The Influence of Race on Short-term Outcomes After Laminectomy and/or Fusion Spine Surgery

The effect of chronic kidney disease on short-term single-level lumbar fusion outcomes

INTRODUCTION

Chronic kidney disease (CKD) has an increasing global prevalence and has previously been associated with increased complications and morbidity after spine surgery. Understanding the isolated effect of CKD on short-term patient outcomes is critical for optimizing perioperative risk management and healthcare utilization.

OBJECTIVE

The aim of this study is to utilize coarsened exact matching (CEM) to analyze the isolated effect of CKD on short-term patient outcomes in single-level posterior lumbar fusion surgery.

METHODS

A retrospective analysis of 4680 consecutive patients undergoing single-level, posterior-only lumbar fusion was performed. Univariate logistic regression comparing the odds of outcomes in patients with CKD (n=40) to patients without medical comorbidities (n=2329) was performed. CEM was then employed to match patients with CKD to those without any comorbidities 1:1 on ten patient characteristics known to affect neurosurgical outcomes. Primary outcomes included intraoperative complications, length of stay, discharge disposition, and 30-day Emergency Department (ED) visits, readmissions, reoperations, and mortality.

RESULTS

In a univariate logistic regression, CKD was associated with increased risk of 30-day ED visits (OR=3.53, p=0.003) but not complication, discharge disposition, or 30-day readmissions or reoperations. Between otherwise exactly matched patients (n=72), CKD similarly remained associated with an increased risk of 30-day ED visits (OR=7.00, p=0.034) and not with other outcomes.

CONCLUSION

Between otherwise exactly matched patients undergoing single-level posterior lumbar fusion, CKD was related to increased risk of 30-day ED utilization but not other markers indicative of inferior surgical outcomes. Further study must investigate the reasons for increased ED visitation and implement risk-mitigation strategies for these patients.

Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis

STUDY DESIGN

A retrospective cohort study using prospectively collected data.

OBJECTIVE

The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes.

MATERIALS AND METHODS

The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF.

RESULTS

Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF.

CONCLUSIONS

In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States.

METHODS

PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients.

RESULTS

53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included.

CONCLUSIONS

AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.

Socioeconomic Influence on Cervical Fusion Outcomes

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

The aim of this study was to compare postoperative outcomes following cervical fusion based on socioeconomic status (SES) variables including race, education, net worth, and homeownership status.

SUMMARY OF BACKGROUND DATA

Previous studies have demonstrated the effects of patient race and income on outcomes following cervical fusion procedures. However, no study to date has comprehensively examined the impact of multiple SES variables. We hypothesized that race, education, net worth, and homeownership influence important outcomes following cervical fusion.

MATERIALS AND METHODS

Optum's de-identified Clinformatics Data Mart (CDM) database was queried for patients undergoing first-time inpatient cervical fusion from 2003 to 2021. Patient demographics, SES variables, and the Charlson comorbidity index were obtained. Primary outcomes were hospital length of stay and 30-day rates of reoperation, readmission, and postoperative complications. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges.

RESULTS

A total of 111,914 patients underwent cervical spinal fusion from 2003 to 2021. Multivariate analysis revealed that after controlling for age, sex, and Charlson comorbidity index, Black race was associated with a higher rate of 30-day readmissions [odds ratio (OR): 1.11, 95% CI: 1.03-1.20]. Lower net worth (vs. >$500K) and renting (vs. owning a home) were significantly associated with both higher rates of 30-day readmissions (OR: 1.29, 95% CI: 1.17-1.41; OR: 1.34, 95% CI: 1.22-1.49), and emergency room visits (OR: 1.29, 95% CI: 1.18-1.42; OR: 1.11, 95% CI: 1.00-1.23). Lower net worth (vs. >$500K) was also associated with increased complications (OR: 1.22, 95% CI: 1.14-1.31).

CONCLUSION

Socioeconomic variables, including patient race, education, and net worth, influence postoperative metrics in cervical spinal fusion surgery. Future studies should focus on developing and implementing targeted interventions based on patient SES to reduce disparity.

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.

Racial Disparities and Surgical Outcomes After Anterior Cervical Discectomy and Fusion: National Surgical Quality Improvement Program Analysis 2015-2020

BACKGROUND

Our objective was to assess the effect of race on outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

We identified 57,913 adult patients who underwent elective ACDF spine surgery from 2015 to 2020. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Demographics, comorbidities, perioperative course, and 30-day postoperative outcomes were stratified by race.

RESULTS

A total of 57,913 patients, white (n = 49,016), African American (AA; n = 7200), Native American (NA; n = 565), and Asian (n = 1132) underwent ACDF fusion surgery. AA patients had higher comorbidities, including diabetes (24.7%), dyspnea (5.9%), and hypertension (61.6%) compared with the other groups (P < 0.001). NA and AA were higher tobacco users, (33.1%) and (28.7%), respectively (P < 0.001). Most of the patients reported in this dataset had single-level surgeries. AAs had a longer average hospital stay (2.51±7.31 days) and operative time (144.13±82.26 min) (P < 0.001). Lower risk of superficial surgical site infection (adjusted odds ratio [ORadj], 0.41; 95% confidence interval [CI], 0.22-0.77; P = 0.005) and greater risk of reintubation (ORadj, 1.65; 95% CI, 1.25-2.17; P < 0.001), pulmonary embolism (ORadj, 1.88; 95% CI, 1.27-2.79; P = 0.001), renal insufficiency (ORadj, 3.15; 95% CI, 1.38-7.20; P = 0.006), and return to the operating room (ORadj, 1.41; 95% CI, 1.18-1.65; P < 0.001 were reported in AAs compared with whites. NAs showed an increased risk of superficial surgical site infection compared with whites (ORadj, 2.59; 95% CI, 1.05-6.36; P = 0.037).

CONCLUSIONS

Racial disparities were found to independently affect rates of complications after surgery for ACDF.

Racial Disparities in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To synthesize previous studies evaluating racial disparities in spine surgery.

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay.

RESULTS

A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications.

CONCLUSIONS

This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Neurosurgeons Deliver Similar Quality Care Regardless of First Assistant Type: Resident Physician versus Nonphysician Surgical Assistant

OBJECTIVE

There are limited data evaluating the outcomes of attending neurosurgeons with different types of first assistants. This study considers a common neurosurgical procedure (single-level, posterior-only lumbar fusion surgery) and examines whether attending surgeons deliver equal patient outcomes, regardless of the type of first assistant (resident physician vs. nonphysician surgical assistant [NPSA]), among otherwise exact-matched patients.

METHODS

The authors retrospectively analyzed 3395 adult patients undergoing single-level, posterior-only lumbar fusion at a single academic medical center. Primary outcomes included readmissions, emergency department visits, reoperation, and mortality within 30 and 90 days after surgery. Secondary outcome measures included discharge disposition, length of stay, and length of surgery. Coarsened exact matching was used to match patients on key demographics and baseline characteristics known to independently affect neurosurgical outcomes.

RESULTS

Among exact-matched patients (n = 1402), there was no significant difference in adverse postsurgical events (readmission, emergency department visits, reoperation, or mortality) within 30 days or 90 days of the index operation between patients who had resident physicians and those who had NPSAs as first assistants. Patients who had resident physicians as first assistants demonstrated a longer length of stay (mean: 100.0 vs. 87.4 hours, P < 0.001) and a shorter duration of surgery (mean: 187.4 vs. 213.8 minutes, P < 0.001). There was no significant difference between the two groups in the percentage of patients discharged home.

CONCLUSIONS

For single-level posterior spinal fusion, in the setting described, there are no differences in short-term patient outcomes delivered by attending surgeons assisted by resident physicians versus NPSAs.

Socioeconomic Effects on Lumbar Fusion Outcomes

BACKGROUND

Recent studies suggest that socioeconomic status (SES) influences outcomes after spinal fusion. The influence of SES on postoperative outcomes is increasingly relevant as rates of lumbar fusion rise.

OBJECTIVE

To determine the influence of SES variables including race, education, net worth, and homeownership on postoperative outcomes.

METHODS

Optum's deidentified Clinformatics Data Mart Database was used to conduct a retrospective review of SES variables for patients undergoing first-time, inpatient lumbar fusion from 2003 to 2021. Primary outcomes included hospital length of stay (LOS) and 30-day reoperation, readmission, and postoperative complication rates. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges.

RESULTS

In total, 217 204 patients were identified. On multivariate analysis, Asian, Black, and Hispanic races were associated with increased LOS (Coeff. [coefficient] 0.92, 95% CI 0.68-1.15; Coeff. 0.61, 95% CI 0.51-0.71; Coeff. 0.43, 95% CI 0.32-0.55). Less than 12th grade education (vs greater than a bachelor's degree) was associated with increased odds of reoperation (OR [odds ratio] 1.88, 95% CI 1.03-3.42). Decreased net worth was associated with increased odds of readmission (OR 1.32, 95% CI 1.25-1.40) and complication (OR 1.14, 95% CI 1.10-1.20). Renting a home (vs homeownership) was associated with increased LOS, readmissions, and total charges (Coeff. 0.30, 95% CI 0.17-0.43; OR 1.19, 95% CI 1.11-1.30; Coeff. 13 200, 95% CI 9000-17 000).

CONCLUSION

Black race, less than 12th grade education, <$25K net worth, and lack of homeownership were associated with poorer postoperative outcomes and increased costs. Increasing perioperative support for patients with these sociodemographic risk factors may improve postoperative outcomes.

Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities Following Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine whether: (1) patients from communities of socioeconomic distress have higher readmission rates or postoperative healthcare resource utilization and (2) there are differences in patient-reported outcome measures (PROMs) based on socioeconomic distress.

SUMMARY OF BACKGROUND DATA

Socioeconomic disparities affect health outcomes, but little evidence exists demonstrating the impact of socioeconomic distress on postoperative resource utilization or PROMs.

METHODS

A retrospective review was performed on patients who underwent lumbar fusion at a single tertiary academic center from January 1, 2011 to June 30, 2021. Patients were classified according to the distressed communities index. Hospital readmission, postoperative prescriptions, patient telephone calls, follow-up office visits, and PROMs were recorded. Multivariate analysis with logistic, negative binomial regression or Poisson regression were used to investigate the effects of distressed communities index on postoperative resource utilization. Alpha was set at P <0.05.

RESULTS

A total of 4472 patients were included for analysis. Readmission risk was higher in distressed communities (odds ratio, 1.75; 95% confidence interval, 1.06-2.87; P =0.028). Patients from distressed communities (odds ratio, 3.94; 95% confidence interval, 1.60-9.72; P =0.003) were also more likely to be readmitted for medical, but not surgical causes ( P =0.514), and distressed patients had worse preoperative (visual analog-scale Back, P <0.001) and postoperative (Oswestry disability index, P =0.048; visual analog-scale Leg, P =0.013) PROMs, while maintaining similar magnitudes of clinical improvement. Patients from distressed communities were more likely to be discharged to a nursing facility and inpatient rehabilitation unit (25.5%, P =0.032). The race was not independently associated with readmissions ( P =0.228).

CONCLUSION

Socioeconomic distress is associated with increased postoperative health resource utilization. Patients from distressed communities have worse preoperative PROMs, but the overall magnitude of improvement is similar across all classes.

LEVEL OF EVIDENCE

Level IV.

Race and Socioeconomic Status Are Associated With Inferior Patient-Reported Outcome Measures Following Rotator Cuff Repair

PURPOSE

To investigate the impact social determinants of health (SDOH) have on National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test scores and postoperative health care use in patients who undergo rotator cuff repair (RCR).

METHODS

All patients who underwent RCR surgery by 3 shoulder and/or sports medicine fellowship-trained orthopaedic surgeons between July 2017 and January 2020 were included. The electronic medical record (EMR) was used to identify SDOH for each patient. PROMIS computer adaptive test measures of Upper Extremity function, Pain Interference, and Depression were completed preoperatively and postoperatively (6 months and 1 year). Postoperative health care use (clinical visits, virtual encounters, imaging encounters, and physical therapy visits) were recorded as well. Univariate associations, multiple linear regressions, and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH.

RESULTS

Three hundred thirty-eight patients who underwent RCR were included. Patients who were Black, in lower median household income quartiles, had public insurance, and female reported lower PROMIS scores compared with their counterparts. Smokers and White patients attended fewer postoperative office visits whereas Black patients had more physical therapy and nonvisit encounters compared with their respective counterparts.

CONCLUSIONS

Black race and lower socioeconomic status are associated with worse function and pain outcomes post-RCR compared with White race. Similarly, Black race and positive smoking status are associated with differential use of health care following RCR. Further attention may be required for these patients to address health care disparities.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Do Community-level Disadvantages Account for Racial Disparities in the Safety of Spine Surgery? A Large Database Study Based on Medicare Claims

BACKGROUND

Racial health disparities across orthopaedic surgery subspecialties, including spine surgery, are well established. However, the underlying causes of these disparities, particularly relating to social determinants of health, are not fully understood.

QUESTIONS/PURPOSES

(1) Is there a racial difference in 90-day mortality, readmission, and complication rates ("safety outcomes") among Medicare beneficiaries after spine surgery? (2) To what degree does the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), a community-level marker of social determinants of health, account for racial disparities in safety outcomes?

METHODS

To examine racial differences in 90-day mortality, readmission, and complications after spine surgery, we retrospectively identified all 419,533 Medicare beneficiaries aged 65 or older who underwent inpatient spine surgery from 2015 to 2019; we excluded 181,588 patients with endstage renal disease or Social Security disability insurance entitlements, who were on Medicare HMO, or who had missing SVI data. Because of the nearly universal coverage of those age 65 or older, Medicare data offer a large cohort that is broadly generalizable, provides improved precision for relatively rare safety outcomes, and is free of confounding from differential insurance access across races. The Master Beneficiary Summary File includes enrollees' self-reported race based on a restrictive list of mutually exclusive options. Even though this does not fully capture the entirety of racial diversity, it is self-reported by patients. Identification of spine surgery was based on five Diagnosis Related Groups labeled "cervical fusion," "fusion, except cervical," "anterior-posterior combined fusion," "complex fusion," and "back or neck, except fusion." Although heterogeneous, these cohorts do not reflect inherently different biology that would lead us to expect differences in safety outcomes by race. We report specific types of complications that did and did not involve readmission. Although complications vary in severity, we report them as composite measures while being cognizant of the inherent limitations of making inferences based on aggregate measures. The SVI was chosen as the mediating variable because it aggregates important social determinants of health and has been shown to be a marker of high risk of poor public health response to external stressors. Patients were categorized into three groups based on a ranking of the four SVI themes: socioeconomic status, household composition, minority status and language, and housing and transportation. We report the "average race effects" among Black patients compared with White patients using nearest-neighbor Mahalanobis matching by age, gender, comorbidities, and spine surgery type. Mahalanobis matching provided the best balance among propensity-type matching methods. Before matching, Black patients in Medicare undergoing spine surgery were disproportionately younger with more comorbidities and were less likely to undergo cervical fusion. To estimate the contribution of the SVI on racial disparities in safety outcomes, we report the average race effect between models with and without the addition of the four SVI themes.

RESULTS

After matching on age, gender, comorbidities, and spine surgery type, Black patients were on average more likely than White patients to be readmitted (difference of 1.5% [95% CI 0.9% to 2.1%]; p < 0.001) and have complications with (difference of 1.2% [95% CI 0.5% to 1.9%]; p = 0.002) or without readmission (difference of 3.6% [95% CI 2.9% to 4.3%]; p < 0.001). Adding the SVI to the model attenuated these differences, explaining 17% to 49% of the racial differences in safety, depending on the outcome. An observed higher rate of 90-day mortality among Black patients was explained entirely by matching using non-SVI patient demographics (difference of 0.00% [95% CI -0.3% to 0.3%]; p = 0.99). However, even after adjusting for the SVI, Black patients had more readmissions and complications.

CONCLUSION

Social disadvantage explains up to nearly 50% of the disparities in safety outcomes between Black and White Medicare patients after spine surgery. This argument highlights an important contribution of socioeconomic circumstances and societal barriers to achieving equal outcomes. But even after accounting for the SVI, there remained persistently unequal safety outcomes among Black patients compared with White patients, suggesting that other unmeasured factors contribute to the disparities. This is consistent with evidence documenting Black patients' disadvantages within a system of seemingly equal access and resources. Research on racial health disparities in orthopaedics should account for the SVI to avoid suggesting that race causes any observed differences in complications among patients when other factors related to social deprivation are more likely to be determinative. Focused social policies aiming to rectify structural disadvantages faced by disadvantaged communities may lead to a meaningful reduction in racial health disparities.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Few Randomized Controlled Trials in Spine Surgery in the United States Include Sociodemographic Patient Data: A Systematic Review

INTRODUCTION

The importance of sociodemographic factors such as race, education, and income on spine surgery outcomes has been well established, yet the representation of sociodemographic data within randomized controlled trials (RCTs) in spine literature remains undefined in the United States (U.S).

METHODS

Medical literature was reviewed within PubMed for RCTs with "spine" in the title or abstract published within the last 8 years (2014 to 2021) in seven major spine journals. This yielded 128 results, and after application of inclusion criteria (RCTs concerning adult spine pathologies conducted in the U.S), 54 RCTs remained for analysis. Each article's journal of publication, year of publication, and spinal pathology was recorded. Pathologies included cervical degeneration, thoracolumbar degeneration, adult deformity, cervical trauma, and thoracolumbar trauma. Sociodemographic variables collected were race, ethnicity, insurance status, income, work status, and education. The Fisher's exact test was used to compare inclusion of sociodemographic data by journal, year, and spinal pathology.

RESULTS

Sociodemographic data were included in the results and in any section of 57.4% (31/54) of RCTs. RCTs reported work status in 25.9% (14/54) of results and 38.9% (21/54) of RCTs included work status in any section. Income was included in the results and mentioned in any section in 13.0% (7/54) of RCTs. Insurance status was in the results or any section of 9.3% (5/54) and 18.5% (10/54) of RCTs, respectively. There was no association with inclusion of sociodemographic data within the results of RCTs as a factor of journal (P = 0.337), year of publication (P = 0.286), or spinal pathology (P = 0.199).

DISCUSSION

Despite evidence of the importance of sociodemographic factors on the natural history and treatment outcomes of myriad spine pathologies, this study identifies a surprising absence of sociodemographic data within contemporary RCTs in spine surgery. Failure to include sociodemographic factors in RCTs potentially bias the generalizability of outcome data.

Associating Social Determinants of Health With PROMIS CAT Scores and Health Care Utilization After ACL Reconstruction

Background

The term "social determinants of health" (SDOH) refers to social and economic factors that influence a patient's health status. The effect of SDOH on the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) scores and postoperative resource utilization in patients with anterior cruciate ligament reconstruction (ACLR) have yet to be thoroughly studied.

Purpose

To investigate the impact SDOH have on PROMIS CAT outcomes and postoperative resource utilization in patients with ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

The electronic medical record was used to identify the SDOH for patients who underwent ACLR by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons between July 2017 and April 2020. PROMIS CAT measures of Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), and Depression (PROMIS-D) were completed at the preoperative, 6-month postoperative, and 12-month postoperative time points. Postoperative health care utilization was recorded as well. Independent 2-group t tests and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH.

Results

Two-hundred and thirty patients who underwent ACLR were included (mean age, 27 years; 59% male). Compared with White patients, Black patients were represented more frequently in the lowest median household income (MHI) quartile (63% vs 23%, respectively; P < .001). White patients were represented more frequently in the highest area deprivation index (ADI) quartile when compared with Black patients (67% vs 12%, respectively; P = .006). Significantly worse PROMIS-PF, PROMIS-PI, and PROMIS-D scores at all 3 time points were found among patients who were Black, female, smokers, and in the lower MHI quartiles, with higher ADI and public health care coverage. In terms of resource utilization, Black patients attended significantly fewer postoperative physical therapy visits when compared with their respective counterparts. Those in the lower MHI quartiles attended significantly fewer postoperative imaging encounters, and female patients attended significantly more postoperative virtual encounters than male patients.

Conclusion

Specific SDOH variables, particularly those that reflect racial and socioeconomic disparities, were associated with differences in postoperative health care utilization and ACLR outcomes as measured by PROMIS CAT domains.

National trends in distribution of underrepresented minorities within United States general surgery residency programs: A longitudinal panel study

BACKGROUND

Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs.

METHODS

We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance.

RESULTS

Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated.

CONCLUSIONS

Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted.

Post-operative neurosurgery outcomes by race/ethnicity among enhanced recovery after surgery (ERAS) participants

OBJECTIVE

Prior work reveals that Enhanced Recovery After Surgery (ERAS) programs decrease opioid use, improve mobilization, and shorten length of stay (LOS) among patients undergoing spine surgery. The impact of ERAS on outcomes by race/ethnicity is unknown. This study examined outcomes by race/ethnicity among neurosurgical patients enrolled in an ERAS program.

METHODS

Patients undergoing elective spine or peripheral nerve surgeries at a multi-hospital university health system from April 2017 to November 2020 were enrolled in an ERAS program that involves preoperative, perioperative, and postoperative phases focused on improving outcomes through measures such as specialty consultations for co-morbidities, multimodal analgesia, early mobilization, and wound care education. The following outcomes for ERAS patients were compared by race/ethnicity: length of stay, discharge disposition, complications, readmission, pain level at discharge, and post-operative health rating. We estimated the association between race/ethnicity and the outcomes using linear and logistic regression models adjusting for age, sex, insurance, BMI, comorbid conditions, and surgery type.

RESULTS

Among participants (n = 3449), 2874 (83.3%) were White and 575 (16.7%) were Black, Indigenous, and people of color (BIPOC). BIPOC patients had significantly longer mean length of stay compared to White patients (3.8 vs. 3.4 days, p = 0.005) and were significantly more likely to be discharged to a rehab or subacute nursing facility compared to White patients (adjusted odds ratio (95% CI): 3.01 (2.26-4.01), p < 0.001). The complication rate did not significantly differ between BIPOC and White patients (13.7% vs. 15.5%, p = 0.29). BIPOC patients were not significantly more likely to be readmitted within 30 days compared to White patients in the adjusted model (adjusted odds ratio (95% CI): 1.30 (0.91-1.86), p = 0.15) CONCLUSION: BIPOC as compared to White ERAS participants in ERAS undergoing neurosurgical procedures had significantly longer hospital stays and were significantly less likely to be discharged home. ERAS protocols present an opportunity to provide consistent high quality post-operative care, however while there is evidence that it improves care in aggregate, our results suggest significant disparities in outcomes by patient race/ethnicity despite enrollment in ERAS. Future inquiry must identify contributors to these disparities in the recovery pathway.

Impact of the 2016 American College of Surgeons Guideline Revision on Overlapping Lumbar Fusion Cases at a Large Academic Medical Center

OBJECTIVE

The American College of Surgeons (ACS) updated its guidelines on overlapping surgery in 2016. The objective was to examine differences in postoperative outcomes following overlapping cases either pre-ACS guideline revision or post-guideline revision, in a coarsened exact matching (CEM) sample.

METHODS

3,327 consecutive adult patients undergoing single-level, posterior lumbar fusion from 2013-2019 were retrospectively analyzed. Patients were separated into a pre-ACS guideline revision cohort (surgery before April 2016) or a post-guideline revision cohort (surgery after October 2016) for comparison. The primary outcomes were proportion of cases performed with any degree of overlap, and adverse events including 30-day and 90-day rates of readmission, reoperation, Emergency Department visit, morbidity, and mortality. Subsequently, CEM was employed among overlapping surgery patients only to assess the impact of the ACS guideline revision on overlapping outcomes, while controlling for attending surgeon and key patient characteristics known to affect surgical outcomes.

RESULTS

After the implementation of the ACS guidelines, fewer cases were performed with overlap (22.0% vs. 53.7%, p<0.001). Patients in the post-ACS guideline revision cohort experienced improved rates of readmission and reoperation within 30 and 90 days. However, when limited to overlapping cases only, no differences were observed in overlap outcomes pre- vs. post-ACS guideline revision. Similarly, when exact matched on risk-associated patient characteristics and attending surgeon, overlapping surgery patients pre- and post-ACS guideline revision experienced similar rates of 30- and 90-day outcomes.

CONCLUSION

After the ACS guideline revision, no discernable impact was observed on postoperative outcomes following lumbar fusion cases performed with overlap.

Effect of Household Income on Short-Term Outcomes Following Cerebellopontine Angle Tumor Resection

Objectives  The objective of this study is to elucidate the impact of income on short-term outcomes in a cerebellopontine angle (CPA) tumor resection population. Design  This is a retrospective regression analysis. Setting  This study was done at a single, multihospital, urban academic medical center. Participants  Over 6 years (from June 7, 2013, to April 24, 2019), 277 consecutive CPA tumor cases were reviewed. Main Outcome Measures  Outcomes studied included readmission, emergency department evaluation, unplanned return to surgery, return to surgery after index admission, and mortality. Univariate analysis was conducted among the entire population with significance set at a p -value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (quartile 1 [Q1]) and highest (quartile 4 [Q4]) socioeconomic quartiles, with significance set at a p -value <0.05. Stepwise regression was conducted to determine the correlations among study variables and to identify confounding factors. Results  Regression analysis of 273 patients demonstrated decreased rates of unplanned reoperation ( p  = 0.015) and reoperation after index admission ( p  = 0.035) at 30 days with higher standardized income. Logistic regression between the lowest (Q1) and highest (Q4) socioeconomic quartiles demonstrated decreased unplanned reoperation ( p  = 0.045) and decreasing but not significant reoperation after index admission ( p  = 0.15) for Q4 patients. No significant difference was observed for other metrics of morbidity and mortality. Conclusion  Higher socioeconomic status is associated with decreased risk of unplanned reoperation following CPA tumor resection.

Use of the LACE+ index to predict readmissions after single-level lumbar fusion

OBJECTIVE

Spinal fusion is one of the most common neurosurgical procedures. The LACE (length of stay, acuity of admission, Charlson Comorbidity Index [CCI] score, and emergency department [ED] visits within the previous 6 months) index was developed to predict readmission but has not been tested in a large, homogeneous spinal fusion population. The present study evaluated use of the LACE+ score for outcome prediction after lumbar fusion.

METHODS

LACE+ scores were calculated for all patients (n = 1598) with complete information who underwent single-level, posterior-only lumbar fusion at a single university medical system. Logistic regression was performed to assess the ability of the LACE+ score as a continuous variable to predict hospital readmissions within 30 days (30D), 30-90 days (30-90D), and 90 days (90D) of the index operation. Secondary outcome measures included ED visits and reoperations. Subsequently, patients with LACE+ scores in the bottom decile were exact matched to the patients with scores in the top 4 deciles to control for sociodemographic and procedural variables.

RESULTS

Among all patients, increased LACE+ score significantly predicted higher rates of readmissions in the 30D (p < 0.001), 30-90D (p = 0.001), and 90D (p < 0.001) postoperative windows. LACE+ score also predicted risk of ED visits at all 3 time points and reoperations at 30-90D and 90D. When patients with LACE+ scores in the bottom decile were compared with patients with scores in the top 4 deciles, higher LACE+ score predicted higher risk of readmissions at 30D (p = 0.009) and 90D (p = 0.005). No significant difference in hospital readmissions was observed between the exact-matched cohorts.

CONCLUSIONS

The present results suggest that the LACE+ score demonstrates utility in predicting readmissions within 30 and 90 days after single-level lumbar fusion. Future research is warranted that utilizes the LACE+ index to identify strategies to support high-risk patients in a prospective population.

Assessment of Gender Disparities in Short-Term and Long-Term Outcomes Following Posterior Fossa Tumor Resection

Introduction

The analysis of social determinants of health (SDOH) across different surgical populations is critical for the identification of health disparities and the development risk mitigation strategies among vulnerable patients. Research into the impact of gender on neurosurgical outcomes remains limited. The aim of the present study was to assess the effect of gender on outcomes, in a matched sample, following posterior fossa tumor resection, a high-risk neurosurgical procedure.

Methods

Two hundred seventy-eight consecutive patients undergoing posterior fossa tumor resection over a six-year period (June 07, 2013, to April 29, 2019) at a single academic medical system were retrospectively evaluated. Short-term outcomes included 30- and 90-day rates of emergency department (ED) visit, readmission, reoperation, and mortality. Long-term outcomes included mortality and reoperation for the duration of follow-up. Firstly, male and female patients in the entire pre-match sample were compared. Thereafter, coarsened exact matching was employed to control for confounding variables, matching male and female patients on key demographic factors - including history of prior surgery, median household income, and race, amongst others - and outcome comparison was repeated.

Results

In both the entire pre-match sample and matched cohort analyses, no significant differences in adverse postsurgical events were discerned between the female and male patients when evaluating 30-day or 90-day rates of ED visit, readmission, reoperation, and mortality. There were also no differences in reoperation or mortality for the duration of follow-up.

Conclusion

Gender does not appear to impact short- or long-term outcomes following posterior fossa tumor resection. As such, risk assessment and mitigation strategies in this population should focus on other SDOH. Further studies should assess the role of other SDOH within this population.

Overlap Before the Critical Step of Lumbar Fusion Does Not Lead to Increased Short-Term Morbidity

BACKGROUND

Few studies have assessed the impact of overlapping surgery during different timepoints of neurosurgical procedures.

OBJECTIVE

To evaluate the impact of overlap before the critical portion of surgery on short-term patient outcomes following lumbar fusion.

METHODS

In total, 3799 consecutive patients who underwent single-level, posterior-only lumbar fusion over 6 yr (2013-2019) at an academic hospital system were retrospectively studied. Outcomes included 30-d emergency department (ED) visit, readmission, reoperation, mortality, overall morbidity, and overall morbidity/surgical complications. Duration of overlap that occurred before the critical portion of surgery was calculated as a percentage of total beginning operative time. Univariate logistic regression was used to assess the impact of incremental 1% increases in the duration of overlap within the whole population and patients with beginning overlap. Subsequently, univariate analysis was used to compare exact matched patients with the least (bottom 40%) and most amounts of overlap (100% beginning overlap). Coarsened exact matching was used to match patients on key demographic factors, as well as attending surgeon. Significance was set at a P-value < .05.

RESULTS

Increased duration of beginning overlap was associated with a decrease in 30-d ED visit (P = .03) within all patients with beginning overlap, but not within the whole population undergoing lumbar fusion. Duration of beginning overlap was not associated with any other short-term morbidity or mortality outcome in either the whole population or patients with beginning overlap.

CONCLUSION

Increased duration of overlap before the critical step of surgery does not predict adverse short-term outcomes after single-level, posterior-only lumbar fusion.

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.

Impact of race on nonroutine discharge, length of stay, and postoperative complications after surgery for spinal metastases

OBJECTIVE

Previous studies have suggested the possibility of racial disparities in surgical outcomes for patients undergoing spine surgery, although this has not been thoroughly investigated in those with spinal metastases. Given the increasing prevalence of spinal metastases requiring intervention, knowledge about potential discrepancies in outcomes would benefit overall patient care. The objective in the present study was to investigate whether race was an independent predictor of postoperative complications, nonroutine discharge, and prolonged length of stay (LOS) after surgery for spinal metastasis.

METHODS

The authors retrospectively examined patients at a single comprehensive cancer center who had undergone surgery for spinal metastasis between April 2013 and April 2020. Demographic information, primary pathology, preoperative clinical characteristics, and operative outcomes were collected. Factors achieving p values < 0.15 on univariate regression were entered into a stepwise multivariable logistic regression to generate predictive models. Nonroutine discharge was defined as a nonhome discharge destination and prolonged LOS was defined as LOS greater than the 75th percentile for the entire cohort.

RESULTS

Three hundred twenty-eight patients who had undergone 348 operations were included: 240 (69.0%) White and 108 (31.0%) Black. On univariable analysis, cohorts significantly differed in age (p = 0.02), marital status (p < 0.001), insurance status (p = 0.03), income quartile (p = 0.02), primary tumor type (p = 0.04), and preoperative Karnofsky Performance Scale (KPS) score (p < 0.001). On multivariable analysis, race was an independent predictor for nonroutine discharge: Black patients had significantly higher odds of nonroutine discharge than White patients (adjusted odds ratio [AOR] 2.24, 95% confidence interval [CI] 1.28-3.92, p = 0.005). Older age (AOR 1.06 per year, 95% CI 1.03-1.09, p < 0.001), preoperative KPS score ≤ 70 (AOR 3.30, 95% CI 1.93-5.65, p < 0.001), preoperative Frankel grade A-C (AOR 3.48, 95% CI 1.17-10.3, p = 0.02), insurance status (p = 0.005), being unmarried (AOR 0.58, 95% CI 0.35-0.97, p = 0.04), number of levels (AOR 1.17 per level, 95% CI 1.05-1.31, p = 0.004), and thoracic involvement (AOR 1.71, 95% CI 1.02-2.88, p = 0.04) were also predictive of nonroutine discharge. However, race was not independently predictive of postoperative complications or prolonged LOS. Higher Charlson Comorbidity Index (AOR 1.22 per point, 95% CI 1.04-1.43, p = 0.01), low preoperative KPS score (AOR 1.84, 95% CI 1.16-2.92, p = 0.01), and number of levels (AOR 1.15 per level, 95% CI 1.05-1.27, p = 0.004) were predictive of complications, while insurance status (p = 0.05), income quartile (p = 0.01), low preoperative KPS score (AOR 1.64, 95% CI 1.03-2.72, p = 0.05), and number of levels (AOR 1.16 per level, 95% CI 1.05-1.30, p = 0.004) were predictive of prolonged LOS.

CONCLUSIONS

Race, insurance status, age, baseline functional status, and marital status were all independently associated with nonroutine discharge. This suggests that a combination of socioeconomic factors and functional status, rather than medical comorbidities, may best predict postdischarge disposition in patients treated for spinal metastases. Further investigation in a prospective cohort is merited.

Overlapping single-level lumbar fusion and adverse short-term outcomes

OBJECTIVE

There is a paucity of research on the safety of overlapping surgery. The purpose of this study was to evaluate the impact of overlapping surgery on a homogenous population of exactly matched patients undergoing single-level, posterior-only lumbar fusion.

METHODS

The authors retrospectively analyzed case data of 3799 consecutive adult patients who underwent single-level, posterior-only lumbar fusion during a 6-year period (June 7, 2013, to April 29, 2019) at a multihospital university health system. Outcomes included 30-day emergency department (ED) visit, readmission, reoperation, and morbidity and mortality following surgery. Thereafter, coarsened exact matching was used to match patients with and without overlap on key demographic factors, including American Society of Anesthesiologists (ASA) class, Charlson Comorbidity Index (CCI) score, sex, and body mass index (BMI), among others. Patients were subsequently matched by both demographic data and by the specific surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographically matched cohort, and the surgeon-matched cohort, with significance set at a p value < 0.05.

RESULTS

There was no significant difference in morbidity or any short-term outcome, including readmission, reoperation, ED evaluation, and mortality. Among the demographically matched cohort and surgeon-matched cohort, there was no significant difference in age, sex, history of prior surgery, ASA class, or CCI score. Overlapping surgery patients in both the demographically matched cohort and the matched cohort limited by surgeon had longer durations of surgery (p < 0.01), but no increased morbidity or mortality was noted. Patients selected for overlap had fewer prior surgeries and lower ASA class and CCI score (p < 0.01). Patients with overlap also had a longer duration of surgery (p < 0.01) but not duration of closure.

CONCLUSIONS

Exactly matched patients undergoing overlapping single-level lumbar fusion procedures had no increased short-term morbidity or mortality; however, duration of surgery was 20 minutes longer on average for overlapping operations. Further studies should assess long-term patient outcomes and the impact of overlap in this and other surgical procedures.

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.

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 Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease.

METHODS

We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups.

RESULTS

We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I² = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I² = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I² = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I² = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates.

CONCLUSIONS

Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Postoperative outcomes and the association with overlap before or after the critical step of lumbar fusion

OBJECTIVE

This study assesses how degree of overlap, either before or after the critical operative portion, affects lumbar fusion outcomes.

METHODS

The authors retrospectively studied 3799 consecutive patients undergoing single-level, posterior-only lumbar fusion over 6 years (2013-2019) at a university health system. Outcomes recorded within 30-90 and 0-90 postoperative days included emergency department (ED) visit, readmission, reoperation, overall morbidity, and mortality. Furthermore, morbidity and mortality were recorded for the duration of follow-up. The amount of overlap that occurred before or after the critical portion of surgery was calculated as a percentage of total beginning or end operative time. Subsequent to initial whole-population analysis, coarsened exact-matched cohorts of patients were created with the least and most amounts of either beginning or end overlap. Univariate analysis was performed on both beginning and end overlap exact-matched cohorts, with significance set at p < 0.05.

RESULTS

Equivalent outcomes were observed when comparing exact-matched patients. Among the whole population, the degree of beginning overlap was correlated with reduced ED visits within 30-90 and 0-90 days (p = 0.007, p = 0.009; respectively), and less 0-90 day morbidity (p = 0.037). Degree of end overlap was correlated with fewer 30-90 day ED visits (p = 0.015). When comparing only patients with overlap, degree of beginning overlap was correlated with fewer 0-90 day reoperations (p = 0.022), and no outcomes were correlated with degree of end overlap.

CONCLUSIONS

The degree of overlap before or after the critical step of surgery does not lead to worse outcomes after lumbar fusion.

Associated factors of patients with spinal stenosis who undergo reoperation after a posterior lumbar spinal fusion in a Hispanic-American population

PURPOSE

The aim of this study was to evaluate the associated factors of patients with LSS who undergo reoperation after a PLSF in a Hispanic-American population.

METHODS

A retrospective single-center review was performed from all non-age-related Hispanic-Americans with LSS who underwent one or two-level PLSF from 2008 to 2018. Baseline characteristics were analyzed between the reoperation and no-reoperation group using a bivariate and multivariate analyses.

RESULTS

Out of 425 patients who underwent PLSF, 38 patients underwent reoperation. At a two-year follow-up, the reoperation rate was 6.1% (26/425), mostly due to pseudoarthrosis (39.5%), recurrent stenosis (26.3%), new condition (15.8%), infection (10.5%), hematoma (5.3%), and dural tear (2.6%). Patients who underwent reoperation were more likely to have a preoperative history of epidural steroid injection (ESI) (OR 5.18, P = 0.009), four or more comorbidities (OR 2.69, P = 0.028), and operated only with a posterolateral fusion without intervertebral fusion (OR 2.15, P = 0.032). Finally, the multivariable analysis showed that ESI was the only independent associated factor in patients who underwent reoperation after a PLSF in our group.

CONCLUSION

Among this population who underwent surgery, a reoperation rate at two years of follow-up was less than ten percent. Our study did not find any associated factor inherent to Hispanic-Americans, as ethnic group, who were reoperated after LSS.

Role of Race in Short-Term Outcomes for 1700 Consecutive Patients Undergoing Brain Tumor Resection

BACKGROUND

Access to medical care seems to be impacted by race. However, the effect of race on outcomes, once care has been established, is poorly understood.

PURPOSE

This study seeks to assess the influence of race on patient outcomes in a brain tumor surgery population.

IMPORTANCE AND RELEVANCE TO HEALTHCARE QUALITY

This study offers insights to if or how quality is impacted based on patient race, after care has been established. Knowledge of disparities may serve as a valuable first step toward risk factor mitigation.

METHODS

Patients differing in race, but matched on other outcomes affecting characteristics, were assessed for differences in outcomes subsequent to brain tumor resection. Coarsened exact matching was used to match 1700 supratentorial brain tumor procedures performed over a 6-year period at a single, multihospital academic medical center. Patient outcomes assessed included unplanned readmission, mortality, emergency department (ED) visits, and unanticipated return to surgery.

RESULTS

There was no significant difference in readmissions, mortality, ED visits, return to surgery after index admission, or return to surgery within 30 days between the two races.

CONCLUSION

This study suggests that race does not independently influence postsurgical outcomes but may instead serve as a proxy for other closely related demographics.

Racial Disparities in the Risk of Complications After Nonobstetric Surgery in Pregnancy

OBJECTIVE

To examine whether there are racial and ethnic differences in postoperative complications after nonobstetric surgery during pregnancy in the United States.

METHODS

We conducted a secondary analysis of the prospective ACS NSQIP (American College of Surgeons National Surgical Quality Improvement) program from 2005 to 2012. We assessed pregnant women 18-50 years without prior surgery in the preceding 30 days who underwent a nonobstetric surgery. Race and ethnicity were categorized as non-Hispanic Black, Hispanic, and non-Hispanic White (reference). The primary outcome was a composite of 30-day major postoperative complications inclusive of cardiovascular, pulmonary, and infectious complications, reoperation, unplanned readmission, blood transfusion, and death. We used modified Poisson regression to estimate the relative risk of complications.

RESULTS

Among 3,093 pregnant women, 18% were non-Hispanic Black, 20% Hispanic, and 62% non-Hispanic White. The most common surgeries were appendectomy (36%) and cholecystectomy (19%). Black women (18%) were more likely to be assigned American Society of Anesthesiologists (ASA) physical status class III or higher than their White (12%) or Hispanic (9%) peers. Non-Hispanic Black pregnant women had a higher risk of 30-day major postoperative complications compared with their White peers (9% vs 6%; adjusted relative risk [aRR] 1.41, 95% CI 1.11-1.99). This difference persisted when limiting the analysis to apparently healthy women (ASA class I or II) (7% vs 4%; aRR 1.64, 95% CI 1.08-2.50), those who underwent appendectomy (10% vs 3%; aRR 2.36, 95% CI 1.13-4.96), and when appendectomy and cholecystectomy were performed by laparoscopy (7% vs 3%; aRR 2.62, 95% CI 1.22-5.58). Hispanic pregnant women were not at an increased risk of complications compared with non-Hispanic pregnant White women.

CONCLUSIONS

Pregnant non-Hispanic Black women were at higher risk of major postoperative complications after nonobstetric surgery compared with their White counterparts.

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.

Postoperative complications after non-obstetric surgery among pregnant patients in the National Surgical Quality Improvement Program, 2005-2012

BACKGROUND

To examine whether pregnant patients have higher risk of major 30-day postoperative complications compared with their non-pregnant counterparts after non-obstetric surgery.

METHODS

A secondary analysis of the prospective National Surgical Quality Improvement Program (NSQIP) from 2005 to 2012 of pregnant patients 18-51 years old, without surgery in the preceding 30 days, and who underwent a non-obstetrical operation. The primary outcome was composite 30-day major postoperative complications. We used modified Poisson regression.

RESULTS

Among 354,251 assessed patients, 3655 (1%) were pregnant. The overall incidence of 30-day major postoperative complication was 6%, and did not vary by pregnancy status. Pregnant patients were not at higher risk of 30-day major postoperative complications compared to non-pregnant patients following non-obstetric surgery. This held for most procedures, except pregnant patients were at a higher risk of complications with colorectal and hernia surgeries. Secondarily, pregnant patients were at higher risk of transfusion.

CONCLUSIONS

Pregnant patients are generally not at higher risk of major postoperative complications following non-obstetric surgery. This information can be used when counseling pregnant patients about the risks versus benefits of non-obstetric surgery.

The impact of gender on long-term outcomes following supratentorial brain tumor resection

PURPOSE

Gender is a known social determinant of health which has been linked disparities in medical care. This study intends to assess the impact of gender on 90-day and long-term morbidity and mortality outcomes following supratentorial brain tumor resection in a coarsened-exact matched population.

MATERIALS AND METHODS

A total of 1970 consecutive patients at a single, university-wide health system undergoing supratentorial brain tumor resection over a six-year period (09 June 2013 to 26 April 2019) were analyzed retrospectively. Coarsened Exact Matching was employed to match patients on key demographic factors including history of prior surgery, smoking status, median household income, American Society of Anesthesiologists (ASA) grade, and Charlson Comorbidity Index (CCI), amongst others. Primary outcomes assessed included readmission, ED visit, unplanned reoperation, and mortality within 90 days of surgery. Long-term outcomes such as mortality and unplanned return to surgery during the entire follow-up period were also recorded.

RESULTS

Whole-population regression demonstrated significantly increased mortality throughout the entire follow-up period for the male cohort (p = 0.004, OR = 1.32, 95% CI = 1.09 - 1.59); however, no significant difference was found after coarsened exact matching was performed (p = 0.08). In both the whole-population regression and matched-cohort analysis, no significant difference was observed between gender and readmission, ED visit, unplanned reoperation, or mortality in the 90-day post-operative window, in addition to return to surgery after throughout the entire follow-up period.

CONCLUSION

After controlling for confounding variables, female birth gender did not significantly predict any difference in morbidity and mortality outcomes following supratentorial brain tumor resection. Difference between mortality outcomes in the pre-matched population versus the matched cohort suggests the need to better manage the underlying health conditions of male patients in order to prevent future disparities.

Duration of overlap during lumbar fusion does not predict outcomes

INTRODUCTION

The relationship between degree of surgical overlap and adverse postoperative outcomes remains poorly defined. This study aims to evaluate the impact of increasing duration of overlap on lumbar fusion outcomes.

PATIENTS AND METHODS

1302 adult patients undergoing overlapping surgery during single-level, posterior-only lumbar fusion at a multi-hospital, university health system were retrospectively assessed. Amount of overlap was calculated as a percentage of total overlap time. Patients were separated into groups with the most (top 10% of patients) and least amounts of overlap (bottom 40% of patients). Using Coarsened Exact Matching, patients with the most and least amounts of overlap were matched on demographics alone, then on both demographics and attending surgeon. Univariate analysis was performed for the whole population and both matched cohorts to compare amount of overlap to risk of adverse postsurgical events. Significance for all analyses was p-value < 0.05.

RESULTS

Duration of overlap was not associated with outcomes in the whole population, demographic-matched, or surgeon-matched analyses. Before exact matching, patients with the most amount of overlap had a significantly higher CCI score (p = 0.031) and shorter length of surgery (p = 0.006). In the demographic matched cohort, patients with increased overlap had a significantly shorter length of surgery (p = 0.001) only. In the surgeon matched cohort, there were no differences in length of surgery or CCI score.

CONCLUSIONS

Duration of surgical overlap does not predict adverse outcomes following lumbar fusion. These results suggest that overlapping surgery is a safe practice within this common neurosurgical indication.

Association of Race with Early Outcomes of Elective Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Propensity-Matched and Subgroup Analysis

OBJECTIVE

To investigate the impact of race on 30-day postoperative complication rates of elective posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

Patients who underwent PSF between 2012 and 2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program pediatric database. Propensity score matching was utilized to evaluate whether patient race (i.e., black vs. white) was correlated with postoperative complications.

RESULTS

A total of 4051 PSF for AIS cases met criteria for inclusion. Of these, 3221 (79.5%) patients were white and 830 (20.5%) were black. Several baseline characteristics significantly differed between cohorts. Patients in the black cohort had a significantly higher body mass index, a greater proportion of female patients, higher ASA scores, preoperative diagnosis of asthma or cardiac risk factors, and prior use of steroids. The total number of vertebral segments fused was also greater in the black cohort. After controlling for differences in baseline characteristics with propensity score matching analysis, the only significant difference in morbidity and mortality identified was a higher incidence of venous thromboembolism among the black cohort (2.8% vs. 0.1%; P < 0.001).

CONCLUSIONS

In contrast to prior literature, our analysis did not identify black race as an independent risk factor for higher perioperative morbidity or mortality in patients of young age group undergoing elective PSF for AIS, except the higher incidence of venous thromboembolism. The findings of the present study suggest that previously reported perioperative morbidity and mortality outcomes in black patients may be secondary to baseline health characteristics, and not due to race itself.

Patients undergoing overlapping posterior single-level lumbar fusion are not at greater risk for adverse 90-day outcomes

OBJECTIVE

This study evaluated overlapping surgery on long-term outcomes following elective, single-level lumbar fusion on exact matched patients undergoing surgery with or without overlap.

PATIENTS AND METHODS

3799 consecutive adult patients undergoing single-level, posterior-only lumbar fusion over a six-year period at a multi-hospital university health system were retrospectively followed. Reported outcomes included reoperation, emergency department (ED) visit, readmission, overall morbidity and mortality in the 90 days following surgery. Coarsened Exact Matching was used to match patients with and without overlap on key demographic factors. Patients were subsequently matched by both demographic data and by the attending surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographic matched cohort, and demographic and surgeon matched cohort, with significance set at a p-value < 0.05.

RESULTS

Patients with overlap had a longer duration of surgery and were less likely to have an ED visit within 90 days of surgery (p < 0.03) but had no other significant differences. Within the demographic matched cohort and demographic/surgeon matched cohort, there was no significant difference in age, gender, history of prior surgery, ASA score, or CCI score, but patients with overlap had a longer duration of surgery (p < 0.01). Patients did not have significant differences with respect to any morbidity or mortality outcome in either the demographic or surgeon matched cohort.

CONCLUSIONS

Patients undergoing overlapping, single-level lumbar fusion were not at greater risk of long-term morbidity or mortality, despite having a significantly longer duration of surgery.

The role of socioeconomic status on outcomes following cerebellopontine angle tumor resection

PURPOSE

It is well documented that the interaction between many social factors can affect clinical outcomes. However, the independent effects of economics on outcomes following surgery are not well understood. The goal of this study is to investigate the role socioeconomic status has on postoperative outcomes in a cerebellopontine angle (CPA) tumor resection population.

MATERIALS AND METHODS

Over 6 years (07 June 2013 to 24 April 2019), 277 consecutive CPA tumor cases were reviewed at a single, multihospital academic medical center. Patient characteristics obtained included median household income, Charlson Comorbidity Index (CCI), race, BMI, tobacco use, amongst 23 others. Outcomes studied included readmission, ED evaluation, unplanned return to surgery (during and after index admission), return to surgery after index admission, and mortality within 90 days, in addition to reoperation and mortality throughout the entire follow-up period. Univariate analysis was conducted amongst the entire population with significance set at a p value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (Q1) and highest (Q4) socioeconomic quartiles, with significance set at a p value <0.05. Stepwise regression was conducted to determine the correlations amongst study variables and identify confounding factors.

RESULTS

Regression analysis of 273 patients did not find household income to be associated with any of the long-term outcomes assessed. Similarly, a Q1 vs Q4 comparison did not yield significantly different odds of outcomes assessed.

CONCLUSION

Although not statistically significant, the odds ratios suggest socioeconomic status may have a clinically significant effect on postsurgical outcomes. Further studies in larger, matched populations are necessary to validate these findings.

Assessing the Role of Patient Race in Disparity of 90-Day Brain Tumor Resection Outcomes

BACKGROUND

This study assesses the influence of race on patient outcomes in a brain tumor surgery population.

METHODS

Coarsened exact matching was used to retrospectively analyze 1700 supratentorial brain tumor procedures over a 6-year period (June 7, 2013 to April 29, 2019) at a single, multihospital academic medical center. Outcome measures included readmission, mortality, emergency room visits, and reoperation.

RESULTS

McNemar test (mid-P) showed no significant difference in 90-day mortality between the 2 races (P = 0.3018). However, there was a significant difference in 90-day readmissions between the 2 races (P = 0.0237). There was no significant difference in 90-day emergency room visits (P = 0.0579), 90-day return to surgery after index admission (P = 0.6015), or return to surgery within 90 days (P = 0.6776) between the 2 races. There was also no significant difference in return to surgery for the duration of the follow-up period (P = 0.8728).

CONCLUSIONS

This study suggests that race alone does not result in disparate outcomes; however, there was an associated difference in 90-day postsurgical readmissions. Despite coarsened exact matching, persistent differences in median household income may play a role in the disparate outcome noted.

Effect of Surgical Setting on Hospital-Reported Outcomes for Elective Lumbar Spinal Procedures: Tertiary Versus Community Hospitals

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and increase quality. To our knowledge, no reported data compare these measures between hospital settings for elective lumbar procedures. The study compares hospital-reported outcomes and costs for elective lumbar procedures performed at a tertiary hospital (TH) versus community hospitals (CH) within a single health care system.

METHODS

Retrospective review of a physician-maintained, prospectively collected database consisting of 1 TH and 4 CH for 3 common lumbar surgeries from 2015 to 2016. Patients undergoing primary elective microdiscectomy for disc herniation, laminectomy for spinal stenosis, and laminectomy with fusion for degenerative spondylolisthesis were included. Patients were excluded for traumatic, infectious, or malignant pathology. Comparing hospital settings, outcomes included length of stay (LOS), rates of 30-day readmissions, potentially preventable complications (PPC), and discharge to rehabilitation facility, and hospital costs.

RESULTS

A total of 892 patients (n = 217 microdiscectomies, n = 302 laminectomies, and n = 373 laminectomy fusions) were included. The TH served a younger patient population with fewer comorbid conditions and a higher proportion of African Americans. The TH performed more decompressions (P < .001) per level fused; the CH performed more interbody fusions (P = .007). Cost of performing microdiscectomy (P < .001) and laminectomy (P = .014) was significantly higher at the TH, but there was no significant difference for laminectomy with fusion. In a multivariable stepwise linear regression analysis, the TH was significantly more expensive for single-level microdiscectomy (P < .001) and laminectomy with single-level fusion (P < .001), but trended toward significance for laminectomy without fusion (P = .052). No difference existed for PPC or readmissions rate. Patients undergoing laminectomy without fusion were discharged to a facility more often at the TH (P = .019).

CONCLUSIONS

We provide hospital-reported outcomes between a TH and CH. Significant differences in patient characteristics and surgical practices exist between surgical settings. Despite minimal differences in hospital-reported outcomes, the TH was significantly more expensive.

Black Race as a Social Determinant of Health and Outcomes After Lumbar Spinal Fusion Surgery: A Multistate Analysis, 2007 to 2014

STUDY DESIGN

A retrospective analysis of patient hospitalization and discharge records.

OBJECTIVE

To examine the association between race and inpatient postoperative complications following lumbar spinal fusion surgery.

SUMMARY OF BACKGROUND DATA

Racial disparities in healthcare have been demonstrated across a range of surgical procedures. Previous research has identified race as a social determinant of health that impacts outcomes after lumbar spinal fusion surgery. However, these studies are limited in that they are outdated, contain data from a single institution, analyze small limited samples, and report limited outcomes. Our study aims to expand and update the literature examining the association between race and inpatient postoperative complications following lumbar spine surgery.

METHODS

We analyzed 267,976 patient discharge records for inpatient lumbar spine surgery using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We used unadjusted bivariate analysis, adjusted multivariable, and stratified analysis to compare patient demographics, present-on-admission comorbidities, hospital characteristics, and complications by categories of race/ethnicity.

RESULTS

Black patients were 8% and 14% more likely than white patients to experience spine surgery specific complications (adjusted odds ratios [aOR]: 1.08, 95% confidence interval [CI]: 1.03-1.13) and general postoperative complications (aOR: 1.14, 95% CI: 1.07-1.20), respectively. Black patients, compared with white patients, also had increased adjusted odds of 30-day readmissions (aOR: 1.13, 95% CI: 1.07-1.20), 90-day readmissions (aOR: 1.07, 95% CI: 1.02-1.13), longer length of stay (LOS) (adjusted Incidence Rate Ratio: 1.15, 95% CI: 1.14-1.16), and higher total charges (adjusted Incidence Rate Ratio: 1.08, 95% CI: 1.07-1.09).

CONCLUSION

Our findings demonstrate that black patients, as compared with white patients, are more likely to have postoperative complications, longer postoperative lengths of stay, higher total hospital charges, and increased odds of 30- and 90-day readmissions following lumbar spinal fusion surgery.

LEVEL OF EVIDENCE

4.

Socioeconomic disparities in the utilization of spine augmentation for patients with osteoporotic fractures: an analysis of National Inpatient Sample from 2011 to 2015

BACKGROUND CONTENT

Vertebral augmentation procedures are used for treatment of osteoporotic compression fractures. Prior studies have reported disparities in the treatment of patients with osteoporotic vertebral fractures, particularly with regards to the use of vertebroplasty and kyphoplasty.

PURPOSE

The purpose of this study is to report updates in racial and health insurance inequalities of spine augmentation procedures in patients with osteoporotic fractures.

METHODS

With the use of the National Inpatient Sample, we identified hospitalized patients with osteoporotic fractures between the period of 2011 and 2015. Patients with spine augmentation, defined by the utilization of vertebroplasty and kyphoplasty, were also identified. Our primary outcome was defined as the utilization of spine augmentation procedures across ethnic (white, hispanic, black, and asian/pacific islander) and insurance (self-pay, private insurance, Medicare, and Medicaid) groups. Variables were identified from the NIS database using International Classification of Diseases, Ninth and Tenth diagnosis codes. Univariate and multivariate regression analysis was used for statistical analysis with p value <.05 considered significant. A subgroup analysis was performed across the utilization of kyphoplasty, vertebroplasty, and Medicare coverage.

RESULTS

We identified a total of 110,028 patients with a primary diagnosis of vertebral fracture between 2011 and 2015 (mean age: 74.4±13.6 years, 68% women). About 16,237 patients (14.8%) underwent any type of spine augmentation with over 75% of the patients receiving kyphoplasty. Multivariate analysis showed that black patients (odds ratio [OR]=0.64, 95% confidence interval [CI]: 0.58-0.70, p<.001), Hispanic patients (OR=0.79, 95% CI: 0.73-0.86, p<.001), and Asian/Pacific Islander (OR=0.79, 95% CI: 0.70-0.89, p<.001) had significantly lower odds for receiving any spine augmentation compared with white patients. Patients with Medicaid (OR=0.59, 95% CI: 0.53-0.66, p<.001), private insurance (OR=0.90, 95% CI: 0.85-0.96, p=.001), and those who self-pay (OR=0.57, 95% CI: 0.47-0.69, p<.001) had significantly lower odds of spine augmentation compared with those with Medicare. Comparative use of kyphoplasty was not significantly different between white and black patients (OR=0.85, 95% CI: 0.70-1.04, p=.12). However, Hispanic patients (OR=0.84, 95% CI: 0.71-0.99, p=.04) and Asian/Pacific Islander patients (OR=0.73, 95% CI: 0.58-0.92, p=.007) had significantly lower use of kyphoplasty compared with white patients. The comparative use of kyphoplasty among patients receiving spine augmentation was not significantly different across each insurances status when compared with patients with Medicare.

CONCLUSIONS

Our study suggests that racial and socioeconomic disparities continue to exist with the utilization of spine augmentation procedures in hospitalized patients with osteoporotic fractures.

Renal Transplantation Is Associated with Increased Complications Following Spinal Fusion Operations: Analysis of a National Database

BACKGROUND

Improved postoperative care for renal transplant recipients has advanced both duration and overall quality of life. However, degenerative spinal pathology is increasingly prevalent after transplant. Outcomes following spinal fusion among the renal transplant population in the United States are rarely addressed.

METHODS

The Healthcare Cost and Utilization Project National Inpatient Sample database was employed. Cases in years 2008-2014 for patients ≥18 years old receiving spinal fusion, exploration/decompression, and/or spinal revision/re-fusion surgeries were included. Cases were divided into kidney transplant recipients (KTR) and non-kidney transplant recipients. Complications, demographics, and socioeconomic outcomes were compared between cohorts.

RESULTS

Of 579,726 patients who met inclusion criteria, 685 (0.1%) were KTRs. The KTR population was older and included more men compared with the non-kidney transplant recipient population (60.1 years vs. 56.6 years, P < 0.001; 58% male vs. 45.5% male, P < 0.001). KTRs experienced higher total complication rates (29.8% vs. 18.9%, P < 0.001). Prevalence of acute posthemorrhagic anemia and need for transfusion was markedly higher for KTRs (15.8% vs. 9.1%, P < 0.001; 13.6% vs. 6.2%, P < 0.001). Multivariate analysis revealed longer length of stay (median 1.23 days, interquartile range 0.94-1.53, P < 0.001), lower routine discharge (odds ratio = 0.57, 95% confidence interval 0.48-0.69, P < 0.001), and higher discharge to alternative care facilities (odds ratio = 1.91, 95% confidence interval 1.57-2.33, P < 0.001) for KTRs. The inpatient course for KTRs undergoing spinal operations was significantly costlier ($87,445 vs. $71,589, P < 0.001).

CONCLUSIONS

History of renal transplant was associated with increased inpatient medical and socioeconomic complications following spinal fusion. Physicians and patients must understand and respect the potentially increased perioperative challenges facing KTRs.

Predicting nonroutine discharge after elective spine surgery: external validation of machine learning algorithms

OBJECTIVE

Nonroutine discharge after elective spine surgery increases healthcare costs, negatively impacts patient satisfaction, and exposes patients to additional hospital-acquired complications. Therefore, prediction of nonroutine discharge in this population may improve clinical management. The authors previously developed a machine learning algorithm from national data that predicts risk of nonhome discharge for patients undergoing surgery for lumbar disc disorders. In this paper the authors externally validate their algorithm in an independent institutional population of neurosurgical spine patients.

METHODS

Medical records from elective inpatient surgery for lumbar disc herniation or degeneration in the Transitional Care Program at Brigham and Women's Hospital (2013-2015) were retrospectively reviewed. Variables included age, sex, BMI, American Society of Anesthesiologists (ASA) class, preoperative functional status, number of fusion levels, comorbidities, preoperative laboratory values, and discharge disposition. Nonroutine discharge was defined as postoperative discharge to any setting other than home. The discrimination (c-statistic), calibration, and positive and negative predictive values (PPVs and NPVs) of the algorithm were assessed in the institutional sample.

RESULTS

Overall, 144 patients underwent elective inpatient surgery for lumbar disc disorders with a nonroutine discharge rate of 6.9% (n = 10). The median patient age was 50 years and 45.1% of patients were female. Most patients were ASA class II (66.0%), had 1 or 2 levels fused (80.6%), and had no diabetes (91.7%). The median hematocrit level was 41.2%. The neural network algorithm generalized well to the institutional data, with a c-statistic (area under the receiver operating characteristic curve) of 0.89, calibration slope of 1.09, and calibration intercept of -0.08. At a threshold of 0.25, the PPV was 0.50 and the NPV was 0.97.

CONCLUSIONS

This institutional external validation of a previously developed machine learning algorithm suggests a reliable method for identifying patients with lumbar disc disorder at risk for nonroutine discharge. Performance in the institutional cohort was comparable to performance in the derivation cohort and represents an improved predictive value over clinician intuition. This finding substantiates initial use of this algorithm in clinical practice. This tool may be used by multidisciplinary teams of case managers and spine surgeons to strategically invest additional time and resources into postoperative plans for this population.

Racial Disparities in Surgical Outcomes After Spine Surgery: An ACS-NSQIP Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Racial disparities in postoperative outcomes are unfortunately common. We present data assessing race as an independent risk factor for postoperative complications after spine surgery for Native American (NA) and African American (AA) patients compared with Caucasians (CA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for spine procedures performed in 2015. Data was subdivided by surgery, demography, comorbidity, and 30-day postoperative outcomes, which were then compared by race. Regression was performed holding race as an independent risk factor.

RESULTS

A total of 4803 patients (4106 CA, 522 AA, 175 NA) were included in this analysis. AA patients experienced longer length of stay (LOS) and operative times (P < .001) excluding lumbar fusion, which was significantly shorter (P = .035). AA patients demonstrated higher comorbidity burden, specifically for diabetes and hypertension (P < .005), while NA individuals were higher tobacco consumers (P < .001). AA race was an independent risk factor associated with longer LOS across all cervical surgeries (β = 1.54, P <.001), lumbar fusion (β = 0.77, P = .009), and decompression laminectomy (β = 1.23, P < .001), longer operative time in cervical fusion (β = 12.21, P = .032), lumbar fusion (β = -24.00, P = .016), and decompression laminectomy (OR = 20.95, P < .001), greater risk for deep vein thrombosis in lumbar fusion (OR = 3.72, P = .017), and increased superficial surgical site infections (OR = 5.22, P = .001) and pulmonary embolism (OR = 5.76, P = .048) in decompression laminectomy. NA race was an independent risk factor for superficial surgical site infections following cervical fusion (OR = 14.58, P = .044) and decompression laminectomy (OR = 4.80, P = .021).

CONCLUSION

AA and NA spine surgery patients exhibit disproportionate comorbidity burden and greater 30-day complications compared with CA patients. AA and NA race were found to independently affect rates of complications, LOS, and operation time.