolescent idiopathic scoliosis (AIS) is a common spinal deformity affecting pediatric patients, with up to 10% requiring surgical intervention. Studies have shown disparities in these patients associated with race, ethnicity, and insurance type, but there is limited information on disparities that exist based on geographical parameters. In this study, we aim to explore the disparities in the care for AIS by looking at differences in the rates of readmission, infection, and revision between patients residing in rural and urban environments.

METHODS

This is a retrospective cohort study utilizing the Pediatric Health Information System. Pediatric patients that underwent posterior spinal fusion (PSF) for AIS from October 2015 to July 2022 were included. Diagnoses and procedures were identified based on ICD-10 codes and internal tools built into the database. Descriptive statistics were used to summarize the data, including demographics, infection rates, readmission rates, and revision rates. T tests, Chi-squared tests, and logistic regression were used to assess differences between the rural and urban populations. We utilized STATA/SE 15.1 for all data analysis.

RESULTS

15,318 patients were included in the final cohort. Demographics and baseline characteristics were similar between the rural and urban patients, although more rural patients used Medicaid over commercial insurance (41.5% vs. 32.7%, p < 0.01), median household income was lower in rural patients (p < 0.01), and there was a higher proportion of Hispanic patients in the urban patient cohort (13.9% vs. 6.4%, p < 0.01). Complication rates were not significantly different between the urban and rural patient cohorts, although rural patients did have a significantly higher 90-day readmission rate (7.3% vs. 6.1%, p = 0.03) and higher rates of instrumentation removal (7.7% vs. 4.9%, p = 0.01).

CONCLUSIONS

The surgical outcomes between rural and urban pediatric AIS patients undergoing PSF are comparable, although 90-day readmission rates and rates of instrumentation removal were higher in rural patients. Insurance status is likely a significant driver for the differences observed in this study. Future research is needed to better understand the reasons for these differences and to develop strategies to improve outcomes.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Social Disadvantage and Transportation Insecurity in Clubfoot Clinic

OBJECTIVES

This study aims to evaluate the association of missing clubfoot clinic visits with transportation barriers and measures of socioeconomic status including the child opportunity index (COI).

METHODS

An 11-question survey was administered to caregivers of patients with clubfoot seen at a single pediatric tertiary hospital between August 2020 and September 2023. A chart review was conducted to obtain zip codes used to determine COI 2.0 scores. The impact of race/ethnicity, income, persons per household, COI, and transportation methods on missing at least one clinic visit was analyzed using descriptive and nonparametric statistics.

RESULTS

The transportation survey was completed by a total of 99 caregivers. The median travel time to the clinic was 45 minutes (IQR: 33, range: 1 to 180). Most participants reported use of a personal car (108/128, 83%), and 72% took time off work to attend the appointment. Those with lower COI had longer travel time (P=0.02) and were less likely to use personal cars (P=0.05). Missed clubfoot clinic visits were more common for families reliant on transportation other than a personal vehicle (P=0.01) and those with annual income under $30,000 (P=0.02).

CONCLUSIONS

Transportation insecurity was associated with greater social disadvantage as indicated by COI and more missed clinic visits.

LEVEL OF EVIDENCE

Level III.

Surgical Outcomes for Patients With Trisomy 21 and Hirschsprung's Disease: An NSQIP-Pediatric Study

INTRODUCTION

Previous studies have demonstrated worse outcomes for Hirschsprung's disease (HD) procedures in Trisomy 21 (T21) patients. Using a large national database, we sought to investigate surgical outcomes in HD patients with T21 compared to non-T21 patients.

METHODS

We utilized the deidentified National Surgical Quality Improvement Program Pediatric database from 2012 to 2021. Using International Classification of Diseases, Ninth Revision codes, children <18 y old with HD were included and stratified by T21 diagnosis. Demographics, Current Procedural Terminology codes, case characteristics, length of hospital stay, and postoperative complications were analyzed.

RESULTS

Of 3456 HD patients, 12.0% (n = 413) patients had a concurrent diagnosis of T21. Pull-through (PT) procedures accounted for 54.9% of surgeries (n = 1896), of which 10.0% (n = 189) had T21. T21 patients who underwent PT had a younger gestational age (P < 0.0001), cardiac risk factors (P < 0.0001), hematologic disorders (P < 0.0001), higher American Society of Anesthesiologists class (P < 0.0001), and were older at their index operation (P = 0.03). Though operative times were similar, T21 patients had a longer total length of stay (P = 0.0263), postoperative length of stay (P = 0.0033), and more unplanned reoperations (P = 0.0094). Though only significant in unadjusted analyses, T21 patients had more postoperative complications after PT (P = 0.0034), specifically deep surgical site infections (P = 0.009), organ/space surgical site infections (P = 0.004), wound disruption (P < 0.001), and sepsis (P = 0.025).

CONCLUSIONS

We confirm significant differences exist between T21 and non-T21 patients undergoing HD procedures, particularly increased total length of stay, postoperative length of stay, and unplanned reoperations. Understanding these differences will lead to more optimal treatment plans for this unique patient population.

AOA Critical Issues Symposium: Advancing Diversity, Equity, and Inclusion in Orthopaedic Surgery

ABSTRACT

In recent years, the medical field has recognized the pivotal role of diversity, equity, and inclusion (DEI) in enhancing patient care and addressing health-care disparities. Orthopaedic surgery has embraced these principles to create a more inclusive and representative workforce. A DEI symposium that was sponsored by the American Orthopaedic Association convened orthopaedic surgeons, researchers, educators, and stakeholders to discuss challenges and strategies for implementing DEI initiatives. The symposium emphasized the importance of equity, and fostered conversations on creating equal opportunities and resources. Speakers covered key topics, including establishing DEI divisions, metrics for success, DEI leadership, and available resources, and promoted excellence and innovation in orthopaedic surgery through a more diverse and inclusive approach.

Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature

CONTEXT

Neighborhood and built environment encompass one key area of the Social Determinants of Health (SDOH) and is frequently assessed using area-level indices.

OBJECTIVE

We sought to systematically review the pediatric surgery literature for use of commonly applied area-level indices and to compare their utility for prediction of outcomes.

DATA SOURCES

A literature search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence search tool (1/2013-2/2023).

STUDY SELECTION

Inclusion required pediatric surgical patients in the US, surgical intervention performed, and use of an area-level metric.

DATA EXTRACTION

Extraction domains included study, patient, and procedure characteristics.

RESULTS

Area Deprivation Index is the most consistent and commonly accepted index. It is also the most granular, as it uses Census Block Groups. Child Opportunity Index is less granular (Census Tract), but incorporates pediatric-specific predictors of risk. Results with Social Vulnerability Index, Neighborhood Deprivation Index, and Neighborhood Socioeconomic Status were less consistent.

LIMITATIONS

All studies were retrospective and quality varied from good to fair.

CONCLUSIONS

While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role of SDOH to building meaningful interventions towards equity in care.

TYPE OF STUDY

Systematic Review.

LEVEL OF EVIDENCE

Level III.

Association Between the COI and Excess Health Care Utilization and Costs for ACSC

BACKGROUND AND OBJECTIVES

The authors of previous work have associated the Childhood Opportunity Index (COI) with increased hospitalizations for ambulatory care sensitive conditions (ACSC). The burden of this inequity on the health care system is unknown. We sought to understand health care resource expenditure in terms of excess hospitalizations, hospital days, and cost.

METHODS

We performed a retrospective cross-sectional study of the Pediatric Health Information Systems database, including inpatient hospitalizations between January 1, 2016 and December 31, 2022 for children <18 years of age. We compared ACSC hospitalizations, mortality, and cost across COI strata.

RESULTS

We identified 2 870 121 hospitalizations among 1 969 934 children, of which 44.5% (1 277 568/2 870 121) were for ACSCs. A total of 49.1% (331 083/674 548) of hospitalizations in the very low stratum were potentially preventable, compared with 39.7% (222 037/559 003) in the very high stratum (P < .001). After adjustment, lower COI was associated with higher odds of potentially preventable hospitalization (odds ratio 1.18, 95% confidence interval [CI] 1.17-1.19). Compared with the very high COI stratum, there were a total of 137 550 (95% CI 134 582-140 517) excess hospitalizations across all other strata, resulting in an excess cost of $1.3 billion (95% CI $1.28-1.35 billion). Compared with the very high COI stratum, there were 813 (95% CI 758-871) excess deaths, with >95% from the very low and low COI strata.

CONCLUSIONS

Children with lower neighborhood opportunity have increased risk of ACSC hospitalizations. The COI may identify communities in which targeted intervention could reduce health care utilization and costs.

Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

BACKGROUND

Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes.

METHODS

Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age.

RESULTS

Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes.

CONCLUSION

COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems.

LEVEL OF EVIDENCE

Level III-prognostic study.

The Association of Social Determinants of Health With Short Term Pediatric Gastrostomy Tube Outcomes

INTRODUCTION

Social determinants of health (SDH) have been found to be important contributors to postoperative outcomes, especially those related to procedures that require significant postoperative resources. The association between short-term gastrostomy tube (GT) outcomes and SDH in the pediatric population is unknown.

METHODS

A retrospective review was performed of all patients less than 18 y old who received a GT between January 2018 and December 2020 at a single institution. Data including demographics, area deprivation index (ADI), and perioperative information were collected. Patient characteristics were compared in those that did and did not have an unexpected emergency department (ED) visit within 6 wk of discharge from GT placement. Statistical analysis was performed using Wilcoxon sum-rank, Chi-squared test, and Fisher's exact test where applicable, and univariable and multivariable logistic regression.

RESULTS

Of the 541 children who underwent GT placement, 112 (20.7%) returned to the ED within 6 wk postdischarge. In univariable analysis, Black children had 1.64 the odds of an unexpected ED visit compared to White children (95% confidence interval [CI] 1.04-2.60, P = 0.03). When controlling for ethnicity, primary language, insurance, ADI and comorbidities, Black children had 1.80 the odds of an unexpected ED visit compared to White children (95% CI 1.10-2.97, P = 0.02). Final model fit which added a race by ADI interaction term revealed Black children had 2.52 the odds of an unexpected ED visit compared to White children in the low (1-6) ADI group (95% CI 1.41-4.60, P = 0.002). Within advantaged neighborhoods (ADI 1-6), the probability of unplanned ED visits for White children was 17.3% (95%CI 8.9% - 31.1%), which was significantly lower than that for Black children (34.6%, 95% CI 18.8% - 54.7%; P value = 0.006).

CONCLUSIONS

Race and neighborhood disadvantage can be associated with unexpected ED visits within 6 wk of discharge from GT placement in the pediatric population. For procedures that require significant postdischarge resources it is important to study the effect of SDH on return to the healthcare system as they can be an important driver of disparities in outcomes.

Impact of Social Determinants of Health on Adolescent Idiopathic Scoliosis Curve Severity

INTRODUCTION

Social determinants of health have been shown to influence the health and outcomes of pediatric patients. Adolescent idiopathic scoliosis (AIS) may be particularly sensitive to such factors as early diagnosis and treatment can obviate the need for surgical intervention. The purpose of this study was to analyze the effect that social determinants of health have on the severity of AIS at presentation and at the time of surgery.

METHODS

A retrospective review was conducted for consecutive patients who underwent posterior spinal fusion for AIS from 2020 to 2022. Demographic data was collected, while insurance status (private vs. public) and childhood opportunity index (COI) categories (LOW vs. HIGH) were used as a proxy for socioeconomic status. Curve magnitude at the initial presentation and at the latest preoperative visit were recorded with a threshold of 25 to 40 degrees considered within the bracing range. Univariate and multivariate analysis was done to compare differences between subgroups as appropriate.

RESULTS

A total of 180 patients with mean initial and preoperative major curve angles of 48 and 60 degrees were included. Statistically significant differences in race and insurance types were appreciated, with the LOW COI group having a higher proportion of underrepresented minority and publicly insured patients than the HIGH COI group ( P <0.001). Patients within the LOW COI group presented with an initial curve that was, on average, 6 degrees more severe than those within the HIGH group ( P =0.009) and a preoperative curve that was 4 degrees larger than those within the HIGH group ( P =0.015). Similarly, only 13% of patients within the LOW COI group presented with curves within the bracing threshold, compared with 31% in the HIGH COI group ( P =0.009).

CONCLUSION

Socioeconomic status plays a significant role in the severity of AIS. Specifically, patients with lower COI tend to present with curve magnitudes beyond what is responsive to nonsurgical treatment, leading to larger curves at the time of surgery. Future work should focus on addressing social inequalities to optimize the treatment and outcomes of AIS patients.

LEVEL OF EVIDENCE

Level III- Retrospective Comparative Study.