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Abstract
ObjectivesOur objective was to analyze the collective effect of social determinants of health (SDoH) on lumbar spine surgery outcomes utilizing two different statistical methods of combining variables.MethodsThis observational study analyzed data from the Quality Outcomes Database, a nationwide United States spine registry. Race/ethnicity, educational attainment, employment status, insurance payer, and gender were predictors of interest. We built two models to assess the collective influence of SDoH on outcomes following lumbar spine surgery—a stepwise model using each number of SDoH conditions present (0 of 5, 1 of 5, 2 of 5, etc) and a clustered subgroup model. Logistic regression analyses adjusted for age, multimorbidity, surgical indication, type of lumbar spine surgery, and surgical approach were performed to identify the odds of failing to demonstrate clinically meaningful improvements in disability, back pain, leg pain, quality of life, and patient satisfaction at 3- and 12-months following lumbar spine surgery.ResultsStepwise modeling outperformed individual SDoH when 4 of 5 SDoH were present. Cluster modeling revealed 4 distinct subgroups. Disparities between the younger, minority, lower socioeconomic status and the younger, white, higher socioeconomic status subgroups were substantially wider compared to individual SDoH.DiscussionCollective and cluster modeling of SDoH better predicted failure to demonstrate clinically meaningful improvements than individual SDoH in this cohort. Viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDoH on outcomes.
Highlights
Lumbar spine surgery is typically reserved for individuals who have responded poorly to conservative care or have marked physiological degeneration that has resulted in very high levels of pain, disability and lower levels of function [1, 2]
Because spine surgery has higher incidences of harms and costs, a significant amount of effort has gone into modeling individuals who are good candidates for surgical intervention and those who are at risk for poor outcomes [3,4,5]
Care pathways and risk stratification schemes commonly take into account biological and psychological factors [7, 8], yet noticeably less attention has been paid to social factors such as social determinants of health (SDoH)
Summary
Lumbar spine surgery is typically reserved for individuals who have responded poorly to conservative care or have marked physiological degeneration that has resulted in very high levels of pain, disability and lower levels of function [1, 2]. Because spine surgery has higher incidences of harms and costs, a significant amount of effort has gone into modeling individuals who are good candidates for surgical intervention and those who are at risk for poor outcomes [3,4,5]. Scientists, clinicians and policy makers have recognized the influence of biopsychosocial factors on self-reported health outcomes[6]. Care pathways and risk stratification schemes commonly take into account biological and psychological factors [7, 8], yet noticeably less attention has been paid to social factors such as social determinants of health (SDoH). Because recovery from spine surgery can be upwards of 6 months and correspond to increased psychological distress and decreased activity [10,11,12,13], we believe that the importance of addressing SDoH in this population is heightened
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