Impact of race on nonroutine discharge, length of stay, and postoperative complications after surgery for spinal metastases

Risk factors for extended hospital stay following minimally invasive transforaminal lumbar interbody fusion

BACKGROUND

Prior literature has examined predictors of length of stay (LOS) for lumbar fusion broadly, grouping multiple surgical approaches into one sample. Evaluating minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) specifically can reduce variability introduced by other approaches to effectively identify predictors of LOS. The purpose of this study is to evaluate preoperative predictors of extended LOS in patients undergoing MIS-TLIF.

METHODS

MIS-TLIF patients were identified from a spine surgeon's database. Preoperative predictors of LOS, including demographics, comorbidity data, spinal pathology, patient-reported back pain, leg pain, physical function, disability, general physical health, mental health, and depressive burden scores were analyzed. Univariate analysis was performed to identify predictors of LOS ≥ 48 and LOS ≥ 72 h, a multivariate analysis confirmed significance. Eight-hundred-one patients were included.

RESULTS

African-American patients were 4.3 times more likely to have a LOS≥48 h compared to Caucasians (p ≤ 0.001). Diagnosis of herniated nucleus pulposus and foraminal stenosis were negative predictors of an LOS ≥ 72 h (p ≤ 0.014, both). Self-identified African American patients were approximately twice as likely to have a LOS ≥ 72 h compared to Caucasians. Preoperative Oswestry Disability Index (ODI) was positively correlated with LOS ≥ 48 h (p = 0.008). Other baseline patient-reported outcomes (PROs) were not predictive of LOS ≥ 48 or 72 h (p > 0.050, all).

CONCLUSIONS

Further research should explore why different demographic characteristics may be associated with extended postoperative LOS to target interventions toward potential health disparities. Understanding preoperative risk factors can help target increased healthcare costs and improve patient care through tailored interventions and future research.

The intersection of race, ethnicity, and urbanicity on treatment paradigms and clinical outcomes for non-malignant primary tumors of the spine

BACKGROUND

Non-malignant primary tumors of the spine (NMPTS) patients in rural areas face unique barriers that may limit their capacity to receive optimal care. With a lower geographical distribution of neurosurgical specialists and limited healthcare infrastructure, rural NMPTS patients may receive certain treatments at a lower frequency than metropolitan patients. NMPTS We sought to examine the association between residential urbanicity, race-ethnicity, treatment patterns, and survival outcomes for cases diagnosed with NMPTS.

METHODS

Cases of NMPTS diagnosed between 2004 and 2019 were identified from the Central Brain Tumor Registry of the United States (CBTRUS), a combined dataset of CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology and End Results (SEER) data. Using multivariable logistic regression, we evaluated the association between urbanicity and treatment (including surgery and radiation), adjusted for age at diagnosis, sex, and race-ethnicity. Patient-level all-cause survival data were obtained from the NPCR Survival Analytical Database (2004-2018).

RESULTS

A total of 38,414 cases were identified, 33,097 of whom lived in metropolitan and 5317 of whom lived in non-metropolitan regions. Nerve sheath tumors and meningiomas were the most common tumor histopathologies across both regions, with no clinically significant difference in other histopathologies (p<0.001). There were statistically significant differences between the frequency and type of surgery received by urbanicity (p<0.001). Overall all-cause survival was significantly lower for NH Blacks residing in non-metropolitan areas when compared to NH Blacks residing in metropolitan areas (p<0.0001).

CONCLUSION

Our data demonstrates significant differences in the incidence of NMPTS across both race-ethnicity and urbanicity. However, a wider analysis of all-cause mortality reveals disparities in health outcomes across both race-ethnicity and urbanicity for Black and Hispanic populations. To address the disparity in health outcomes, policymakers and health providers need to work with local communities in rural areas to improve access to equitable and quality healthcare.

Predictors of Clavien-Dindo Grade III-IV or Grade V Complications after Metastatic Spinal Tumor Surgery: An Analysis of Sociodemographic, Socioeconomic, Clinical, Oncologic, and Operative Parameters

The rate of major complications and 30-day mortality after surgery for metastatic spinal tumors is relatively high. While most studies have focused on baseline comorbid conditions and operative parameters as risk factors, there is limited data on the influence of other parameters such as sociodemographic or socioeconomic data on outcomes. We retrospectively analyzed data from 165 patients who underwent surgery for spinal metastases between 2012-2023. The primary outcome was development of major complications (i.e., Clavien-Dindo Grade III-IV complications), and the secondary outcome was 30-day mortality (i.e., Clavien-Dindo Grade V complications). An exploratory data analysis that included sociodemographic, socioeconomic, clinical, oncologic, and operative parameters was performed. Following multivariable analysis, independent predictors of Clavien-Dindo Grade III-IV complications were Frankel Grade A-C, lower modified Bauer score, and lower Prognostic Nutritional Index. Independent predictors of Clavien-Dindo Grade V complications) were lung primary cancer, lower modified Bauer score, lower Prognostic Nutritional Index, and use of internal fixation. No sociodemographic or socioeconomic factor was associated with either outcome. Sociodemographic and socioeconomic factors did not impact short-term surgical outcomes for metastatic spinal tumor patients in this study. Optimization of modifiable factors like nutritional status may be more important in improving outcomes in this complex patient population.

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.

External Validation of an Online Wound Infection and Wound Reoperation Risk Calculator After Metastatic Spinal Tumor Surgery

STUDY DESIGN

This was a single-institutional retrospective cohort study.

OBJECTIVE

Wound infections are common following spine metastasis surgery and can result in unplanned reoperations. A recent study published an online wound complication risk calculator but has not yet undergone external validation. Our aim was to evaluate the accuracy of this risk calculator in predicting 30-day wound infections and 30-day wound reoperations using our operative spine metastasis population.

METHODS

An internal operative database was used to identify patients between 2012 and 2022. The primary outcomes were 1) any surgical site infection and 2) wound-related revision surgery within 30 days following surgery. Patient details were manually collected from electronic medical records and entered into the calculator to determine predicted complication risk percentages. Predicted risks were compared to observed outcomes using receiver operator characteristic (ROC) curves with areas under the curve (AUC).

RESULTS

A total of 153 patients were included. The observed 30-day postoperative wound infection incidence was 5% while the predicted wound infection incidence was 6%. In ROC analysis, good discrimination was found for the wound infection model (AUC = 0.737; P = 0.024). The observed wound reoperation rate was 5% and the predicted wound reoperation rate was 6%. ROC analysis demonstrated poor discrimination for wound reoperations (AUC = 0.559; P = 0.597).

CONCLUSIONS

The online wound-related risk calculator was found to accurately predict wound infections but not wound reoperations within our metastatic spine surgery cohort. We suggest that the model may be clinically useful despite underlying population differences, but further work must be done to generate and validate accurate prediction tools.

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.

Association Between Race and Short-Term Outcomes Across 3988 Consecutive Single-Level Spinal Fusions

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.

Racial disparities in the management and outcomes of primary osseous neoplasms of the spine: a SEER analysis

PURPOSE

Primary osseous neoplasms of the spine, including Ewing's sarcoma, osteosarcoma, chondrosarcoma, and chordoma, are rare tumors with significant morbidity and mortality. The present study aims to identify the prevalence and impact of racial disparities on management and outcomes of patients with these malignancies.

METHODS

The 2000 to 2020 Surveillance, Epidemiology, and End Results (SEER) Registry, a cancer registry, was retrospectively reviewed to identify patients with Ewing's sarcoma, osteosarcoma, chondrosarcoma, or chordoma of the vertebral column or sacrum/pelvis. Study patients were divided into race-based cohorts: White, Black, Hispanic, and Other. Demographics, tumor characteristics, treatment variables, and mortality were assessed.

RESULTS

2,415 patients were identified, of which 69.8% were White, 5.8% Black, 16.1% Hispanic, and 8.4% classified as "Other". Tumor type varied significantly between cohorts, with osteosarcoma affecting a greater proportion of Black patients compared to the others (p < 0.001). A lower proportion of Black and Other race patients received surgery compared to White and Hispanic patients (p < 0.001). Utilization of chemotherapy was highest in the Hispanic cohort (p < 0.001), though use of radiotherapy was similar across cohorts (p = 0.123). Five-year survival (p < 0.001) and median survival were greatest in White patients (p < 0.001). Compared to non-Hispanic Whites, Hispanic (p < 0.001) and "Other" patients (p < 0.001) were associated with reduced survival.

CONCLUSION

Race may be associated with tumor characteristics at diagnosis (including subtype, size, and site), treatment utilization, and mortality, with non-White patients having lower survival compared to White patients. Further studies are necessary to identify underlying causes of these disparities and solutions for eliminating them.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions

INTRODUCTION

Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially.

METHODS

We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients.

RESULTS

A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes.

CONCLUSIONS

The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

Socioeconomic disparities in musculoskeletal oncology

Musculoskeletal oncology is a clinical specialty dealing with a diverse population of patients with metastatic bone disease, hematological malignancies with musculoskeletal manifestations, primary bone malignancies and soft tissue sarcomas. There are wide-spread disparities including socioeconomic (SES) and insurance-related disparities reported in the literature. In this review, we'll summarize the disparities surrounding the musculoskeletal oncology.

Sociodemographic Characteristics of Patients Undergoing Surgery for Metastatic Disease of the Spine

INTRODUCTION

Some patients, particularly those who are socioeconomically deprived, are diagnosed with primary and/or metastatic cancer only after presenting to the emergency department. Our objective was to determine sociodemographic characteristics of patients undergoing surgery for metastatic spine disease at our institution.

METHODS

This retrospective case series included patients 18 years and older who presented to the emergency department with metastatic spine disease requiring surgery. Demographics and survival data were collected. Sociodemographic characteristics were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI) for the state of California. Univariate log-rank tests and Kaplan-Meier curves were used to assess differences in survival for predictors of interest.

RESULTS

Between 2015 and 2021, 64 patients underwent surgery for metastatic disease of the spine. The mean age was 61.0 ± 12.5 years, with 60.9% being male (n = 39). In this cohort, 89.1% of patients were non-Hispanic (n = 57), 71.9% were White (n = 46), and 62.5% were insured by Medicare/Medicaid (n = 40). The mean SDI and ADI were 61.5 ± 28.0 and 7.7 ± 2.2, respectively. 28.1% of patients (n = 18) were diagnosed with primary cancer for the first time while 39.1% of patients (n = 25) were diagnosed with metastatic cancer for the first time. During index hospitalization, 37.5% of patients (n = 24) received palliative care consult. The 3-month, 6-month, and all-time mortality rates were 26.7% (n = 17), 39.5% (n = 23), and 50% (n = 32), respectively, with 10.9% of patients (n = 7) dying during their admission. Payor plan was significant at 3 months ( P = 0.02), and palliative consultation was significant at 3 months ( P = 0.007) and 6 months ( P = 0.03). No notable association was observed with SDI and ADI in quantiles or as continuous variables.

DISCUSSION

In this study, 28.1% of patients were diagnosed with cancer for the first time. Three-month and 6-month mortality rates for patients undergoing surgery were 26.7% and 39.5%, respectively. Furthermore, mortality was markedly associated with palliative care consultation and insurance status, but not with SDI and ADI.

LEVEL OF EVIDENCE

Retrospective case series, Level III evidence.

Influence of Sociodemographic and Psychosocial Factors on Length of Stay After Surgical Management of Traumatic Spine Fracture with Spinal Cord Injury

OBJECTIVE

Identifying patients at risk of increased health care resource utilization is a valuable opportunity to develop targeted preoperative and perioperative interventions. In the present investigation, we sought to examine patient sociodemographic factors that predict prolonged length of stay (LOS) after traumatic spine fracture.

METHODS

We performed a cohort analysis using the National Trauma Data Bank tabulated during 2012-2016. Eligible patients were those who were diagnosed with cervical or thoracic spine fracture with spinal cord injury and who were treated surgically. We evaluated the effects of sociodemographic as well as psychosocial variables on LOS by negative binomial regression and adjusted for injury severity, injury mechanism, and hospital characteristics.

RESULTS

We identified 3856 eligible patients with a median LOS of 9 days (interquartile range, 6-15 days). Patients in older age categories, who were male (incidence rate ratio (IRR), 1.05; 95% confidence interval [CI], 1.01-1.09), black (IRR, 1.12; CI, 1.05-1.19) or Hispanic (IRR, 1.09; CI, 1.03-1.16), insured by Medicaid (IRR, 1.24; CI, 1.17-1.31), or had a diagnosis of alcohol use disorder (IRR, 1.12; CI, 1.06-1.18) were significantly more likely to have a longer LOS. In addition, patients with severe injury on Injury Severity Score (IRR, 1.32; CI, 1.14-1.53) and lower Glasgow Coma Scale (GCS) scores (GCS score 3-8, IRR, 1.44; CI, 1.35-1.55; GCS score 9-11, IRR, 1.40; CI, 1.25-1.58) on admission had a significantly lengthier LOS. Patients admitted to a hospital in the Southern United States (IRR, 1.09; CI, 1.05-1.14) had longer LOS.

CONCLUSIONS

Socioeconomic factors such as race, insurance status, and alcohol use disorder were associated with a prolonged LOS after surgical management of traumatic spine fracture with spinal cord injury.

A novel online calculator to predict nonroutine discharge, length of stay, readmission, and reoperation in patients undergoing surgery for intramedullary spinal cord tumors

BACKGROUND CONTEXT

Intramedullary spinal cord tumors (IMSCTs) are rare tumors associated with significant morbidity and mortality. Surgical resection is often indicated for symptomatic lesions but may result in new neurological deficits and decrease quality of life. Identifying predictors of these adverse outcomes may help target interventions designed to reduce their occurrence. Nonetheless, most prior studies have employed population-level datasets with limited granularity.

PURPOSE

To determine independent predictors of nonroutine discharge, prolonged length of stay (LOS), and 30 day readmission and reoperation, and to deploy these results as a web-based calculator.

STUDY DESIGN

Retrospective cohort study PATIENT SAMPLE: A total of 235 patients who underwent resection of IMSCTs at a single comprehensive cancer center.

OUTCOME MEASURES

Nonroutine discharge, prolonged LOS, 30 day readmission, and 30 day reoperation METHODS: Patients who underwent surgery from June 2002 to May 2020 at a single tertiary center were included. Data was collected on patient demographics, clinical presentation, tumor histology, surgical procedures, and 30 day readmission and reoperation. Functional status was assessed using the Modified McCormick Scale (MMS) and queried preoperative neurological symptoms included weakness, urinary and bowel dysfunction, numbness, and back and radicular pain. Variables significant on univariable analysis at the α≤0.15 level were entered into a stepwise multivariable logistic regression model.

RESULTS

Of 235 included cases, 131 (56%) experienced a nonhome discharge and 68 (29%) experienced a prolonged LOS. Of 178 patients with ≥ 30 days of follow-up, 17 (9.6%) were readmitted within 30 days and 13 (7.4%) underwent reoperation. Wound dehiscence (29%) was the most common reason for readmission. Nonhome discharge was independently predicted by older age (OR=1.03/year; p<.01), thoracic location of the tumor (OR=2.36; p=.01), presenting with bowel dysfunction (OR=4.09; p=.03), and longer incision length (OR=1.44 per level; p=.03). Independent predictors of prolonged LOS included presenting with urinary incontinence (OR=2.65; p=.05) or a higher preoperative white blood cell count (OR=1.08 per 10³/μL); p=.01), while GTR predicted shorter LOS (OR=0.40; p=.02). Independent predictive factors for 30 day unplanned readmission included experiencing ≥1 complications during the first hospitalization (OR=6.13; p<.01) and having a poor (A-C) versus good (D-E) baseline neurological status on the ASIA impairment scale (OR=0.23; p=.03). The only independent predictor of unplanned 30 day reoperation was experiencing ≥1 inpatient complications during the index hospitalization (OR=6.92; p<.01). Receiver operating curves for the constructed models produced C-statistics of 0.67-0.77 and the models were deployed as freely available web-based calculators (https://jhuspine5.shinyapps.io/Intramedullary30day).

CONCLUSIONS

We found that neurological presentation, patient demographics, and incision length were important predictors of adverse perioperative outcomes in patients with IMSCTs. The calculators can be used by clinicians for risk stratification, preoperative counseling, and targeted interventions.

Modifiers of and Disparities in Palliative and Supportive Care Timing and Utilization among Neurosurgical Patients with Malignant Central Nervous System Tumors

Patients with primary or secondary central nervous system (CNS) malignancies benefit from utilization of palliative care (PC) in addition to other supportive services, such as home health and social work. Guidelines propose early initiation of PC for patients with advanced cancers. We analyzed a cohort of privately insured patients with malignant brain or spinal tumors derived from the Optum Clinformatics Datamart Database to investigate health disparities in access to and utilization of supportive services. We introduce a novel construct, "provider patient racial diversity index" (provider pRDI), which is a measure of the proportion of non-white minority patients a provider encounters to approximate a provider's patient demographics and suggest a provider's cultural sensitivity and exposure to diversity. Our analysis demonstrates low rates of PC, home health, and social work services among racial minority patients. Notably, Hispanic patients had low likelihood of engaging with all three categories of supportive services. However, patients who saw providers categorized into high provider pRDI (categories II and III) were increasingly more likely to interface with supportive care services and at an earlier point in their disease courses. This study suggests that prospective studies that examine potential interventions at the provider level, including diversity training, are needed.

Impact of socio-economic factors on radiation treatment after resection of metastatic brain tumors: trends from a private insurance database

BACKGROUND

Stereotactic radiosurgery (SRS) to the surgical bed of resected brain metastases is now considered the standard of care due to its advantages over whole brain radiation therapy (WBRT). Despite the upward trend in SRS adoption since the 2000s, disparities have been reported suggesting that socio-economic factors can influence SRS utilization.

OBJECTIVE

To analyze recent trends in SRS use and identify factors that influence treatment.

METHODS

We conducted a retrospective cohort study with the Optum Commercial Claims and Encounters Database and included all patients from 2004 to 2021 who received SRS or WBRT within 60 days after resection of tumors metastatic to the brain.

RESULTS

A total of 3495 patients met the inclusion and exclusion criteria. There were 1998 patients in the SRS group and 1497 patients in the WBRT group. SRS use now supersedes WBRT by a wide margin. Lung, breast and colon were the most common sites of primary tumor. Although we found no significant differences based on race among the treatment groups, patients with annual household income greater than $75,000 and those with some college or higher education are significantly more likely to receive SRS (OR 1.44 and 1.30; 95% CI 1.18-1.76 and 1.08-1.56; P = 0.001 and 0.005, respective). Patients with Elixhauser Comorbidity Index of three or more were significantly more likely to receive SRS treatment.

CONCLUSION

The use of post-surgical SRS for brain metastasis has increased significantly over time, however education and income were associated with differential SRS utilization.