Impact of race and insurance status on surgical approach for cervical spondylotic myelopathy in the United States

A population-based analysis

Shearwood McClelland, Bryan Marascalchi, Peter G. Passias, Themistocles S. Protopsaltis, Anthony K. Frempong-Boadu, Thomas J. Errico

Research output: Contribution to journalArticle

Abstract

Study Design. Retrospective cohort study. Objective. The aim of the study was to assess factors potentially impacting the operative approach chosen for cervical spondylotic myelopathy (CSM) patients on a nationwide level. Summary of Background Data. CSM is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterioronly, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status. Methods. The nationwide inpatient sample from 2001 to 2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03, 81.32/81.33, 81.02/81.03, or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type. Results. Multivariate analyses revealed that non-white race (black [odds ratio, OR =1.39; 95% confidence interval, CI =1.32-1.47; P <0.0001], Hispanic [OR =1.51; 95% CI=1.38-1.66; P<0.0001], Asian/Pacific Islander [OR=1.40; 95% CI=1.15-1.70; P=0.0007], Native American [OR=1.33; 95% CI=1.02-1.73; P=0.037]) and increasing age (OR=1.03; P <0.0001) were predictive of receiving posterior-only approaches. Female sex (OR =1.39; 95% CI =1.34-1.43; P<0.0001), private insurance (OR=1.19; 95% CI=1.14-1.25; P<0.0001), and nontrauma center admission type (OR =1.29-1.39; 95% CI =1.16-1.56; P <0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR =1.35; 95% CI =1.14-1.59; P=0.0004) and admission source (another hospital [OR=1.65; 95% CI =1.20-2.27; P =0.0023], other health facility [OR =1.68; 95% CI=1.13-2.51; P=0.011]) were the only variables predictive of increased combined anterior-posterior approaches; Native American race (OR=0.32; 95% CI=0.13-0.78; P =0.013) decreased the likelihood of a combined anterior-posterior approach. Conclusion. Private insurance status, female sex, and white race independently predict receipt of anterior-only CSM approaches, whereasd non-white race (black, hispanic, Asian/Pacific Islander, Native American) and nonprivate insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al, 2015), our findings indicate that for CSM patients, non-white race may significantly increase mortality risk, whereas private insurance status may significantly decrease the risk of mortality. Further prospective study will be needed to more definitively address these issues.

Original languageEnglish (US)
Pages (from-to)186-194
Number of pages9
JournalSpine
Volume42
Issue number3
DOIs
StatePublished - Jan 1 2017

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Insurance Coverage
Spinal Cord Diseases
North American Indians
Population
Hispanic Americans
Insurance
Mortality
Oceanic Ancestry Group
Spinal Canal
Health Facilities
Decompression
Inpatients
Primary Health Care
Spine
Cohort Studies
Multivariate Analysis
Retrospective Studies
Odds Ratio
Demography
Prospective Studies

Keywords

  • Cervical spondylotic myelopathy
  • Insurance status
  • Mortality
  • Operative approach
  • Race

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Clinical Neurology

Cite this

Impact of race and insurance status on surgical approach for cervical spondylotic myelopathy in the United States : A population-based analysis. / McClelland, Shearwood; Marascalchi, Bryan; Passias, Peter G.; Protopsaltis, Themistocles S.; Frempong-Boadu, Anthony K.; Errico, Thomas J.

In: Spine, Vol. 42, No. 3, 01.01.2017, p. 186-194.

Research output: Contribution to journalArticle

McClelland, Shearwood ; Marascalchi, Bryan ; Passias, Peter G. ; Protopsaltis, Themistocles S. ; Frempong-Boadu, Anthony K. ; Errico, Thomas J. / Impact of race and insurance status on surgical approach for cervical spondylotic myelopathy in the United States : A population-based analysis. In: Spine. 2017 ; Vol. 42, No. 3. pp. 186-194.
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abstract = "Study Design. Retrospective cohort study. Objective. The aim of the study was to assess factors potentially impacting the operative approach chosen for cervical spondylotic myelopathy (CSM) patients on a nationwide level. Summary of Background Data. CSM is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterioronly, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status. Methods. The nationwide inpatient sample from 2001 to 2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03, 81.32/81.33, 81.02/81.03, or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type. Results. Multivariate analyses revealed that non-white race (black [odds ratio, OR =1.39; 95{\%} confidence interval, CI =1.32-1.47; P <0.0001], Hispanic [OR =1.51; 95{\%} CI=1.38-1.66; P<0.0001], Asian/Pacific Islander [OR=1.40; 95{\%} CI=1.15-1.70; P=0.0007], Native American [OR=1.33; 95{\%} CI=1.02-1.73; P=0.037]) and increasing age (OR=1.03; P <0.0001) were predictive of receiving posterior-only approaches. Female sex (OR =1.39; 95{\%} CI =1.34-1.43; P<0.0001), private insurance (OR=1.19; 95{\%} CI=1.14-1.25; P<0.0001), and nontrauma center admission type (OR =1.29-1.39; 95{\%} CI =1.16-1.56; P <0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR =1.35; 95{\%} CI =1.14-1.59; P=0.0004) and admission source (another hospital [OR=1.65; 95{\%} CI =1.20-2.27; P =0.0023], other health facility [OR =1.68; 95{\%} CI=1.13-2.51; P=0.011]) were the only variables predictive of increased combined anterior-posterior approaches; Native American race (OR=0.32; 95{\%} CI=0.13-0.78; P =0.013) decreased the likelihood of a combined anterior-posterior approach. Conclusion. Private insurance status, female sex, and white race independently predict receipt of anterior-only CSM approaches, whereasd non-white race (black, hispanic, Asian/Pacific Islander, Native American) and nonprivate insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al, 2015), our findings indicate that for CSM patients, non-white race may significantly increase mortality risk, whereas private insurance status may significantly decrease the risk of mortality. Further prospective study will be needed to more definitively address these issues.",
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TY - JOUR

T1 - Impact of race and insurance status on surgical approach for cervical spondylotic myelopathy in the United States

T2 - A population-based analysis

AU - McClelland, Shearwood

AU - Marascalchi, Bryan

AU - Passias, Peter G.

AU - Protopsaltis, Themistocles S.

AU - Frempong-Boadu, Anthony K.

AU - Errico, Thomas J.

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Study Design. Retrospective cohort study. Objective. The aim of the study was to assess factors potentially impacting the operative approach chosen for cervical spondylotic myelopathy (CSM) patients on a nationwide level. Summary of Background Data. CSM is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterioronly, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status. Methods. The nationwide inpatient sample from 2001 to 2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03, 81.32/81.33, 81.02/81.03, or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type. Results. Multivariate analyses revealed that non-white race (black [odds ratio, OR =1.39; 95% confidence interval, CI =1.32-1.47; P <0.0001], Hispanic [OR =1.51; 95% CI=1.38-1.66; P<0.0001], Asian/Pacific Islander [OR=1.40; 95% CI=1.15-1.70; P=0.0007], Native American [OR=1.33; 95% CI=1.02-1.73; P=0.037]) and increasing age (OR=1.03; P <0.0001) were predictive of receiving posterior-only approaches. Female sex (OR =1.39; 95% CI =1.34-1.43; P<0.0001), private insurance (OR=1.19; 95% CI=1.14-1.25; P<0.0001), and nontrauma center admission type (OR =1.29-1.39; 95% CI =1.16-1.56; P <0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR =1.35; 95% CI =1.14-1.59; P=0.0004) and admission source (another hospital [OR=1.65; 95% CI =1.20-2.27; P =0.0023], other health facility [OR =1.68; 95% CI=1.13-2.51; P=0.011]) were the only variables predictive of increased combined anterior-posterior approaches; Native American race (OR=0.32; 95% CI=0.13-0.78; P =0.013) decreased the likelihood of a combined anterior-posterior approach. Conclusion. Private insurance status, female sex, and white race independently predict receipt of anterior-only CSM approaches, whereasd non-white race (black, hispanic, Asian/Pacific Islander, Native American) and nonprivate insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al, 2015), our findings indicate that for CSM patients, non-white race may significantly increase mortality risk, whereas private insurance status may significantly decrease the risk of mortality. Further prospective study will be needed to more definitively address these issues.

AB - Study Design. Retrospective cohort study. Objective. The aim of the study was to assess factors potentially impacting the operative approach chosen for cervical spondylotic myelopathy (CSM) patients on a nationwide level. Summary of Background Data. CSM is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterioronly, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status. Methods. The nationwide inpatient sample from 2001 to 2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03, 81.32/81.33, 81.02/81.03, or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type. Results. Multivariate analyses revealed that non-white race (black [odds ratio, OR =1.39; 95% confidence interval, CI =1.32-1.47; P <0.0001], Hispanic [OR =1.51; 95% CI=1.38-1.66; P<0.0001], Asian/Pacific Islander [OR=1.40; 95% CI=1.15-1.70; P=0.0007], Native American [OR=1.33; 95% CI=1.02-1.73; P=0.037]) and increasing age (OR=1.03; P <0.0001) were predictive of receiving posterior-only approaches. Female sex (OR =1.39; 95% CI =1.34-1.43; P<0.0001), private insurance (OR=1.19; 95% CI=1.14-1.25; P<0.0001), and nontrauma center admission type (OR =1.29-1.39; 95% CI =1.16-1.56; P <0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR =1.35; 95% CI =1.14-1.59; P=0.0004) and admission source (another hospital [OR=1.65; 95% CI =1.20-2.27; P =0.0023], other health facility [OR =1.68; 95% CI=1.13-2.51; P=0.011]) were the only variables predictive of increased combined anterior-posterior approaches; Native American race (OR=0.32; 95% CI=0.13-0.78; P =0.013) decreased the likelihood of a combined anterior-posterior approach. Conclusion. Private insurance status, female sex, and white race independently predict receipt of anterior-only CSM approaches, whereasd non-white race (black, hispanic, Asian/Pacific Islander, Native American) and nonprivate insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al, 2015), our findings indicate that for CSM patients, non-white race may significantly increase mortality risk, whereas private insurance status may significantly decrease the risk of mortality. Further prospective study will be needed to more definitively address these issues.

KW - Cervical spondylotic myelopathy

KW - Insurance status

KW - Mortality

KW - Operative approach

KW - Race

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