My name is Andrew Chan, and on behalf of the QOD Cervical Myelopathy Study Group, I'd like to present to you our work investigating the association between race, ethnicity, and socioeconomic status on outcomes following surgery for cervical myelopathy. I'd like to thank the NREF for their support of our study group. So as background, we know that across medicine, self-reported race, ethnicity, and socioeconomic status has been shown to associate with differential access to care, clinical decision making, and outcomes. However, in cervical spine surgery, no significant disparities have been identified in previous studies. So our objective was to investigate the impact of self-reported race, ethnicity, and socioeconomic status on surgical outcomes following surgery for cervical myelopathy. We queried the QOD cervical module for the present study. Patients undergoing surgical treatment for cervical myelopathy between 2016 and 2018 at 14 sites were included. We included those undergoing surgery with MJOA less than 17 with the predominant symptom and main surgical indication of cervical myelopathy. The primary predictors of interest for our study were race, ethnicity, and socioeconomic status index, and outcomes included discharge disposition, length of stay, return to work, 30% improvement in NDI and EQ5D, and patient satisfaction as measured by the NAS satisfaction score. For our predictors, race and ethnicity were divided into four self-reported groups, non-Hispanic Caucasians, Hispanic Caucasians, African Americans, and other. We also used a measure of socioeconomic status known as the socioeconomic status index. This is calculated on a zip code level for each patient, and this method employs the use of occupational status, educational achievement, income, poverty, and wealth as measures of socioeconomic status. Data for these measures was obtained from the American Community Survey website, and SES was then grouped into quartiles, where quartiles 1 and 2 were defined as low socioeconomic status, and quartiles 3 and 4 were grouped under high socioeconomic status. Overall, we included 1,151 patients with cervical myelopathy, of which three-quarters were non-Hispanic Caucasians, 15.3% were African American, and 3.2% were Hispanic Caucasians, and 6.5% were in other race ethnicity groups. In terms of socioeconomic status grouping, 51.5% were in the high SES quartiles, and 48.5% were in the low SES quartiles. On the bottom table, you can see that socioeconomic status associates with race and ethnicity, with African Americans and Hispanic Caucasians having a lower socioeconomic status compared to non-Hispanic Caucasians. Looking at baseline demographics, African American patients were generally younger with a higher mean BMI. African American and Hispanic Caucasian patients had lower levels of education and lower levels of employment. However, there were similar occupation types regardless of race ethnicity designation. There were also multiple differences depending on race for clinical presentation and comorbidities, which were ultimately adjusted for in multivariable analyses. In terms of baseline patient reported outcome metrics, African Americans presented with more severe myelopathy and more arm pain, and African American and Hispanic Caucasians presented with more neck pain, disability, and worse quality of life at baseline. In terms of the surgical characteristics, African Americans more often received posterior cervical procedures, including posterior cervical fusions. However, regardless of race ethnicity designation, there were similar numbers of levels operated. Now looking at the outcomes as sorted by race ethnicity designation, the length of hospital stay and discharge status were significantly different between the groups, with African Americans having the longest length of stay and the highest rates of non-routine discharge. African American designation was also related to the lowest rates of return to work. African Americans also had the lowest rates of patient satisfaction and quality of life at both follow-up time points. Notably, there were no differences for 30% change in neck disability index. Now we conducted subgroup analyses looking at those with low and high socioeconomic status separately. African Americans in the low socioeconomic status quartiles remained with the longest length of hospital stay, the highest rates of non-routine discharge, and along with Hispanic Caucasians with the lowest three-month return to work rates. Similarly, for clinical outcomes, African American patients had lower three- and 12-month satisfaction and quality of life, but similar 30% change in NDI, just as in the overall analyses. However, in those with high socioeconomic status alone, race was no longer associated with length of stay, discharge disposition, satisfaction, or three-month quality of life. On the other hand, African American race still remained associated with worse return to work and 12-month quality of life. Importantly, then, it is important to investigate the interaction between race and ethnicity and socioeconomic status, and we did just that with multivariable modeling. In multivariable adjusted analyses, we found that African American race was independently associated with worse three-month return to work. Also, the interaction between African American race and low socioeconomic status was associated with worse 12-month EQ5D. However, we did not find any other associations between African American race and the interaction between African American race and low socioeconomic status for the remaining outcomes. So, in conclusion, in multivariable adjusted analyses, African American race was associated with lower rates of return to work following surgery for cervical myelopathy. Additionally, there was an interaction between race and socioeconomic status where African American race, for those with low socioeconomic status, was associated with worse 12-month quality of life. The factors mediating these racial and socioeconomic disparities should be further investigated and addressed in future investigations. I'd like to thank the entire QOD cervical module study team, including those that spearhead the study group, including Praveen Mumineni, Erica Bisson, Mohammed Biden, and Tony Asher, and the remainder of the study site PIs as pictured here. Thank you so much for your attention, and please do reach out by email if you have any questions.

race

ethnicity

socioeconomic status

surgical outcomes

cervical myelopathy