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

Mohanty, Sarthak; Harowitz, Jenna; Lad, Meeki; Rouhi, Armaun D.; Casper, David S.; Saifi, Comron

doi:10.1097/brs.0000000000004344

Cited by 20 publications

(16 citation statements)

References 39 publications

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“…16 Previous literature has highlighted the notable variation in orthopaedic service availability, inferior outcomes, and increased risk of complications in racial and ethnic minorities. [16][17][18] African American patients report higher pain intensity scores, longer lengths of hospital stay, higher mortality rates, and lower satisfaction with their care and outcomes, compared with White patients. 17,19,20 However, the literature scarcely evaluated differences in care in Hispanics compared with other races or ethnicities.…”

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confidence: 99%

Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial

Ramírez-Gonzalez,

Torres-Lugo,

Deliz-Jimenez

et al. 2023

J Am Acad Orthop Surg

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Introduction: Posterior lumbar fusion surgery has become more common amid an aging population, with degenerative disease as its most common indication. Historically, postoperative pain control for spine surgery has relied on opioids. However, opioid use is associated with adverse effects such as dependence, respiratory depression, and altered cognition. Our study aimed to determine whether an opioid-sparing multimodal analgesia regimen (ketorolac, orphenadrine, and gabapentin) could be a viable alternative to diminish opioid use compared with a standard opioid-based regimen in Hispanic patients undergoing posterior lumbar spinal fusion. Methods: This was a randomized controlled trial of Hispanic patients scheduled to undergo elective posterior spinal fusion. Inclusion criteria included age 30 to 85 years, Hispanic ethnicity, lumbar stenosis between L1 and S1, elective posterior spinal fusion with instrumentation, American Society of Anesthesiologists Score <2, and consent to participate in the study. Patients were randomized into two groups, an experimental multimodal analgesia and control (opioid-based) treatment groups, and outcomes such as morphine milligram equivalents used, visual analog scale score, and length of hospital stay were compared between the groups. Results: The MMA experimental group used significantly lower amounts of opioid (measured with morphine milligram equivalent) than the opioid-based group during the 12-hour and 24-hour postoperative periods (P-value = 0.023 and P-value = 0.033, respectively). No statistically significant difference was observed in opioid use in the 48-hour postoperative period between both groups (P-value = 0.066). The MMA group had significantly lower VAS scores reported at the 12-hour, 24-hour, and 48-hour postoperative periods compared with the opioid-based group (P-values = 0.016, 0.020, and 0.020, respectively). No difference was observed in the length of hospital stay between groups (P-value = 0.169). Discussion: Implementing an MMA protocol in Hispanic patients undergoing posterior lumbar fusion resulted in decreased overall opioid use and decreased pain intensity compared with the opioid-based group. MMA is an effective alternative for pain control in patients who want to avoid opioid use. Clinical Trial Registration: Identifier: NCT05413902

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confidence: 99%

Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial

Ramírez-Gonzalez,

Torres-Lugo,

Deliz-Jimenez

et al. 2023

J Am Acad Orthop Surg

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“…Prior studies have demonstrated that socioeconomic factors are associated with disparities in PROs completion, 45 spine patient outcomes, [46][47][48] and the elements of health measured by the PROMIS-GH instrument. 49 Thus, their exclusion from the current study represents a significant limitation of our findings. A larger, multicenter study should be performed to expand these results to other institutions and populations with larger, more varied populations.…”

Section: Health Services Researchmentioning

confidence: 87%

Are We Considering the Whole Patient? The Impact of Physical and Mental Health on the Outcomes of Spine Care

Turcotte

Baxter

Pipkin

et al. 2023

Spine

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Study Design. Retrospective, observational. Objective. To evaluate the influence of baseline health status on the physical and mental health (MH) outcomes of spine patients. Summary of Background Data. Spine conditions can have a significant burden on both the physical and MH of patients. To date, few studies have evaluated the outcomes of both dimensions of health, particularly in nonoperative populations. Materials and Methods. At their first visit to a multidisciplinary spine clinic, 2668 nonoperative patients completed the Patient-reported Outcomes Measurement Information System-Global Health (PROMIS-GH) instrument and a questionnaire evaluating symptoms and goals of care. Patients were stratified by their baseline percentile score of the MH and physical health (PH) components of the PROMIS-GH. Four groups of patients were compared based on the presence or absence of bottom quartile PH or MH scores. The primary end point was the achievement of a minimal clinically important difference (MCID) on the MH or PH components at follow-up. Multivariate regression assessed the predictors of MCID achievement. Results. After controlling for demographics, symptoms, and goals, each 1-point increase in baseline PROMIS-GH mental score reduced the odds of achieving MH MCID by 9.0% (P<0.001). Conversely, each 1-point increase in baseline GH-physical score increased the odds of achieving MCID by 4.5% (P=0.005). Each 1-point increase in baseline GH-physical score reduced the odds of achieving PH MCID by 12.5% (P<0.001), whereas each 1-point increase in baseline GH-mental score increased the odds of achieving MCID by 5.0% (P<0.001). Conclusions. Spine patients presenting with the lowest levels of physical or MH were most likely to experience clinically significant improvement in those domains. However, lower levels of physical or mental health made it less likely that patients would experience significant improvement in the alternative domain. Physicians should evaluate and address the complex spine population holistically to maximize improvement in both physical and mental health status.

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“…Thus, patients from low SES communities made up only 28% of our comparative group. Even after combining low SES groups together, our study may have been underpowered to detect differences across SES given the relative unequal distribution of patients that our power analysis was based on 16. Moreover, only 2.8% of patients did not have Medicare or private insurance, thus our study may not capture patients who reside within the lowest SES of their respective communities 28.…”

Section: Discussionmentioning

confidence: 99%

“…A power analysis indicated that a minimum of 780 patients was necessary for adequate statistical comparisons between DCI groups. 16 Following Institutional Review Board approval from our urban academic medical center, we retrospectively identified patients who underwent an ACDF between 2014 and 2020 using a Structured Query Language (SQL) search from Current Procedural Terminology (CPT) code 22551. All adult patients (18 years or older) who underwent primary, elective one-level to four-level ACDF procedures met inclusion criteria.…”

Section: Data Collection and Study Designmentioning

confidence: 99%

Patients from Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion

Lambrechts

Toci

Issa

et al. 2022

Spine

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Objectives. The aim was to compare patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF) when categorizing patients based on socioeconomic status. Secondarily, we sought to compare PROMs based on race. Summary of Background Data. Social determinants of health are believed to affect outcomes following spine surgery, but there is limited literature on how combined socioeconomic status metrics affect PROMs following ACDF. Materials and Methods. The authors identified patients who underwent primary elective one-level to four-level ACDF from 2014 to 2020. Patients were grouped based on their distressed community index (DCI) quintile (Distressed, At-Risk, Mid-tier, Comfortable, and Prosperous) and then race (White or Black). Multivariate regression for ΔPROMs was performed based on DCI group and race while controlling for baseline demographics and surgical characteristics. Results. Of 1204 patients included in the study, all DCI groups improved across all PROMs, except mental health component score (MCS-12) for the Mid-tier group (P = 0.091). Patients in the Distressed/At-Risk group had worse baseline MCS-12, visual analog scale (VAS) Neck, and neck disability index (NDI). There were no differences in magnitude of improvement between DCI groups. Black patients had significantly worse baseline VAS Neck (P = 0.002) and Arm (P = 0.012) as well as worse postoperative MCS-12 (P = 0.016), PCS-12 (P = 0.03), VAS Neck (P < 0.001), VAS Arm (P = 0.004), and NDI (P < 0.001). Multivariable regression analysis did not identify any of the DCI groupings to be significant independent predictors of ΔPROMs, but being White was an independent predictor of greater improvement in ΔPCS-12 (β = 3.09, P = 0.036) and ΔNDI (β = −7.32, P = 0.003). Conclusions. All patients experienced clinical improvements regardless of DCI or race despite patients in Distressed communities and Black patients having worse preoperative PROMs. Being from a distressed community was not an independent predictor of worse improvement in any PROMs, but Black patients had worse improvement in NDI compared with White patients.

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

Cited by 20 publications

References 39 publications

Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial

Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial

Are We Considering the Whole Patient? The Impact of Physical and Mental Health on the Outcomes of Spine Care

Patients from Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion

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