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

Does Medicare Insurance Mitigate Racial/Ethnic Disparities in Access to Lumbar Spinal Surgery When Compared to Commercial Insurance?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Compare disparities in lumbar surgical care utilization in Commercially insured versus Medicare patients.

SUMMARY OF BACKGROUND DATA

While disparities in spinal surgery have been previously described, less evidence exists on effective strategies to mitigate them. Theoretically, universal health care coverage under Medicare should improve health care access.

MATERIALS AND METHODS

Utilizing National Inpatient Sample data (2003-2018), we included inpatient lumbar discectomy or laminectomy/fusion cases in black, white, or Hispanic patients aged 18-74 years, with Commercial or Medicare insurance. A multivariable Poisson distribution model determined race/ethnicity subgroup-specific rate ratios (RRs) of patients undergoing lumbar surgery compared to their respective population distribution (using US Census data) based on race/ethnicity, region, gender, primary payor, and age (Commercially insured age subgroups: 18-39, 40-54, and 55-64 y; Medicare age subgroup: 65-74 y).

RESULTS

Of the 2,310,956 lumbar spine procedures included, 88.9%, 6.1%, and 5.0% represented white, black, and Hispanic patients, respectively. Among Commercially insured patients, black and Hispanic (compared to white) patients had lower rates of surgical care utilization; however, these disparities decreased with increasing age: black (RR=0.37, 95% CI: 0.37-0.38) and Hispanic patients (RR=0.53, 95% CI: 0.52-0.54) aged 18-39 years versus black (RR=0.72, 95% CI: 0.71-0.73) and Hispanic patients (RR=0.64, 95% CI: 0.63-0.65) aged 55-64 years. Racial/ethnic disparities persisted in Medicare patients, especially when compared to the neighboring age subgroup that was Commercially insured: black (RR=0.61, 95% CI: 0.60-0.62) and Hispanic patients (RR=0.61, 95% CI: 0.60-0.61) under Medicare.

CONCLUSIONS

Disparities in surgical care utilization among black and Hispanic patients persist regardless of health care coverage, and an expansion of Medicare eligibility alone may not comprehensively address health care disparities.

LEVEL OF EVIDENCE

Level III.

Impact of Racial and Socioeconomic Disparities on Access to Interspinous Spacer for Treatment of Lumbar Spinal Stenosis: A Nationwide Medicare Analysis

BACKGROUND

In mild to moderate lumbar spinal stenosis (LSS) where conservative care treatments fail, minimally invasive treatments, such as interspinous spacers without decompression or fusion (ISD), may be appropriate. While previous studies have demonstrated racial and socioeconomic disparities in the surgical treatment of LSS, there are limited data on how those factors impact accessibility to these procedures. This study explored demographic, socioeconomic, and geographic differences in the use of ISD.

METHODS

Using the Medicare 100% files from 2017 through 2022, this retrospective claims analysis identified when and if patients diagnosed with LSS received ISD implantation. Cox proportional hazards regression was used to examine the association between racial and socioeconomic characteristics and the rate of ISD implantation, stratified by geographic region.

RESULTS

A total of 1,316,622 individuals met the inclusion criteria; 4730 (0.4%) underwent ISD implantation, with a mean (standard deviation) time to treatment of 11.9 (13.2) months after diagnosis. The likelihood of ISD implantation was higher for older patients (except for the oldest group), males, those with lower disease burden, and White patients. Cox regression revealed that the associations of racial and socioeconomic factors with ISD implantation varied by U.S. region. In the Midwest and Northeast, lower median household income was associated with a decreased likelihood of ISD implantation regardless of race, while in the South, Black patients were less likely to undergo ISD implantation regardless of income.

CONCLUSIONS

The observed disparities in access to ISD implantation mirror existing trends in surgical interventions for LSS, suggesting further study and interventions are needed to address inequities.

Disparities in Provider Ordering Practices of Image-Guided Interventions and Surgery for Patients With Low Back Pain: A Cohort Study

OBJECTIVE

To assess individual- and neighborhood-level sociodemographic factors associating with providers' ordering of nonpharmacologic treatments for patients with low back pain (LBP), specifically physical therapy, image-guided interventions, and lumbar surgery.

METHODS

Our cohort included all patients diagnosed with LBP from 2000 to 2017 in a statewide database of all hospitals and ambulatory surgical facilities within Utah. We compared sociodemographic and clinical characteristics of (1) patients with LBP who received any treatment with those who received none and (2) patients with LBP who received invasive LBP treatments with those who only received noninvasive LBP treatments using the Student's t test, Wilcoxon's rank-sum tests, and Pearson's χ2 tests, as applicable, and two separate multivariate logistic regression models: (1) to determine whether sociodemographic characteristics were risk factors for receiving any LBP treatments and (2) risk factors for receiving invasive LBP treatments.

RESULTS

Individuals in the most disadvantaged neighborhoods were less likely to receive any nonpharmacologic treatment orders (odds ratio [OR] 0.74 for most disadvantaged, P < .001) and received fewer invasive therapies (0.92, P = .018). Individual-level characteristics correlating with lower rates of treatment orders were female sex, Native Hawaiian or other Pacific Islander race (OR 0.50, P < .001), Hispanic ethnicity (OR 0.77, P < .001), single or unmarried status (OR 0.69, P < .001), and no insurance or self-pay (OR 0.07, P < .001).

CONCLUSION

Neighborhood and individual sociodemographic variables associated with treatment orders for LBP with Area Deprivation Index, sex, race or ethnicity, insurance, and marital status associating with receipt of any treatment, as well as more invasive image-guided interventions and surgery.

Provider's exposure to diversity contributes to socioeconomic disparities in lumbar and cervical fusion outcomes

Background

Studies report patient race, income, and education influence spinal fusion outcomes; fewer studies, however, examine the influence of provider factors such as exposure to diversity or cultural sensitivity.

Objective

To examine how providers' experience with diverse patient populations affects spinal fusion outcomes.

Methods

Retrospective review of 39,680 patients undergoing lumbar and cervical fusions, 2003-2021, in Clinformatics® Data Mart national database. We used the provider patient racial diversity index (pRDI)-a published metric of physician exposure to diverse patients-to divide patients into groups based their provider's category (I, II, III) where patients treated by category III providers had surgeons with the most diverse patient populations. Multivariate regression models on propensity score-matched cohorts examined the association between patient SES and provider category on post-operative outcomes.

Results

Black patients had decreased discharge home (OR 0.67; 95% CI 0.54-0.83) compared to white patients. Patients treated by category III providers had increased length of stay (Coeff. 0.62; 95% CI 0.43-0.81), charge (Coeff. 36800; 95% CI 29,200-44,400), and decreased discharge home (OR 0.90; 95% CI 0.83-0.97) compared to patients treated by category I providers. Asian patients treated by category II providers had decreased readmission (OR 0.38; 95% CI 0.14-0.96), and Black patients treated by category III providers had increased discharge home (OR 1.41; 95% CI 1.1-1.9) compared to those treated by category I providers.

Conclusion

While our study found two specific instances of improved spine surgery outcomes for minority patients treated by providers serving diverse patient populations, we present mixed findings overall. This study serves as the foundation for future research to better understand how provider pRDI affects outcomes in patients undergoing lumbar and cervical spine surgery.

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.

Social Determinants of Health and Associations With Outcomes in Pediatric Patients With Brain Tumors

BACKGROUND AND OBJECTIVES

Social determinants of health (SDOH) are nonmedical factors that affect health outcomes. Limited investigation has been completed on the potential association of these factors to adverse outcomes in pediatric populations. In this study, the authors aimed to analyze the effects of SDOH disparities and their relationship with outcomes after brain tumor resection or biopsy in children.

METHODS

The authors retrospectively reviewed the records of their center's pediatric patients with brain tumor. Black race, public insurance, median household income, and distance to hospital were the investigated SDOH factors. Univariate analysis was completed between number of SDOH factors and patient demographics. Multivariate linear regression models were created to identify coassociated determinants and outcomes.

RESULTS

A total of 272 patients were identified and included in the final analysis. Among these patients, 81 (29.8%) had no SDOH disparities, 103 (37.9%) had 1, 71 (26.1%) had 2, and 17 (6.2%) had 3. An increased number of SDOH disparities was associated with increased percentage of missed appointments ( P = .002) and emergency room visits ( P = .004). Univariate analysis demonstrated increased missed appointments ( P = .01), number of postoperative imaging ( P = .005), and number of emergency room visits ( P = .003). In multivariate analysis, decreased median household income was independently associated with increased length of hospital stay ( P = .02).

CONCLUSION

The SDOH disparities are prevalent and impactful in this vulnerable population. This study demonstrates the need for a shift in research focus toward identifying the full extent of the impact of these factors on postoperative outcomes in pediatric patients with brain tumor.

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.

Time to achievement of minimum clinically important difference after lumbar decompression

OBJECTIVE

The objective of this study is to examine factors associated with delayed time to achieve minimum clinically important difference (MCID) in patients undergoing lumbar decompression (LD) for the Patient-Reported Outcomes (PROs) of Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back, and VAS leg pain.

METHODS

Patients undergoing LD with preoperative and postoperative ODI, VAS back, and VAS leg scores were retrospectively reviewed from April 2016 to January 2021. MCID values from previously established studies were utilized to determine MCID achievement. Kaplan-Meier survival analysis determined the time to achieve MCID. Hazard ratios from multivariable Cox regression were utilized to determine the preoperative factors predictive of MCID achievement.

RESULTS

Three-hundred and forty-three patients were identified undergoing LD. Overall MCID achievement rates were 67.4% for ODI, 67.1% for VAS back, and 65.0% for VAS leg. The mean time in weeks for MCID achievement was 22.52 ± 30.48 for ODI, 18.90 ± 27.43 for VAS back, and 20.96 ± 29.81 for VAS leg. Multivariable Cox regression revealed active smoker status, preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), ODI, VAS Back, and VAS Leg (HR 1.03-2.14) as predictors of early MCID achievement, whereas an American Society of Anesthesiologist (ASA) classification of 2, Black ethnicity, workers' compensation, private insurance, and diagnosis of foraminal stenosis were predictors of late MCID achievement (HR 0.34-0.58).

CONCLUSION

Most patients undergoing LD achieved MCID within 6 months of surgery. Significant factors for early MCID achievement were active smoking status and baseline PROs. Significant factors for late MCID achievement were ASA = 2, Black ethnicity, type of insurance, and foraminal stenosis diagnosis. These factors may be considered by surgeons in setting patient expectations.

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.

Reporting demographics in randomized control trials in spine surgery - we must do better

BACKGROUND CONTEXT

Demographic factors contribute significantly to spine surgery outcomes. Although race and ethnicity are not proxies for disease states, the intersection between these patient characteristics and socioeconomic status significantly impact patient outcomes.

PURPOSE

The purpose of this study is to investigate the frequency of demographic reporting and analysis in randomized controlled clinical trials (RCTs) published in the three highest impact spine journals.

STUDY DESIGN

Systematic review.

PATIENT SAMPLE

We analyzed 278 randomized control trials published in The Spine Journal, Spine, and Journal of Neurosurgery: Spine between January 2012 - January 2022.

OUTCOME MEASURES

Extracted manuscript characteristics included the frequency of demographic reporting, sample size, and demographic composition of studies.

METHODS

We conducted a systematic review of RCTs published between January 2012 - January 2022 in the three highest impact factor spine journals in 2021: The Spine Journal, Spine, and Journal of Neurosurgery: Spine. We determined if age, gender, BMI, race, and ethnicity were reported and analyzed for each study. The overall frequency of demographic reporting was assessed, and the reporting trends were analyzed for each individual year and journal. Among studies that did report demographics, the populations were analyzed in comparison to the national population per United States (US) census reports. Studies were evaluated for bias using Cochrane risk-of-bias.

RESULTS

Our search identified 278 RCTs for inclusion. 166 were published in Spine, 65 in The Spine Journal, and 47 in Journal of Neurosurgery: Spine. Only 9.35% (N=26) and 3.9% (N=11) of studies reported race and ethnicity, respectively. Demographic reporting frequency did not vary based on the publishing journal. Reporting of age and BMI increased over time, but reporting of race and ethnicity did not. Among RCTs that reported race, 88% were conducted in the US, and 85.71% of the patients in these US studies were White. White subjects were overly represented compared to the US population (85.71% vs. 61.63%, p<.001), and non-White or Black patients were most underrepresented (2.89% vs. 25.96%, p<.001).

CONCLUSIONS

RCTs published in the three highest impact factor spine journals failed to frequently report patient race or ethnicity. Among studies published in the US, study populations are increasingly represented by non-Hispanic White patients. As we strive to care for an increasingly diverse population and reduce disparities to care, spine surgeons must do a better job reporting these variables to increase the external validity and generalizability of RCTs.

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.

Risk Factors for 30-day Unplanned Readmission following Surgery for Lumbar Degenerative Diseases: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Surgical procedures for lumbar degenerative diseases (LDD), which have emerged in the 21-century, are commonly practiced worldwide. Regarding financial burdens and health costs, readmissions within 30days following surgery are inconvenient. We performed a systematic review to integrate real-world evidence and report the current risk factors associated with 30-day readmission following surgery for LDD.

METHODS

The Cochrane Library, Embase, and Medline electronic databases were searched from inception to April 2022 to identify relevant studies reporting risk factors for 30-day readmission following surgery for LDD.

RESULTS

Thirty-six studies were included in the review. Potential risk factors were identified in the included studies that reported multivariate analysis results, including age, race, obesity, higher American Society of Anesthesiologists score, anemia, bleeding disorder, chronic pulmonary disease, heart failure, dependent status, depression, diabetes, frailty, malnutrition, chronic steroid use, surgeries with anterior approach, multilevel spinal surgeries, perioperative transfusion, presence of postoperative complications, prolonged operative time, and prolonged length of stay.

CONCLUSIONS

There are several potential perioperative risk factors associated with unplanned readmission following surgery for LDD. Preoperatively identifying patients that are at increased risk of readmission is critical for achieving the best possible outcomes.

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.

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.

Race as a factor in adverse outcomes following unruptured aneurysm surgery

INTRODUCTION

Strong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States.

METHODS

Data from the 2012-2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type.

RESULTS

7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07-1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients.

CONCLUSION

Our nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.

Do racial disparities exist in a spine surgery practice that serves a predominately minority population? Outcomes of transforaminal lumbar interbody fusion: A retrospective review

Background

Racial minority status is associated with inferior peri-operative outcomes following spinal fusion. Findings have largely been reported within institutions serving few minority patients. This study aimed to identify if racial disparities exist for transforaminal lumbar interbody fusion (TLIF) procedures within an urban academic medical center which serves a majority non-White population.

Methods

This is a retrospective review of patients who underwent a TLIF procedure at our institution between 06/2016-10/2019. Primary outcome measures included length of stay (LOS), discharge disposition, 30-day return to the emergency department (ED), 30-day readmission rate, and 30-day complication rates. One-hundred-fifty-six patients (female: male, 99: 57) met inclusion criteria. Demographic and clinical data (body mass index (BMI), comorbidities, preoperative lab values) were compared.

Results

The mean LOS was 6.2, 5.9, and 6 days in the White, Hispanic, and Black cohorts, respectively (p = 0.92). There were no differences in discharge disposition between groups (p = 0.52). Thirty-day post-operative complication rates did not differ between groups (p > 0.07). Readmission rates did not differ between groups (p > 0.05). ED visits were more prevalent in the Hispanic group with 16 visits as compared to 8 and 4 in the White and Black groups respectively (p = 0.01).

Conclusions

We found no racial disparities in terms of LOS, discharge disposition, or 30-day readmission rates. Hispanic patients demonstrated an increased utilization of the ED in the early post-operative period. Efforts to overcome language barriers, communicate instructions clearly, and outline post-operative expectations and plans may prevent the need for post-operative ED visits.

Racial Disparities in Tympanoplasty Surgery: A 30-Day Morbidity and Mortality National Cohort Study

OBJECTIVES

To assess the impact of race and ethnicity on 30-day complications after tympanoplasty surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for tympanoplasty procedures from 2005 to 2019. Demographic, comorbidity, and postoperative complication data were compared according to race using univariate and binary logistic regression analyses.

RESULTS

A total of 11,701 patients were included, consisting of 80.3% White, 3.0% Black, 7.7% Asian, 5.7% Hispanic, 2.5% American Indian/Alaska Native, and 0.8% other. Binary logistic regression model indicated that Black patients had increased odds of unplanned readmittance (p = 0.033; odds ratio [OR], 3.110) and deep surgical site infections (p = 0.008; OR, 6.292). American Indian/Alaska Native patients had increased odds of reoperation (p = 0.022; OR, 6.343), superficial surgical site infections (p < 0.001; OR, 5.503), urinary tract infections (p < 0.001; OR, 18.559), surgical complications (p < 0.001; OR, 3.820), medical complications (p = 0.001; OR, 10.126), and overall complications (p < 0.001; OR, 4.545).

CONCLUSION

Although Black and American Indian/Alaskan Native patients were more likely to have complications after tympanoplasty surgery after adjusting for comorbidities, age, and sex, these results are tempered by an overall low rate of complications. Future studies should be devoted to understanding the drivers of these health inequities in access to otologic care and surgical treatment to improve outcomes and achieve equitable care.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty

BACKGROUND

Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA.

METHODS

We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores.

RESULTS

Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS.

CONCLUSION

Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.

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.

Regional Implicit Bias Does Not Account for Racial Disparity in Total Joint Arthroplasty Utilization

BACKGROUND

Racial disparities surrounding the utilization of total hip and total knee arthroplasty (THA, TKA) are well documented. The Implicit Association Test (IAT) is a validated tool used to measure implicit and explicit bias. The purpose of this study is to evaluate if variations in IAT scores by geographical region in the United States (US) correspond with regional variations in THA and TKA utilization by blacks compared to whites.

METHODS

Data from the US Census and National Inpatient Sample from 2012 to 2014 were used to calculate THA and TKA utilization rates among Medicare-aged blacks and whites. Data were aggregated by US Census Bureau Division. Regional implicit bias was assessed by calculating a weighted average of IAT scores for each division.

RESULTS

Across all geographic regions and years, the surveyed population demonstrated an implicit bias favoring whites over blacks. The population adjusted ratio of white-to-black utilization of THA and TKA by geographic division varied between 0.86-1.85 and 0.87-2.01, respectively. The difference in utilization between geographic divisions reached statistical significance (P < .001). No correlation was found between the IAT scores and race-specific utilization ratios among geographic divisions.

CONCLUSION

Implicit bias as measured by regional IAT did not reflect THA and TKA utilization disparities. The racial disparity in utilization of THA and TKA significantly varied between divisions. The observed disparity was greater in divisions with a relatively higher proportion of blacks. To the authors' knowledge, this is the first study to evaluate the impact of implicit bias on utilization of THA and TKA.

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.

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.

Association Between Social Determinants of Health and Postoperative Outcomes in Patients Undergoing Single-Level Lumbar Fusions: A Matched Analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The aim of this study was to analyze association between social determinants of health (SDH) disparity on postoperative complication rates, and 30-day and 90-day all-cause readmission in patients undergoing single-level lumbar fusions.

SUMMARY OF BACKGROUND DATA

Decreasing postoperative complication rates is of great interest to surgeons and healthcare systems. Postoperative complications are associated with poor convalescence, inferior patient reported outcomes measures, and increased health care resource utilization. Better understanding of the association between Social Determinants of Health (SDH) on postoperative outcomes maybe helpful to decrease postoperative complication rates.

METHODS

MARINER 2020, an all-payer claims database, was utilized to identify patients undergoing single-level lumbar fusions between 2010 and 2018. The primary outcomes were the rates of any postoperative complication, symptomatic pseudarthrosis, need for revision surgery, or 30-day and 90-day all-cause readmission.

RESULTS

The exact matched population analyzed in this study contained 16,560 patients (8280 [50.0%] patients undergoing single-level lumbar fusion with an SDH disparity; 8280 [50.0%] patients undergoing single-level lumbar fusion without a disparity). Both patient groups were balanced at baseline. The rate of symptomatic pseudarthrosis (1.0% vs. 0.6%, P < 0.05) or any postoperative complication (16.3% vs. 10.4%, P < 0.05) in the matched analysis was higher in the disparity group. The presence of a disparity was associated with 70% increased odds of developing any complication (OR 1.7, 95% CI 1.53-1.84) or symptomatic pseudarthrosis (OR 1.7, 95% CI 1.17-2.37). Unadjusted and adjusted sensitivity analyses yielded similar results as the primary analysis.

CONCLUSION

Social Determinants of Health affect outcomes in spine surgery patients and are associated with an increased risk of developing postoperative complications following lumbar spine fusion.Level of Evidence: 3.

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.

Defining the relative contribution of health care environmental components to patient outcomes in the model of 30-day readmission after coronary artery bypass graft (CABG)

BACKGROUND

Patient outcomes following health care interventions may be dependent on a variety of factors: patient, surgeon, hospital, information technology, and temporal, cultural, and socioeconomic factors, among others. In this study, we characterize the relative contribution of each of these factors using a model of 30-day readmission following coronary artery bypass graft.

METHODS

The Healthcare Cost and Utilization Project, the American Hospital Association Annual Health Survey Databases, the Healthcare Information and Management Systems Society, and the Distressed Communities Index from 2010 to 2013 were linked for Florida, Iowa, Massachusetts, Maryland, New York, and Washington. Logistic regression, random forest, decision tree, gradient boosting, k-nearest-neighbors classification, and XGBoost tree models were implemented. Modeling results were compared on the basis of predictive accuracy, sensitivity, specificity, and area under the curve. Decision tree performed best and was selected for further analysis. A gradient-boosted model was used to quantify factor contribution.

RESULTS

The model had 45,352 patients, 54,096 admissions, and a 16.2% 30-day readmission rate after coronary artery bypass graft. The top 10 predictors were disposition at discharge, number of chronic conditions, total procedures, median household income, adults without high school diplomas, primary payer method, Agency for Healthcare Research and Quality comorbidity: renal failure, patient location (urban-rural), admission type, and age categories. The top 3 socioeconomic predictors were estimated state median household income, adults without high school diplomas, and patient location (urban versus rural designation). The relative contribution of patient/temporal, socioeconomic, hospital information technology, and hospital factors to readmission is 83.45%, 5.71%, 6.34%, and 4.31%, respectively.

CONCLUSION

In this model, the contribution of socioeconomic factors is substantive but lags significantly behind patient/temporal factors. With ever increasing availability of data, identification of contributors to patient outcomes within the overall health care macroenvironment will allow prioritization of interventions.