Racial and Ethnic Disparities in the Inpatient Management of Primary Spinal Cord Tumors

The impact of socioeconomic determinants on the access to care and survival in patients with spinal chordomas- a national cancer database analysis

PURPOSE

Chordomas are rare malignant neoplasms primarily treated surgically. Disparities related to race and socioeconomic status, may affect patient outcomes. This study aims to identify prognostic factors for access to care and survival in patients with spinal chordomas.

METHODS

The NCDB database was queried between the years 2004 and 2017. Kaplan-Meier curves were constructed to compare survival probabilities among different groups, based on race and socioeconomic determinents.

RESULTS

1769 patients were identified, with 87% being White, 5% Hispanic, 4% Black, and Asian each. The mean age was 61.3 years. Most patients received care at academic/research centers and lived in a large metropolitan area, with no difference between races. A significantly higher percentage of Black patients did not undergo surgery (p < 0.001), with no statistically significant difference in survival between races (p = 0.97). A higher survival probability was seen in patients with other government insurances (p < 0.0001), in higher income quartiles (p < 0.0001), in metropolitan areas (p = 0.023), and at an academic/research center (p < 0.0001). A lower survival probability was seen in patients who are uninsured, in rural areas, and at community cancer programs (p < 0.0001).

CONCLUSION

This study highlights disparities in access to surgical intervention for patients with spinal chordomas, especially among Black individuals. It emphasizes the significant impact of insurance status and income on access to surgical care and highlights geographical and institutional variations in survival rates. Addressing socioeconomic differences is crucial for fostering equity in neurosurgical outcomes.

Racial and Socioeconomic Status among a Patient Population Presenting with Aneurysmal Subarachnoid Hemorrhage versus Unruptured Intracranial Aneurysm: A Single-Center Study

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.

Association Between Race and Short-Term Outcomes Across 3988 Consecutive Single-Level Spinal Fusions

BACKGROUND AND OBJECTIVES

Race has implications for access to medical care. However, the impact of race, after access to care has been attained, remains poorly understood. The objective of this study was to isolate the relationship between race and short-term outcomes across patients undergoing a single, common neurosurgical procedure.

METHODS

In this retrospective cohort study, 3988 consecutive patients undergoing single-level, posterior-only open lumbar fusion at a single, multihospital, academic medical center were enrolled over a 6-year period. Among them, 3406 patients self-identified as White, and 582 patients self-identified as Black. Outcome disparities between all White patients vs all Black patients were estimated using logistic regression. Subsequently, coarsened exact matching controlled for outcome-mitigating factors; White and Black patients were exact-matched 1:1 on key demographic and health characteristics (matched n = 1018). Primary outcomes included 30-day and 90-day hospital readmissions, emergency department (ED) visits, reoperations, mortality, discharge disposition, and intraoperative complication.

RESULTS

Before matching, Black patients experienced increased rate of nonhome discharge, readmissions, ED visits, and reoperations (all P < .001). After exact matching, Black patients were less likely to be discharged to home (odds ratio [OR] 2.68, P < .001) and had higher risk of 30-day and 90-day readmissions (OR 2.24, P < .001; OR 1.91, P < .001; respectively) and ED visits (OR 1.79, P = .017; OR 2.09, P < .001). Black patients did not experience greater risk of intraoperative complication (unintentional durotomy).

CONCLUSION

Between otherwise homogenous spinal fusion cohorts, Black patients experienced unfavorable short-term outcomes. These disparities were not explained by differences in intraoperative complications. Further investigation must characterize and mitigate institutional and societal factors that contribute to outcome disparities.

Disparities in anterior cervical discectomy and fusion provision and outcomes for cervical stenosis

Background

Disparities in neurosurgical care have emerged as an area of interest when considering the impact of social determinants on access to health care. Decompression via anterior cervical discectomy and fusion (ACDF) for cervical stenosis (CS) may prevent progression towards debilitating complications that may severely compromise one's quality of life. This retrospective database analysis aims to elucidate demographic and socioeconomic trends in ACDF provision and outcomes of CS-related pathologies.

Methods

The Healthcare Cost and Utilization Project National Inpatient Sample database was queried between 2016 and 2019 using International Classification of Diseases 10th edition codes for patients undergoing ACDF as a treatment for spinal cord and nerve root compression. Baseline demographics and inpatient stay measures were analyzed.

Results

Patients of White race were significantly less likely to present with manifestations of CS such as myelopathy, plegia, and bowel-bladder dysfunction. Meanwhile, Black patients and Hispanic patients were significantly more likely to experience these impairments representative of the more severe stages of the degenerative spine disease process. White race conferred a lesser risk of complications such as tracheostomy, pneumonia, and acute kidney injury in comparison to non-white race. Insurance by Medicaid and Medicare conferred significant risks in terms of more advanced disease prior to intervention and negative inpatient. Patients in the highest quartile of median income consistently fared better than patients in the lowest quartile across almost every aspect ranging from degree of progression at initial presentation to incidence of complications to healthcare resource utilization. All outcomes for patients age > 65 were worse than patients who were younger at the time of the intervention.

Conclusions

Significant disparities exist in the trajectory of CS and the risks associated with ACDF amongst various demographic cohorts. The differences between patient populations may be reflective of a larger additive burden for certain populations, especially when considering patients' intersectionality.

Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis

BACKGROUND

Disparities in treatment and outcomes disproportionately affect minority ethnic and racial populations in many surgical fields. Although substantial research in racial disparities has focused on outcomes, little is known about how surgeon recommendations can be influenced by patient race. The aim of this study was to investigate racial and socioeconomic disparities in the surgical management of primary brain tumors.

METHODS

In this registry-based cohort study, we used data from the Surveillance, Epidemiology, and End Results (SEER) database (1975-2016) and the American College of Surgeons National Cancer Database (NCDB) in the USA for independent analysis. Adults (aged ≥20 years) with a new diagnosis of meningioma, glioblastoma, pituitary adenoma, vestibular schwannoma, astrocytoma, and oligodendroglioma, with information on tumour size and surgical recommendation were included in the analysis. The primary outcome of this study was the odds of a surgeon recommending against surgical resection at diagnosis of primary brain neoplasms. This outcome was determined using multivariable logistic regression with clinical, demographic, and socioeconomic factors.

FINDINGS

This study included US national data from the SEER (1975-2016) and NCDB (2004-17) databases of adults with a new diagnosis of meningioma (SEER n=63 674; NCDB n=222 673), glioblastoma (n=35 258; n=104 047), pituitary adenoma (n=27 506; n=87 772), vestibular schwannoma (n=11 525; n=30 745), astrocytoma (n=5402; n=10 631), and oligodendroglioma (n=3977; n=9187). Independent of clinical and demographic factors, including insurance status and rural-urban continuum code, Black patients had significantly higher odds of recommendation against surgical resection of meningioma (adjusted odds ratio 1·13, 95% CI 1·06-1·21, p<0·0001), glioblastoma (1·14, 1·01-1·28, p=0·038), pituitary adenoma (1·13, 1·05-1·22, p<0·0001), and vestibular schwannoma (1·48, 1·19-1·84, p<0·0001) when compared with White patients in the SEER dataset. Additionally, patients of unknown race had significantly higher odds of recommendation against surgical resection for pituitary adenoma (1·80, 1·41-2·30, p<0·0001) and vestibular schwannoma (1·49, 1·10-2·04, p=0·011). Performing a validation analysis using the NCDB dataset confirmed these significant results for Black patients with meningioma (1·18, 1·14-1·22, p<0·0001), glioblastoma (1·19, 1·12-1·28, p<0·0001), pituitary adenoma (1·21, 1·16-1·25, p<0·0001), and vestibular schwannoma (1·19, 1·04-1·35, p=0·0085), and indicated and indicated that the findings are independent of patient comorbidities. When further restricted to the most recent decade in SEER, these inequities held true for Black patients, except those with glioblastoma (meningioma [1·18, 1·08-1·28, p<0·0001], pituitary adenoma [1·20, 1·09-1·31, p<0·0001], and vestibular schwannoma [1·54, 1·16-2·04, p=0·0031]).

INTERPRETATION

Racial disparities in surgery recommendations in the USA exist for patients with primary brain tumours, independent of potential confounders including clinical, demographic, and select socioeconomic factors. Further studies are needed to understand drivers of this bias and enhance equality in surgical care.

FUNDING

None.

Modifiers of and Disparities in Palliative and Supportive Care Timing and Utilization among Neurosurgical Patients with Malignant Central Nervous System Tumors

Patients with primary or secondary central nervous system (CNS) malignancies benefit from utilization of palliative care (PC) in addition to other supportive services, such as home health and social work. Guidelines propose early initiation of PC for patients with advanced cancers. We analyzed a cohort of privately insured patients with malignant brain or spinal tumors derived from the Optum Clinformatics Datamart Database to investigate health disparities in access to and utilization of supportive services. We introduce a novel construct, "provider patient racial diversity index" (provider pRDI), which is a measure of the proportion of non-white minority patients a provider encounters to approximate a provider's patient demographics and suggest a provider's cultural sensitivity and exposure to diversity. Our analysis demonstrates low rates of PC, home health, and social work services among racial minority patients. Notably, Hispanic patients had low likelihood of engaging with all three categories of supportive services. However, patients who saw providers categorized into high provider pRDI (categories II and III) were increasingly more likely to interface with supportive care services and at an earlier point in their disease courses. This study suggests that prospective studies that examine potential interventions at the provider level, including diversity training, are needed.

Language is brain: Improving neurologic health equity for linguistically diverse populations

Neurologic clinical care requires that clinicians gather and synthesize complex information, including a thorough, precise history and a detailed physical examination that maximizes the patient's cooperation. Yet, for patients who do not speak the dominant language in the country or region where they live, effective communication with their clinician may not always occur. In this article, we discuss the impact of language on neurologic care, focusing on access to care and on the diagnosis and treatment of two common and potentially life-threatening conditions: stroke and epilepsy. We then review implications for clinical neurologic care as well as medical education and present evidence-based recommendations for improving neurologic health equity for linguistically diverse populations. Strategies should integrate professional medical interpreters (for oral communication) and translators (for written materials) into the neurologic team, account for families and caregivers in a culturally humble manner, and teach learners to apply clinical neurologic skills in both language-concordant and discordant situations.

Predictors of Nonelective Surgery for Spinal Metastases: Insights from a National Database

STUDY DESIGN

Secondary analysis of a national all-payer database.

OBJECTIVE

Our objectives were to identify patient- and hospital-level factors independently associated with the receipt of nonelective surgery and determine whether nonelective surgery portends differences in perioperative outcomes compared to elective surgery for spinal metastases.

SUMMARY OF BACKGROUND DATA

Spinal metastases may progress to symptomatic epidural spinal cord compression that warrants urgent surgical intervention. Although nonelective surgery for spinal metastases has been associated with poor postoperative outcomes, literature evaluating disparities in the receipt of nonelective versus elective surgery in this population is lacking.

METHODS

The National Inpatient Sample (2012-2015) was queried for patients who underwent surgical intervention for spinal metastases. Multivariable logistic regression models were constructed to evaluate the association of patient- and hospital-level factors with the receipt of nonelective surgery, as well as to evaluate the influence of admission status on perioperative outcomes.

RESULTS

After adjusting for disease-related factors and other baseline covariates, our multivariable logistic regression model revealed several sociodemographic differences in the receipt of nonelective surgery. Patients of black (odds ratio [OR] = 1.38, 95% confidence interval [CI]: 1.03-1.84, P = 0.032) and other race (OR = 1.50, 95% CI: 1.13-1.98, P = 0.005) had greater odds of undergoing nonelective surgery than their white counterparts. Patients of lower income (OR = 1.40, 95% CI: 1.06-1.84, P = 0.019) and public insurance status (OR = 1.56, 95% CI: 1.26-1.93, P < 0.001) were more likely to receive nonelective surgery than higher income and privately insured patients, respectively. Higher comorbidity burden was also associated with greater odds of non-elective admission (OR = 2.94, 95% CI: 2.07-4.16, P  < 0.001). With respect to perioperative outcomes, multivariable analysis revealed that patients receiving nonelective surgery were more likely to experience nonroutine discharge (OR = 2.50, 95% CI: 2.09-2.98, P  < 0.001) and extended length of stay [LOS] (OR = 2.45, 95% CI: 1.91-3.16, P < 0.001).

CONCLUSION

The present study demonstrates substantial disparities in the receipt of nonelective surgery across sociodemographic groups and highlights its association with nonroutine discharge and extended LOS.Level of Evidence: 3.

Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review

BACKGROUND

Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement.

METHODS

We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES).

RESULTS

Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric.

CONCLUSIONS

This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery.

Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action

The health disparities which drive inequities in health outcomes have long plagued our already worn healthcare system and are often dismissed as being a result of social determinants of health. Herein, we explore the nature of these inequities by comparing outcomes for racial and ethnic minorities patients suffering from traumatic brain injury (TBI). We retrospectively reviewed all patients enrolled in the Trauma One Database at the Oregon Health & Science University Hospital from 2006 to October 2017 with an abbreviated injury scale (AIS) for the head or neck >2. Racial and ethnic minority patients were defined as non-White or Hispanic. A total of 6,352 patients were included in our analysis with 1,504 in the racial and ethnic minority cohort vs. 4,848 in the non-minority cohort. A propensity score (PS) model was generated to account for differences in baseline characteristics between these cohorts to generate 1,500 matched pairs. The adjusted hazard ratio for in-hospital mortality for minority patients was 2.21 [95% Confidence Interval (CI) 1.43-3.41, p < 0.001] using injury type, probability of survival, and operative status as covariates. Overall, this study is the first to specifically look at racial and ethnic disparities in the field of neurosurgical trauma. This research has demonstrated significant inequities in the mortality of TBI patients based on race and ethnicity and indicates a substantive need to reshape the current healthcare system and advocate for safer and more supportive pre-hospital social systems to prevent these life-threatening sequelae.