Clinical Study
Racial disparities in medicaid patients after brain tumor surgery

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Abstract

The presence of healthcare-related disparities is an ongoing, widespread, and well-documented societal and health policy issue. We investigated the presence of racial disparities among post-operative patients either with meningioma or malignant, benign, or metastatic brain tumors. We used the Medicaid component of the Thomson Reuter’s MarketScan database from 2000 to 2009. Univariate and multivariate analysis assessed death, 30-day post-operative risk of complications, length of stay, and total charges. We identified 2321 patients, 73.7% were Caucasian, 57.8% were women; with Charlson comorbidity scores of <3 (56.2%) and treated at low-volume centers (73.4%). Among all, 26.3% of patients were of African-American ethnicity and 22.1% had meningiomas. Mortality was 2.0%, mean length of stay (LOS) was 9 days, mean total charges were US$42,422, an adverse discharge occurred in 22.5% of patients, and overall 30-day complication rate was 23.4%. In a multivariate analysis, African-American patients with meningiomas had higher odds of developing a 30-day complication (p = 0.05) and were significantly more likely to have longer LOS (p < 0.001) and greater total charges (p < 0.001) relative to Caucasian counterparts. The presence of one post-operative complication doubled LOS and nearly doubled total charges, while the presence of two post-operative complications tripled these outcomes. Patients of African-American ethnicity had significantly higher post-operative complications than those of Caucasian ethnicity. This higher rate of complications seems to have driven greater healthcare utilization, including greater LOS and total charges, among African-American patients. Interventions aimed at reducing complications among African-American patients with brain tumor may help reduce post-operative disparities.

Introduction

Since the Institute of Medicine’s “Crossing the Quality Chasm” was published in 2001, equitable delivery has remained a key aspect in defining quality healthcare.1 However, the presence of healthcare-related disparities between different racial groups within the USA remains an ongoing, widespread, and well-documented societal and health policy issue.2, 3 Disparate access and outcomes after treatment of numerous acute and chronic medical conditions, inclusive of cancer, have been shown consistently over the past several decades, even after accounting for differences in geographic location, patient educational level, and other potential determinants of health and behavior.4, 5

With the publication of “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” by the Institute of Medicine in 2003, the prevalence of such disparities began to reach a higher level of attention within the realm of health services research.6 As a result, projects within the general medical literature focusing upon disparities grew over the subsequent decade, with newer reports suggesting patient mistrust as well as provider bias may have both played roles in the disparate outcomes observed among otherwise similar groups treated equally.7, 8

Until recently, relatively few studies have evaluated disparities in short-term and long-term outcomes within the subspeciality of neurosurgery.9, 10, 11, 12, 13 The few reports that have attempted to explore racial disparities in post-operative brain tumor patient outcomes have reported that patients of African-American ethnicity diagnosed with malignant brain tumors have shorter survival,9, 10 more severe disease at presentation,13 and are treated more often at low-volume hospitals11, 12 compared to their Caucasian counterparts.

However, most of these studies attempt to control for important determinants of health including socioeconomic status using suboptimal regional surrogates, such as median income within the patient’s postal code or county of residence. In an attempt to mitigate potentially confounding variables such as socioeconomic status, we utilized the Medicaid portion of the MarketScan database to evaluate racial disparities in a homogeneous, low-income population of patients undergoing craniotomy for tumor resection.

Section snippets

Database

Thomson Reuter’s MarketScan database from 2000 to 2009 was used for analysis. The MarketScan database is a collection of six different data files, including the: (i) Commercial Claims and Encounters file, (ii) Medicare Supplemental and Coordination of Benefits (COB) file, (iii) Benefit Plan Design file, (iv) Health and Productivity Management file, (v) Medicaid file, and (vi) Lab file. For the current project, we used only the Medicaid database, which is formed by health-care use information

Results

Our study identified 2321 patients in the Medicaid database who underwent craniotomy for brain tumor between 2000 and 2009. The mean age of patients was 49 years of age and 57.8% were women. Patients of African-American ethnicity comprised 26.3% (n = 611) and only 26.6% of patients were treated at high-volume hospitals. Charlson comorbidity index was >3 in 43.8% of patients. Overall inpatient mortality was 2.0% with a mean LOS of 9 days and mean total charges of US$42,422. An adverse discharge

Discussion

In this study, we demonstrate several significant racial disparities in both inpatient and short-term post-operative outcomes after craniotomy for resection of brain tumors. Among all tumor types, we found in multivariate analyses that African-American patients had significantly higher 30-day complication rates, significantly longer LOS, and accrued significantly greater healthcare related charges. Post-operatively African-American patients with meningioma seemingly had the worst disparities.

Conflict of interest/disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

Acknowledgement

The authors wish to thank Sherry Brandon for her expert help with copyediting, referencing and administrative support provided on this project.

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      Citation Excerpt :

      In this discussion, we address the most salient findings in our study and discuss potential root causes of these disparities to help guide further research and policy. Most studies reported that minority patients and specifically African American5,10,11,14,17,25,29,31,36-38 patients had the highest rates of mortality, decreased postoperative survival, increased complications after surgery, increased rates of readmission, and worst access to high-volume centers across a wide variety of intracranial tumor diseases. Although mortality was well studied, studies examining LOS, complications, discharge disposition, readmission, and reoperation were fewer.

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    These authors contributed equally to the manuscript.

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