The Impact of Social Determinants of Health on 30 and 90-Day Readmission Rates After Spine Surgery

Social Vulnerability Index Provides Greater Granularity Compared With the Area Deprivation Index When Assessing Outcomes Following Elective Lumbar Fusion

STUDY DESIGN

Retrospective review of a single institution cohort.

OBJECTIVE

To determine whether area deprivation index (ADI) or social vulnerability index (SVI) is more suitable for evaluating minimum clinically important difference (MCID) achievement following elective lumbar fusion as captured by the Patient-Reported Outcomes Measurement Information System (PROMIS).

SUMMARY OF BACKGROUND DATA

A total of 182 patients who underwent elective one-level to two-level posterior lumbar fusion between January 2015 and September 2021.

MATERIALS AND METHODS

ADI and SVI values were calculated from patient-supplied addresses. Patients were grouped into quartiles based on values; higher quartiles represented greater disadvantage. MCID thresholds for Pain Interference (PI) and Physical Function (PF) were determined through a distribution-based method. Multivariable logistic regression was performed to identify factors impacting MCID attainment. Univariate logistic regression was performed to determine which themes comprising SVI values affected MCID achievement. Statistical significance was set at P <0.05.

RESULTS

Multivariable logistic regression demonstrated that ADI and SVI quartile assignment significantly impacted achievement of MCID for PI ( P =0.04 and 0.01, respectively) and PF ( P =0.03 and 0.02, respectively). Specifically, assignment to the third ADI and SVI quartiles were significant for PI (OR: 0.39 and 0.23, respectively), and PF (OR: 0.24 and 0.22, respectively). Race was not a significant predictor of MCID for either PI or PF. Univariate logistic regression demonstrated that among SVI themes, the socioeconomic status theme significantly affected achievement of MCID for PI ( P =0.01), while the housing type and transportation theme significantly affected achievement of MCID for PF ( P =0.01).

CONCLUSION

ADI and SVI quartile assignment were predictors of MCID achievement. While ADI and SVI may both identify patients at risk for adverse outcomes following lumbar fusion, SVI offers greater granularity in terms of isolating themes of disadvantage impacting MCID achievement.

A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient

BACKGROUND

Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care.

METHODS

A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant.

RESULTS

High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI.

CONCLUSIONS

Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost.

LEVEL OF EVIDENCE

III.

Social Determinants of Health Disparities Increase 5-Year Revision Rates but Not Postoperative Complications After Primary Hip Arthroscopy

PURPOSE

To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and 5-year secondary surgery rates after primary hip arthroscopy using a large national database.

METHODS

A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Queries were performed to identify patients who experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH disparities within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. The odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of 5-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis.

RESULTS

A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who did not experience SDOH disparities (age of 41.0 years and 79.6% female sex in both cohorts). The odds of adverse events after arthroscopy were low and did not differ between the SDOH cohort (1.51%) and no-SDOH cohort (1.57%, P = .09). Additionally, there was no difference in the odds of 30-day ED visits between the SDOH cohort (5.65%) and no-SDOH cohort (4.79%, P = .10). The rate of 5-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs 4.1%, P = .02); however, there was no difference in the rate of any secondary surgery between cohorts (11.8% vs 10.4%, P = .10).

CONCLUSIONS

Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of 5-year revision hip arthroscopy compared with a matched-control cohort of patients not experiencing SDOH disparities.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Social determinants of health and disparities in spine surgery: a 10-year analysis of 8,565 cases using ensemble machine learning and multilayer perceptron

BACKGROUND CONTEXT

The influence of SDOH on spine surgery is poorly understood. Historically, researchers commonly focused on the isolated influences of race, insurance status, or income on healthcare outcomes. However, analysis of SDOH is becoming increasingly more nuanced as viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDOH on healthcare delivery.

PURPOSE

The aim of this study was to evaluate the effects of patient social history on length of stay (LOS) and readmission within 90 days following spine surgery using ensemble machine learning and multilayer perceptron.

STUDY DESIGN

Retrospective chart review.

PATIENT SAMPLE

8,565 elective and emergency spine surgery cases performed from 2013 to 2023 using our institution's database of longitudinally collected electronic medical record information.

OUTCOMES MEASURES

Patient LOS, discharge disposition, and rate of 90-day readmission.

METHODS

Ensemble machine learning and multilayer perceptron were employed to predict LOS and readmission within 90 days following spine surgery. All other subsequent statistical analysis was performed using SPSS version 28. To further assess correlations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Independent sample t-tests, paired sample t-tests, one-way analysis of variance (ANOVA) with post-hoc Bonferroni and Tukey corrections, and Pearson's chi-squared test were applied where appropriate for analysis of continuous and categorical variables.

RESULTS

Black patients demonstrated a greater LOS compared to white patients, but race and ethnicity were not significantly associated with 90-day readmission rates. Insured patients had a shorter LOS and lower readmission rates compared to non-insured patients, as did privately insured patients compared to publicly insured patients. Patients discharged home had lower LOS and lower readmission rates, compared to patients discharged to other facilities. Marriage decreased both LOS and readmission rates, underweight patients showcased increased LOS and readmission rates, and religion was shown to impact LOS and readmission rates. When utilizing patient social history, lab values, and medical history, machine learning determined the top 5 most-important variables for prediction of LOS -along with their respective feature importances-to be insurance status (0.166), religion (0.100), ICU status (0.093), antibiotic use (0.061), and case status: elective or urgent (0.055). The top 5 most-important variables for prediction of 90-day readmission-along with their respective feature importances-were insurance status (0.177), religion (0.123), discharge location (0.096), emergency case status (0.064), and history of diabetes (0.041).

CONCLUSIONS

This study highlights that SDOH is influential in determining patient length of stay, discharge disposition, and likelihood of readmission following spine surgery. Machine learning was utilized to accurately predict LOS and 90-day readmission with patient medical history, lab values, and social history, as well as social history alone.

Preoperative Oswestry Disability Index Should not be Utilized to Determine Surgical Eligibility for Patients Requiring Lumbar Fusion for Degenerative Lumbar Spine Disease

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion.

SUMMARY OF BACKGROUND DATA

As payers invest in alternative payment models, some are suggesting threshold cutoffs of patient-reported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery.

MATERIALS/METHODS

We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated.

RESULTS

A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N=90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI>70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI>20: 1.96; ODI>30: 2.40; ODI>40: 2.75; ODI>50: 3.03; ODI>60: 3.54; ODI>70: 3.75).

CONCLUSION

Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI>20 demonstrating the lowest predictive value for MCID achievement.

LEVEL OF EVIDENCE

3.

The Effect of Social Deprivation on Hospital Utilization Following Distal Radius Fracture Treatment

Purpose

Social determinants of health disparities have been shown to adversely impact outcomes following distal radius fracture (DRF) treatment. Identifying risk factors for increased hospital use following DRF has been historically difficult; however, it is of utmost concern to orthopedic surgeons to improve outcomes and decrease the total cost of care. The effect of social deprivation following DRF has yet to be fully investigated.

Methods

This is a retrospective cohort analysis of a single institution's experience in treating DRF with either an operative or nonsurgical modality between 2005 and 2020. Patient demographic information and health care utilization (hospital readmission, emergency department [ED] visitation, office visits, and telephone use) were collected from within 90 days of treatment. Area Deprivation Index (ADI) national percentiles were recorded. Patients were stratified into terciles based on their relative level of deprivation, and their outcomes were compared. Secondary analyses included stratifying patients based on treatment modality, race, and legal sex.

Results

In total, 2,149 patients were included. The least, intermediate, and most deprived groups consisted of 552, 1,067, and 530 patients, respectively. Risk factors for hospital readmission included higher levels of relative deprivation. Identifying as Black or African American and nonsurgical management were risk factors for increased ED visitation. No differences in rate of hospital readmission, ED visitation, office visitation, or telephone use were seen based on deprivation level.

Conclusions

High levels of social deprivation, treatment modality, race, and legal sex disparities may influence the amount of hospital resource utilization following DRF treatment. Understanding and identifying risk factors for greater resource utilization can help to mitigate inappropriate use and decrease health care costs. We hope to use these findings to guide clinical decision making, educate patient populations, and optimize outcomes following DRF treatment.

Type of Study/Level of Evidence

Therapeutic III.

The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury

INTRODUCTION

Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI.

METHODS

All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed.

RESULTS

We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005).

CONCLUSION

Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.

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

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

Food Insecurity, Neighborhood Disadvantage, and Hospital Readmission in Health System Adults: A Population Health Study

PURPOSE

The purpose of the study was to examine the relationship between food insecurity, neighborhood disadvantage, and hospital readmission within 90 days of discharge for health system patients.

DESIGN

The study used a retrospective, correlational design with a single cohort.

METHODS

Records of adult patients with a health system primary care provider and discharged from hospital to home were included. Data were obtained from health system billing database, medical record, and publicly available population databases. A time-to-readmission analysis was conducted with a Kaplan-Meier plot, log-rank test, and Cox regression analysis.

RESULTS

The final sample included 41 566 records; the rate of food insecurity was 1.45%, and 90-day readmission rate was 16.7%. The mean area deprivation index score was 54.4 (SD, 26.0). After adjusting for patient demographics, comorbidity, and length of stay, food insecurity resulted in 1.94 times higher risk of readmission (hazard ratio, 1.94; 95% confidence interval, 1.69-2.23; P < .001). Neighborhood disadvantage and lower food access were not significant in final models.

CONCLUSIONS

Food insecurity should be identified and addressed as part of transitional care to improve patient outcomes. Future research should focus on models of care that ensure connection to community resources to resolve food insecurity and evaluate the impact on patient outcomes.

Social Determinants of Health Disparities Increase the Rate of Complications After Total Knee Arthroplasty

BACKGROUND

Few studies have investigated whether social determinants of health disparities (SDHD), which include economic, social, education, health care, and environmental factors, identified through International Classification of Diseases (ICD) codes are associated with increased odds for poor health outcomes. We aimed to investigate the association between SDHD, identified through this novel methodology, as well as postoperative complications following total knee arthroplasty (TKA).

METHODS

Using a national insurance claims database, a retrospective cohort analysis was performed. Patients were selected using Current Procedural Terminology and ICD codes for primary TKA between 2010 and 2019. Patients were stratified into 2 groups using ICD codes, those who had SDHD and those who did not, and propensity matched 1:1 for age, sex, a comorbidity score, and other comorbidities. After matching, 207,844 patients were included, with 103,922 patients in each cohort. Odds ratios (ORs) for 90-day medical and 2-year surgical complications were obtained using multivariable logistical regressions.

RESULTS

In patients who have SDHD, multivariable analysis demonstrated higher odds of readmission (OR): 1.12; P = .013) and major and minor medical complications (OR: 2.09; P < .001) within 90-days as well as higher odds of revision surgery (OR: 1.77; P < .001) and periprosthetic joint infection (OR: 1.30; P < .001) within 2-years.

CONCLUSION

The SDHD are an independent risk factor for revision surgery and periprosthetic joint infection after TKA. In addition, SDHD is also an independent risk factor for all-cause hospital readmissions and both minor and major complications.

LEVEL OF EVIDENCE

III.

Why Treat Patients with a Major Orthopaedic Surgery Only to Send Them Back to the Vulnerable Conditions That Made Them Sick in the First Place? A Conceptual Scenario to Improve Patient's Journey

Individuals with severe cartilage degeneration of the hip or knee or collapsed vertebrae that cause spine deformities can suffer from joint and neuropathic pain in the back, disuse of the affected limb, and restriction of movements. Surgical intervention is the most widespread and successful solution to date. There is a general belief that eating healthy and staying physically and mentally active might have a preventive role against musculoskeletal disease occurrence, while instead, we are more certain of the benefits deriving from a healthy diet and exercise therapy after major orthopaedic procedures. These aspects are in fact vital components in enhanced recovery after surgery programmes. However, they are applied in hospital settings, are often centre-dependent, and lack primary and tertiary preventive efficacy since end once the patient is discharged. There is the lack of initiatives at the territorial level that ensure a continuum in the patient's journey towards orthopaedic surgery, home transition, and a healthy and long-lasting life. The expert panel advocates the integration of an intermediate lifestyle clinic that promotes healthy eating, physical activity, and sleep hygiene. In this facility directed by professionals in enhancing recovery after surgery, patients can be referred after the surgical indication and before home discharge. Surgery is in fact a moment when individuals are more curious to do their best to heal and stay healthy, representing a timepoint and opportunity for educating patients on how lifestyle changes may optimise not only their surgical recovery but also long-term future health state.

The role of socioeconomic factors as barriers to patient reported outcome measure completion following lumbar spine fusion

BACKGROUND CONTEXT

Although incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population.

PURPOSE

To identify patient barriers to PROM completion one year following lumbar spine fusion.

STUDY DESIGN/SETTING

Retrospective single-institution cohort study.

PATIENT SAMPLE

A total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 OUTCOME MEASURES: Completion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively.

METHODS

A retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients' zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders.

RESULTS

A total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers' compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion.

CONCLUSIONS

Social determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research.

Impact of social determinants of health on perioperative opioid utilization in patients with lumbar degeneration

Background

Social determinants of health (SDOH), have been demonstrated to significantly impact health outcomes in spine patients. There may be interaction between opioid use and these factors in spine surgical patients. We aimed to evaluate the social determinants of health (SDOH) which are associated with perioperative opioid use among lumbar spine patients.

Methods

This retrospective cohort study included patients undergoing spine surgery for lumbar degeneration in 2019. Opioid use was determined based on prescription records from the electronic medical records. Preoperative opioid users (OU) were compared with opioid-naïve patients regarding SDOH including demographics like age and race, and clinical data such as activity and tobacco use. Demographics and surgical data, including age, comorbidities, surgical invasiveness, and other variables were also collected from the records. Multivariate logistic regression was used for analysis of these factors.

Results

Ninety-eight patients were opioid-naïve and 90 used opioids preoperatively. All OU had ≥3 months of use, had more prior spine surgeries (1.07 vs. 0.44, p<.001) and more comorbidities including diabetes, hypertension, and depression (p=.021, 0.043, 0.017). Patients from lower community median income areas, unemployed, or with lower physical capacity (METS<5) were more likely to use opioids preoperatively. Postoperative opioid use was strongly associated with preoperative opioid use, as well as alcohol use, and lower community median income. At one year postoperatively, OU had higher rates of opioid use [72.2% vs. 15.3%, p<.001].

Conclusions

Unemployment, low physical activity level, and lower community median income were associated with preoperative opioid use and longer-term opioid use postoperatively.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

Systematic review.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Equity-Driven Implementation of Patient-Reported Outcome Measures in Musculoskeletal Care: Advancing Value for All

ABSTRACT

The clinical use of patient-reported outcome measures (PROMs) in musculoskeletal care is expanding, encompassing both individual patient management and population-level applications. However, without thoughtful implementation, we risk introducing or exacerbating disparities in care processes or outcomes. We outline examples of opportunities, challenges, and priorities throughout PROM implementation to equitably advance value-based care at both the patient and population level. Balancing standardization with tailored strategies can enable the large-scale implementation of PROMs while optimizing care processes and outcomes for all patients.

Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection

OBJECTIVES

Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity.

METHODS

This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity.

RESULTS

Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively.

CONCLUSIONS

This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.

Patients From Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

The aim was to compare patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF) when categorizing patients based on socioeconomic status. Secondarily, we sought to compare PROMs based on race.

SUMMARY OF BACKGROUND DATA

Social determinants of health are believed to affect outcomes following spine surgery, but there is limited literature on how combined socioeconomic status metrics affect PROMs following ACDF.

MATERIALS AND METHODS

The authors identified patients who underwent primary elective one-level to four-level ACDF from 2014 to 2020. Patients were grouped based on their distressed community index (DCI) quintile (Distressed, At-Risk, Mid-tier, Comfortable, and Prosperous) and then race (White or Black). Multivariate regression for ∆PROMs was performed based on DCI group and race while controlling for baseline demographics and surgical characteristics.

RESULTS

Of 1204 patients included in the study, all DCI groups improved across all PROMs, except mental health component score (MCS-12) for the Mid-tier group ( P =0.091). Patients in the Distressed/At-Risk group had worse baseline MCS-12, visual analog scale (VAS) Neck, and neck disability index (NDI). There were no differences in magnitude of improvement between DCI groups. Black patients had significantly worse baseline VAS Neck ( P =0.002) and Arm ( P =0.012) as well as worse postoperative MCS-12 ( P =0.016), PCS-12 ( P =0.03), VAS Neck ( P <0.001), VAS Arm ( P =0.004), and NDI ( P <0.001). Multivariable regression analysis did not identify any of the DCI groupings to be significant independent predictors of ∆PROMs, but being White was an independent predictor of greater improvement in ∆PCS-12 (β=3.09, P =0.036) and ∆NDI (β=-7.32, P =0.003).

CONCLUSIONS

All patients experienced clinical improvements regardless of DCI or race despite patients in Distressed communities and Black patients having worse preoperative PROMs. Being from a distressed community was not an independent predictor of worse improvement in any PROMs, but Black patients had worse improvement in NDI compared with White patients.

LEVEL OF EVIDENCE

3.

Disparity in hospital admissions and length of stay based on income status for emergency department hypertensive crisis visits

OBJECTIVE

Racial, gender, and socioeconomic status have been shown to impact the delivery of care. How this impacts the management of hypertensive crisis remains unclear. We aim to identify disparities on admission frequency and length of stay (LOS) among those presenting with hypertensive crisis, as a function of household income.

METHODS

This is a cross-sectional analysis of 2016 emergency department visits and supplemental inpatient data from the Nationwide Emergency Department Sample. Median household income quartiles were established. A multivariable logistic regression model was used to estimate odds of admission in each income quartile. A multivariable linear regression model was used to predict LOS.

RESULTS

After applying sample weighting, the total number of emergency department visits was 33 727 with 6906, 25 443, and 1378 visits for hypertensive emergency, hypertensive urgency, and unspecified crisis, respectively. There were 13 191, 8889, 6400, 5247 visits in the (first) lowest, second, third , and fourth (highest) income quartiles, respectively. The median age for the study population was 60. The most common comorbidity was chronic kidney disease. Individuals with the highest income, had a lower likelihood of admission, compared with the lowest quartile (adjusted odds ratio: 0.41, 95% CI 0.22-0.74). There was a significant association between income quartile and LOS among hypertensive emergency patients (beta coefficient: 0.407, P value = 0.019).

CONCLUSION

In this study, patients with lower income were more likely to be admitted, whereas those with higher income exhibited a longer LOS. Clinicians must be made aware these disparities to ensure equitable delivery of care.