Are There Racial or Socioeconomic Disparities in Ambulatory Outcome or Survival After Oncologic Spine Surgery for Metastatic Cancer? Results From a Medically Underserved Center

Area Socioeconomic Status is Associated with Refusal of Recommended Surgery in Patients with Metastatic Bone and Joint Disease

BACKGROUND

This study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease.

METHODS

Patients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates.

RESULTS

A total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30-1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14-1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001).

CONCLUSIONS

nSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed.

Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty

INTRODUCTION

Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't.

MATERIALS AND METHODS

A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05.

RESULTS

48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04).

CONCLUSION

Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.

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

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

In-hospital mortality trends after surgery for traumatic thoracolumbar injury: A national inpatient sample database study

Introduction

Given the increasing incidence of traumatic thoracolumbar injuries in recent years, studies have sought to investigate potential risk factors for outcomes in these patients.

Research question

The aim of this study was to investigate trends and risk factors for in-hospital mortality after fusion for traumatic thoracolumbar injury.

Materials and methods

Patients undergoing thoracolumbar fusion after traumatic injury were queried from the National Inpatient Sample (NIS) from 2012 to 2017. Analysis was performed to identify risk factors for inpatient mortality after surgery.

Results

Patients in 2017 were on average older (51.0 vs. 48.5, P = 0.004), had more admitting diagnoses (15.5 vs. 10.7, p < 0.001), were less likely to be White (75.8% vs. 81.2%, p = 0.006), were from a ZIP code with a higher median income quartile (Quartile 1: 31.4% vs. 28.6%, p = 0.011), and were more likely to have Medicare as a primary payer (22.9% vs. 30.1%, p < 0.001). Bivariate analysis of demographics and surgical characteristics demonstrated that patients in the in-hospital mortality group (n = 90) were older (70.2 vs. 49.6, p < 0.001), more likely to be male (74.4% vs. 62.8%, p = 0.031), had a great number of admitted diagnoses (21.3 vs. 12.7, p < 0.001), and were more likely to be insured by Medicare (70.0% vs. 27.0%, p < 0.001). Multivariate regression analysis found age (OR 1.06, p < 0.001) and Black race (OR 3.71, p = 0.007) were independently associated with in-hospital mortality.

Conclusion

Our study of nationwide, traumatic thoracolumbar fusion procedures from 2012 to 2017 in the NIS database found older, black patients were at increased risk for in-hospital mortality after surgery.

Effect of race, sex, and socioeconomic factors on overall survival following the resection of intramedullary spinal cord tumors

INTRODUCTION

Intramedullary spinal cord tumors (IMSCTs) account for 2-4% of all primary CNS tumors. Given their low prevalence and the intricacy of their diagnosis and management, it is critical to address the surrounding racial and socioeconomic factors that impact the care of patients with IMSCTs. This study aimed to investigate the association between race and socioeconomic factors with overall 5 year mortality following the resection of IMSCTs.

METHODS

The study used the National Cancer Database to retrospectively analyze patients who underwent resection of IMSCTs from 2004 to 2017. Patients were divided into four cohorts by race/ethnicity, facility type, insurance, median income quartiles, and living area. The primary outcome of interest was 5 year survival, and secondary outcomes included postoperative length of stay and 30 day readmission. Descriptive and multivariable analyses were used to identify independent factors associated with mortality, with statistical significance assessed at a 2-sided p < 0.05.

RESULTS

We evaluated the patient characteristics and outcomes for 8,028 patients who underwent surgical treatment for IMSCTs between 2004 and 2017. Most patients were white males (52.4%) with a mean age of 44 years where 7.17% of patients were Black, 7.6% were Hispanic, and 3% were Asian. Most were treated in an academic/research program (72.4%) and had private insurance (69.2%). Black patients had a higher odd of 5 year mortality (OR 1.4; 95% CI 1.1 to 1.77; p = 0.04) compared to white patients, while no significant differences in mortality were observed among other races. Factors associated with lower odds of mortality included being female (OR 0.89; 95% CI 0.78 to 1.02; p < 0.01), receiving treatment in an academic/research program (OR 0.51; 95% CI 0.33 to 0.79; p = 0.04), having private insurance (OR 0.65; 95% CI 0.45 to 0.93; p = 0.02), and having higher income quartiles (OR 0.77; 95% CI 0.62 to 0.96; p = 0.02).

CONCLUSION

Our study sheds light on the healthcare disparities that exist in the surgical management of IMSCTs. Our findings indicate that race, sex, socioeconomic status, and treatment facility are independent predictors of 5 year mortality, with Black patients, males, those with lower socioeconomic status, and those treated at non-academic centers experiencing significantly higher mortality rates. These alarming disparities underscore the urgent need for policymakers and researchers to address the underlying factors contributing to these discrepancies and provide equal access to high-quality surgical care for patients with IMSCTs.