Racial and Socioeconomic Disparities in Prompt Craniosynostosis Workup and Treatment

Abstract

The purpose of this study was to identify racial and socioeconomic disparities in craniosynostosis evaluation and treatment, from referral to surgery. Patients diagnosed with craniosynostosis between 2012 and 2020 at a single center were identified. Chart review was used to collect demographic variables, age at referral to craniofacial care, age at diagnosis, age at surgery, and surgical technique (open versus limited incision). Multivariable linear and logistic regression models with lasso regularization assessed the independent effect of each variable. A total of 298 patients were included. Medicaid insurance was independently associated with a delay in referral of 83 days [95% confidence interval (CI) 4–161, P=0.04]. After referral, patients were diagnosed a median of 21 days later (interquartile range 7–40), though this was significantly prolonged in patients who were not White (β 23 d, 95% CI 9–38, P=0.002), had coronal synostosis (β 24 d, 95% CI 2–46, P=0.03), and had multiple suture synostosis (β 47 d, 95% CI 27–67, P<0.001). Medicaid insurance was also independently associated with diagnosis over 3 months of age (risk ratio 1.3, 95% CI 1.1–1.4, P=0.002) and undergoing surgery over 1 year of age (risk ratio 3.9, 95% CI 1.1–9.4, P=0.04). In conclusion, Medicaid insurance was associated with a 3-month delay in referral to craniofacial specialists and increased risk of diagnosis over 3 months of age, limiting surgical treatment options in this group. Patients with Medicaid also faced a 4-fold greater risk of delayed surgery, which could result in neurodevelopmental sequelae.

Geospatial and Socioeconomic Disparities Influencing the Management of Craniosynostosis

“…These findings contribute to the current literature, which has described race, ethnicity, and insurance payor as socioeconomic predictors of delayed presentation and treatment in the craniosynostosis population. [14][15][16][17][18][19][20] Our study provided additional insight to factors such as parental education and household income, which have previously been defined as indicators of socioeconomic status. 26 Perhaps unsurprisingly, lower parental percent educational attainment and lower median household income were associated with worse outcomes.…”

“…Insurance payor, race, and median zip code income quartiles have been well-described socioeconomic indicators related to craniosynostosis management. [14][15][16][17][18][19][20] However, systematic review of the literature highlighted a knowledge gap surrounding geospatial disparities and other socioeconomic indicators such as parental education attainment. In addition, zip code-based metrics lack granularity and vary tremendously in size, shape, and population.…”

Scoping Review of Healthcare Disparities in Treatment of Craniosynostosis: Assessing Impacts of Race, Insurance, and Socioeconomic Status

“…Access to craniosynostosis evaluation and surgical care varied based on patient race, insurance status, and socioeconomic status (Table 1). Seventeen of the 28 studies analyzed differences in time to craniosynostosis diagnosis, referral, or surgical intervention (7 single-institution cohort reviews, 10 national database reviews, and 2 dual-institution cohort revi ews) 3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] . Ten 3,4,[7][8][9]11,13,15,17,19 of the 17 studies investigated racial disparities in access to care, all of which found that non-white patients were more likely to experience a delay to at least one step of the diagnostic process (i.e., diagnosis, referral, or intervention) compared to White patients.…”

“…Seventeen of the 28 studies analyzed differences in time to craniosynostosis diagnosis, referral, or surgical intervention (7 single-institution cohort reviews, 10 national database reviews, and 2 dual-institution cohort revi ews) 3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] . Ten 3,4,[7][8][9]11,13,15,17,19 of the 17 studies investigated racial disparities in access to care, all of which found that non-white patients were more likely to experience a delay to at least one step of the diagnostic process (i.e., diagnosis, referral, or intervention) compared to White patients. Seven studies found that Black and Hispanic patients were older at the time of surgery, 3,4,7,13,15,17,19 and 3 studies found that patients of these demographics were less likely to undergo surgery before 1 year.…”

“…8,11,15 Eight studies examined the impact of insurance status on the diagnostic timeline. 3,4,8,9,[11][12][13]15,17 Seven studies showed that patients with Medicaid or self-pay experienced delays in referral to a craniofacial specialist or intervention and were significantly more likely to present to surgery at an older age than those with private insurance. 4,8,9,12,13,15,17 In their single-institution cohort review, Gandolfi et al showed no significant association between insurance type and time to referral.…”