95. Racial, ethnic and financial disparities in spine surgery in the state of Washington

BACKGROUND CONTEXT Racial and financial disparities in health care remain an obstacle to providing quality patient care. Although previous studies have identified these disparities as being risk factors for postoperative complications, none have examined the preoperative variables that may contribute to these disparities. PURPOSE This study aims to evaluate the determinants of health that contribute to racial and ethnic disparities in spine surgeries, and to investigate whether patient race and ethnicity is an independent predictor of preoperative and postoperative outcomes in Washington State. STUDY DESIGN/SETTING Retrospective review of the Washington State Surgical Clinical Outcomes Assessment Program (Spine COAP) database. PATIENT SAMPLE A total of 43,288 adult patients (>18 years old) undergoing four or fewer spinal levels surgery. OUTCOME MEASURES The Spine COAP database was queried for all elective spine surgery cases performed from January 1st 2015 to December 31st 2020. Patient's race and ethnicity were recorded by patient's self-report in the survey of Spine COAP into six racial categories: American Indian/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, White/Caucasian or Other/Multiple, and one ethnicity: Latino or Hispanic. Due to the reduced number in some of the racial groups, we grouped the patients into White Non-Hispanic (WNH), White Hispanic (WH), Black/African American (AA), Asian (AS) and Other (Native Hawaiian/Pacific islander, Native American/ Alaskan Native, and Multiracial). Demographic variables comprised patient's age, sex, body mass index, insurance type and work status. Patient comorbidities included were hypertension, diabetes mellitus and smoking status. Preoperative interventions included were pain management (record of preoperative analgesia use and type), conservative management, and glucose management (evaluation in pre- and postoperative time period of blood glucose levels and insulin use). Surgical procedure type, lumbar (fusion/nonfusion) or cervical (fusion/nonfusion), were obtained. Postoperative outcomes included were length of hospital stay, discharge location (home vs others) and 30-day complications (reoperations and infections). METHODS Descriptive analysis showing the distribution of the demographics, financial, preoperative, operative and postoperative factors across the racial/ethnic groups were performed. Multivariate analysis for the association between racial groups and preoperative & postoperative outcomes were performed using logistic regression models to calculate odds ratios [OR (95%CI)] for binary outcomes. All variables were adjusted for a priori selected sex, patient age, BMI and insurance status at admission. All analyses were conducted in Stata 14.0 (College Station, TX) (StataCorp, 2015), with a significance level considered at 0.05 alpha level for the outcome analysis. RESULTS A total of 43,288 patients were identified of whom 87.7% were White-Non-Hispanic (WNH), 3.4% were White-Hispanic (WH), 3% were African-American (AA), 2.7% were Asian (AS) and 2.1% were Other (including American Indian/Alaska Native and Hawaiian/Pacific Islander and multiracial). WNH patients were older than all the minority groups. The AS group had a higher proportion of females compared with all the other racial groups. All minority groups reported higher prevalence of DM compared to WNH patients. BMI was higher for WNH, WH, AA and Others compared to AS patients. AA patients had higher prevalence of hypertension and current smoking status compared to the other racial groups. Minority groups demonstrated highest rate of not having medical insurance. Minority groups were less likely to have conservative management (physical therapy, acupuncture, etc) prior to surgery. Minority groups were more likely to have pain management (analgesics, steroid injections) and more likely to have preoperative glucose management compared to the WNH patients prior to surgery. Minority groups were more likely to have hospital stay greater than 4 days (the AA group being twice likely compared to WNH) and they were less likely to be discharged home (the AA group being the most affected group). We found that the Minority groups were more likely to have postop complications (including SSI and reoperations) compared to the WNH group. In the context that the 30-day postoperative complications rate was very low, this is in addition to only 12% of the people having surgery are part of the minority group. CONCLUSIONS Our results indicate differences on the preoperative management and postoperative outcomes among the racial/ethnic groups. This suggests that disparities among minority groups still exist in spinal surgery in Washington State. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Racial and financial disparities in health care remain an obstacle to providing quality patient care. Although previous studies have identified these disparities as being risk factors for postoperative complications, none have examined the preoperative variables that may contribute to these disparities. This study aims to evaluate the determinants of health that contribute to racial and ethnic disparities in spine surgeries, and to investigate whether patient race and ethnicity is an independent predictor of preoperative and postoperative outcomes in Washington State. Retrospective review of the Washington State Surgical Clinical Outcomes Assessment Program (Spine COAP) database. A total of 43,288 adult patients (>18 years old) undergoing four or fewer spinal levels surgery. The Spine COAP database was queried for all elective spine surgery cases performed from January 1st 2015 to December 31st 2020. Patient's race and ethnicity were recorded by patient's self-report in the survey of Spine COAP into six racial categories: American Indian/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, White/Caucasian or Other/Multiple, and one ethnicity: Latino or Hispanic. Due to the reduced number in some of the racial groups, we grouped the patients into White Non-Hispanic (WNH), White Hispanic (WH), Black/African American (AA), Asian (AS) and Other (Native Hawaiian/Pacific islander, Native American/ Alaskan Native, and Multiracial). Demographic variables comprised patient's age, sex, body mass index, insurance type and work status. Patient comorbidities included were hypertension, diabetes mellitus and smoking status. Preoperative interventions included were pain management (record of preoperative analgesia use and type), conservative management, and glucose management (evaluation in pre- and postoperative time period of blood glucose levels and insulin use). Surgical procedure type, lumbar (fusion/nonfusion) or cervical (fusion/nonfusion), were obtained. Postoperative outcomes included were length of hospital stay, discharge location (home vs others) and 30-day complications (reoperations and infections). Descriptive analysis showing the distribution of the demographics, financial, preoperative, operative and postoperative factors across the racial/ethnic groups were performed. Multivariate analysis for the association between racial groups and preoperative & postoperative outcomes were performed using logistic regression models to calculate odds ratios [OR (95%CI)] for binary outcomes. All variables were adjusted for a priori selected sex, patient age, BMI and insurance status at admission. All analyses were conducted in Stata 14.0 (College Station, TX) (StataCorp, 2015), with a significance level considered at 0.05 alpha level for the outcome analysis. A total of 43,288 patients were identified of whom 87.7% were White-Non-Hispanic (WNH), 3.4% were White-Hispanic (WH), 3% were African-American (AA), 2.7% were Asian (AS) and 2.1% were Other (including American Indian/Alaska Native and Hawaiian/Pacific Islander and multiracial). WNH patients were older than all the minority groups. The AS group had a higher proportion of females compared with all the other racial groups. All minority groups reported higher prevalence of DM compared to WNH patients. BMI was higher for WNH, WH, AA and Others compared to AS patients. AA patients had higher prevalence of hypertension and current smoking status compared to the other racial groups. Minority groups demonstrated highest rate of not having medical insurance. Minority groups were less likely to have conservative management (physical therapy, acupuncture, etc) prior to surgery. Minority groups were more likely to have pain management (analgesics, steroid injections) and more likely to have preoperative glucose management compared to the WNH patients prior to surgery. Minority groups were more likely to have hospital stay greater than 4 days (the AA group being twice likely compared to WNH) and they were less likely to be discharged home (the AA group being the most affected group). We found that the Minority groups were more likely to have postop complications (including SSI and reoperations) compared to the WNH group. In the context that the 30-day postoperative complications rate was very low, this is in addition to only 12% of the people having surgery are part of the minority group. Our results indicate differences on the preoperative management and postoperative outcomes among the racial/ethnic groups. This suggests that disparities among minority groups still exist in spinal surgery in Washington State.