Racial and Social Determinants of Health Disparities in Spine Surgery Affect Preoperative Morbidity and Postoperative Patient Reported Outcomes

Retrospective Observational Study

Sarthak Mohanty, BS; Jenna Harowitz, BA; Meeki K. Lad, MPH; Armaun D. Rouhi, BA; David Casper, MD; Comron Saifi, MD

Disclosures

Spine. 2022;47(11):781-791. 

In This Article

Abstract and Introduction

Abstract

Study Design: Retrospective observational study.

Objective: To elucidate racial and socioeconomic factors driving preoperative disparities in spine surgery patients.

Summary of Background Data: There are racial and socioeconomic disparities in preoperative health among spine surgery patients, which may influence outcomes for minority and low socioeconomic status (SES) populations.

Methods: Presenting, postoperative day 90 (POD90), and 12-month (12M) outcome scores (PROMIS global physical and mental [GPH, GMH] and visual analog scale pain [VAS]) were collected for patients undergoing deformity arthrodesis or cervical, thoracic, or lumbar laminotomy or decompression/fusion; these procedures were the most common in our cohort. Social determinants of health for a patient's neighborhood (county, zip code, or census tract) were extracted from public databases. Multivariable linear regression with stepwise selection was used to quantify the association between a patient's preoperative GPH score and sociodemographic variables.

Results: Black patients presented with 1 to 3 point higher VAS pain scores (7–8 vs. 5–6) and lower (worse) GPH scores (6.5–10 vs. 11–12) than White patients (P < 0.05 for all comparisons); similarly, lower SES patients presented with 1.5 points greater pain (P < 0.0001) and 3.5 points lower GPH (P < 0.0001) than high SES patients. Patients with lowest-quartile presenting GPH scores reported 36.8% and 37.5% lower (worse) POD-90 GMH and GPH scores than the highest quartile, respectively (GMH: 12 vs. 19, P < 0.0001; GPH: 15 vs. 24, P < 0.0001); this trend extended to 12 months (GMH: 19.5 vs. 29.5, P < 0.0001; GPH: 22 vs. 30, P < 0.0001). Reduced access to primary care (B = −1.616, P < 0.0001) and low SES (B = –1.504, P = 0.001), proxied by median household value, were independent predictors of worse presenting GPH scores.

Conclusion: Racial and socioeconomic disparities in patients' preoperative physical and mental health at presentation for spine surgery are associated adversely with postoperative outcomes. Renewed focus on structural factors influencing preoperative presentation, including timeliness of care, is essential.

Level of Evidence: 3.

Introduction

Timely care, one of the Institute of Medicine's six key priorities, depends upon the rapid identification of healthcare needs and the subsequent provision of appropriate care.[1] When timeliness is compromised, patients endure emotional and physical distress and higher treatment expenses;[2] further, hospitalization rates and cost per quality-adjusted life year increase.[3–5] This has been demonstrated in orthopedics, where earlier intervention in cases of definitively indicated surgery improves outcomes.[11–13] However, acquiring such intervention relies on myriad factors: baseline health, insurance status;[14] ability to present early to a primary care physician (PCP);[15] familial/social support; transportation;[16] specialty referrals;[17] preoperative specialty waitlists; and ability to accommodate lost time/income from surgery. As such, minority and socioeconomically disadvantaged patients with impaired care access are more likely to present with advanced chronic disease and face worsened morbidity and mortality.[6–10] Indeed, one recent study found that among patients undergoing hip fracture repair, Black and Medicaid patients experienced 43% higher odds of delayed surgery, and twice the risk of perioperative complications, compared with white patients.[18–20]

An increasingly utilized metric of presenting impairment, and by proxy timeliness of care, has been patient-reported outcomes (PROs). However, though minority patients undergoing spine surgery are more likely to present with worse symptom severity, functioning, pain, and baseline PROs (bodily pain, physical functioning),[22] the association between minority status and attenuated short-term healing trajectories via this propensity for poor preoperative status remains unexplored.

Thus, in this study, we investigate how disparities in baseline pathology impact spinal outcomes at 3 and 12 months postoperatively, examining racial and socioeconomic disparities in health impairment as measured via PROMIS (Patient-Reported Outcomes Measurement Information System) scores for mental and physical impairment. This investigation provides a novel analysis of the interaction of race and socioeconomic status (SES) in influencing preoperative wellbeing and postoperative outcomes in spine surgery.

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