This analysis sought to elucidate how socioeconomic and racial disparities in preoperative physical functionality (GPH), mental distress (GMH), and pain (VAS) among patients undergoing spine surgery impact postoperative outcomes. Though Black/AA patients were found to generally have more severe presenting pathology than White patients, these differences were largely abrogated when patients were further sub-stratified by SES (proxied by median household income). Compared with higher SES patients, White and Black patients in the lowest-SES cohort reported lower GPH and GMH scores, suggesting that in our population, racial disparities in presenting health were linked to SES and care access. Indeed, we found that patients with the worst preoperative physical impairment resided in neighborhoods with greater chronic disease, greater poverty, and lower PCP access, the latter two of which were confirmed by multivariable linear regression to be independent predictors of worse physical wellbeing. Finally, this study demonstrated that patients with more severe presentations (worse GPH scores) had worse outcomes by POD90 and 1 year.
The present investigation is timely given the growing focus on systemic racism and structural disparities in healthcare. Delayed care incurs risk of emotional and physical distress to patients, disproportionately affecting those of disadvantaged backgrounds.[6–10] While our dataset did not permit a causal analysis of these disparities, the literature demonstrates how social determinants of health (SDOH) modulate the process of accessing definitive treatment. Minority patients are less likely to have high quality insurance, jobs with paid medical leave, and transportation. Patients of lower SES experience similar innate barriers; for instance, among trauma patients, time to orthopedic evaluation/surgery and time from MRI to surgery are increased in patients with government insurance (compared with commercial)[31,32] and lower median household incomes, respectively. Moreover, minority and low-SES patients have smaller specialist networks and are less likely to receive referrals.[33–35]
Hereto, orthopedic research has overwhelmingly focused on predictors of suboptimal surgical outcomes, overlooking preoperative health. However, among patients undergoing lumbar spine surgery, those with higher preoperative anesthesiologists' physical status classification scores (i.e., physical impairment) are twice as likely to have poor outcomes, and those with extended preoperative pain, worse baseline disability, and worse health-related QOL are more likely to report deteriorating functional trajectories postoperatively. These findings underlie a common theme: impaired preoperative health is associated with worse orthopedic patient-reported outcomes, functioning, and pain.[37–40]
The present study is among the first to consider preoperative mental and physical health in relation to both racial and socioeconomic inequities. Consistent with literature attributing racial disparities in preoperative health to socioeconomic disparities, we demonstrated this phenomenon in orthopedic patients, observing that patients of the lowest SES were more vulnerable to functional impairment than higher SES patients. Given that more severe presenting pathology correlates with worse POD90 and 1-year outcomes, this study's findings corroborate the need for greater patient education and outreach as it pertains to elective spinal procedures. Indeed, it is logical that disadvantaged patients with barriers to care would be inclined to delay evaluation until their pain escalates to the point of true functional impairment, a decision that is likely bolstered by ineffective communication of the utility of early intervention for spinal pathologies. Such delays predispose these patients to attenuated long-term outcomes, and hence, there exists an imperative among the orthopedic community to better disseminate information regarding this urgency to both the general community and PCPs specifically, who can better guide and refer patients. In the same way that a universal dogma exists around early lipid and blood pressure control for the prevention of hyperlipidemia and hypertension-related complications, a similar mindset should be adopted for the management of back pain.
Given this study's retrospective design, we cannot attribute causality to our findings; while a lower-SES patient may face barriers to care that exacerbate presenting disability, it is plausible that their impairment could preclude career advancement and likewise affect their SES. Nonetheless, intervention earlier in the disease process remains critical. Additional data considerations included the granularity of social metrics, which were limited in some cases to patient county. Social metrics at the individual patient level may yield different results, especially as it relates to patient financial status, which was estimated using regional household income data. Further, our analysis did not include patient insurance status, which likely would influence preoperative wellbeing, with underinsured patients suffering delays to presentation. While we cannot delineate the unique effect of insurance coverage on preoperative health, since underinsurance is strongly correlated with lower SES, the implications of our findings remain unaltered. Finally, our findings cannot be generalized to the healing trajectory beyond 12 months postoperatively; results may differ with extended follow-up. Of note, GMH and GPH are relatively novel measures in orthopedics compared with "legacy" metrics (NDI, ODI, and SF-36).[25,26] However, studies have demonstrated convergent validity and responsiveness analogous to these legacy measures using PROMIS in spinal surgical patients. In fact, one study of 3000 such patients found that PROMIS health domains were more responsive to longitudinal changes and facilitated time-efficient evaluations of perceived health status compared with legacy metrics.
Relevant financial activities outside the submitted work: consultancy.
Ethical Board Review Statement
This study was approved by the Institutional Review Board at the University of Pennsylvania. Each author certifies that our institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
Spine. 2022;47(11):781-791. © 2022 Lippincott Williams & Wilkins