Disease severity and treatment in adolescent idiopathic scoliosis: the impact of race and economic status

Background context: Ethnic disparities have been documented in the incidence and treatment of many diseases. Additionally, race and socioeconomic status (SES) have been shown to affect disease severity and access to care in the recent orthopedic literature.

Purpose: To assess the role, if any, that race, SES, and health insurance type play in disease severity and treatment decisions in patients with adolescent idiopathic scoliosis.

Study design: Retrospective chart review.

Patient sample: Pediatric patients seen in a single surgeon's practice over 6 years (2004-2009).

Outcome measures: Treatment modality (observation, bracing, or surgery).

Methods: Data were obtained from 403 patients seen over 6 years (2004-2009). A patient-reported questionnaire was used to collect race, age, family income, and parent marital status data. Race was self-reported as "Asian," "black or African American," "Hispanic or Latino," "white or Caucasian," or "Other." Socioeconomic status was determined using family income and type of health insurance as indicators. Major curve magnitude and prescribed initial treatment (observation, brace, or surgery) were assessed from physician records. An independent sample t test was used to detect differences in curve magnitude of the different racial groups. A Pearson chi-square analysis was used to detect group differences for curves in surgical patients, defined as curves greater than 40°, and their initial treatment.

Results: Patients self-identified with one of the following racial groups: white (N=219), black (N=86), Hispanic (N=44), Asian (N=37), or Other (N=17). Mean curve magnitude was greater in black than in white patients (33° vs. 28°, p<.05). Black patients were more likely to present with curves in the surgical range (34% vs. 24%, p<.05) and were more likely to have surgery as their initial treatment than white patients (34% vs. 19%, p<.05). Black patients had more limited health care plans and lower incomes compared with whites (p<.001). Patients with higher access insurance plans presented at a younger age than patients with more limited access plans, irrespective of race (13.6 vs. 14.1, p<.05). There was no difference in Cobb angle at presentation by income or type of insurance.

Conclusions: Curve magnitude and percentage of patients with curves in the surgical range were greater in black than in white patients. There was no difference in age on presentation or treatment offered across all racial groups. Black patients were more likely to have surgery as their initial treatment than white patients. While race did have an impact on disease severity in this single surgeon's practice, SES did not.