The authors of this study, done at the Johns Hopkins School of Medicine, reviewed a number of reports which "suggest that patients with surgical pituitary disease are much more likely to have improved surgical outcomes if diagnosed and treated by more experienced surgeons..." They looked at a national survey of neurosurgeons done in the U.S. and a similar study published in the U.K., both of which "found that complication rates were inversely related to surgical experience".These studies showed patients undergoing the preferred method of pituitary adenoma removal, transsphenoidal resection, had lower mortality rates and less complications if admitted to "high-volume centers".
Referring to "recent reports in general surgery" which "indicate that referral to high-volume hospitals is dependent on racial and socioeconomic factors", the authors realized that little is known about the same possible disparity with the aforementioned pituitary surgery patients.
Using the data from 1988-2005 found in the National Inpatient Sample (NIS) in-hospital discharge database, they identified the pituitary tumor patients by operative code (vs. diagnostic code) for its "higher fidelity". Then, socioeconomic and environmental factors were "assessed through Area Resource File (ARF), maintained by the Health Resources and Services Administration". Only patients over 18 years of age were identified, and only those meeting the criteria of codes were included.
Centers which did over 25 pituitary surgeries per year were defined as "high-volume centers". Age, gender, race, income, wealth, insurance status and the Charlson comorbidity index score were variables used to delineate the racial and socioeconomic factors.
"There was no statistically significant difference between African-Americans (OR: 0.86, 95% CI: 0.74-1.00) and whites in access to high-volume centers (Table 3). On the other hand, Hispanic (OR: 0.53, 95% CI: 0.45-0.63) and Asian (OR: 0.78, 95% CI: 0.61-0.98) patients were significantly less likely to be seen at high-volume centers."
However, when using only the last five years (2001-2005), there was a significantly greater chance that Caucasians would admitted to high volume centers.
In this study, they also found "patients from counties with high neurosurgeon density experience a greater chance of admission to quality medical centers". Younger patients were more likely to be admitted to these same centers as compared to older patients. This was partially attributed to a "widespread access to internet in younger patients".
Females were also more likely to be admitted to high-volume centers than males. Since women are more likely to be uninsured and have less healthcare than men according to the authors, this was surprising. They surmised the need to preserve pituitary and hormonal function in women may have an active role.
What I found more telling, but only mentioned briefly, was how skewed the numbers were for those who were referred anywhere. The number of patients receiving care in the >$60,000/yr income-bracket was almost double the other income levels. In fact, the other income levels were very close.The authors conclude: "This study demonstrates potential key policy areas for meaningful intervention to help ease disparities in access to quality care for surgical pituitary disease."
Mukherjee, D., Zaidi, H., Kosztowski, T., Chaichana, K., Salvatori, R., Chang, D., & Quinones-Hinojosa, A. (2009). Predictors of Access to Pituitary Tumor Resection in the United States, 1988-2005 European Journal of Endocrinology DOI: 10.1530/EJE-09-0043
Interesting and rather depressing. I think you're right about the income levels being interesting, Wikipedia gives the proportions of households in similar income brackets as 38% under $35K, 11% $36-45K, 13% $45-60K, and 39% $60K+. I can't even be bothered testing the differences for statistical significance, it's fairly obvious there's a huge effect there.
ReplyDeleteI can't get the paper, but is table 2 actually about household income of those treated, or about household income in the area where they live?
Hi, Charlotte. It's about the household income of those treated.
ReplyDelete"The distribution of patients from all four income brackets was slightly positively skewed, with more patients in the >$60,000 income bracket (36.4%) (Table 2). The mean percent of patients under the poverty line were 1.10% (median 1.05%). On average, there were approximately 3.64 (median 2.51) neurosurgeons per 100,000 people."
Statistics can be made to say anything. Having lived through huge medical bills since 2006, I don't buy that you can't get to the medical care. How many people not going to these high quality centers are even told about them?
ReplyDeleteWe know most people are like lemmings when it comes to their own medical care. Doctor's know all. Are their doctors sending them to where they have the best chance? In my opinion, the doctors are probably to blame more than race or socioeconomic factors. I don't buy what I think the author is trying to subtly say.