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Wu JY, Tang M, Touponse G, Theologitis M, Williamson T, Zygourakis CC. Socioeconomic disparities in lumbar fusion rates were exacerbated during the COVID-19 pandemic. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100321. [PMID: 38741936 PMCID: PMC11089397 DOI: 10.1016/j.xnsj.2024.100321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024]
Abstract
Background The COVID-19 pandemic disrupted healthcare access and utilization throughout the US, with variable impact on patients of different socioeconomic status (SES) and race. We characterize pre-pandemic and pandemic demographic and SES trends of lumbar fusion patients in the US. Methods Adults undergoing first-time lumbar fusion 1/1/2004-3/31/2021 were assessed in Clinformatics® Data Mart for patient age, geographical location, gender, race, education level, net worth, and Charlson Comorbidity Index (CCI). Multivariable regression models were used to evaluate the significance of trends over time, with a focus on pandemic trends 2020-2021 versus previous trends 2004-2019. Results The total 217,204 patients underwent lumbar fusions, 1/1/2004-3/31/2021. The numbers and per capita rates of lumbar fusions increased 2004-2019 and decreased in 2020 (first year of COVID-19 pandemic), with large variation in geographic distribution. There was overall a significant decrease in proportion of White patients undergoing lumbar fusion over time (OR=0.997, p<.001), though they were more likely to undergo surgery during the pandemic (OR=1.016, p<.001). From 2004-2021, patients were more likely to be educated beyond high school. Additionally, patients in the highest (>$500k) and lowest (<$25k) net worth categories had significantly more fusions over time (p<.001). During the pandemic (2020-2021), patients in higher net worth groups were more likely to undergo lumbar fusions ($150k-249k & $250k-499k: p<.001) whereas patients in the lowest net worth group had decreased rate of surgeries (p<.001). Lastly, patients' CCI increased significantly from 2004 to 2021 (coefficient=0.124, p<.001), and this trend held true during the pandemic (coefficient=0.179, p<.001). Conclusions To the best of our knowledge, our work represents the most comprehensive and recent characterization of SES variables in lumbar fusion rates. Unsurprisingly, lumbar fusions decreased overall with the onset of the COVID-19 pandemic. Importantly, disparities in fusion patients across patient race and wealth widened during the pandemic, reversing years of progress, a lesson we can learn for future public health emergencies.
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Affiliation(s)
- Janet Y. Wu
- School of Medicine, Stanford University Medical Center, 291 Campus Drive, Stanford, CA 94305, United States
| | - Megan Tang
- Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, United States
| | - Gavin Touponse
- School of Medicine, Stanford University Medical Center, 291 Campus Drive, Stanford, CA 94305, United States
| | - Marinos Theologitis
- School of Medicine, University of Crete, Voutes Campus, P.O. Box 2208, 71003 Heraklion, Crete, Greece
| | - Theresa Williamson
- Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Corinna C. Zygourakis
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road Palo Alto, CA 94304, United States
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Licciardone JC, Miller CL, Nazzal AJ, Hernandez CT, Nguyen LH, Aryal S. Racial Disparities in Opioid Use and Lumbar Spine Surgery for Chronic Pain and in Pain and Function Over 3 Years: A Retrospective Cohort Study. THE JOURNAL OF PAIN 2024; 25:659-671. [PMID: 37777036 DOI: 10.1016/j.jpain.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 10/02/2023]
Abstract
This study aims to compare treatments and outcomes among Black and White patients with chronic low back pain in the United States. A retrospective cohort study was conducted within a pain research registry, including 1,443 participants with up to 3 years of follow-up. Pain treatments were measured at quarterly research encounters using reported current opioid use and prior lumbar spine surgery. Pain intensity and functional disability were also measured quarterly with a numerical rating scale and the Roland-Morris Disability Questionnaire, respectively. Longitudinal data were analyzed with generalized estimating equations, including multivariable models to measure temporal trends and adjust for potential confounders. The mean baseline age of participants was 53.5 years (SD, 13.1 years); 1,074 (74.4%) were female, and 260 (18.0%) were Black. In longitudinal multivariable analyses, Black participants reported more frequent current opioid use (odds ratio, 1.40; 95% confidence interval [CI], 1.03-1.91; P = .03) and less frequent lumbar spine surgery (odds ratio, .45; 95% CI, .28-.72; P < .001). Black participants also reported greater pain intensity (mean, 6.6; 95% CI, 6.3-6.9 vs mean, 5.6; 95% CI, 5.4-5.8; P < .001) and functional disability (mean, 15.3; 95% CI, 14.6-16.0 vs mean, 13.8; 95% CI, 13.2-14.3; P = .002). Racial disparities were clinically important (risk ratio = 1.28 and risk ratio = .49, respectively, for opioid use and surgery; and d = .46 and d = .24, respectively, for pain and function). Racial disparities in pain and function also widened over time. Thus, barriers to guideline-adherent and specialized pain care among Black patients may affect pain and function outcomes. Greater efforts are needed to address the observed racial disparities. PERSPECTIVE: Widening racial disparities in pain and function over time indicate that new approaches to chronic pain management are needed in the United States. Considering race as a social framework represents an emerging strategy for planning and improving pain treatment services for Black patients.
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Affiliation(s)
- John C Licciardone
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Chase L Miller
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Alex J Nazzal
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Christian T Hernandez
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Linh H Nguyen
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Subhash Aryal
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
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Herrera MM, Tiao J, Rosenberg A, Zubizarreta N, Poeran J, Chaudhary SB. Does Medicare Insurance Mitigate Racial/Ethnic Disparities in Access to Lumbar Spinal Surgery When Compared to Commercial Insurance? Clin Spine Surg 2024:01933606-990000000-00263. [PMID: 38366343 DOI: 10.1097/bsd.0000000000001576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/29/2023] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
| | - Justin Tiao
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Departments of Population Health Science and Policy/Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Saad B Chaudhary
- Institute for Healthcare Delivery Science, Departments of Population Health Science and Policy/Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York
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4
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Agarwal AR, Nelson S, Johnson M, Ahmed AF, Wessel LE, Best MJ, Srikumaran U. Social determinants of health and race are independent predictors of reduced rotator cuff surgery rates in the Medicare population. J Shoulder Elbow Surg 2023; 32:2232-2238. [PMID: 37247778 DOI: 10.1016/j.jse.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Racial disparities have been shown to influence rates of surgery for patients with rotator cuff disease. Some individuals have attributed adverse social determinants of health (SDOHs) as potential confounders of this relationship between race and surgery rate. However, there is a paucity of literature observing whether adverse SDOHs and race independently influence rotator cuff surgery rates. Therefore, the purpose of this study was to determine whether adverse SDOHs and race are independent predictors of rotator cuff surgery rates for Medicare beneficiaries. METHODS A retrospective analysis was conducting using the Medicare Standard Analytic Files (SAF) data set of the PearlDiver database, observing 211,340 patients with rotator cuff pathology. Univariate and multivariable regression analyses were performed to observe whether race and adverse SDOHs were independent variables associated with rotator cuff surgery rates. To determine whether adverse SDOHs significantly influenced racial disparities, stratified analyses of patients with ≥1 adverse SDOH and those without adverse SDOHs were conducted to compare the odds ratios (ORs) and 95% confidence intervals (CIs) of racial disparities. RESULTS Among patients with rotator cuff disease, 21,679 (10.26%) were of nonwhite race and 21,835 (10.33%) had ≥1 adverse SDOH. The variables of nonwhite race (OR, 0.622; 95% CI, 0.599-0.668; P < .001) and having ≥1 adverse SDOH (OR, 0.715; 95% CI, 0.501-0.814; P < .001) were independent predictors of not undergoing surgery. On stratified analysis, there was no significant difference in racial disparities in patients with ≥1 adverse SDOH (OR, 0.620; 95% CI, 0.440-0.875) and those without adverse SDOHs (0.635; 95% CI, 0.601-0.671) based on overlapping 95% CIs. DISCUSSION This study demonstrated that among Medicare beneficiaries, adverse SDOHs and race are independent predictors of lower rotator cuff surgery rates, emphasizing the need to address disparities based on race alone.
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Affiliation(s)
- Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC, USA; Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA.
| | - Sarah Nelson
- Walter Reed Orthopaedics, Walter Reed Medical Center, Bethesda, MD, USA
| | - Maya Johnson
- Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Abdulaziz F Ahmed
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
| | - Lauren E Wessel
- Department of Orthopaedic Surgery, University of California Health, Los Angeles, CA, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
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Harianja G, Razzouk J, Lindsey W, Urbina B, Cabrera A, Thomas L, Bouterse A, Wycliffe N, Cheng W, Danisa O. Anatomic Assessment of L1-S1 Neuroforaminal Dimensions Using Computed Tomography. J Bone Joint Surg Am 2023; 105:1512-1518. [PMID: 37471568 DOI: 10.2106/jbjs.22.01394] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
BACKGROUND Although the radiographic parameters for diagnosing central lumbar canal stenosis are well described, parameters for the diagnosis of neuroforaminal stenosis (NFS) are less well defined. Previous studies have used magnetic resonance imaging (MRI) and radiography to describe neuroforaminal dimensions (NFDs). Those methods, however, have limitations that may substantially distort measurements. Existing literature on the use of computed tomography (CT) to investigate normal NFDs is limited. METHODS This anatomic assessment evaluated CT imaging of 300 female and 300 male subjects between 18 and 35 years of age to determine normal NFDs, specifically the sagittal anteroposterior width, axial anteroposterior width, craniocaudal height, and area. Statistical analyses were performed to assess differences in NFDs according to variables including sex, age, height, weight, body mass index, and ethnicity. RESULTS Overall, mean NFDs were 9.08 mm for sagittal anteroposterior width, 8.93 mm for axial anteroposterior width, 17.46 mm for craniocaudal height, and 134.78 mm 2 for area (n = 6,000 measurements each). Male subjects had larger NFDs than females at multiple levels. Both Caucasian and Asian subjects had larger NFDs than African-American subjects at multiple levels. There were no associations between foraminal dimensions and anthropometric factors. CONCLUSIONS This study describes CT-based L1-S1 NFDs in young, healthy patients who presented with reasons other than back pain or pathology affecting the neuroforamen. Dimensions were influenced by sex and ethnicity but were not influenced by anthropometric factors. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gideon Harianja
- Loma Linda University Medical Center, Loma Linda, California
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Zelenty WD, Paek S, Dodo Y, Sarin M, Shue J, Soffin E, Lebl DR, Cammisa FP, Girardi FP, Sokunbi G, Sama AA, Hughes AP. Utilization Trends of Intraoperative Neuromonitoring for Anterior Cervical Discectomy and Fusion in New York State. Spine (Phila Pa 1976) 2023; 48:492-500. [PMID: 36576864 DOI: 10.1097/brs.0000000000004569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/04/2022] [Indexed: 12/29/2022]
Abstract
STUDY DESIGN Retrospective cohort analysis. OBJECTIVE To elucidate trends in the utilization of intraoperative neuromonitoring (IONM) during anterior cervical discectomy and fusion (ACDF) procedures in NY state using the Statewide Planning and Research Cooperative System and to determine if utilization of IONM resulted in a reduction in postoperative neurological deficits. SUMMARY OF BACKGROUND DATA IONM has been available to spinal surgeons for several decades. It has become increasingly prevalent in all facets of spinal surgery including elective ACDF procedures. The utility of IONM for preventing a neurological deficit in elective spine procedures has recently been called into question. MATERIALS AND METHODS The Statewide Planning and Research Cooperative System database were accessed to perform a retrospective cohort study comparing monitored versus unmonitored ACDF procedures between 2007 and 2018 as defined by the International Classification of Disease-9 and 10 Procedural Coding System (ICD-9 PCS, ICD-10 PCS) codes. Patient demographics, medical history, surgical intervention, pertinent in-hospital events, and urban versus rural medical centers (as defined by the United States Office of Management and Budget) were recorded. Propensity-score-matched comparisons were used to identify factors related to the utilization of IONM and risk factors for neurological deficits after elective ACDF. RESULTS A total of 70,838 [15,092 monitored (21.3%) and 55,746 (78.7%) unmonitored] patients' data were extracted. The utilization of IONM since 2007 has increased in a linear manner from 0.9% of cases in 2007 to 36.7% by 2018. Overall, baseline characteristics of patients who were monitored during cases differed significantly from unmonitored patients in age, race/ethnicity, insurance type, presence of myelopathy or radiculopathy, and Charlson Comorbidity Index; however, only race/ethnicity was statistically significant when analyzed using propensity-score-matched. When comparing urban and rural medical centers, there is a significant lag in the adoption of the technology with no monitored cases in rural centers until 2012 with significant fluctuations in utilization compared with steadily increasing utilization among urban centers. From 2017 to 2018, reporting of neurological deficits after surgery resembled literature-established norms. Pooled analysis of these years revealed that the incidence of neurological complications occurred more frequently in monitored cases than in unmonitored (3.0% vs. 1.4%, P < 0.001). CONCLUSIONS The utility of IONM for elective ACDF remains uncertain; however, it continues to gain popularity for routine cases. For medical centers that lack similar resources to centers in more densely populated regions of NY state, reliable access to this technology is not a certainty. In our analysis of intraoperative neurological complications, it seems that IONM is not protective against neurological injury.
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Affiliation(s)
- William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Samuel Paek
- Geisinger Commonwealth School of Medicine, Scranton, PA
| | - Yusuke Dodo
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Michele Sarin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Ellen Soffin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
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Bayne CO. The Value of Diversity, Equity, and Inclusion: Race and Ethnicity Affecting Patients. Hand Clin 2023; 39:9-15. [PMID: 36402531 DOI: 10.1016/j.hcl.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patient race and ethnicity are important factors in health-care inequity, including care for the patient with hand and upper extremity pathologic condition. Physician diversity has been shown to promote better access, improve health-care quality, and improve satisfaction for underserved populations. Concordance, most often defined as a similarity or shared identity between physician and patient, has been shown to have a positive influence on health-care disparities. Although diversity among Hand surgeons is increasing, it is not matching the diversity of the population as a whole. It is imperative that we work to increase and maintain diversity in order to provide the best care for our patients.
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Affiliation(s)
- Christopher O Bayne
- Department of Orthopaedic Surgery, University of California, Davis, 4860 Y Street, Suite 3800, Sacramento, CA 95817, USA.
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Volaski HA, Sharfman ZT, Shah P, Eleswarapu A, Geller DS, Krystal J. Do racial disparities exist in a spine surgery practice that serves a predominately minority population? Outcomes of transforaminal lumbar interbody fusion: A retrospective review. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 12:100171. [PMID: 36185343 PMCID: PMC9520264 DOI: 10.1016/j.xnsj.2022.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/23/2022] [Accepted: 09/09/2022] [Indexed: 11/25/2022]
Abstract
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.
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Hwang A, Zhang L, Ramirez G, Maloney M, Voloshin I, Thirukumaran C. Black Race, Hispanic Ethnicity, and Medicaid Insurance Are Associated With Lower Rates of Rotator Cuff Repair in New York State. Arthroscopy 2022; 38:3001-3010.e2. [PMID: 35817374 DOI: 10.1016/j.arthro.2022.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the use of operative rotator cuff repair for rotator cuff pathology in New York State and analyze the racial, ethnic, and income-based disparities in receiving rotator cuff repair. METHODS A retrospective review of the Statewide Planning and Research Cooperative System Database of New York State was conducted to include patients with a new diagnosis of rotator cuff tear between July 1, 2017, and June 30, 2019, with at least 6 months of follow-up. Bivariate analysis using χ2 tests and multivariable logistic regression models were used to determine racial, ethnic, and income-based disparities in the use of surgical treatment with rotator cuff repair. RESULTS A total of 87,660 patients were included in the study. Of these, 36,422 patients (41.5%) underwent surgical treatment with rotator cuff repair. Multivariable analysis showed that Black race (adjusted odds ratio [aOR] 0.78; 95% confidence interval [CI] 0.69-0.87; P < .001), Hispanic/Latino ethnicity (aOR 0.91; 95% CI 0.85-0.97); P = .004), and Medicaid (aOR 0.75; 95% CI 0.70-0.80; P < .001), or other government insurance (aOR 0.82; 95% CI 0.78-0.86; P < .001) were independently associated with lower rates of rotator cuff repair. Male sex (aOR 1.18; 95% CI 1.14-1.22; P < .001), Asian race (aOR 1.27; 95% CI 1.00-1.62; P = .048), workers' compensation insurance (aOR 1.12; 95% CI 1.07-1.18; P < .001), and greater home ZIP code income quartile (aOR 1.19; 95% CI 1.09-1.30; P < .001) were independently associated with greater rates of operative management. Although race was an independent covariate affecting rate of rotator cuff repair, the effects of race were altered when accounting for the other covariates, suggesting that race alone does not account for the differences in rate of surgery for rotator cuff pathology. CONCLUSIONS In this analysis of all adult patients presenting with rotator cuff tears to New York hospital systems from 2017 to 2019, we identified significant racial, ethnic, and socioeconomic disparities in the likelihood of rotator cuff repair surgery for patients with rotator cuff tears. These include lower rates of rotator cuff repair for those Black, Hispanic, and low-income populations as represented by Medicaid insurance and low home ZIP code income quartile. CLINICAL RELEVANCE This study reports disparities in the use of rotator cuff repair for individuals with rotator cuff pathology.
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Affiliation(s)
- Alan Hwang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A..
| | - Linda Zhang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Gabriel Ramirez
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael Maloney
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Ilya Voloshin
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Caroline Thirukumaran
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
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Canseco JA, Karamian BA, Patel PD, Hilibrand AS, Rihn JA, Kurd MF, Anderson DG, Kepler CK, Vaccaro AR, Schroeder GD. The Impact of the Affordable Care Act on Outpatient Spine Trauma Consult Follow-up. Clin Spine Surg 2022; 35:E412-E418. [PMID: 34907936 DOI: 10.1097/bsd.0000000000001277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 09/20/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to assess the impact of the Affordable Care Act (ACA) on spine trauma patient follow-up. SUMMARY OF BACKGROUND DATA Although damage to the spinal column accounts for a small proportion of all traumatic injuries, it results in a significant burden on the patient, provider, and health care system. Postoperative follow-up is essential to direct rehabilitation, prevent early deterioration, and manage complications early in the postoperative period. Previous studies have established the role of insurance coverage on follow-up compliance, however, the impact of the ACA on follow-up has been scant. MATERIALS AND METHODS A retrospective cohort study was performed upon institutional review board approval of spine trauma patients consulted by orthopedic spine or neurosurgery from January 2013 to December 2013 (pre-ACA) and January 2015 to December 2015 (post-ACA). Patient demographics, surgical case characteristics, and follow-up compliance were assessed via manual chart review. Multivariate regression analysis was used to identify predictors of follow-up in the overall cohort, as well as within nonoperative and operative patients. RESULTS A total of 827 patients were included in the final analysis after inclusion and exclusion criteria. Overall, patient follow-up significantly increased after implementation of the ACA (P<0.001), with pre-ACA follow-up at 35.0% (144/411) and post-ACA follow-up at 50.0% (208/516). Multivariate regression analysis further corroborated these findings, showing post-ACA status associated with a 1.66-fold higher likelihood of follow-up. Among nonoperative patients, the ACA failed to make a significant difference in follow-up (P=0.56), however, patients treated operatively showed a significantly higher likelihood of follow-up (odds ratio=2.92, P<0.001). CONCLUSIONS Postoperative follow-up is an essential part of patient care, aiding in improving clinical outcomes and limiting the economic burden on the health care system. This study suggests that passage of the ACA significantly improved patient follow-up for operatively managed patients but not for nonoperatively managed patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jose A Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
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Resad Ferati S, Parisien RL, Joslin P, Knapp B, Li X, Curry EJ. Socioeconomic Status Impacts Access to Orthopaedic Specialty Care. JBJS Rev 2022; 10:01874474-202202000-00007. [PMID: 35171876 DOI: 10.2106/jbjs.rvw.21.00139] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
» Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care. » Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States. » Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes. » Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.
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Affiliation(s)
- Sehar Resad Ferati
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Robert L Parisien
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Patrick Joslin
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Brock Knapp
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Emily J Curry
- Boston University School of Public Health, Boston, Massachusetts
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12
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Cardinal T, Bonney PA, Strickland BA, Lechtholz-Zey E, Mendoza J, Pangal DJ, Liu J, Attenello F, Mack W, Giannotta S, Zada G. Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review. World Neurosurg 2021; 158:290-304.e1. [PMID: 34688939 DOI: 10.1016/j.wneu.2021.10.121] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - John Liu
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Frank Attenello
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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13
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Pérez-López JC, Olivella G, Cartagena M, Nieves-Ríos C, Acosta-Julbe J, Ramírez N, Massanet-Volrath J, Montañez-Huertas J, Escobar E. Associated factors of patients with spinal stenosis who undergo reoperation after a posterior lumbar spinal fusion in a Hispanic-American population. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1491-1499. [PMID: 34550474 DOI: 10.1007/s00590-021-03127-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- José C Pérez-López
- Orthopaedic Surgery Department, Medical Sciences Campus, UPR, PO Box 365067, San Juan, PR, 00936-5067, USA
| | - Gerardo Olivella
- Orthopaedic Surgery Department, Medical Sciences Campus, UPR, PO Box 365067, San Juan, PR, 00936-5067, USA.
| | - Miguel Cartagena
- Surgery Department, School of Medicine, Ponce Health Sciences University, Ponce, PR, 00716, USA
| | - Christian Nieves-Ríos
- Surgery Department, School of Medicine, Ponce Health Sciences University, Ponce, PR, 00716, USA
| | - José Acosta-Julbe
- School of Medicine, Medical Sciences Campus, UPR, San Juan, PR, 00936-5067, USA
| | - Norman Ramírez
- Pediatric Orthopaedic Surgery Department, Mayagüez Medical Center, Mayagüez, PR, 00681, USA
| | - José Massanet-Volrath
- Orthopaedic Surgery Department, Medical Sciences Campus, UPR, PO Box 365067, San Juan, PR, 00936-5067, USA
| | - José Montañez-Huertas
- Orthopaedic Surgery Department, Medical Sciences Campus, UPR, PO Box 365067, San Juan, PR, 00936-5067, USA
| | - Enrique Escobar
- Orthopaedic Surgery Department, Medical Sciences Campus, UPR, PO Box 365067, San Juan, PR, 00936-5067, USA
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14
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Current Concept Review: Inclusion and Analysis of Diverse Study Populations in Orthopaedic Research. J Am Acad Orthop Surg 2021; 29:e479-e487. [PMID: 33443389 DOI: 10.5435/jaaos-d-20-01087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023] Open
Abstract
As disparities in healthcare access and outcomes have been increasingly identified across medical specialties, the importance of recognizing and understanding the diversity of our patient populations and the influence of individual characteristics such as age, sex, gender, race, and ethnicity on clinical outcomes has been emphasized. Orthopaedic literature has advanced dramatically in the quality and quantity of research generated over the past 25 years, yet a consistent, sustained focus on studying musculoskeletal health in the context of these unique patient-specific variables has not been maintained. The result of this inattention may be the provision of orthopaedic care that is ill-suited for the individual patient whose biologic characteristics, life experiences, and cultural constructs differ from that of the typical research subject. The recent proliferation of meta-analyses-whose intention is to optimize statistical power-likely compounds the problem because improper, inconsistent, or absent categorization of patients in research articles precludes meaningful subgroup analysis. This article describes the current variability in demographic reporting in the orthopaedic literature, highlights the importance of complete, consistent demographic reporting and subgroup analysis, and reviews specific examples of orthopaedic conditions that illustrate how clinical outcomes may be affected by patient-specific variables such as age, sex, gender, race, and ethnicity.
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15
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Reyes AM, Katz JN, Schoenfeld AJ, Kang JD, Losina E, Chang Y. National utilization and inpatient safety measures of lumbar spinal fusion methods by race/ethnicity. Spine J 2021; 21:785-794. [PMID: 33227551 PMCID: PMC8113062 DOI: 10.1016/j.spinee.2020.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/07/2020] [Accepted: 11/09/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Degenerative lumbar conditions are prevalent, disabling, and frequently managed with decompression and fusion. Black patients have lower spinal fusion rates than White patients. PURPOSE Determine whether specific lumbar fusion procedure utilization differs by race/ethnicity and whether length of stay (LOS) or inpatient complications differ by race/ethnicity after accounting for procedure performed. STUDY DESIGN Large database retrospective cohort study PATIENT SAMPLE: Lumbar fusion recipients at least age 50 in the 2016 National Inpatient Sample with diagnoses of degenerative lumbar conditions. OUTCOME MEASURES Type of fusion procedure used and inpatient safety measures including LOS, prolonged LOS, inpatient medical and surgical complications, mortality, and cost. METHODS We examined the association between race/ethnicity and the safety measures above. Covariates included several patient and hospital factors. We used multiple linear or logistic regression to determine the association between race and fusion type (PLF, P/TLIF, ALIF, PLF + P/TLIF, and PLF + ALIF [anterior-posterior fusion]) and to determine whether race was associated independently with inpatient safety measures, after adjustment for patient and hospital factors. RESULTS Fusion method use did not differ among racial/ethnic groups, except for somewhat lower anterior-posterior fusion utilization in Black patients compared to White patients (crude odds ratio [OR]: 0.81 [0.67-0.97]). Inpatient safety measures differed by race/ethnicity for rates of prolonged LOS (Blacks 18.1%, Hispanics 14.5%, and Whites 11.7%), medical complications (Blacks 9.9%, Hispanics 8.7%, and Whites 7.7%), and surgical complications (Blacks 5.2%, Hispanics 6.9%, and Whites 5.4%). Differences persisted after adjustment for procedure type as well as patient and hospital factors. Blacks and Hispanics had higher risk for prolonged LOS compared to Whites (adjusted OR Blacks 1.39 [95% confidence interval {CI} 1.22-1.59]; Hispanics 1.24 [95% CI 1.02-1.52]). Blacks had higher risk for inpatient medical complications compared to Whites (adjusted OR 1.24 [95% CI 1.05-1.48]), and Hispanics had higher risk for inpatient surgical complications compared to Whites (adjusted OR 1.34 [95% CI 1.06-1.68]). CONCLUSIONS Fusion method use was generally similar between racial/ethnic groups. Inpatient safety measures, adjusted for procedure type, patient and hospital factors, were worse for Blacks and Hispanics.
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Affiliation(s)
- Angel M Reyes
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 02115 USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA.
| | - Jeffrey N Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 02115 USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA; Division of Rheumatology, Section of Clinical Sciences, Immunology and Allergy, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 02115 USA; Departments of Epidemiology and Environmental Health, Harvard T.H. Chan School of Public Health, 677 Huntingon Ave, Boston, MA 02115 USA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 USA
| | - James D Kang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 USA
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 02115 USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA; Division of Rheumatology, Section of Clinical Sciences, Immunology and Allergy, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 02115 USA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 USA; Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave 3rd floor, Boston, MA 02118 USA
| | - Yuchiao Chang
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA; Division of General Medicine, Massachusetts General Hospital, 50 Staniford St, 9th floor, Boston, MA 02114 USA
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16
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Harris A, Guadix SW, Riley LH, Jain A, Kebaish KM, Skolasky RL. Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014. Spine J 2021; 21:64-70. [PMID: 32768655 DOI: 10.1016/j.spinee.2020.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/19/2020] [Accepted: 07/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients. PURPOSE To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA. STUDY DESIGN Retrospective analysis. PATIENT SAMPLE Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014. OUTCOME MEASURES Racial disparities in discharge rates before versus after ACA passage. METHODS Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders. RESULTS All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001). CONCLUSION Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.
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Affiliation(s)
- Andrew Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Sergio W Guadix
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Lee H Riley
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA; Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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17
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Adjacent Segment Reoperation and Other Perioperative Outcomes in Patients Who Underwent Anterior Lumbar Interbody Fusions at One and Two Levels. World Neurosurg 2020; 139:e480-e488. [DOI: 10.1016/j.wneu.2020.04.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 11/19/2022]
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18
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Unfolding the outcomes of surgical treatment of lumbar spinal stenosis—a prospective 5- and 10-year follow-up study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2231-2242. [DOI: 10.1007/s00586-020-06424-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/25/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
Abstract
Purpose
In this prospective study, we aim to determine surgical outcomes in patients with lumbar spinal stenosis (LSS) 10 years after surgery.
Methods
The study population consisted of 96 LSS patients who underwent decompressive surgery, 72 of whom participated in the 10-year follow-up. The patients completed a questionnaire preoperatively and 3 months, 5 years, and 10 years postoperatively. Outcome measures were satisfaction with the surgical outcomes, the Oswestry Disability Index (ODI), the visual analog scale (VAS), the numeric rating scale (NRS-11), and walking ability quantified in meters. Postoperative improvements at 5 and 10 years were analyzed using linear mixed models. Furthermore, comparisons between postoperative time points were made for clinical courses of pain, disability, and walking ability.
Results
At the 10-year follow-up, 68% of the patients were satisfied with the surgical outcomes. All the measured outcomes showed statistically significant improvement from baseline to the 5- and 10-year follow-up. The mean VAS score was 9.8 mm higher at the 5-year follow-up and 7.8 mm at the 10-year follow-up compared to the 3-month follow-up point. Similarly, the mean ODI was 4.8% higher at the 10-year follow-up compared to the 3-month follow-up point.
Conclusion
This study reports the clinical course of pain, disability, and walking distance after LSS surgery with the 10-year follow-up. Based on our study results, patients with LSS could expect to have positive effects of their back surgery up to 10 years. However, minor worsening in pain and disability may occur and one-fourth of the patients may need a reoperation during the 10-year follow-up period.
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De Silva T, Vedula SS, Perdomo-Pantoja A, Vijayan R, Doerr SA, Uneri A, Han R, Ketcha MD, Skolasky RL, Witham T, Theodore N, Siewerdsen JH. SpineCloud: image analytics for predictive modeling of spine surgery outcomes. J Med Imaging (Bellingham) 2020; 7:031502. [PMID: 32090136 DOI: 10.1117/1.jmi.7.3.031502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/20/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose: Data-intensive modeling could provide insight on the broad variability in outcomes in spine surgery. Previous studies were limited to analysis of demographic and clinical characteristics. We report an analytic framework called "SpineCloud" that incorporates quantitative features extracted from perioperative images to predict spine surgery outcome. Approach: A retrospective study was conducted in which patient demographics, imaging, and outcome data were collected. Image features were automatically computed from perioperative CT. Postoperative 3- and 12-month functional and pain outcomes were analyzed in terms of improvement relative to the preoperative state. A boosted decision tree classifier was trained to predict outcome using demographic and image features as predictor variables. Predictions were computed based on SpineCloud and conventional demographic models, and features associated with poor outcome were identified from weighting terms evident in the boosted tree. Results: Neither approach was predictive of 3- or 12-month outcomes based on preoperative data alone in the current, preliminary study. However, SpineCloud predictions incorporating image features obtained during and immediately following surgery (i.e., intraoperative and immediate postoperative images) exhibited significant improvement in area under the receiver operating characteristic (AUC): AUC = 0.72 ( CI 95 = 0.59 to 0.83) at 3 months and AUC = 0.69 ( CI 95 = 0.55 to 0.82) at 12 months. Conclusions: Predictive modeling of lumbar spine surgery outcomes was improved by incorporation of image-based features compared to analysis based on conventional demographic data. The SpineCloud framework could improve understanding of factors underlying outcome variability and warrants further investigation and validation in a larger patient cohort.
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Affiliation(s)
- Tharindu De Silva
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - S Swaroop Vedula
- Johns Hopkins University, Malone Center for Engineering in Healthcare, Baltimore, Maryland, United States
| | - Alexander Perdomo-Pantoja
- Johns Hopkins University, School of Medicine, Department of Neurosurgery, Baltimore, Maryland, United States
| | - Rohan Vijayan
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Sophia A Doerr
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Ali Uneri
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Runze Han
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Michael D Ketcha
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Richard L Skolasky
- Johns Hopkins University, School of Medicine, Department of Orthopedic Surgery, Baltimore, Maryland, United States
| | - Timothy Witham
- Johns Hopkins University, School of Medicine, Department of Neurosurgery, Baltimore, Maryland, United States
| | - Nicholas Theodore
- Johns Hopkins University, School of Medicine, Department of Neurosurgery, Baltimore, Maryland, United States
| | - Jeffrey H Siewerdsen
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States.,Johns Hopkins University, Malone Center for Engineering in Healthcare, Baltimore, Maryland, United States.,Johns Hopkins University, School of Medicine, Department of Neurosurgery, Baltimore, Maryland, United States
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20
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de Jager E, Levine AA, Udyavar NR, Burstin HR, Bhulani N, Hoyt DB, Ko CY, Weissman JS, Britt LD, Haider AH, Maggard-Gibbons MA. Disparities in Surgical Access: A Systematic Literature Review, Conceptual Model, and Evidence Map. J Am Coll Surg 2020; 228:276-298. [PMID: 30803548 DOI: 10.1016/j.jamcollsurg.2018.12.028] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Adele A Levine
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - N Rhea Udyavar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Nizar Bhulani
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - Melinda A Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.
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21
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Do Medicare Accountable Care Organizations Reduce Disparities After Spinal Fracture? J Surg Res 2019; 246:123-130. [PMID: 31569034 DOI: 10.1016/j.jss.2019.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/19/2019] [Accepted: 09/05/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.
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22
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Sanford Z, Taylor H, Fiorentino A, Broda A, Zaidi A, Turcotte J, Patton C. Racial Disparities in Surgical Outcomes After Spine Surgery: An ACS-NSQIP Analysis. Global Spine J 2019; 9:583-590. [PMID: 31448190 PMCID: PMC6693061 DOI: 10.1177/2192568218811633] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Zachary Sanford
- Center for Spine Surgery, Anne Arundel Medical Center, Annapolis, MD,
USA,Zachary Sanford, Department of Orthopedic and Sports
Medicine, Anne Arundel Medical Center, 2000 Medical Parkway Suite 100, Annapolis, MD
21401, USA.
| | - Haley Taylor
- Center for Spine Surgery, Anne Arundel Medical Center, Annapolis, MD,
USA,Department of Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Alyson Fiorentino
- Center for Spine Surgery, Anne Arundel Medical Center, Annapolis, MD,
USA
| | - Andrew Broda
- Center for Spine Surgery, Anne Arundel Medical Center, Annapolis, MD,
USA
| | - Amina Zaidi
- Center for Spine Surgery, Anne Arundel Medical Center, Annapolis, MD,
USA
| | - Justin Turcotte
- Department of Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Chad Patton
- Center for Spine Surgery, Anne Arundel Medical Center, Annapolis, MD,
USA,Orthopedic and Sports Medicine Specialists, Anne Arundel Medical Center,
Annapolis, MD, USA
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Abstract
Healthcare delivery is profoundly affected by race/ethnicity, sex, and socioeconomic status. The effect of these factors on patient health and the quality of care received is being studied in more detail. Orthopaedic surgery over the past several years has paid increasing attention to these disparities as well. Not only do these disparities exist with regard to accessing care but also with regard to the quality of care received and postoperative outcomes. Total joint arthroplasty, hip fractures, and spine surgery represent areas where the effect of these factors has been reported. Not only is it essential for the clinician to understand the extent of care disparities but also the manner in which these disparities affect patient health and outcomes within the orthopaedic surgery setting. Strategies should be devised to minimize the effect of these factors on clinical care and patient health.
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Pediatric spondylolysis/spinal stenosis and disc herniation: national trends in decompression and discectomy surgery evaluated through the Kids' Inpatient Database. Childs Nerv Syst 2017. [PMID: 28643037 DOI: 10.1007/s00381-017-3471-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study is to describe national trends in spinal decompression without fusion and discectomy procedures in the US pediatric inpatient population. METHODS The Kids' Inpatient Database (KID) was queried for pediatric patients with primary diagnoses of spinal spondylolysis/stenosis or disc herniation and having undergone spinal decompression without fusion or discectomy over more than a decade (2000 to 2012). The primary (indirect) outcomes of interest were in-hospital complication rates, length of stay (LOS), total costs, and discharge dispositions. RESULTS A total of 7315 patients, comprised of pediatric spinal spondylolysis/stenosis (n = 287, 3.92%) and pediatric disc herniation (n = 7028, 96.1%) patients, were included in the study. During the years 2000 to 2012, diagnoses of pediatric spondylolysis/spinal stenosis increased from 61 to 90 diagnoses per 3-year period, while diagnoses of pediatric disc herniation decreased from 2133 to 1335 diagnoses per 3-year period. Spinal decompression was associated with higher in-hospital complication rates (18.1 vs 5.3%, p < 0.0001), longer hospital stays (5 vs 1.69 days, p < 0.0001), higher mean total charges ($49,186 vs $19,057, p < 0.0001), and higher non-routine discharge rates (12.3 vs 2.5%, p < 0.0001) versus discectomy. CONCLUSIONS Spinal decompression is associated with longer hospital stays, more complications, higher costs, and more non-routine discharges when compared to discectomy. The data supports the disparate nature of these disease processes and elucidates basic clinical trends in uncommon spinal disorders affecting children.
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Outcomes Following Surgical Management of Cauda Equina Syndrome: Does Race Matter? J Racial Ethn Health Disparities 2017; 5:287-292. [DOI: 10.1007/s40615-017-0369-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 03/29/2017] [Accepted: 04/03/2017] [Indexed: 01/21/2023]
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Elsamadicy AA, Adogwa O, Sergesketter A, Hobbs C, Behrens S, Mehta AI, Vasquez RA, Cheng J, Bagley CA, Karikari IO. Impact of Race on 30-Day Complication Rates After Elective Complex Spinal Fusion (≥5 Levels): A Single Institutional Study of 446 Patients. World Neurosurg 2017; 99:418-423. [DOI: 10.1016/j.wneu.2016.12.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
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Abstract
STUDY DESIGN A retrospective cohort analysis of prospectively collected clinical data. OBJECTIVE The aim of this study was to assess the effect of race on outcomes in patients undergoing elective laminectomy and/or fusion spine surgery. SUMMARY OF BACKGROUND DATA Studies that have looked at the effect of race on spine surgery outcomes have failed to take into account baseline risk factors that may influence peri-operative outcomes. METHODS We identified 48,493 adult patients who underwent elective spine surgery consisting of elective laminectomy and/or fusion, from 2006 to 2012, at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a prospectively collected, national clinical database with established reproducibility and validity. Pre- and intraoperative characteristics and 30-day outcomes were stratified by race. We used propensity scores to match African-American and Caucasian patients on all pre- and intraoperative factors, including by principal diagnosis leading to surgery as well as surgery performed. We used regular and conditional logistic regression to predict the effect of race on adverse postoperative outcomes in the full sample and matched sample. RESULTS Caucasians comprised 82% of our sample. We found no differences in the incidence of pre- and intraoperative factors when comparing Caucasian patients with all minority patients, and only minimal increased odds for prolonged length of length of hospitalization (LOS) and discharge with continued care. However, African-American patients, who comprised 39% of our minority sample, had more preoperative comorbidities than Caucasian patients. Even after eliminating all differences between pre- and intraoperative factors between Caucasian and African-American patients, African-American patients continued to have LOS that was, on average, one day longer than Caucasian patients. African-American patients also had higher odds for major complications [odds ratio (OR) = 1.3; 95% confidence interval (95% CI) 1.1-1.6], and to be discharged requiring continued care (OR = 2.3; 95% CI 1.8-2.8). CONCLUSION African-American race is independently associated with prolonged LOS, major complications, and a need to be discharged with continued care in patients undergoing elective spine surgery. LEVEL OF EVIDENCE 3.
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Abstract
The prevalence of lumbar spinal stenosis is approximately 9.3%, with people most commonly affected in the sixth or seventh decade of life. Patients often have pain, cramping, and weakness in their legs that is worsened with standing and walking. Although the Spine Patient Outcomes Research Trial clearly demonstrated that surgery improves health-related quality of life, treatment for lumbar spinal stenosis varies widely from the type of decompression performed to the need for fusion. This variability can be attributed largely to the lack of an accepted classification system. A good classification system serves as a common language to define the severity of a condition, guide treatment, and facilitate clinical research.
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Abstract
STUDY DESIGN Retrospective, large administrative database. OBJECTIVE To investigate cost variation within current spinal fusion diagnosis-related groups (DRGs). SUMMARY OF BACKGROUND DATA Medicare reimbursement to hospitals for spinal fusion surgery is provided as a fixed payment for each admission based on DRG. This assumes that patients can be grouped into homogenous units of resource use such that a single payment will cover the costs of hospitalization for most patients within a given DRG. However, major differences in costs exist for different methods of spinal fusion surgery. A previous study in total joint arthroplasty (TJA) showed that variation within DRGs can lead to differences between hospital costs and Medicare reimbursement, resulting in predictable financial losses to hospitals and hindering access to care for some patients. No study to our knowledge has investigated cost variation within current spinal fusion DRGs. METHODS Direct hospital costs were obtained from the 2011 Nationwide Inpatient Sample (NIS) for patients in spinal fusion DRGs 453-460 and TJA DRGs 466-470. Our primary outcome was the coefficient of variation (CV), defined as the ratio of the standard deviation (SD) to the mean (CV = SD/mean × 100), for all costs within a given DRG. CVs were compared to an established TJA benchmark for within-DRG cost variation. RESULTS CVs for costs within spinal fusion DRGs ranged from 44.16 to 52.6 and were significantly higher than the CV of 38.2 found in the TJA benchmark group (P < 0.0001). CONCLUSION As in TJA, the cost variation observed within spinal fusion DRGs in this study may be leading to differences between costs and reimbursement that places undue financial burden on some hospitals and potentially compromises access to care for some patients. Future studies should seek to identify drivers of cost variation to determine whether changes can be made to further homogenize current payment groups and ensure equal access for all patients. LEVEL OF EVIDENCE 3.
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Witiw CD, Mansouri A, Mathieu F, Nassiri F, Badhiwala JH, Fessler RG. Exploring the expectation-actuality discrepancy: a systematic review of the impact of preoperative expectations on satisfaction and patient reported outcomes in spinal surgery. Neurosurg Rev 2016; 41:19-30. [DOI: 10.1007/s10143-016-0720-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/19/2016] [Accepted: 03/23/2016] [Indexed: 11/25/2022]
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Markman JD, Gewandter JS, Frazer ME, Pittman C, Cai X, Patel KV, Jahromi BS, Dworkin RH, Burke LB, Farrar JT. Evaluation of outcome measures for neurogenic claudication: A patient-centered approach. Neurology 2015; 85:1250-6. [PMID: 26354988 PMCID: PMC4607594 DOI: 10.1212/wnl.0000000000002000] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 06/11/2015] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To determine whether patients with neurogenic claudication associated with lumbar spinal stenosis would prefer a treatment that makes it possible for them to walk farther or walk with less pain; to examine associations between this treatment preference and patient-reported and in-clinic treadmill testing measures of walking ability and walking-associated pain. METHODS In this cross-sectional study, 269 patients with neurogenic claudication were asked to report their pain intensity when walking, complete the Swiss Spinal Stenosis Questionnaire, rank their outcome preferences for treatment, and undergo standardized treadmill testing, including measures of final pain rating and time to first pain of moderate intensity (Tfirst). Descriptive statistics were used to characterize patient preferences for treatment outcome. Associations between self-report questionnaires and standardized treadmill testing outcomes were evaluated using Spearman correlations. RESULTS Seventy-nine percent of patients expressed a preference for treatment that allowed them to walk with less pain. Preference for reduced pain was associated with higher pain during daily walking, along with a shorter Tfirst and higher final pain severity on treadmill testing. In contrast, patient preference for treatment outcome was not associated with self-reported measures of daily walking capacity or walking distance on the treadmill. CONCLUSIONS A majority of patients with neurogenic claudication prioritized walking with reduced pain over walking farther. Reduction in pain while walking may therefore constitute a sufficient patient-focused treatment outcome for the majority of these patients. These results have implications for clinical trial design and assessment of treatment efficacy in neurogenic claudication.
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Affiliation(s)
- John D Markman
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia.
| | - Jennifer S Gewandter
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Maria E Frazer
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Christine Pittman
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Xueya Cai
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Kushang V Patel
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Babak S Jahromi
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Robert H Dworkin
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Laurie B Burke
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - John T Farrar
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
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Patel VV, Nunley PD, Whang PG, Haley TR, Bradley WD, Davis RP, Block JE, Geisler FH. Superion(®) InterSpinous Spacer for treatment of moderate degenerative lumbar spinal stenosis: durable three-year results of a randomized controlled trial. J Pain Res 2015; 8:657-62. [PMID: 26491369 PMCID: PMC4599047 DOI: 10.2147/jpr.s92633] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE This report provides the 3-year clinical outcomes from the randomized, controlled US Food and Drug Administration Investigational Device Exemption trial of the Superion(®) for the treatment of moderate degenerative lumbar spinal stenosis. PATIENTS AND METHODS The Superion(®) was evaluated in the treatment of subjects aged 45 years or older suffering from symptoms of intermittent neurogenic claudication, secondary to a confirmed diagnosis of moderate degenerative lumbar spinal stenosis at one or two contiguous levels from L1 to L5. Patients were treated between June 2008 and December 2011 at 31 investigational sites. Three hundred ninety-one subjects were included in the randomized study group consisting of 190 Superion(®) and 201 X-STOP(®) control subjects. The primary composite endpoint was individual patient success based on four components: improvement in two of three domains of the Zurich Claudication Questionnaire, no reoperations at the index level, no major implant/procedure-related complications, and no clinically significant confounding treatments. RESULTS At 3 years, the proportion of subjects achieving the primary composite endpoint was greater for Superion(®) (63/120, 52.5%) than for X-STOP(®) (49/129, 38.0%) (P=0.023) and the corresponding success rates exceeded 80% for each of the individual components of the primary endpoint in the Superion(®) group (range: 81%-91%). Improvements in back and leg pain severity as well as back- and disease-specific functional outcomes were also maintained through 36 months. CONCLUSION The 3-year outcomes from this randomized controlled trial demonstrate durable clinical improvement consistently across all clinical outcomes for the Superion(®) in the treatment of patients with moderate degenerative lumbar spinal stenosis.
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Affiliation(s)
- Vikas V Patel
- The Spine Center, University of Colorado Hospital, Denver, CO, USA
| | | | - Peter G Whang
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas R Haley
- Performance Spine and Sports Physicians, PC, Pottstown, PA, USA
| | | | - Raphael P Davis
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, NY, USA
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Skolasky RL, Maggard AM, Li D, Riley LH, Wegener ST. Health behavior change counseling in surgery for degenerative lumbar spinal stenosis. Part I: improvement in rehabilitation engagement and functional outcomes. Arch Phys Med Rehabil 2015; 96:1200-7. [PMID: 25827657 DOI: 10.1016/j.apmr.2015.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 03/10/2015] [Accepted: 03/11/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine whether a brief motivational interviewing [MI]-based health behavior change counseling (HBCC) intervention increased patient participation in physical therapy and/or home exercise programs (HEPs), reduced disability, and improved health status after surgery for degenerative lumbar spinal stenosis. DESIGN Prospective clinical trial. SETTING Academic medical center. PARTICIPANTS From December 2009 through August 2012, consecutive patients (N=122) underwent surgery for degenerative lumbar spinal stenosis and, based on enrollment date, were prospectively assigned to a control (n=59) or HBCC intervention (n=63) group in a prospective, lagged-control clinical trial. INTERVENTIONS Brief MI-based HBCC versus attention control. MAIN OUTCOME MEASURES Rehabilitation participation (primary); disability and health status (secondary). Therapists assessed engagement in, and patients reported attendance at, postoperative rehabilitation (physical therapy and/or HEP). At 3 and 6 months, disability and health status were assessed (Oswestry Disability Index [ODI] and Medical Outcomes Study 12-Item Short-Form Health Survey, version 2 [SF-12v2]) (significance, P<.05). RESULTS Compared with controls, HBCC patients had significantly higher rehabilitation engagement (21.20±4.56 vs 23.57±2.71, respectively; P<.001), higher physical therapy (.67±.21 vs .82±.16, respectively; P<.001) and HEP (.65±.23 vs .75±.22, respectively; P=.019) attendance, and better functional outcomes at 3 months (difference: ODI, -10.7±4.4, P=.015; SF-12v2, 6.2±2.2, P=.004) and 6 months (difference: ODI, -12.7±4.8, P=.008; SF-12v2, 8.9±2.4, P<.001). The proportion of the HBCC intervention impact on functional recovery mediated by rehabilitation participation was approximately half at 3 months and one-third at 6 months. CONCLUSIONS HBCC can improve outcomes after spine surgery through improved rehabilitation participation.
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Affiliation(s)
- Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Anica M Maggard
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Li
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lee H Riley
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD
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The Spine Surgical Care and Outcomes Assessment Program (Spine SCOAP): a surgeon-led approach to quality and safety. Spine (Phila Pa 1976) 2015; 40:332-41. [PMID: 25901980 DOI: 10.1097/brs.0000000000000750] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective registry of spine surgery. OBJECTIVE To identify variation in utilization, processes of care, and outcomes in spine surgery to improve statewide quality and safety. SUMMARY OF BACKGROUND DATA Variability in the utilization and outcomes of elective spine surgery across different regions in the United States and internationally has become a growing focus of critical evaluation. In 2011, surgeons in Washington State created the Spine Surgical Care and Outcomes Assessment Program to address variability in use, process, and outcome of spine surgery. METHODS Prospective cohort study from consecutive spine fusion cases and 30% sampling of other spine procedures from up to 20 hospitals (2011-2013). Logistic regression models were developed using data from 10 quarters to determine factors associated with combined adverse events inclusive of index hospital death, reintervention, and adverse events not requiring intervention, and then applied to patients in the last 2 quarters. RESULTS A total of 10,166 (58.9 ± 13.4 yr, 52.2% females) underwent surgery including 3767 (37%) lumbar and 6399 (63%) cervical procedures. Of the total, 75.3% of the cohort had a spine fusion and among those, neurological symptoms were described in 92.5% of patients, with baseline limb pain numeric rating scale (NRS) scores of 5.9 among those classified as having neurological symptoms. The NRS mean score for back pain was 5.9 with a mean Oswestry Disability Index/Neck Disability Index of 44. There was significant intersite variation in rates of cigarette smoking among patients undergoing fusion surgery (range, 0%-40%) and rates of combined adverse events with 10 hospitals having a significantly lower observed/expected ratio and 3 having a significantly greater observed to expected ratio. CONCLUSION Spine Surgical Care and Outcomes Assessment Program identified significant variability in the indications, process of care, and outcomes related to spine surgery. This variability indicates the need for continued surveillance initiatives and point to opportunities for quality improvement and research. LEVEL OF EVIDENCE 2.
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Manchikanti L, Kaye AD, Manchikanti K, Boswell M, Pampati V, Hirsch J. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med 2015; 5:e23139. [PMID: 25789241 PMCID: PMC4350165 DOI: 10.5812/aapm.23139] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/12/2014] [Indexed: 12/13/2022] Open
Abstract
Context: Lumbar central spinal stenosis is common and often results in chronic persistent pain and disability, which can lead to multiple interventions. After the failure of conservative treatment, either surgical or nonsurgical modalities such as epidural injections are contemplated in the management of lumbar spinal stenosis. Evidence Acquisition: Recent randomized trials, systematic reviews and guidelines have reached varying conclusions about the efficacy of epidural injections in the management of central lumbar spinal stenosis. The aim of this systematic review was to determine the efficacy of all three anatomical epidural injection approaches (caudal, interlaminar, and transforaminal) in the treatment of lumbar central spinal stenosis. A systematic review was performed on randomized trials published from 1966 to July 2014 of all types of epidural injections used in the management of lumbar central spinal stenosis. Methodological quality assessment and grading of the evidence was performed. Results: The evidence in managing lumbar spinal stenosis is Level II for long-term improvement for caudal and lumbar interlaminar epidural injections. For transforaminal epidural injections, the evidence is Level III for short-term improvement only. The interlaminar approach appears to be superior to the caudal approach and the caudal approach appears to be superior to the transforaminal one. Conclusions: The available evidence suggests that epidural injections with local anesthetic alone or with local anesthetic with steroids offer short- and long-term relief of low back and lower extremity pain for patients with lumbar central spinal stenosis. However, the evidence is Level II for the long-term efficacy of caudal and interlaminar epidural injections, whereas it is Level III for short-term improvement only with transforaminal epidural injections.
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Affiliation(s)
- Laxmaiah Manchikanti
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, USA
- Pain Management Center of Paducah, Paducah, USA
- Corresponding author: Laxmaiah Manchikanti, Pain Management Center of Paducah, Paducah, USA. Tel: +1-2705548373, Fax: +1-2705548987, E-mail:
| | - Alan David Kaye
- Department of Anesthesia, LSU Health Science Center, New Orleans, USA
| | - Kavita Manchikanti
- University of Kentucky Medical School, University of Kentucky, Lexington, USA
| | - Mark Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, USA
| | - Vidyasagar Pampati
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, USA
| | - Joshua Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Skolasky RL, Thorpe RJ, Wegener ST, Riley LH. Complications and mortality in cervical spine surgery: racial differences. Spine (Phila Pa 1976) 2014; 39:1506-12. [PMID: 24859586 DOI: 10.1097/brs.0000000000000429] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective national database analysis. OBJECTIVE Our goal was to estimate racial and ethnic differences in in-hospital complication and mortality rates associated with cervical spine surgery. SUMMARY OF BACKGROUND DATA The impact of observed racial and ethnic disparities in orthopedic spine care use on morbidity and mortality is not well understood. METHODS On the basis of the Nationwide Inpatient Sample, there were 983,420 adult nontrauma hospital discharges from 2000 through 2009. In-hospital complications and mortality were the outcome variables. The primary independent variable was race/ethnicity (defined as non-Hispanic white [white], non-Hispanic black [black], and Hispanic). Covariates were age, sex, household income, insurance status, geographical location, hospital volume, and comorbidities. Multivariable regression models were used to determine the association between race/ethnicity and in-hospital complication and mortality. Significance was set at a P value less than 0.05. RESULTS The overall rates of an in-hospital complication or mortality were 4.09% and 0.42%, respectively. There were no differences in the rates of in-hospital complications or mortality between Hispanics and Caucasians. Compared with Caucasians, African Americans had higher odds of experiencing an in-hospital complication (odds ratio, 1.37; 95% confidence interval, 1.27-1.48) and higher odds of dying during hospitalization (odds ratio, 1.59; 95% confidence interval, 1.30-1.96). CONCLUSION Although there were no differences between Caucasians and Hispanics, African Americans had significantly higher rates of in-hospital complications and mortality associated with cervical spine surgery than did Caucasians. These differences persisted after adjusting for known risk factors for complications and mortality. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Richard L Skolasky
- *Orthopaedic Surgery †Health Behavior and Society and Hopkins Center for Health Disparities Solutions, and ‡Physical Medicine and Rehabilitation, The Johns Hopkins University, Baltimore, MD
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Leopold SS, Fu MC. Editor's spotlight/take 5: longitudinal urban-rural discrepancies in the US orthopaedic surgeon workforce. Interview by Seth S. Leopold. Clin Orthop Relat Res 2013; 471:3071-3. [PMID: 23928709 PMCID: PMC3773109 DOI: 10.1007/s11999-013-3217-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 07/29/2013] [Indexed: 01/31/2023]
Affiliation(s)
- Seth S. Leopold
- Clinical Orthopaedics and Related Research, 1600 Spruce Street, Philadelphia, PA 19013 USA
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