Black and low-income teens have more ED visits, major complications after scoliosis surgery

New research by Nemours Children's Health has found that teens who are Black, publicly insured and of lower socioeconomic status (SES) tend to have more major complications after surgery for adolescent idiopathic scoliosis (AIS), the most common type of scoliosis. In addition, patients with public insurance are much more likely to return to the Emergency Department within 90 days of surgery. The study was published in the Journal of Pediatric Orthopaedics.

"The greatest disparities in care existed between patients who are Caucasian, privately insured and of higher socioeconomic status and those who are Black, publicly insured and of lower socioeconomic status," said senior author Suken A. Shah, MD, Pediatric Orthopedic Surgeon and The Shands/MacEwen Endowed Chair of Orthopedics and Chair of the Department of Orthopedic Surgery at Nemours Children's Health, Delaware Valley.

"Our results suggest that these patient characteristics have a clear influence on pre- and post-operative care and, most concerningly, on post-surgical outcomes."

In scoliosis, the spine develops an abnormal side-to-side curve shaped like an S or a C. In most cases the cause is unknown, or idiopathic. It can occur in younger children but generally develops between ages 10 to 15. Severe cases can cause joint damage, arthritis, pain and lung problems. Treatments include a back brace to keep the curve from worsening and, for more severe cases, surgery to reduce the curve.

In this retrospective cohort study, researchers found that being Black, of lower SES and having public insurance correlated with lower rates of being prescribed a brace and of obtaining a second opinion before posterior spinal fusion (PSF) surgery for AIS:

• Black patients (36%) were less likely to have been initially treated with a brace (vs. 60% of Caucasians) or to have received a second opinion (8.7%) before surgery (vs. 26% of Caucasians).
• Patients with public insurance (45%) were less likely to have received initial treatment with a brace (vs. 57% of those with private insurance) or to have obtained a second opinion (9.4%) before surgery (vs. 26% with private insurance).
• Among low-SES patients, only 31% were prescribed a brace as initial treatment (vs. 55% of high-SES patients); just 13% received a preoperative second opinion (vs. 27% of high-SES patients); and 31% missed post-operative checkups (vs. 13% of high SES patients).

The study reviewed the cases of 421 patients aged 10 to 21 years with AIS: 74% were Caucasian, 16% Black and 9.4% of other racial/ethnic backgrounds; and 80% had private insurance and 20%, public insurance. Each underwent posterior spinal fusion (PSF) between 2015 and 2021 at a single, high-volume pediatric institution.

The authors note that patients who are more likely to miss pre- or post-operative appointments may benefit from a series of reminders or from telemedicine visits.

"Missed appointments are concerning because pre-operative assessments offer opportunities to optimize treatment and educate patients about procedures, including non-surgical options and research study enrollment," said Shah.

"Post-operative appointments allow for potential changes to the treatment plan and for early detection and treatment of any complications, to avoid potentially more significant complications when treatment is delayed."