1
|
Frassica M, Kern DS, Afshari M, Connolly AT, Wu C, Rowland N, Ramirez-Castaneda J, Ushe M, Salazar C, Mason X. Racial disparities in access to DBS: results of a real-world U.S. claims data analysis. Front Neurol 2023; 14:1233684. [PMID: 37602243 PMCID: PMC10433186 DOI: 10.3389/fneur.2023.1233684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Deep brain stimulation (DBS) is an effective and standard-of-care therapy for Parkinson's Disease and other movement disorders when symptoms are inadequately controlled with conventional medications. It requires expert care for patient selection, surgical targeting, and therapy titration. Despite the known benefits, racial/ethnic disparities in access have been reported. Technological advancements with smartphone-enabled devices may influence racial disparities. Real-world evidence investigations can shed further light on barriers to access and demographic disparities for DBS patients. Methods A retrospective cross-sectional study was performed using Medicare claims linked with manufacturer patient data tracking to analyze 3,869 patients who received DBS. Patients were divided into two categories: traditional omnidirectional DBS systems with dedicated proprietary controllers ("traditional"; n = 3,256) and directional DBS systems with smart controllers ("smartphone-enabled"; n = 613). Demographics including age, sex, and self-identified race/ethnicity were compared. Categorical demographics, including race/ethnicity and distance from implanting facility, were analyzed for the entire population. Results A significant disparity in DBS utilization was evident. White individuals comprised 91.4 and 89.9% of traditional and smartphone-enabled DBS groups, respectively. Non-White patients were significantly more likely to live closer to implanting facilities compared with White patients. Conclusion There is great racial disparity in utilization of DBS therapy. Smartphone-enabled systems did not significantly impact racial disparities in receiving DBS. Minoritized patients were more likely to live closer to their implanting facility than White patients. Further research is warranted to identify barriers to access for minoritized patients to receive DBS. Technological advancements should consider the racial discrepancy of DBS utilization in future developments.
Collapse
Affiliation(s)
| | - Drew S. Kern
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Mitra Afshari
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States
| | | | - Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, PA, United States
| | - Nathan Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Juan Ramirez-Castaneda
- Methodist Physicians, Neurosurgery and Neurology Specialists, San Antonio, TX, United States
| | - Mwiza Ushe
- Department of Neurology, Washington University, St. Louis, MO, United States
| | - Claudia Salazar
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, United States
| | - Xenos Mason
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| |
Collapse
|
2
|
Kortz MW, Kongs BM, McCray E, Grassia F, Hosokawa P, Bernstein JE, Moore SP, Yanovskaya M, Ojemann SG. How neuropsychiatric comorbidity, modulatory indication, demographics, and other factors impact deep brain stimulation inpatient outcomes in the United States: A population-based study of 27,956 patients. Clin Neurol Neurosurg 2021; 208:106842. [PMID: 34339900 DOI: 10.1016/j.clineuro.2021.106842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine how neuropsychiatric comorbidity, modulatory indication, demographics, and other characteristics affect inpatient deep brain stimulation (DBS) outcomes. METHODS This is a retrospective study of 45 months' worth of data from the National Inpatient Sample. Patients were aged ≥ 18 years old and underwent DBS for Parkinson Disease (PD), essential tremor (ET), general dystonia and related disorders, other movement disorder (non-PD/ET), or obsessive-compulsive disorder (OCD) at a US hospital. Primary endpoints were prolonged length of stay (PLOS), high-end hospital charges (HEHCs), unfavorable disposition, and inpatient complications. Logistic models were constructed with odds ratios under 95% confidence intervals. A p-value of 0.05 determined significance. RESULTS Of 214,098 records, there were 27,956 eligible patients. Average age was 63.9 ± 11.2 years, 17,769 (63.6%) were male, and 10,182 (36.4%) patients were female. Most of the cohort was White (51.1%), Medicare payer (64.3%), and treated at a large-bed size (80.7%), private non-profit (76.9%), and metro-teaching (94.0%) hospital. Neuropsychiatric comorbidity prevalence ranged from 29.9% to 47.7% depending on indication. Compared with PD, odds of complications and unfavorable disposition were significantly higher with other movement disorders and dystonia, whereas OCD conferred greater risk for HEHCs (p < 0.05). Patients with ET had favorable outcomes. Neuropsychiatric comorbidity, Black race, and Charlson Comorbidity Index > 0 were significantly associated with unfavorable outcomes (p < 0.05). CONCLUSION The risk of adverse inpatient outcomes for DBS in the United States is independently correlated with non-PD/ET disorders, neuropsychiatric comorbidity, and non-White race, reflecting the heterogeneity and infancy of widespread DBS for these patients.
Collapse
Affiliation(s)
- Michael W Kortz
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Brian M Kongs
- College of Osteopathic Medicine, Kansas City University, Kansas City, MO, USA
| | - Edwin McCray
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Fabio Grassia
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patrick Hosokawa
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jacob E Bernstein
- Department of Neurosurgery, Riverside University Health System, Riverside, CA, USA
| | - Sean P Moore
- College of Osteopathic Medicine, Kansas City University, Kansas City, MO, USA
| | - Mariya Yanovskaya
- College of Osteopathic Medicine, Kansas City University, Kansas City, MO, USA
| | - Steven G Ojemann
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
3
|
Tafreshi AR, Shahrestani S, Lien BV, Ransom S, Brown NJ, Ransom RC, Ballatori AM, Ton A, Chen XT, Sahyouni R, Lee B. Indication-based analysis of patient outcomes following deep brain stimulation surgery. Clin Neurol Neurosurg 2020; 200:106372. [PMID: 33246250 DOI: 10.1016/j.clineuro.2020.106372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/03/2020] [Accepted: 11/14/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND While considered a safe operation, deep brain stimulation (DBS) has been associated with various morbidities. We assessed differences in postsurgical complication rates in patients undergoing the most common types of neurostimulation surgery. METHODS The National Readmission Database (NRD) was queried to identify patients undergoing neurostimulation placement with the diagnosis of Parkinson disease (PD), epilepsy, dystonia, or essential tremor (ET). Demographics and complications, including infection, pneumonia, and neurostimulator revision, were queried for each cohort and compiled. Readmissions were assessed in 30-, 90-, and 180-day intervals. We implemented nearest-neighbor propensity score matching to control for demographic and sample size differences between groups. RESULTS We identified 3230 patients with Parkinson disease, 1289 with essential tremor, 965 with epilepsy, and 221 with dystonia. Following propensity score matching, 221 patients remained in each cohort. Readmission rates 30-days after hospital discharge for PD patients (15.5 %) were significantly greater than those for ET (7.8 %) and seizure patients (4.4 %). Pneumonia was reported for PD (1.6 %), seizure (3.3 %) and dystonia (1.7 %) patients but not individuals ET. No PD patients were readmitted at 30-days due to dysphagia while individuals treated for ET (6.5 %), seizure (1.6 %) and dystonia (5.2 %) were. DBS-revision surgery was performed for 11.48 % of PD, 6.52 % of ET, 1.64 % of seizure and 6.90 % of dystonia patients within 30-days of hospital discharge. CONCLUSION 30-day readmission rates vary significantly between indications, with patients receiving DBS for PD having the highest rates. Further longitudinal studies are required to describe drivers of variation in postoperative outcomes following DBS surgery for different indications.
Collapse
Affiliation(s)
- Ali R Tafreshi
- Department of Neurological Surgery, Geisinger Health System, Danville, PA, USA
| | - Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Brian V Lien
- School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Seth Ransom
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nolan J Brown
- School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Ryan C Ransom
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander M Ballatori
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andy Ton
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Xiao T Chen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, USA
| | - Brian Lee
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
4
|
Crispo JAG, Lam M, Le B, Richard L, Shariff SZ, Ansell DR, Squarzolo M, Marras C, Willis AW, Seitz D. Disparities in Deep Brain Stimulation Use for Parkinson's Disease in Ontario, Canada. Can J Neurol Sci 2020; 47:642-55. [PMID: 32329424 DOI: 10.1017/cjn.2020.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine whether sociodemographic characteristics and health care utilization are associated with receiving deep brain stimulation (DBS) surgery for Parkinson's disease (PD) in Ontario, Canada. METHODS Using health administrative data, we identified a cohort of individuals aged 40 years or older diagnosed with incident PD between 1995 and 2009. A case-control study was used to examine whether select factors were associated with DBS for PD. Patients were classified as cases if they underwent DBS surgery at any point 1-year after cohort entry until December 31, 2016. Conditional logistic regression modeling was used to estimate the adjusted odds of DBS surgery for sociodemographic and health care utilization indicators. RESULTS A total of 46,237 individuals with PD were identified, with 543 (1.2%) receiving DBS surgery. Individuals residing in northern Ontario were more likely than southern patients to receive DBS surgery [adjusted odds ratio (AOR) = 2.23, 95% confidence interval (CI) = 1.15-4.34]; however, regional variations were not observed after accounting for medication use among older adults (AOR = 1.04, 95% CI = 0.26-4.21). Patients living in neighborhoods with the highest concentration of visible minorities were less likely to receive DBS surgery compared to patients living in predominantly white neighborhoods (AOR = 0.27, 95% CI = 0.16-0.46). Regular neurologist care and use of multiple PD medications were positively associated with DBS surgery. CONCLUSIONS Variations in use of DBS may reflect differences in access to care, specialist referral pathways, health-seeking behavior, or need for DBS. Future studies are needed to understand drivers of potential disparities in DBS use.
Collapse
|
5
|
Apostolakis S. Use of Focused Ultrasound (Sonication) for the Diagnosis of Infections in Neurosurgical Operations: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 136:364-373.e2. [PMID: 31899387 DOI: 10.1016/j.wneu.2019.12.143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/22/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Postoperative infections are one of the most devastating complications in neurosurgery, and their results are even more disastrous when biocompatible implants are involved. As the application of these implants increases, the need for a sensitive and efficient method to detect pathogens becomes imperative. The application of sonication appears to be a viable option. METHODS A systematic review and meta-analysis of the available literature was conducted, looking for studies reporting findings from the application of sonication following neurosurgical operations. To be included, an article needed to contain information about the material that was subjected to sonication, indication of other culture methods that were applied, and information about the isolated pathogens. RESULTS Six studies comprising 437 patients were included in the meta-analysis. Potential superiority of sonication over conventional microbiologic methods was found in the detection of gram-positive bacteria and in particular of coagulase-negative Staphylococcus species. A sensitivity of 0.87 and a specificity of 0.57 were calculated. CONCLUSIONS Regardless of the potential of sonication, it is still not a panacea. Additional studies are expected to provide significant insight into the indications and limitations of this technique.
Collapse
|
6
|
Shi K, Liu X, Hou L, Qiao D, Lin X. Effects of exercise on mGluR-mediated glutamatergic transmission in the striatum of hemiparkinsonian rats. Neurosci Lett 2019; 705:143-150. [PMID: 31029678 DOI: 10.1016/j.neulet.2019.04.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/17/2019] [Accepted: 04/24/2019] [Indexed: 12/21/2022]
Abstract
Hyperexcitability in the corticostriatal glutamatergic pathway may have a pivotal role in the pathogenesis of Parkinson's disease (PD). Metabotropic glutamate receptors (mGluRs) modulate glutamate transmission by both pre- and postsynaptic mechanisms, making them attractive targets for modifying pathological changes in the corticostriatal pathway. Exercise reportedly alleviates motor dysfunction and induced neuroplasticity in glutamatergic transmission. Here, the mGluR-mediated plasticity mechanism underlying behavioral improvement by exercise intervention was investigated. The experimental models were prepared by 6-hydroxydopamine injection into the right medial forebrain bundle. The models were evaluated with the apomorphine-induced rotation test. Starting 2 weeks postoperatively, exercise intervention was applied to the PD + Ex group for 4 weeks. The exercise-intervention effects on locomotor behavior, glutamate levels, and mGluR (mGluR2/3 and mGluR5) expression in hemiparkinsonian rats were investigated. The results showed that hemiparkinsonian rats have a significant increase in extracellular glutamate levels in the lesioned-lateral striatum. MGluR2/3 protein expression was reduced while mGluR5 protein expression was increased in the striatum. Notably, treadmill exercise markedly reversed these abnormal changes in the corticostriatal glutamate system and promoted motor performance in PD rats. These findings suggest that mGluR-mediated glutamatergic transmission in the corticostriatal pathway may serve as an attractive target for exercise-induced neuroplasticity in hemiparkinsonian rats.
Collapse
Affiliation(s)
- Kaixuan Shi
- Department of Physical Education, China University of Geosciences, Beijing, 100083, China; College of Physical Education and Sports, Beijing Normal University, Beijing, 100875, China.
| | - Xiaoli Liu
- College of Physical Education and Sports, Beijing Normal University, Beijing, 100875, China
| | - Lijuan Hou
- College of Physical Education and Sports, Beijing Normal University, Beijing, 100875, China
| | - Decai Qiao
- College of Physical Education and Sports, Beijing Normal University, Beijing, 100875, China
| | - Xiangming Lin
- College of Physical Education and Sports, Beijing Normal University, Beijing, 100875, China
| |
Collapse
|