title: Disparities in deep brain stimulation surgery among insured elders with Parkinson disease.
abstract: OBJECTIVE
  To identify sociodemographic, clinical, and physician/practice factors associated with deep brain stimulation (DBS). DBS is a proven surgical therapy for Parkinson disease (PD), but is recommended only for patients with excellent health, results in significant out-of-pocket costs, and requires substantial physician involvement.
  
  
  METHODS
  Retrospective cohort study of more than 657,000 Medicare beneficiaries with PD. Multivariable logistic regression models examined the association between demographic, clinical, socioeconomic status (SES), and physician/practice factors, and DBS therapy.
  
  
  RESULTS
  There were significant disparities in the use of DBS therapy among Medicare beneficiaries with PD. The greatest disparities were associated with race: black (adjusted odds ratio [AOR] 0.20, 95% confidence interval [CI] 0.16-0.25) and Asian (AOR 0.55, 95% CI 0.44-0.70) beneficiaries were considerably less likely to receive DBS than white beneficiaries. Women (AOR 0.79, 95% CI 0.75-0.83) also had lower odds of receiving DBS compared with men. Eighteen percent of procedures were performed on patients with PD who had cognitive impairment/dementia, a reported contraindication to DBS. Beneficiaries treated in minority-serving PD practices were less likely to receive DBS, regardless of individual race (AOR 0.76, 95% CI 0.66-0.87). Even after adjustment for demographic and clinical covariates, high neighborhood SES was associated with 1.4-fold higher odds of receiving DBS (AOR 1.42, 95% CI 1.33-1.53).
  
  
  CONCLUSIONS
  Among elderly Medicare beneficiaries with PD, race, sex, and neighborhood SES are strong independent predictors of DBS receipt. Racial disparities are amplified when adjusting for physician/clinic characteristics. Future investigations of the demographic differences in clinical need/usefulness of DBS, ease of DBS attainment, and actual/opportunity DBS costs are needed to inform policies to reduce DBS disparities and improve PD quality of care.
authors: From the Departments of Neurology and Epidemiology and Biostatistics and the Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (X.-Y.W., J.S.P., N.K., B.A.R.), and Departments of Radiology and Neurobiology and Programs in Physical Therapy and Occupational Therapy (J.S.P.), Washington University School of Medicine, St. Louis; and Departments of Epidemiology and Health Services Research and Medicine (M.S.), St. Louis University, MO.
authors: Allison W
authors: AW
authors: Willis
authors: Mario
authors: M
authors: Schootman
authors: Nathan
authors: N
authors: Kung
authors: Xiao-Yu
authors: XY
authors: Wang
authors: Joel S
authors: JS
authors: Perlmutter
authors: Brad A
authors: BA
authors: Racette
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D015897:Comorbidity; D046690:Deep Brain Stimulation / Q000191:economics / Q000706:statistics & numerical data*; D005006:Ethnicity; D005260:Female; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D010300:Parkinson Disease / Q000401:mortality / Q000628:therapy*; D011153:Population; D012424:Rural Population; D012737:Sex Factors; D012923:Social Class; D014481:United States / Q000453:epidemiology; D014505:Urban Population