Survival Disparity Based on Household Income in 1970 Patients Following Brain Tumor Surgery

The Impact of Neighborhood Socioeconomic Disadvantage on Operative Outcomes after Single-Level Lumbar Fusion

INTRODUCTION

The relationship between socioeconomic status and neurosurgical outcomes has been investigated with respect to insurance status or median household income, but few studies have considered more comprehensive measures of socioeconomic status. This study examines the relationship between Area Deprivation Index (ADI), a comprehensive measure of neighborhood socioeconomic disadvantage, and short-term postoperative outcomes after lumbar fusion surgery.

METHODS

1861 adult patients undergoing single-level, posterior-only lumbar fusion at a single, multihospital academic medical center were retrospectively enrolled. An ADI matching protocol was used to identify each patient's 9-digit zip code and the zip code-associated ADI data. Primary outcomes included 30- and 90-day readmission, emergency department visits, reoperation, and surgical complication. Coarsened exact matching was used to match patients on key demographic and baseline characteristics known to independently affect neurosurgical outcomes. Odds ratios (ORs) were computed to compare patients in the top 10% of ADI versus lowest 40% of ADI.

RESULTS

After matching (n = 212), patients in the highest 10% of ADI (compared to the lowest 40% of ADI) had significantly increased odds of 30- and 90-day readmission (OR = 5.00, P < 0.001 and OR = 4.50, P < 0.001), ED visits (OR = 3.00, P = 0.027 and OR = 2.88, P = 0.007), and reoperation (OR = 4.50, P = 0.039 and OR = 5.50, P = 0.013). There was no significant association with surgical complication (OR = 0.50, P = 0.63).

CONCLUSIONS

Among otherwise similar patients, neighborhood socioeconomic disadvantage (measured by ADI) was associated with worse short-term outcomes after single-level, posterior-only lumbar fusion. There was no significant association between ADI and surgical complications, suggesting that perioperative complications do not explain the socioeconomic disparities in outcomes.

The Impact of Social Determinants of Health in Pediatric Shunted Hydrocephalus

BACKGROUND

Social risk factors have been shown to negatively affect health outcomes in children. However, this has not been characterized regarding pediatric shunted hydrocephalus.

OBJECTIVE

To explore the impact of social risk factors on outcomes in pediatric shunted hydrocephalus with the goal of identifying specific areas of intervention that might improve the outcomes of children undergoing cerebrospinal fluid (CSF) diversion.

METHODS

In an all-payer administrative database, records between January 2010 and October 2020 were analyzed to identify children undergoing CSF shunting procedures. Children with social risk factors were compared with those without regarding rates of infection, shunt-related interventions, and mortality within 5 years of their shunting procedure.

RESULTS

Among the 5420 children who underwent first-time shunting procedures, 263 (4.9%) were identified to have social risk factors. Children with identified social risk factors had increased odds of central nervous system infection (odds ratio [OR] 2.06, 95% CI 1.45-2.91), revision (OR 2.43, 95% I 1.89-3.12), and mortality (OR 2.86, 95% CI 1.23-5.72). The mean numbers of computed tomography studies (14.60 ± 17.78 vs 6.34 ± 6.10), MRI studies (18.76 ± 24.37 vs 7.88 ± 24.37), and shunt series X-rays (17.22 ± 19.04 vs 7.66 ± 8.54) were increased among children with social risk factors.

CONCLUSION

Children with social risk factors had increased rates of central nervous system infection, shunt-related interventions, and mortality within 5 years of CSF shunting. We underscore the importance of characterizing the impact of social risk factors in specific conditions, such as pediatric shunted hydrocephalus, and look to future directions aimed to mitigate these risk factors with coordination and direction of individualized resources, encouragement of advocacy, and community partnership.

Facility patient volume and survival among individuals diagnosed with malignant central nervous system tumors

PURPOSE

Prior research indicates that the volume of central nervous system (CNS) tumor patients seen by a facility is associated with outcomes. However, most studies have focused on short-term survival and specific CNS tumor subtypes. Our objective was to examine whether facility CNS tumor patient volume is associated with longer-term CNS tumor survival overall and by subtype.

METHODS

We obtained National Cancer Database (NCDB) data including individuals diagnosed with CNS tumors from 2004 to 2016. Analyses were stratified by age group (0-14, 15-39, 40-64, and ≥ 65 years) and tumor type. We used Cox Proportional Hazards (PH) regression and restricted mean survival time (RMST) analyses to examine associations between survival and facility patient volume percentile category adjusting for potential confounding factors.

RESULTS

Our analytic dataset included data from 130,830 individuals diagnosed with malignant first primary CNS tumors. We found a consistently reduced hazard rate of death across age groups for individuals reported by higher vs. lower (> 95th vs. ≤ 70th percentile) volume facilities (hazard ratio (HR)_0-14 = 0.78, 95% confidence interval (CI) 0.64-0.95; HR_15-39 = 0.87, 95% CI 0.78-0.96; HR_40-64 = 0.82, 95% CI 0.76-0.88; HR_≥65 = 0.80, 95% CI 0.75-0.86). Significantly longer survival times within 5 years for higher vs. lower volume facilities were observed ranging from 1.20 months (15-39) to 3.08 months (40-64) higher. Associations varied by CNS tumor subtype for all age groups.

CONCLUSIONS

These results suggest facility factors influence CNS tumor survival with longer survival for patients reported by higher volume facilities. Understanding these factors will be critical to developing strategies that eliminate modifiable differences in survival times.

Socioeconomic Status Predicts Short-Term Emergency Department Utilization Following Supratentorial Meningioma Resection

Introduction By identifying drivers of healthcare disparities, providers can better support high-risk patients and develop risk-mitigation strategies. Household income is a social determinant of health known to contribute to healthcare disparities. The present study evaluates the impact of household income on short-term morbidity and mortality following supratentorial meningioma resection. Methods A total of 349 consecutive patients undergoing supratentorial meningioma resection over a six-year period (2013-2019) were analyzed retrospectively. Primary outcomes were unplanned hospital readmission, reoperations, emergency department (ED) visits, return to the operating room, and all-cause mortality within 30 days of the index operation. Standardized univariate regression was performed across the entire sample to assess the impact of household income on outcomes. Subsequently, outcomes were compared between the lowest (household income ≤ $51,780) and highest (household income ≥ $87,958) income quartiles. Finally, stepwise regression was executed to identify potential confounding variables. Results Across all supratentorial meningioma resection patients, lower household income was correlated with a significantly increased rate of 30-day ED visits (p = 0.002). Comparing the lowest and highest income quartiles, the lowest quartile was similarly observed to have a significantly higher rate of 30-day ED evaluation (p = 0.033). Stepwise regression revealed that the observed association between household income and 30-day ED visits was not affected by confounding variables. Conclusion This study suggests that household income plays a role in short-term ED evaluation following supratentorial meningioma resection.

The Influence of Household Income on Survival following Posterior Fossa Tumor Resection at a Large Academic Medical Center

Objectives  The present study examines the effect of median household income on mid- and long-term outcomes in a posterior fossa brain tumor resection population. Design  This is a retrospective regression analysis. Setting  The study conducted at a single, multihospital, urban academic medical center. Participants  A total of 283 consecutive posterior fossa brain tumor cases, excluding cerebellar pontine angle tumors, over a 6-year period (June 09, 2013-April 26, 2019) was included in this analysis. Main Outcome Measures  Outcomes studied included 90-day readmission, 90-day emergency department evaluation, 90-day return to surgery, reoperation within 90 days after index admission, reoperation throughout the entire follow-up period, mortality within 90 days, and mortality throughout the entire follow-up period. Univariate analysis was conducted for the whole population and between the lowest (Q1) and highest (Q4) socioeconomic quartiles. Stepwise regression was conducted to identify confounding variables. Results  Lower socioeconomic status was found to be correlated with increased mortality within 90 postoperative days and throughout the entire follow-up period. Similarly, analysis between the lowest and highest household income quartiles (Q1 vs. Q4) demonstrated Q4 to have significantly decreased mortality during total follow-up and a decreasing but not significant difference in 90-day mortality. No significant difference in morbidity was observed. Conclusion  This study suggests that lower household income is associated with increased mortality in both the 90-day window and total follow-up period. It is possible that there is an opportunity for health care providers to use socioeconomic status to proactively identify high-risk patients and provide additional resources in the postoperative setting.

A Scoping Review of the Literature on the Relationship Between Social and Structural Determinants of Health and Neurosurgical Outcomes

In the present study, we performed a scoping review of the social and structural determinant of health (SSDOH)-related academic literature from neurosurgery. To identify the studies to include or consider for our systematic review, we worked with a medical librarian to develop detailed search strategies for each database. The search was limited to studies reported from January 1, 1990 to December 3, 2020. All reports retrieved from the database searches were exported and stored in EndNote X.9 bibliographic and reference manager (Clarivate, Philadelphia, Pennsylvania, USA). The reports were screened by title and abstract independently by two of the co-authors (G.G. and A.O.). Any disagreements between the 2 reviewers were resolved by a third reviewer, who was unaware of the decisions of the primary reviewers. The search resulted in 5940 studies. After exclusions during data extraction, 99 studies remained for the final analysis. From the 99 included studies, 6 social determinants were analyzed, with 3 studies evaluating the highest level of educational attainment, 14 studies evaluating gender, 52 studies evaluating race, and 41 studies evaluating economic stability. Studies referencing SSDOH were found in 8 subspecialties, with 40 studies in spine surgery, 4 studies in functional neurosurgery, 14 studies in vascular neurosurgery, 27 studies in cranial oncology, 5 studies in spinal oncology, 5 studies in pediatric neurosurgery, 1 study in trauma, and 3 studies in general/unspecified subspecialties. Research gaps included the remaining neurosurgical subspecialties and numerous other SSDOHs. These gaps should be areas of future study, with the goal of aligning research with new healthcare initiatives and ensuring consideration of SSDOHs.

Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in Neurosurgical Care for Intracranial Tumors

BACKGROUND

The impact of race, socioeconomic status (SES), insurance status, and other social metrics on the outcomes of patients with intracranial tumors has been reported in several studies. However, these findings have not been comprehensively summarized.

METHODS

We conducted a PRISMA systematic review of all published articles between 1990 and 2020 that analyzed intracranial tumor disparities, including race, SES, insurance status, and safety-net hospital status. Outcomes measured include access, standards of care, receipt of surgery, extent of resection, mortality, complications, length of stay (LOS), discharge disposition, readmission rate, and hospital charges.

RESULTS

Fifty-five studies were included. Disparities in mortality were reported in 27 studies (47%), showing minority status and lower SES associated with poorer survival outcomes in 14 studies (52%). Twenty-seven studies showed that African American patients had worse outcomes across all included metrics including mortality, rates of surgical intervention, extent of resection, LOS, discharge disposition, and complication rates. Thirty studies showed that privately insured patients and patients with higher SES had better outcomes, including lower mortality, complication, and readmission rates. Six studies showed that worse outcomes were associated with treatment at safety-net and/or low-volume hospitals. The influence of Medicare or Medicaid status, or inequities affecting other minorities, was less clearly delineated. Ten studies (18%) were negative for evidence of disparities.

CONCLUSIONS

Significant disparities exist among patients with intracranial tumors, particularly affecting patients of African American race and lower SES. Efforts at the hospital, state, and national level must be undertaken to identify root causes of these issues.

Social Determinants of Health and Neurosurgical Outcomes: Current State and Future Directions

The relationship between social determinants of health (SDOH) and neurosurgical outcomes has become increasingly relevant. To date, results of prior work evaluating the impact of social determinants in neurosurgery have been mixed, and the need for robust data on this subject remains. The present review evaluates how gender, race, and socioeconomic status (SES) influence outcomes following various brain tumor resection procedures. Results from a number of prior studies from the senior author's lab are summarized, with all data acquired using the EpiLog tool (Epilog Laser). Separate analyses were performed for each procedure, evaluating the unique, isolated impact of gender, race, and SES on outcomes. A comprehensive literature review identified any prior studies evaluating the influence of these SDOH on neurosurgical outcomes. The review presented herein suggests that the effect of gender and race on outcomes is largely mitigated when equal access to care is attained, and socioeconomic factors and comorbidities are controlled for. Furthermore, when patients are matched upon for a number of clinically relevant covariates, SES impacts postoperative mortality. Elucidation of this disparity empowers surgeons to initiate actionable change to equilibrate future outcomes.