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Shin D, Razzouk J, Thomas J, Nguyen K, Cabrera A, Bohen D, Lipa SA, Bono CM, Shaffrey CI, Cheng W, Danisa O. Social Determinants of Health and Disparities in Spine Surgery: A Ten-Year Analysis of 8,565 Cases using Ensemble Machine Learning and Multilayer Perceptron. Spine J 2024:S1529-9430(24)00890-8. [PMID: 39033881 DOI: 10.1016/j.spinee.2024.07.003] [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: 01/17/2024] [Revised: 06/28/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
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 2013-2023 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.
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Affiliation(s)
- David Shin
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jacob Razzouk
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jonathan Thomas
- Department of Ophthalmology, Loma Linda University, Loma Linda, CA, USA
| | - Kai Nguyen
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Andrew Cabrera
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Daniel Bohen
- Information Sciences Institute, University of Southern California, Los Angeles, CA
| | - Shaina A Lipa
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis Memorial Veterans Hospital, Loma Linda, CA, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA.
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Pennings JS, Oleisky ER, Master H, Davidson C, Coronado RA, Brintz CE, Archer KR. Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis. Spine (Phila Pa 1976) 2024; 49:873-883. [PMID: 38270397 PMCID: PMC11196202 DOI: 10.1097/brs.0000000000004935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/10/2024] [Indexed: 01/26/2024]
Abstract
STUDY DESIGN Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database. OBJECTIVE To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery. SUMMARY OF BACKGROUND DATA Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear. MATERIALS AND METHODS PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively. RESULTS On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW. CONCLUSIONS Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.
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Affiliation(s)
- Jacquelyn S. Pennings
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Emily R. Oleisky
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
| | - Hiral Master
- Vanderbilt Institute of Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Claudia Davidson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
| | - Rogelio A. Coronado
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Carrie E. Brintz
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN
| | - Kristin R. Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN
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Adjei J, Tang M, Lipa S, Oyekan A, Woods B, Mesfin A, Hogan MV. Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States. J Bone Joint Surg Am 2024; 106:631-638. [PMID: 38386767 DOI: 10.2106/jbjs.22.01155] [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] [Indexed: 02/24/2024]
Abstract
➤ 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.
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Affiliation(s)
- Joshua Adjei
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Tang
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shaina Lipa
- Department of Orthopedic Surgery, Brigham and Woman's Hospital, Boston, Massachusetts
| | - Anthony Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barrett Woods
- Department of Orthopedic Surgery, Rothman Orthopedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, Medstar Orthopaedic Institute, Georgetown University School of Medicine, Washington, DC
| | - MaCalus V Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Borja AJ, Karsalia R, Chauhan D, Gallagher RS, Malhotra EG, Punchak MA, Na J, McClintock SD, Marcotte PJ, Yoon JW, Ali ZS, Malhotra NR. Association Between Race and Short-Term Outcomes Across 3988 Consecutive Single-Level Spinal Fusions. Neurosurgery 2024:00006123-990000000-01046. [PMID: 38334372 DOI: 10.1227/neu.0000000000002860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 12/09/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Race has implications for access to medical care. However, the impact of race, after access to care has been attained, remains poorly understood. The objective of this study was to isolate the relationship between race and short-term outcomes across patients undergoing a single, common neurosurgical procedure. METHODS In this retrospective cohort study, 3988 consecutive patients undergoing single-level, posterior-only open lumbar fusion at a single, multihospital, academic medical center were enrolled over a 6-year period. Among them, 3406 patients self-identified as White, and 582 patients self-identified as Black. Outcome disparities between all White patients vs all Black patients were estimated using logistic regression. Subsequently, coarsened exact matching controlled for outcome-mitigating factors; White and Black patients were exact-matched 1:1 on key demographic and health characteristics (matched n = 1018). Primary outcomes included 30-day and 90-day hospital readmissions, emergency department (ED) visits, reoperations, mortality, discharge disposition, and intraoperative complication. RESULTS Before matching, Black patients experienced increased rate of nonhome discharge, readmissions, ED visits, and reoperations (all P < .001). After exact matching, Black patients were less likely to be discharged to home (odds ratio [OR] 2.68, P < .001) and had higher risk of 30-day and 90-day readmissions (OR 2.24, P < .001; OR 1.91, P < .001; respectively) and ED visits (OR 1.79, P = .017; OR 2.09, P < .001). Black patients did not experience greater risk of intraoperative complication (unintentional durotomy). CONCLUSION Between otherwise homogenous spinal fusion cohorts, Black patients experienced unfavorable short-term outcomes. These disparities were not explained by differences in intraoperative complications. Further investigation must characterize and mitigate institutional and societal factors that contribute to outcome disparities.
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Affiliation(s)
- Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ritesh Karsalia
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daksh Chauhan
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan S Gallagher
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emelia G Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria A Punchak
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jianbo Na
- McKenna EpiLog Fellowship in Population Health at the Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott D McClintock
- Department of Mathematics, The West Chester Statistical Institute, West Chester University, West Chester, Pennsylvania, USA
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jang W Yoon
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zarina S Ali
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- McKenna EpiLog Fellowship in Population Health at the Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Filler R, Nayak R, Razzouk J, Ramos O, Cannon D, Brandt Z, Thakkar SC, Parel P, Chiu A, Cheng W, Danisa O. The Reoperation, Readmission, and Complication Rates at 30 Days Following Lumbar Decompression for Cauda Equina Syndrome. Cureus 2023; 15:e49059. [PMID: 38116344 PMCID: PMC10730150 DOI: 10.7759/cureus.49059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023] Open
Abstract
Background and objective Cauda equina syndrome (CES) is considered a surgical emergency, and its primary treatment involves decompression of the nerve roots, typically in the form of discectomy or laminectomy. The primary aim of this study was to determine the complication, reoperation, and readmission rates within 30 days of surgical treatment of CES secondary to disc herniation by using the PearlDiver database (PearlDiver Technologies, Colorado Springs, CO). The secondary aim was to assess preoperative risk factors for a higher likelihood of complication occurrence within 30 days of surgery for CES. Methods A total of 524 patients who had undergone lumbar discectomy or laminectomy for CES were identified. The outcome measures were 30-day reoperation rate for revision decompression or lumbar fusion, and 30-day readmissions related to surgery. The patient data collected included medical history and surgical data including the number of levels of discectomy and laminectomy. Results Based on our findings, intraoperative dural tears, valvular heart disease, and fluid and electrolyte abnormalities were significant risk factors for readmission to the hospital within 30 days following surgery for CES. The most common postoperative complications were as follows: visits to the emergency department (63 patients, 12%), surgical site infection (21 patients, 4%), urinary tract infection (14 patients, 3%), and postoperative anemia (11 patients, 2%). Conclusions In the 30-day period following lumbar decompression for cauda equina syndrome, our findings demonstrated an 8% reoperation rate and 17% readmission rate. Although CES is considered an indication for urgent surgery, gaining awareness about reoperation, readmission, and complication rates in the immediate postoperative period may help calibrate expectations and inform medical decision-making.
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Affiliation(s)
- Ryan Filler
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Rusheel Nayak
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Jacob Razzouk
- Department of Orthopaedic Surgery, School of Medicine, Loma Linda University, Loma Linda, USA
| | - Omar Ramos
- Spine Surgery, Twin Cities Spine Center, Minneapolis, USA
| | - Damien Cannon
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Zachary Brandt
- School of Medicine, Loma Linda University, Loma Linda, USA
| | | | - Philip Parel
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington D.C., USA
| | - Anthony Chiu
- Department of Orthopaedics, University of Maryland, Baltimore, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis VA Medical Center, Loma Linda, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
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Abstract
PURPOSE OF REVIEW Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity. RECENT FINDINGS Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.
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Butterfield JT, Golzarian S, Johnson R, Fellows E, Dhawan S, Chen CC, Marcotte EL, Venteicher AS. Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis. Lancet 2022; 400:2063-2073. [PMID: 36502844 DOI: 10.1016/s0140-6736(22)00839-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/12/2022] [Accepted: 04/29/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Disparities in treatment and outcomes disproportionately affect minority ethnic and racial populations in many surgical fields. Although substantial research in racial disparities has focused on outcomes, little is known about how surgeon recommendations can be influenced by patient race. The aim of this study was to investigate racial and socioeconomic disparities in the surgical management of primary brain tumors. METHODS In this registry-based cohort study, we used data from the Surveillance, Epidemiology, and End Results (SEER) database (1975-2016) and the American College of Surgeons National Cancer Database (NCDB) in the USA for independent analysis. Adults (aged ≥20 years) with a new diagnosis of meningioma, glioblastoma, pituitary adenoma, vestibular schwannoma, astrocytoma, and oligodendroglioma, with information on tumour size and surgical recommendation were included in the analysis. The primary outcome of this study was the odds of a surgeon recommending against surgical resection at diagnosis of primary brain neoplasms. This outcome was determined using multivariable logistic regression with clinical, demographic, and socioeconomic factors. FINDINGS This study included US national data from the SEER (1975-2016) and NCDB (2004-17) databases of adults with a new diagnosis of meningioma (SEER n=63 674; NCDB n=222 673), glioblastoma (n=35 258; n=104 047), pituitary adenoma (n=27 506; n=87 772), vestibular schwannoma (n=11 525; n=30 745), astrocytoma (n=5402; n=10 631), and oligodendroglioma (n=3977; n=9187). Independent of clinical and demographic factors, including insurance status and rural-urban continuum code, Black patients had significantly higher odds of recommendation against surgical resection of meningioma (adjusted odds ratio 1·13, 95% CI 1·06-1·21, p<0·0001), glioblastoma (1·14, 1·01-1·28, p=0·038), pituitary adenoma (1·13, 1·05-1·22, p<0·0001), and vestibular schwannoma (1·48, 1·19-1·84, p<0·0001) when compared with White patients in the SEER dataset. Additionally, patients of unknown race had significantly higher odds of recommendation against surgical resection for pituitary adenoma (1·80, 1·41-2·30, p<0·0001) and vestibular schwannoma (1·49, 1·10-2·04, p=0·011). Performing a validation analysis using the NCDB dataset confirmed these significant results for Black patients with meningioma (1·18, 1·14-1·22, p<0·0001), glioblastoma (1·19, 1·12-1·28, p<0·0001), pituitary adenoma (1·21, 1·16-1·25, p<0·0001), and vestibular schwannoma (1·19, 1·04-1·35, p=0·0085), and indicated and indicated that the findings are independent of patient comorbidities. When further restricted to the most recent decade in SEER, these inequities held true for Black patients, except those with glioblastoma (meningioma [1·18, 1·08-1·28, p<0·0001], pituitary adenoma [1·20, 1·09-1·31, p<0·0001], and vestibular schwannoma [1·54, 1·16-2·04, p=0·0031]). INTERPRETATION Racial disparities in surgery recommendations in the USA exist for patients with primary brain tumours, independent of potential confounders including clinical, demographic, and select socioeconomic factors. Further studies are needed to understand drivers of this bias and enhance equality in surgical care. FUNDING None.
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Affiliation(s)
- John T Butterfield
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, MN, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Sina Golzarian
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Reid Johnson
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Emily Fellows
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Erin L Marcotte
- Division of Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Andrew S Venteicher
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, MN, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA.
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Hamilton T, Macki M, Oh SY, Bazydlo M, Schultz L, Zakaria HM, Khalil JG, Perez-Cruet M, Aleem I, Park P, Easton R, Nerenz DR, Schwalb J, Abdulhak M, Chang V. The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study. J Neurosurg Spine 2021:1-9. [PMID: 34891131 DOI: 10.3171/2021.9.spine21421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities. METHODS The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios. RESULTS A total of 26,229 lumbar spine patients had data available for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)-level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts. CONCLUSIONS This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.
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Affiliation(s)
| | | | - Seok Yoon Oh
- 2Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | | | - Lonni Schultz
- Departments of1Neurosurgery and.,3Public Health Sciences, and
| | | | | | | | | | - Paul Park
- 7Neurosurgery, University of Michigan Hospital, Ann Arbor
| | - Richard Easton
- 8Department of Orthopedic Surgery, William Beaumont Hospital-Troy, Michigan; and
| | - David R Nerenz
- 9Center for Health Services Research, Henry Ford Hospital, Detroit
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