title: Disparities in access to deep brain stimulation surgery for Parkinson disease: interaction between African American race and Medicaid use.
abstract: OBJECTIVE
  African American individuals experience barriers to accessing many types of health care in the United States, resulting in substantial health care disparities. To improve health care in this patient population, it is important to recognize and study the potential factors limiting access to care.
  
  
  OBJECTIVE
  To examine deep brain stimulation (DBS) use in Parkinson disease (PD) to determine which factors, among a variety of demographic, clinical, and socioeconomic variables, drive DBS use in the United States.
  
  
  METHODS
  We queried the Nationwide Inpatient Sample in combination with neurologist and neurological surgeon countywide density data from the Area Resource File. We used International Classification of Diseases, Ninth Revision codes to identify discharges of patients at multicenter, all-payer, nonfederal hospitals in the United States diagnosed with PD (code 332.0) who were admitted for implantation of intracranial neurostimulator lead(s) (code 02.39), DBS.
  
  
  METHODS
  We analyzed factors predicting DBS use in PD using a hierarchical logistic regression analysis including patient and hospital characteristics. Patient characteristics included age, sex, comorbidity score, race, income quartile of zip code, and insurance type. Hospital characteristics included teaching status, size, regional location, urban vs rural setting, experience with DBS discharges, year, and countywide density of neurologists and neurological surgeons.
  
  
  RESULTS
  Query of the Nationwide Inpatient Sample yielded 2,408,302 PD discharges from 2002 to 2009; 18,312 of these discharges were for DBS. Notably, 4.7% of all PD discharges were African American, while only 0.1% of DBS for PD discharges were African American. A number of factors in the hierarchical multivariate analysis predicted DBS use including younger age, male sex, increasing income quartile of patient zip code, large hospitals, teaching hospitals, urban setting, hospitals with higher number of annual discharges for PD, and increased countywide density of neurologists (P < .05). Predictors of nonuse included African American race (P < .001), Medicaid use (P < .001), and increasing comorbidity score (P < .001). Countywide density of neurological surgeons and Hispanic ethnicity were not significant predictors.
  
  
  CONCLUSIONS
  AND RELEVANCE: Despite the fact that African American patients are more often discharged from hospitals with characteristics predicting DBS use (ie, urban teaching hospitals in areas with a higher than average density of neurologists), these patients received disproportionately fewer DBS procedures compared with their non-African American counterparts. Increased reliance on Medicaid in the African American population may predispose to the DBS use disparity. Various other factors may be responsible, including disparities in access to care, cultural biases or beliefs, and/or socioeconomic status.
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Chan
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Robert A
authors.initials: RA
authors.lastname: McGovern
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Lauren T
authors.initials: LT
authors.lastname: Brown
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York3currently with Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
authors.forename: John P
authors.initials: JP
authors.lastname: Sheehy
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Brad E
authors.initials: BE
authors.lastname: Zacharia
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Charles B
authors.initials: CB
authors.lastname: Mikell
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Samuel S
authors.initials: SS
authors.lastname: Bruce
authors.affiliation: Department of Neurology, Columbia University Medical Center, New York, New York.
authors.forename: Blair
authors.initials: B
authors.lastname: Ford
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Guy M
authors.initials: GM
authors.lastname: McKhann
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D046690:Deep Brain Stimulation / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D008875:Middle Aged; D010300:Parkinson Disease / Q000453:epidemiology / Q000601:surgery / Q000628:therapy*; D012737:Sex Factors; D014481:United States / Q000453:epidemiology