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

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.