Social risk factors predicting outcomes of cervical myelopathy surgery

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  • 1 Department of Orthopaedics, Duke University, Durham;
  • | 2 Department of Population Health Sciences, Durham;
  • | 3 Duke Clinical Research Institute, Duke University, Durham, North Carolina;
  • | 4 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 5 Department of Neurosurgery, Washington University in St. Louis, Missouri;
  • | 6 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah;
  • | 7 Department of Neurosurgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas HealthCare System, Charlotte, North Carolina;
  • | 8 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;
  • | 9 Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;
  • | 10 Department of Neurosurgery, University of Tennessee and Semmes-Murphey Clinic, Memphis, Tennessee;
  • | 11 Department of Neurological Surgery, Weill Cornell Medicine, New York, New York;
  • | 12 Altair Health Spine and Wellness, Morristown, New Jersey;
  • | 13 Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan;
  • | 14 Goodman Campbell Brain and Spine, Indianapolis, Indiana;
  • | 15 Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina;
  • | 16 Barrow Neurological Institute, Phoenix, Arizona;
  • | 17 Saint Luke’s Neurological and Spine Surgery, Kansas City, Missouri;
  • | 18 Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida; and
  • | 19 Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
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OBJECTIVE

Combinations of certain social risk factors of race, sex, education, socioeconomic status (SES), insurance, education, employment, and one’s housing situation have been associated with poorer pain and disability outcomes after lumbar spine surgery. To date, an exploration of such factors in patients with cervical spine surgery has not been conducted. The objective of the current work was to 1) define the social risk phenotypes of individuals who have undergone cervical spine surgery for myelopathy and 2) analyze their predictive capacity toward disability, pain, quality of life, and patient satisfaction–based outcomes.

METHODS

The Cervical Myelopathy Quality Outcomes Database was queried for the period from January 2016 to December 2018. Race/ethnicity, educational attainment, SES, insurance payer, and employment status were modeled into unique social phenotypes using latent class analyses. Proportions of social groups were analyzed for demonstrating a minimal clinically important difference (MCID) of 30% from baseline for disability, neck and arm pain, quality of life, and patient satisfaction at the 3-month and 1-year follow-ups.

RESULTS

A total of 730 individuals who had undergone cervical myelopathy surgery were included in the final cohort. Latent class analysis identified 2 subgroups: 1) high risk (non-White race and ethnicity, lower educational attainment, not working, poor insurance, and predominantly lower SES), n = 268, 36.7% (class 1); and 2) low risk (White, employed with good insurance, and higher education and SES), n = 462, 63.3% (class 2). For both 3-month and 1-year outcomes, the high-risk group (class 1) had decreased odds (all p < 0.05) of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Being in the low-risk group (class 2) resulted in an increased odds of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Neither group had increased or decreased odds of being satisfied with surgery.

CONCLUSIONS

Although 2 groups underwent similar surgical approaches, the social phenotype involving non-White race/ethnicity, poor insurance, lower SES, and poor employment did not meet MCIDs for a variety of outcome measures. This finding should prompt surgeons to proactively incorporate socially conscience care pathways within healthcare systems, as well as to optimize community-based resources to improve outcomes and personalize care for populations at social risk.

ABBREVIATIONS

ACDF = anterior cervical discectomy and fusion; ASA = American Society of Anesthesiologists; LCA = latent class analysis; MCID = minimal clinically important difference; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; QOD = Quality Outcomes Database; SES = socioeconomic status.

Illustration from Kong et al. (pp 4–12). Copyright Qing-Jie Kong. Used with permission.

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