Do Community-level Disadvantages Account for Racial Disparities in the Safety of Spine Surgery? A Large Database Study Based on Medicare Claims

Health Disparities in Aseptic Revision Total Hip Arthroplasty: Assessing the Impact of Social Determinants of Health

BACKGROUND

Social determinants of health (SDOH) have been shown to reliably predict outcomes in patients undergoing orthopaedic procedures. However, there remains a paucity of data in the literature on whether SDOH can predict adverse outcomes in those undergoing aseptic revision THA (rTHA). The purpose of this study was to examine the relationship between SDOH and clinical outcomes in patients undergoing aseptic rTHA.

METHODS

This retrospective study identified 843 patients undergoing aseptic rTHA using an institutional joint registry. Data on demographics, length of stay (LOS), 90-day complications, discharge disposition, and re-revisions was recorded. The Area Deprivation Index (ADI) and four subscales of the Social Vulnerability Index (SVI) were identified using census tract codes. High vulnerability to SDOH was defined as the top quartile for ADI and each SVI category. A multivariate regression was performed to identify risk factors for worse clinical outcomes.

RESULTS

Patients who had a higher ADI (43.2 versus 22.6%, P < 0.001) and SVI (32.9 versus 22.9%, P = 0.011) were revised for aseptic loosening at a higher proportion compared to their counterparts. Additionally, a lower prevalence of osteolysis was observed in patients who had a high ADI compared to those who had a low ADI (3.7 versus 10.6%, P = 0.048). In multivariate analyses, a high overall SVI was an independent risk factor for mortality (OR [odds ratio] = 2.40, P = 0.020). A higher household SVI was associated with increased mortality (OR = 2.13, P = 0.038) and reoperations (OR = 1.89, P = 0.039). Similarly, patients who had a high housing and transportation SVI had higher odds of 90-day complications (OR = 1.66, P = 0.045) and PJI episodes (OR = 2.33, P = 0.028). Having a high ADI was not associated with adverse clinical outcomes.

CONCLUSION

Patients who had higher levels of deprivation exhibited different surgical indications and poorer clinical outcomes following aseptic rTHA. This study provides further evidence of health disparities in rTHA and suggests that SVI is an effective tool for assessing SDOH.

Community-level Socioeconomic Status Is a Poor Predictor of Outcomes Following Lumbar and Cervical Spine Surgery

STUDY DESIGN

Retrospective Cohort study.

OBJECTIVE

Our objective was to compare 3 socioeconomic status (SES) indexes and evaluate associations with outcomes after anterior cervical discectomy and fusion (ACDF) or lumbar fusion.

BACKGROUND DATA

Socioeconomic disparities affect patients' baseline health and clinical outcomes following spine surgery. It is still unclear whether community-level indexes are accurate surrogates for patients' socioeconomic status (SES) and whether they are predictive of postoperative outcomes.

METHODS

Adult patients undergoing ACDF (N=1189) or lumbar fusion (N=1136) from 2014 to 2020 at an urban tertiary medical center were retrospectively identified. Patient characteristics, patient-reported outcomes (PROMs), and surgical outcomes (90-day readmissions, complications, and nonhome discharge) were collected from the electronic medical record. SES was extracted from 3 indexes (Area Deprivation Index, Social Vulnerability Index, and Distressed Communities Index). Patients were classified into SES quartiles for bivariate and multivariate regression analysis. We utilized Youden's index to construct receiver operating characteristic curves for all surgical outcomes using indexes as continuous variables.

RESULTS

Preoperatively, lumbar fusion patients in the poorest ADI community exhibited the greatest ODI ( P =0.001) and in the poorest DCI and SVI communities exhibited worse VAS back ( P <0.001 and 0.002, respectively). Preoperatively, ACDF patients in the lowest DCI community had significantly worse MCS-12, VAS neck, and NDI, and in the poorest ADI community had worse MCS-12 and NDI. There were no differences in the magnitude of improvement for any PROM. All indexes performed poorly at predicting surgical outcomes (AUC: 0.467-0.636, all P >0.05).

CONCLUSIONS

Community-wide SES indexes are not accurate proxies for individual SES. While patients from poorer communities present with worse symptoms, community-level SES is not associated with overall outcomes following spine fusion. Patient-specific factors should be employed when attempting to stratify patients based on SES given the inherent limitations present with these indexes.

LEVEL OF EVIDENCE

Level III.

Social Vulnerability Index and Health Outcomes in the United States: A Systematic Review

The Centers for Disease Control and Prevention created the Social Vulnerability Index (SVI) for the purpose of allocating resources in times of emergency based on social determinants of health (SDOH). The purpose of this systematic review was to evaluate how the SVI tool has been applied in health care literature focused on health in the United States (US). A systematic literature review was conducted in 7 research databases with an 11-year time frame reflecting the launch of SVI, with the last search completed on September 29, 2022. Studies were included that involved humans, health, SVI, and conducted in the US. Articles were excluded if the SVI was used in COVID-19, disaster, pandemic, environment, or hazards. A total of 47 articles were included in the systematic review. The majority of studies analyzed individual/population health outcomes in clinical, surgical, mortality, or health promotion areas. The majority of studies showed a relationship between neighborhood-level SDOH and health outcomes. Study authors reported strengths, limitations, and recommendations of the SVI tool. A potential limitation of the study was the exclusion of studies that used the SVI related to disaster. The SVI represents a powerful tool to assess neighborhood-level SDOH and examine upstream drivers health outcomes with direct implications for research, policy, and practice.

The Association of Area Deprivation Index and Spine Surgery Outcomes: A Systematic and Narrative Review

BACKGROUND AND OBJECTIVES

With an aging population, the prevalence of spine pathology including degenerative spine disease continues to increase. These pathologies present a significant disease burden, often requiring long-term and expensive care. Recent literature has linked several socioeconomic determinants of health with outcomes after spine surgery. We sought to conduct a systematic review to determine the relationship between Area Deprivation Index (ADI), a measure of neighborhood-level socioeconomic status, and objective and patient-reported outcome (PRO) measures after spine surgery and to propose potential interventions.

METHODS

An Embase and Medline search was conducted from inception to April 1st, 2024, for relevant articles assessing ADI and spine surgery outcomes. The inclusion criteria were all North American observational studies available in English that reported on the association of ADI and adult cervical, lumbar, neoplastic, or deformity spine surgery outcomes.

RESULTS

Ten articles met the inclusion criteria resulting in a combined 56 925 patients who had undergone elective surgery for cervical, lumbar, spine metastases, and adult spine deformity pathologies. Two studies reported ADI to be associated with increased costs of care and postoperative lengths of stay after cervical spine surgery. Five studies found the association between high ADI with increased rates of respiratory failure, 90-day emergency room visits, longer lengths of stay, 90-day reoperation rates, and poor PROs after lumbar spine surgery. One study found an association with high ADI and increased 30-day and 90-day readmissions across all spine surgeries, and 1 study found no association between ADI and overall survival after surgery for spinal metastases.

CONCLUSION

Across available literature, high ADI seems to be associated with higher rates of postoperative readmissions and worse PROs. Further studies are needed to better understand the mechanisms underlying the effects of ADI on spine surgery outcomes and identify possible interventions to optimize outcomes.

Disparities in Patient-reported Outcome Measure Completion Rates and Baseline Function in Newly Presenting Spine Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study was to evaluate disparities in patient-reported outcome measures (PROM) completion rates and baseline function scores among newly presenting spine patients.

SUMMARY OF BACKGROUND DATA

Prior studies have demonstrated that minority patients and those of low socioeconomic status may present with worse physical and mental health on PROMs. As PROMs are increasingly used in clinical care, research, and health policy, accurate assessment of health status among populations relies on the successful completion of PROM instruments.

METHODS

A retrospective review of 10,803 consecutive new patients presenting to a single multidisciplinary spine clinic from June 2020 to September 2022 was performed. Univariate statistics were performed to compare demographics between patients who did and did not complete PROMs. Multivariable analysis was used to compare PROM instrument completion rates by race, ethnicity, and Social Vulnerability Index (SVI) and baseline scores among responders.

RESULTS

A total of 68.4% of patients completed PROMs at the first clinic visit. After adjusting for age, sex, body mass index, and diagnosis type, patients of non-White race (OR=0.661, 95% CI=0.599-0.729, P <0.001), Hispanic ethnicity (OR=0.569, 95% CI=0.448-0.721, P <0.001), and increased social vulnerability (OR=0.608, 95% CI=0.511-0.723, P <0.001) were less likely to complete PROMs. In the multivariable models, patients of non-White race reported lower levels of physical function (β=-6.5, 95% CI=-12.4 to -0.6, P =0.032) and higher levels of pain intensity (β=0.6, 95% CI=0.2-1.0, P =0.005). Hispanic ethnicity (β=1.5, 95% CI=0.5-2.5, P =0.004) and increased social vulnerability (β=1.1, 95% CI=0.4-1.8, P =0.002) were each associated with increased pain intensity.

CONCLUSIONS

Among newly presenting spine patients, those of non-White race, Hispanic ethnicity, and with increased social vulnerability were less likely to complete PROMs. As these subpopulations also reported worse physical function or pain intensity, additional strategies are needed to better capture patient-reported health status to avoid bias in clinical care, outcomes research, and health policy.

LEVEL OF EVIDENCE

4.

Disparities in Surgical Intervention and Health-Related Quality of Life Among Racial/Ethnic Groups With Degenerative Lumbar Spondylolisthesis

BACKGROUND AND OBJECTIVES

Racial and socioeconomic disparities in spine surgery for degenerative lumbar spondylolisthesis persist in the United States, potentially contributing to unequal health-related quality of life (HRQoL) outcomes. This is important as lumbar spondylolisthesis is one of the most common causes of surgical low back pain, and low back pain is the largest disabler of individuals worldwide. Our objective was to assess the relationship between race, socioeconomic factors, treatment utilization, and outcomes in patients with lumbar spondylolisthesis.

METHODS

This cohort study analyzed prospectively collected data from 9941 patients diagnosed with lumbar spondylolisthesis between 2015 and 2020 at 5 academic hospitals. Exposures were race, socioeconomic status, health coverage, and HRQoL measures. Main outcomes and measures included treatment utilization rates between racial groups and the association between race and treatment outcomes using logistic regression, adjusting for patient characteristics, socioeconomic status, health coverage, and HRQoL measures.

RESULTS

Of the 9941 patients included (mean [SD] age, 67.37 [12.40] years; 63% female; 1101 [11.1%] Black, Indigenous, and People of Color [BIPOC]), BIPOC patients were significantly less likely to use surgery than White patients (odds ratio [OR] = 0.68; 95% CI, 0.62-0.75). Furthermore, BIPOC race was associated with significantly lower odds of reaching the minimum clinically important difference for physical function (OR = 0.74; 95% CI, 0.60; 0.91) and pain interference (OR = 0.77; 95% CI, 0.62-0.97). Medicaid beneficiaries were significantly less likely (OR = 0.65; 95% CI, 0.46-0.92) to reach a clinically important improvement in HRQoL when accounting for race.

CONCLUSION

This study found that BIPOC patients were less likely to use spine surgery for degenerative lumbar spondylolisthesis despite reporting higher pain interference, suggesting an association between race and surgical utilization. These disparities may contribute to unequal HRQoL outcomes for patients with lumbar spondylolisthesis and warrant further investigation to address and reduce treatment disparities.

Are social determinants of health associated with an increased length of hospitalization after revision total hip and knee arthroplasty? A comparison study of social deprivation indices

INTRODUCTION

Length of stay (LOS) has been extensively assessed as a marker for healthcare utilization, functional outcomes, and cost of care for patients undergoing arthroplasty. The notable patient-to-patient variation in LOS following revision hip and knee total joint arthroplasty (TJA) suggests a potential opportunity to reduce preventable discharge delays. Previous studies investigated the impact of social determinants of health (SDoH) on orthopaedic conditions and outcomes using deprivation indices with inconsistent findings. The aim of the study is to compare the association of three publicly available national indices of social deprivation with prolonged LOS in revision TJA patients.

MATERIALS AND METHODS

1,047 consecutive patients who underwent a revision TJA were included in this retrospective study. Patient demographics, comorbidities, and behavioral characteristics were extracted. Area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index (SVI) were recorded for each patient, following which univariate and multivariate logistic regression analyses were performed to determine the relationship between deprivation measures and prolonged LOS (greater than five days postoperatively).

RESULTS

193 patients had a prolonged LOS following surgery. Categorical ADI was significantly associated with prolonged LOS following surgery (OR = 2.14; 95% CI = 1.30-3.54; p = 0.003). No association with LOS was found using SDI and SVI. When accounting for other covariates, only ASA scores (ORrange=3.43-3.45; p < 0.001) and age (ORrange=1.00-1.03; prange=0.025-0.049) were independently associated with prolonged LOS.

CONCLUSION

The varying relationship observed between the length of stay and socioeconomic markers in this study indicates that the selection of a deprivation index could significantly impact the outcomes when investigating the association between socioeconomic deprivation and clinical outcomes. These results suggest that ADI is a potential metric of social determinants of health that is applicable both clinically and in future policies related to hospital stays including bundled payment plan following revision TJA.

Geospatial Evaluation of Disparities in Access to Cervical Spine Fusion in Metropolitan Areas Across the United States

STUDY DESIGN

Retrospective study with epidemiologic analysis of public Medicare data.

OBJECTIVE

The purpose of this study is to use geospatial analysis to identify disparities in access to cervical spine fusions in metropolitan Medicare populations.

SUMMARY OF BACKGROUND DATA

Cervical spine fusion is among the most common elective procedures performed by spine surgeons and is the most common surgical intervention for degenerative cervical spine disease. Although some studies have examined demographic and socioeconomic trends in cervical spine fusion, few have attempted to identify where disparities exist and quantify them at a community level.

METHODS

Center for Medicare and Medicaid Services physician billing and Medicare demographic data sets from 2013 to 2020 were filtered to contain only cervical spine fusion procedures and then combined with US Census socioeconomic data. The Moran Index geospatial clustering algorithm was used to identify statistically significant hotspot and coldspots of cervical spine fusions per 100,000 Medicare members at a county level. Univariate and multivariate analysis was subsequently conducted to identify demographic and socioeconomic factors that are associated with access to care.

RESULTS

A total of 285,405 cervical spine fusions were analyzed. Hotspots of cervical spine fusion were located in the South, while coldspots were throughout the Northern Midwest, the Northeast, South Florida, and West Coast. The percent of Medicare patients that were Black was the largest negative predictor of cervical spine fusions per 100,000 Medicare members ( β =-0.13, 95% CI: -0.16, -0.10).

CONCLUSIONS

Barriers to access can have significant impacts on health outcomes, and these impacts can be disproportionately felt by marginalized groups. Accounting for socioeconomic disadvantage and geography, this analysis found the Black race to be a significant negative predictor of access to cervical spine fusions. Future studies are needed to further explore potential socioeconomic barriers that exist in access to specialized surgical care.

LEVEL OF EVIDENCE

Level III-retrospective.

Higher odds of meniscectomy compared with meniscus repair in a young patient population with increased neighbourhood disadvantage

OBJECTIVES

To investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients and to identify trends in surgical management of meniscus tears based on surgeon volume.

METHODS

Data from a large healthcare system on patients aged 14-44 years who underwent isolated meniscus surgery between 2016 and 2022 were analysed. Patient demographics, socioeconomic factors and surgeon volume were recorded. Patient age was categorised as 14-29 years and 30-44 years old. Area Deprivation Index (ADI), a measure of neighbourhood disadvantage with increased ADI corresponding to more disadvantage, was grouped as <25th, 25-75th and >75th percentile. Multivariate comparisons were made between procedure groups while univariate comparisons were made between surgeon groups.

RESULTS

The study included 1552 patients treated by 84 orthopaedic surgeons. Older age and higher ADI were associated with higher odds of undergoing meniscectomy. Patients of older age and with non-private insurance were more likely to undergo treatment by a lower-volume knee surgeon. Apart from the year 2022, higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume knee surgeons. When controlling for surgeon volume, higher ADI remained a significant predictor of undergoing meniscectomy over meniscus repair.

CONCLUSION

Significant associations exist between patient factors and surgical choices for isolated meniscus tears in younger patients. Patients of older age and with increased neighbourhood disadvantage were more likely to undergo meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons.

LEVEL OF EVIDENCE

Retrospective cohort study, level III.

Disparities Exist in the Experience of Financial Burden Among Orthopedic Trauma Patients: A Systematic Review

PURPOSE OF REVIEW

There are substantial costs associated with orthopedic injury and management. These costs are likely not experienced equally among patients. At the level of the healthcare and hospital systems, disparities in financial burden and patient demographics have already been identified among orthopedic trauma patients. Accordingly, disparities may also arise at the level of the patient and how they experience the cost of their care. We sought to determine (1) how patient demographics are associated with financial burden/toxicity and (2) if patients experience disproportionate financial burden/toxicity and social support secondary to their economic standing.

RECENT FINDINGS

It has been described that there is an inequitable experience in clinical and economic outcomes in certain socioeconomic demographics leading to disparities in financial burden. It has been further reported that orthopedic injury, management, and outcomes are not experienced equitably among all demographic and socioeconomic groups. Ten articles met inclusion criteria, among which financial burden was disproportionately experienced amid orthopedic trauma patients across age, gender, race, education, and marital status. Financial hardship was also unequally distributed among different levels of income, employment, insurance status, and social deprivation. Younger, female, non-White, and unmarried patients experience increased financial burden. Patients with less education, lower income, limited or no insurance, and greater social deprivation disproportionately experienced financial toxicity compared to patients of improved economic standing. Further investigation into policy changes, social support, and barriers to appropriate care should be addressed to prevent unnecessary financial burden and promote greater patient welfare.

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

Introduction

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

Research question

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

Materials and methods

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

Results

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

Conclusion

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

Geriatric Distal Femur Fractures Treated With Distal Femoral Replacement Are Associated With Higher Rates of Readmissions and Complications

OBJECTIVE

Compare mortality and complications of distal femur fracture repair among elderly patients who receive operative fixation versus distal femur replacement (DFR).

DESIGN

Retrospective comparison.

SETTING

Medicare beneficiaries.

PATIENTS/PARTICIPANTS

Patients 65 years of age and older with distal femur fracture identified using Center for Medicare & Medicaid Services data from 2016 to 2019.

INTERVENTION

Operative fixation (open reduction with plating or intramedullary nail) or DFR.

MAIN OUTCOME MEASUREMENTS

Mortality, readmissions, perioperative complications, and 90-day cost were compared between groups using Mahalanobis nearest-neighbor matching to account for differences in age, sex, race, and the Charlson Comorbidity Index.

RESULTS

Most patients (90%, 28,251/31,380) received operative fixation. Patients in the fixation group were significantly older (81.1 vs. 80.4 years, P < 0.001), and there were more an open fractures (1.6% vs. 0.5%, P < 0.001). There were no differences in 90-day (difference: 1.2% [-0.5% to 3%], P = 0.16), 6-month (difference: 0.6% [-1.5% to 2.7%], P = 0.59), and 1-year mortality (difference: -3.3% [-2.9 to 2.3], P = 0.80). DFR had greater 90-day (difference: 5.4% [2.8%-8.1%], P < 0.001), 6-month (difference: 6.5% [3.1%-9.9%], P < 0.001), and 1-year readmission (difference: 5.5% [2.2-8.7], P = 0.001). DFR had significantly greater rates of infection, pulmonary embolism, deep vein thrombosis, and device-related complication within 1 year from surgery. DFR ($57,894) was significantly more expensive than operative fixation ($46,016; P < 0.001) during the total 90-day episode.

CONCLUSIONS

Elderly patients with distal femur fracture have a 22.5% 1-year mortality rate. DFR was associated with significantly greater infection, device-related complication, pulmonary embolism, deep vein thrombosis, cost, and readmission within 90 days, 6 months, and 1 year of surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Differentiating Urgent from Elective Cases Matters in Minority Populations: Developing an Ordinal "Desirability of Outcome Ranking" to Increase Granularity and Sensitivity of Surgical Outcomes Assessment

BACKGROUND

Surgical analyses often focus on single or binary outcomes; we developed an ordinal Desirability of Outcome Ranking (DOOR) for surgery to increase granularity and sensitivity of surgical outcome assessments. Many studies also combine elective and urgent procedures for risk adjustment. We used DOOR to examine complex associations of race/ethnicity and presentation acuity.

STUDY DESIGN

NSQIP (2013 to 2019) cohort study assessing DOOR outcomes across race/ethnicity groups risk-adjusted for frailty, operative stress, preoperative acute serious conditions, and elective, urgent, and emergent cases.

RESULTS

The cohort included 1,597,199 elective, 340,350 urgent, and 185,073 emergent cases with patient mean age of 60.0 ± 15.8, and 56.4% of the surgeries were performed on female patients. Minority race/ethnicity groups had increased odds of presenting with preoperative acute serious conditions (adjusted odds ratio [aORs] range 1.22 to 1.74), urgent (aOR range 1.04 to 2.21), and emergent (aOR range 1.15 to 2.18) surgeries vs the White group. Black (aOR range 1.23 to 1.34) and Native (aOR range 1.07 to 1.17) groups had increased odds of higher/worse DOOR outcomes; however, the Hispanic group had increased odds of higher/worse DOOR (aOR 1.11, CI 1.10 to 1.13), but decreased odds (aORs range 0.94 to 0.96) after adjusting for case status; the Asian group had better outcomes vs the White group. DOOR outcomes improved in minority groups when using elective vs elective/urgent cases as the reference group.

CONCLUSIONS

NSQIP surgical DOOR is a new method to assess outcomes and reveals a complex interplay between race/ethnicity and presentation acuity. Combining elective and urgent cases in risk adjustment may penalize hospitals serving a higher proportion of minority populations. DOOR can be used to improve detection of health disparities and serves as a roadmap for the development of other ordinal surgical outcomes measures. Improving surgical outcomes should focus on decreasing preoperative acute serious conditions and urgent and emergent surgeries, possibly by improving access to care, especially for minority populations.