Black Patients at High Risk of Poor Outcomes From Lumbar Spinal Fusion

Black patients undergoing lumbar spine fusion experience a worse postoperative course, including a higher rate of complications, longer length of stay, higher total charges, and increased readmissions compared with white patients, according to an analysis of Healthcare Cost and Utilization Project’s State Inpatient Databases (HCUP-SID) administrative data from 5 states. The findings were published online ahead of print in Spine.

scissors cut through inequalityThe first step is to acknowledge disparities exist in healthcare. Photo Source: iStock.com.

Senior author Robert S. White, MD, MS, hopes that the findings “make the spine community aware of these disparities in care. This is a first major step in acknowledgement that a problem exists. Increasing providers’ awareness of disparities is also one of Institute of Medicine’s recommendations for combating healthcare inequality.”1

“It this our hope that this paper will start a conversation that also includes implicit bias training so that we can identify and combat disparities,” said Dr. White who is an anesthesiologist at NewYork-Presbyterian Hospital/Weill Cornell Medicine in New York City.

Study Design

The researchers analyzed patient discharge records from 2007 to 2014 in 5 states (California, Florida, New York, Maryland, and Kentucky) to identify cases of lumbar posterior, lateral, or anterior spine surgery. These states were selected as they are among the largest states with HCUP-SID data available for analysis, Dr. White explained. A total of 267,976 records met inclusion criteria for analysis.

The study population included 208,088 (77.7%) white patients and 17,326 (6.5%) black patients. Compared with white patients, the Black patients were more likely to be female, younger, in the poorest quartile of median income, or obese, and have diabetes or hypertension.

Higher Complication Rate Found Among Blacks Undergoing Spinal Surgery

Black patients were more likely than white patients to experience spine surgery specific complications and general postoperative complications as well as a higher readmissions rate, even after adjusting for patient demographics/comorbidities, hospital characteristics, surgical approach, and year and state of surgery. In addition, length of hospital stay, and total hospital charges were higher in Black patients than in white patients.

Table: Outcomes of lumbar spinal surgery among black patients

Potential Causes of Disparity

Black patients were more likely to undergo surgery at hospitals with low surgical volume or with a high safety net burden, which have limited resources, are slower to adapt to new technology, and have fewer specialists, the researchers noted.2 In addition, black patients have poorer preoperative baseline health, including higher rates of diabetes, obesity, and other comorbidities.3

Furthermore, black patients may have poor presurgical optimization and greater delays in surgery, as Black patients were more likely to undergo emergency or urgent procedures versus elective surgeries. Also, previous studies have shown that Black patients have significantly fewer visits to spine clinics, have fewer physical therapy appointments, and are less likely to receive imaging studies for acute low back pain.4

“It is important to better understand causal factor for differences in elective spine surgery outcomes as related to race through prospective studies,” commented Andreea Seicean, MD, PhD, MPH, Psychiatrist at River North Psychiatry and Adjunct Professor of Psychiatry at the University of Illinois at Chicago. Dr. Seicean and colleagues’ 2017 retrospective study found a similar link between African-American race and worse outcomes after undergoing elective spine surgery.

“Our study was comprised of 48,493 adult patients who underwent elective spine surgery consisting of elective laminectomy and/or fusion between 2006 and 2012 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a prospectively collected, national clinical database with established reproducibility and validity,” Dr. Seicean told SpineUniverse.

“We found that African-American patients had length of hospital stay that was, on average, 1 day longer than that for Caucasian patients even after controlling for differences between pre- and intraoperative factors,” Dr. Seicean said. “African-American patients also had higher odds for major complications [odds ratio (OR) = 1.3; 95% confidence interval (95% CI) 1.1-1.6], and to be discharged requiring continued care (OR = 2.3; 95% CI 1.8-2.8).”

Strategies to Reduce Spine Surgery Disparities Among Black Patients

“Spine surgeons can help reduce these disparities through better communication and outreach amongst medical professionals to the Black community at large,” Dr. White said. Short-term strategies include improvements in cultural competency and outreach, while long-term strategies include recruitment of Black and URM [underrepresented minority] physicians to promote trust between doctors and the community.”

In addition, use of standardized Enhanced Recovery After Surgery (ERAS) programs may be a possible solution to reducing the disparities in care found in among Black patients in this study, Dr. White said.

“ERAS programs are designed to deliver evidence-based medicine according to guidelines—ie, every patient receives standardized care that should be the best care based on the best evidence,” Dr. White said. “This will help to prevent implicit bias from clouding judgements impacting care delivered to patients.”

“ERAS program adoption maybe a cost-effective solution. Unfortunately, no one to my knowledge has studied this aspect,” Dr. White told SpineUniverse. Additionally, “These programs may or may not work at low-volume or safety net hospitals; it depends on the hospital’s culture of change and acceptance.”

Disclosures
Dr. White has no relevant disclosures. Dr. Seicean has served on the physician advisory panel for Janssen.

Updated on: 02/10/20
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