Lower Neighborhood Socioeconomic Status May Influence Medical Complications, Emergency Department Utilization, and Costs of Care After 1-2 Level Lumbar Fusion

Abstract

Study Design. Retrospective Case-Control Study. Objectives. The objectives were to determine whether patients from poor social determinants of health, undergoing primary 1- to 2-level lumbar fusion, demonstrate differences in (1) medical complications, (2) emergency department (ED) utilizations, (3) readmission rates, and (4) costs of care. Summary of Background Data. Measures of socioeconomic disadvantage may enable improved targeting and prevention of potentially increased health care utilization. The Area Deprivation Index (ADI) is a validated index of 17 census-based markers of material deprivation and poverty. Materials and Methods. A retrospective query of the 2010-2020 PearlDiver database was performed for primary 1- to 2-level lumbar fusions for degenerative lumbar pathology. High ADI (scale: 0–100) is associated with a greater disadvantage. Patients with high ADI (90%+) were 1:1 propensity score matched to controls (ADI: 0–89%) by age, sex, and Elixhauser Comorbidity Index. This yielded 34,442 patients, evenly matched between cohorts. Primary outcomes were to compare 90-day complications, ED utilizations, readmissions, and costs of care. Multivariable logistic regression models computed the odds ratios (OR) of ADI on complications, ED utilizations, and readmissions. P-values <0.05 were significant. Results. Patients with a high ADI incurred higher rates and odds of developing respiratory failures (1.17% vs. 0.87%; OR: 1.35, P=0.005). Acute kidney injuries (2.61% vs. 2.29%; OR: 1.14, P=0.056), deep venous thromboses (0.19% vs. 0.17%; OR: 1.14, P=0.611), cerebrovascular accidents (1.29% vs. 1.31%; OR: 0.99, P=0.886), and total medical complications (23.35% vs. 22.93%; OR: 1.02, P=0.441) were similar between groups. High ADI patients experienced higher rates and odds of ED visits within 90 days (9.67% vs. 8.91%; OR: 1.10, P=0.014) and overall 90-day expenditures ($54,459 vs. $47,044; P<0.001). Conclusions. Socioeconomically disadvantaged patients have increased rates and odds of respiratory failure within 90 days. ED utilization within 90 days of surgery was higher in socioeconomically disadvantaged patients. Social determinants of health could be used to inform health care policy and improve postdischarge care. Level of Evidence. Level III.

Area-Level Socioeconomic Disadvantage and Health Care Spending

“…In the ADI-based studies that examined dollar amounts for these spending outcomes from claims data, total spending for surgical care (including postacute care and readmissions) for 4 common surgeries was $2654 higher among those in the highest ADI quintile compared with the lowest, and index hospitalization spending associated with general surgery cases was $1811 higher for those in the highest ADI quartile . Overall 90-day spending following a surgical procedure was $3003 to $7415 higher among patients from the highest-decile ADI areas . Total annual spending for Medicare beneficiaries in Maryland was $3519 higher in the highest ADI quintile compared with the lowest and $48 more per point increase in national ADI percentile for Medicare beneficiaries nationally .…”

“…24 Overall 90-day spending following a surgical procedure was $3003 to $7415 higher among patients from the highest-decile ADI areas. 25,30 Total annual spending for Medicare beneficiaries in Maryland was $3519 higher in the highest ADI quintile compared with the lowest 18 and $48 more per point increase in national ADI percentile for Medicare beneficiaries nationally. 19 In a study using Medicare fee-for-service claims from New York City-area health systems, residence in the highest ADI quintile was associated with similar total Medicare spending but $53 or 12% higher potentially preventable spending than residence in the middle quintile.…”

“…We created an evidence Most included studies used a retrospective cohort (13 [54%]) or cross-sectional (7 [29%]) study design. The most common medical specialty areas for these studies included general adult medicine 12,[16][17][18][19][20] (5 of 14 ADI-based studies and 2 of 10 SVI-based studies) or surgery (5 of 14 ADI-based studies and 5 of 10 SVI-based studies), including general, [21][22][23][24] cardiothoracic, 25 vascular, 26 and orthopedic [27][28][29][30] surgery. A smaller number were more specialty focused on oncology, [31][32][33] cardiology, 34 pediatrics, 35 and COVID-19.…”

Socioeconomic Status and Postoperative Emergency Department Visits

“…First, socioeconomic status (SES) stands out as a potential confounder in the association between the type of surgical center (FASC or HOSC) and postoperative ED visits. SES is known to influence both the likelihood of ED visits postoperatively and the accessibility and location of ambulatory surgery centers . We believe the study could have been strengthened by adjusting for SES, possibly using the hospital zip code data available in the Healthcare Cost and Utilization Project database, or by incorporating other SES-related variables if more granular data were accessible.…”

CORR Insights®: What Factors Identified in Initial Osteoarthritis Management Are Associated With Poor Patient-reported Outcomes After THA? A Register-based Study

“…They found that patients with depression did worse than patients with a BMI > 35 kg/m 2 . A study on 28,410 shoulder arthroplasties [1] likewise found that depressive disorders are associated with longer lengths of stay and more complications, and another study [2] found that preoperative depression screening decreased complications and healthcare costs in lumbar fusion. Another striking finding of this study [4] was that patients who had multiple-joint arthritis also reported poorer outcomes.…”