Cluster Analysis reveals Socioeconomic Disparities among Elective Spine Surgery Patients.
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ABSTRACT:
SUBMITTER: Orlenko A
PROVIDER: S-EPMC11250986 | biostudies-literature | 2024
REPOSITORIES: biostudies-literature
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Cluster Analysis reveals Socioeconomic Disparities among Elective Spine Surgery Patients.
Orlenko Alena A Freda Philip J PJ Ghosh Attri A Choi Hyunjun H Matsumoto Nicholas N Bright Tiffani J TJ Walker Corey T CT Obafemi-Ajayi Tayo T Moore Jason H JH
Pacific Symposium on Biocomputing. Pacific Symposium on Biocomputing 20240101
This work demonstrates the use of cluster analysis in detecting fair and unbiased novel discoveries. Given a sample population of elective spinal fusion patients, we identify two overarching subgroups driven by insurance type. The Medicare group, associated with lower socioeconomic status, exhibited an over-representation of negative risk factors. The findings provide a compelling depiction of the interwoven socioeconomic and racial disparities present within the healthcare system, highlighting ...[more]
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Project description:BackgroundIn the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery.MethodsWe employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively.Results779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge.ConclusionsPatient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.
| S-EPMC9763740 | biostudies-literature
Project description:BackgroundIncreasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types.MethodsA comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses.ResultsThirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007).ConclusionsPatients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.
| S-EPMC10964016 | biostudies-literature
Project description:BackgroundDisparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery.MethodsWe performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model.Results24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy.ConclusionsInterventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.
| S-EPMC10033325 | biostudies-literature
Project description:BackgroundThere is limited data available on the use of orthoses across varying elective spine surgeries. When previously studied in 2009, inconsistent lumbar postoperative bracing practices were reported. The present study aimed to provide a ten-year update regarding postoperative bracing practices after elective lumbar surgery among United States (U.S.) spine surgeons.MethodsA questionnaire was distributed to attendees of the Lumbar Spine Research Society Annual Meeting (April 2019). The questionnaire collected demographic information, and asked surgeons to identify if they used orthoses postoperatively after ten elective lumbar surgeries. Information regarding type of brace, duration of use, and reason for bracing was also collected. Chi-square tests and one-way analysis of variance (ANOVA) were used for comparisons.ResultsSeventy-three of 88 U.S. attending surgeons completed the questionnaire (response rate: 83%). The majority of respondents were orthopaedic surgery-trained (78%), fellowship-trained (84%), and academic surgeons (73%). The majority of respondents (60%) did not use orthoses after any lumbar surgery. Among the surgeons who braced, the overall bracing frequency was 26%. This rate was significantly lower than that reported in the literature ten years earlier (p<0.0001). Respondents tended to use orthoses most often after stand-alone lateral interbody fusions (43%) (p<0.0001). The average bracing frequency after lumbar fusions (34%) was higher than the average bracing frequency after non-fusion surgeries (16%) (p<0.0001). The most frequently utilized brace was an off the shelf lumbar sacral orthosis (66%), and most surgeons braced patients to improve pain (42%). Of surgeons who braced, most commonly did so for 2-4 months (57%).ConclusionMost surgeon respondents did not prescribe orthoses after varying elective lumbar surgeries, and the frequency overall was lower than a similar study conducted in 2009. There continues to be inconsistencies in postoperative bracing practices. In an era striving for evidence-based practices, this is an area needing more attention.
| S-EPMC8820027 | biostudies-literature
Project description:UNLABELLED: The literature suggests preoperative autologous blood donation in total joint arthroplasty is associated with increased overall transfusion rates compared with nondonation and is not cost-effective for all patients. We asked whether the amount of intraoperative blood loss and blood replacement differs between autologous donors and nondonors in elective spine surgery and whether the rates of allogeneic blood transfusions differ between the two groups; we then determined the cost of wasted predonated units. We retrospectively reviewed 676 patients who underwent elective lumbar spine surgery and compared relevant data to that in a matched cohort of 51 patients who predonated blood and 51 patients who received only cell-saver blood and underwent instrumented spinal fusion. Patients who predonated blood had similar blood loss as patients who did not predonate, but they had more blood replacement (1391 cc compared with 410 cc). Patients who predonated blood also had a lower preoperative hemoglobin level and wasted a half unit of blood on average. There was no major difference in allogeneic blood transfusion rates between the two groups. Our data suggest for short, instrumented lumbar fusion surgeries in patients with a normal coagulation profile, preoperative blood donation is not beneficial. LEVEL OF EVIDENCE: Level II, therapeutic study.
| S-EPMC2584245 | biostudies-other
Project description:Study designRetrospective cohort study.ObjectiveTo assess the impact of race on complications following spinal tumor surgery.MethodsAdults with cancer who underwent spine tumor surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program datasets from 2012 to 2016. Clavien-Dindo Grade I-II (minor complications) and Clavien-Dindo Grade III-V (major complications including 30-day mortality) complications were compared between non-Hispanic Whites (NHW) and Black patients. A multivariable analysis was also conducted.ResultsOf 1,226 identified patients, 85.9% were NHW (n = 1,053) and 14.1% were Black (n = 173). The overall rate of Grade I-II complications was 16.2%; 15.1% for NHW patients and 23.1% for Black patients (P = .008). On multivariable analysis, Black patients had significantly higher odds of having a minor complication (OR 1.87; 95% CI, 1.16-3.01; P = .010). On the other hand, the overall rate of Grade III-V complications was 13.3%; 12.5% for NHW patients and 16.2% for Black patients (P = .187). On multivariable analysis, Black race was not independently associated with major complications (OR 1.26; 95% CI, 0.71-2.23; P = .430). Median length of stay was 8 days (IQR 5-13) for NHW patients and 10 days (IQR 6-15) for Black patients (P = .011).ConclusionBlack patients who underwent metastatic spinal tumor surgery were at a significantly increased risk of perioperative morbidity compared to NHW patients independent of baseline and operative characteristics. Major complications did not differ between groups. Race should be further studied in the context of metastatic spine disease to improve our understanding of these disparities.
| S-EPMC10416608 | biostudies-literature
Project description:Study designRetrospective cohort study.ObjectivesThe purpose of this study was to report incidence of cardiopulmonary complications in elective spine surgery, demographic and surgical predictors, and outcomes. Understanding the risks and predictors of these sentinel events is important for risk evaluation, allocation of hospital resources, and counseling patients.MethodsA retrospective review of the National Surgical Quality Improvement Program (NSQIP) was performed on 60 964 patients undergoing elective spine surgery (any region; laminectomy, arthrodesis, discectomy, or laminoplasty) between 2011 and 2013. Incidence of myocardial infarction, cardiac arrest, unplanned reintubation, on ventilator >48 hours, perioperative pneumonia, and pulmonary embolism was measured. Demographic and surgical predictors of cardiopulmonary complications and associated outcomes (length of stay, discharge disposition, and mortality) were measured using binary logistic regression controlling for confounders.ResultsIncidence rates per 1000 elective spine patients were 2.1 myocardial infarctions, 1.3 cardiac arrests, 4.3 unplanned intubations, 3.5 on ventilator >48 hours, 6.1 perioperative pneumonia, and 3.7 pulmonary embolisms. In analysis of procedure, diagnosis, and approach risk factors, thoracic cavity (odds ratio = 2.47; confidence interval = 1.95-3.12), scoliosis diagnosis, and combined approach (odds ratio = 1.51; confidence interval = 1.15-1.96) independently added the most risk for cardiopulmonary complication. Cardiac arrest had the highest mortality rate (34.57%). Being on ventilator greater than 48 hours resulted in the greatest increase to length of stay (17.58 days).ConclusionsExpected risk factors seen in the Revised Cardiac Risk Index were applicable in the context of spine surgery. Surgical planning should take into account patients who are at higher risk for cardiopulmonary complications and the implications they have on patient outcome.
| S-EPMC5958483 | biostudies-literature
Project description:BackgroundWhile insurance reimbursements allay a portion of costs associated with cardiac operations, uncovered and additional fees are absorbed by patients. An examination of financial toxicity (FT), defined as the burden of patient medical expenses on quality of life, is warranted. Therefore, the present study used a nationally representative database to demonstrate the association between insurance status and risk of financial toxicity (FT) among patients undergoing major cardiac operations.MethodsAdults admitted for elective coronary artery bypass grafting (CABG) and isolated or concomitant valve operations were assessed using the 2016-2019 National Inpatient Sample. FT risk was defined as out-of-pocket expenditure >40% of post-subsistence income. Regression models were developed to determine factors associated with FT risk in insured and uninsured populations. To demonstrate the association between insurance status and risk of FT among patients undergoing major cardiac operations.ResultsOf an estimated 567,865 patients, 15.6% were at risk of FT. A greater proportion of uninsured patients were at risk of FT (81.3 vs. 14.8%, p<0.001), compared to insured. After adjustment, FT risk among insured patients was not affected by non-income factors. However, Hispanic race (Adjusted Odds Ratio [AOR] 1.60), length of stay (AOR 1.17/day), and combined CABG-valve operations (AOR 2.31, all p<0.05) were associated with increased risk of FT in the uninsured.ConclusionUninsured patients demonstrated higher FT risk after undergoing major cardiac operation. Hispanic race, longer lengths of stay, and combined CABG-valve operations were independently associated with increased risk of FT amongst the uninsured. Conversely, non-income factors did not impact FT risk in the insured cohort. Culturally-informed reimbursement strategies are necessary to reduce disparities in already financially disadvantaged populations.
| S-EPMC10830059 | biostudies-literature
Project description:BackgroundApproximately 30% to 64% of patients experience inadequate pain control following spine surgery. The Calgary postoperative pain after spine surgery (CAPPS) score was developed to identify this subset of patients. The impact of preoperative insomnia on postoperative pain control is unknown. This study aimed to investigate the relationship between preoperative insomnia and poor pain control after spine surgery, as well as improve the predictive accuracy of the CAPPS score.MethodsA prospective cohort study was conducted in patients undergoing elective spine surgery. Poor pain control was defined as a mean numeric rating scale pain score >4 at rest within the first 24-hours after surgery. Patients were evaluated using the CAPPS score, which included 7 prognostic factors. A multivariable logistic regression model was used to examine the association between preoperative insomnia severity index (ISI) and poor pain control, adjusting for the CAPPS score. The Modified CAPPS score was derived from this model.ResultsOf 219 patients, 49.7% experienced poorly controlled pain. Prevalence of clinical insomnia (ISI≥15) was 26.9%. Preoperative ISI was independently associated with poor pain control (odds ratio [OR] 1.09, [95%CI=1.03-1.16], p=.004), after adjusting for the CAPPS score (OR 1.61, [95%CI=1.38-1.89], p<.001). The model exhibited good discrimination (c-statistics 0.80, [95%CI=0.74-0.86]) and calibration (Hosmer-Lemeshow chi-square=8.95, p=.35). The Modified CAPPS score also demonstrated good discrimination (c-statistic 0.78, [95%CI=0.72-0.84]) and calibration (Hosmer-Lemeshow chi-square=2.92, p=.57). Low-, high-, and extreme-risk groups stratified by the Modified CAPPS score had 17.3%, 49.1%, and 80.7% predicted probability of experiencing inadequate pain control compared to 32.0%, 64.0%, and 85.1% in the CAPPS score.ConclusionsPreoperative insomnia is prevalent and is a modifiable risk factor for poor pain control following spine surgery. Early identification and management of preoperative insomnia may lead to improved postoperative pain outcomes. Future external validation is needed to confirm the accuracy of the Modified CAPPS score.
| S-EPMC10518606 | biostudies-literature
Project description:Study designRetrospective administrative database review.ObjectiveAnalyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population.Summary of background dataOpioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients.Materials and methodsLongitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU).ResultsA total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001).ConclusionsMost SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.
| S-EPMC9825641 | biostudies-literature