title: Impact of Race and Insurance Status on Surgical Approach for Cervical Spondylotic Myelopathy in the United States: A Population-Based Analysis.
abstract: METHODS
  Retrospective cohort study.
  
  
  OBJECTIVE
  The aim of the study was to assess factors potentially impacting the operative approach chosen for cervical spondylotic myelopathy (CSM) patients on a nationwide level.
  
  
  BACKGROUND
  CSM is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterior-only, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status.
  
  
  METHODS
  The nationwide inpatient sample from 2001 to 2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03, 81.32/81.33, 81.02/81.03, or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type.
  
  
  RESULTS
  Multivariate analyses revealed that non-white race (black [odds ratio, OR = 1.39; 95% confidence interval, CI = 1.32-1.47; P < 0.0001], Hispanic [OR = 1.51; 95% CI = 1.38-1.66; P < 0.0001], Asian/Pacific Islander [OR = 1.40; 95% CI = 1.15-1.70; P = 0.0007], Native American [OR = 1.33; 95% CI = 1.02-1.73; P = 0.037]) and increasing age (OR = 1.03; P < 0.0001) were predictive of receiving posterior-only approaches. Female sex (OR = 1.39; 95% CI = 1.34-1.43; P < 0.0001), private insurance (OR = 1.19; 95% CI = 1.14-1.25; P < 0.0001), and nontrauma center admission type (OR = 1.29-1.39; 95% CI = 1.16-1.56; P < 0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR = 1.35; 95% CI = 1.14-1.59; P = 0.0004) and admission source (another hospital [OR = 1.65; 95% CI = 1.20-2.27; P = 0.0023], other health facility [OR = 1.68; 95% CI = 1.13-2.51; P = 0.011]) were the only variables predictive of increased combined anterior-posterior approaches; Native American race (OR = 0.32; 95% CI = 0.13-0.78; P = 0.013) decreased the likelihood of a combined anterior-posterior approach.
  
  
  CONCLUSIONS
  Private insurance status, female sex, and white race independently predict receipt of anterior-only CSM approaches, whereasd non-white race (black, hispanic, Asian/Pacific Islander, Native American) and nonprivate insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al, 2015), our findings indicate that for CSM patients, non-white race may significantly increase mortality risk, whereas private insurance status may significantly decrease the risk of mortality. Further prospective study will be needed to more definitively address these issues.
  
  
  METHODS
  3.
authors.affiliation: Division of Spine Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY.
authors.forename: Shearwood
authors.initials: S
authors.lastname: McClelland
authors.affiliation: Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Bryan J
authors.initials: BJ
authors.lastname: Marascalchi
authors.affiliation: Division of Spine Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Passias
authors.affiliation: Division of Spine Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY.
authors.forename: Themistocles S
authors.initials: TS
authors.lastname: Protopsaltis
authors.affiliation: Department of Neurosurgery, NYU Langone Medical Center, New York, NY.
authors.forename: Anthony K
authors.initials: AK
authors.lastname: Frempong-Boadu
authors.affiliation: Division of Spine Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Errico
mesh_terms: D001741:Black or African American; D002574:Cervical Vertebrae / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D006630:Hispanic or Latino; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D007796:Laminectomy / Q000379:methods; D065406:Laminoplasty / Q000379:methods; D008297:Male; D011446:Prospective Studies; D044469:Racial Groups; D012019:Reflex Sympathetic Dystrophy / Q000401:mortality / Q000601:surgery; D013123:Spinal Fusion / Q000379:methods; D013128:Spinal Osteophytosis / Q000601:surgery; D055009:Spondylosis / Q000601:surgery*; D016896:Treatment Outcome; D014481:United States