Elsevier

The Spine Journal

Volume 11, Issue 5, May 2011, Pages 381-388
The Spine Journal

Clinical Study
Outcomes after spine surgery among racial/ethnic minorities: a meta-analysis of the literature

https://doi.org/10.1016/j.spinee.2011.03.013Get rights and content

Abstract

Background context

Prior research has identified disparities in access to care, resource utilization, and outcomes in members of racial and ethnic minorities. However, the role that race/ethnicity may play in influencing outcomes after spine surgery has not been previously studied.

Purpose

To characterize the effect of race and ethnicity on outcome after spine surgery.

Study design

Systematic literature review and meta-analysis.

Patient sample

Of 11 investigations selected in the initial analysis, four reported results in a fashion that enabled their inclusion in the meta-analysis. These four studies included a total of 128,635 patients.

Outcome measures

“Favorable” or “unfavorable” postsurgical outcomes were determined based on parameters described in each included investigation.

Methods

A systematic literature review was performed to identify all studies documenting outcomes, complications, or mortality after spine surgical procedures. Eligible studies had to include raw data that enabled separate analysis of white and nonwhite patients. Outcome was categorized as “favorable” or “unfavorable” based on scales included in each investigation. The Q-statistic was used to determine heterogeneity, and a meta-analysis was performed to assess the relative risk for unfavorable outcome among nonwhite patients after spine surgery.

Results

Eleven studies met initial selection criteria but only four were eligible for inclusion in the meta-analysis. The meta-analysis included 128,635 patients among whom 12,194 (9.5%) had unfavorable outcomes. Among white patients, 9.4% sustained an unfavorable outcome as compared with 10.4% of nonwhites.

Conclusions

In light of the small number of studies able to be included in the meta-analysis, no firm conclusions can be drawn regarding the effect of race/ethnicity on outcome after spinal surgery. There is a pressing need for more robust research regarding spine surgical outcomes among different racial and ethnic minority groups.

Introduction

Evidence & Methods

For several diseases and treatments medical literature has demonstrated that racial or ethnic factors might impact clinical outcomes. This article, using a meta-analysis technique, aims to determine if this is the case for the outcomes of spinal surgery.

The meta-analysis demonstrated that no firm conclusion could be drawn regarding the potential contribution of race or ethnicity to outcomes following spinal surgery. This uncertainty derives from insufficient evidence, and the authors recommend further exploration.

The authors’ recommendation is certainly reasonable on two fronts. First, careful delineation of factors associated with outcomes is vital for informed and individualized consent consideration. Second, and more importantly, in the specific case of racial and ethnic differences, well-known historical factors in the United States and elsewhere have influenced broad patterns of access to timely care and treatment options available at that point of care. These factors may underlie addressable sources of outcomes variation.

—The Editors

Racial disparities in access to care, resource utilization, complications, and outcomes have been increasingly recognized by health-care researchers in the last few decades [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. A number of investigations have found that black patients are less likely to receive effective medical interventions, such as aortic valve replacement, pacemaker implantation, coronary artery bypass grafting, and renal transplantation [2], [5], [7], [12]. Such inequalities have been documented for common orthopedic procedures as well, including total hip and total knee arthroplasty [11], [14]. Prior research has indicated disparate access to orthopedic care between various ethnic and racial groups, as well as an increased risk of complications for nonwhite patients after major orthopedic procedures [6], [11], [14].

Variations in surgical rates have not been found to occur among populations when the procedure under investigation is widely accepted as efficacious or the standard of care [15], [16]. Substantial variation has been found to occur, however, when procedural efficacy is less clearly defined [11], [15], [16]. In these instances, disparity can arise from demographic factors within the patient population, physician practices within a region, and access to medical care between groups [7], [13], [15], [16], [17].

The Institute of Medicine [12] and the American Academy of Orthopedic Surgeons [17] have both issued calls for increased research addressing the etiology, epidemiology, and innovative approaches to ameliorate racial disparities in orthopedic care. Unfortunately, there is a dearth of information regarding access to orthopedic surgeons and outcomes after surgical interventions among racial and ethnic minorities. The data currently available within the orthopedic literature tend to focus on the field of joint arthroplasty [11], [14], [18], and there is a paucity of research regarding the role that race or ethnicity may play in influencing outcomes after spine surgical procedures. Recent studies point to inadequate access to treatments [6], [7], [13], less intense therapeutic approaches [4], and inequalities in terms of the quality of spine care [13] offered to blacks and other minorities. The purpose of this investigation was to assess the effect of race/ethnicity on outcome after spine surgery by performing a systematic review and meta-analysis of the existing literature. To the best of our knowledge, this is the first study to address this issue.

Section snippets

Literature search

A computerized search of the PubMed database was independently performed by two authors for studies published in print, or electronically, in English from January 1966 to February 2010. A search algorithm was created that entailed the systematic utilization of “and” statements to sequentially link search terms that included spine procedures, outcome-focused terminology, and descriptions of race or ethnicity. Spine procedural terms consisted of neurosurgery, spine surgery, spine fusion,

Results

The computerized literature search identified 1,941 eligible studies from the PubMed database. Of these studies, 1,886 (97.1%) were excluded after review of the abstracts. Fifty-five articles were reviewed in full, and after further exclusions were made, 11 articles were deemed eligible for this study [1], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29]. Table 1 provides details for the 11 included investigations. Seven studies were retrospective in nature [1], [20], [21], [24], [25]

Discussion

Recent literature suggests that racial and ethnic disparities may exist within health care, impacting the health and quality of life of underserved populations [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [17], [21], [23], [24], [25], [26], [27], [28], [29]. While this sentiment can be applied to the field of medicine as whole, inequalities in access to care, health-care delivery, and patient outcomes are particularly disturbing in the arena of musculoskeletal

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    Author disclosures: AJS: Nothing to disclose. RNS: Nothing to disclose. GL: Nothing to disclose. JOB: Nothing to disclose. PJB: Nothing to disclose. CMB: Royalties: Life Spine (B); Consulting: DePuy Spine (B), Medtronic Sofamor Danek (B); Speaking/Teaching Arrangements: DePuy Spine (C), Stryker Spine (B); Board of Directors: North American Spine Society (nonfinancial); Other Office: Applied Spine (B); Research Support (Staff/Materials): Archus Orthopeadics (B), Synthes Spine (D); Grants: Stryker Spine (D); Fellowship Support: DePuy Spine (E).

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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