Health Care Disparities in the Surgical Treatment of Vestibular Schwannomas

Introduction: Vestibular schwannomas (VS) are benign tumors with various treatment modalities. Outcomes following observation, radiation or surgery have been studied, however less is known about the impact of socioeconomic and demographic factors on outcomes. In this study, we compare patients treated for VS in a public and private hospital setting in the same geographic region.

Methods: Patients who underwent primary resection of a VS from 2010 to 2020 were identified in each hospital. Twenty-two patients were identified at the public hospital, while 258 patients were identified at the private hospital. Their charts were retrospectively reviewed for data on their pre-operative, operative and post-operative courses. Demographic information, including age, race, insurance status, preferred language, average income by zip code, and Charlson Comorbidity Index, for each population was collected. Patients from the public hospital were then matched by tumor size and age to patients from the private hospital and their outcomes were compared.

Results: Insured patients composed 96% and 36% of the private and public groups respectively. The preferred language was English for 94% of private patients and 36% of public patients. The majority of private patients (75%) were white, while public patients represented a diverse group (9% white). Average tumor size in largest dimension of the matched groups was 2.9 cm for private patients and 3.0 cm for public patients. Average age was 49 for both groups. Patients from the public group presented with hydrocephalus 27% of the time compared with private patients at 13%. Private patients on average reached the operating room 49 days after operative management was chosen, while public patients waited 77 days. Post operatively, 2 private patients who had intact facial nerves preoperatively developed permanent House Brackman scores greater than 4, 4 developed a CSF leak and 1 had a stroke. Amongst public patients, 7 developed House Brackman scores greater than 4, 3 had strokes, 2 had CSF leaks, 4 had infections and 1 patient died. All private patients received a post-operative MRI; 73% of public patients had at least one post-operative MRI.

Discussion: Overall, when matched by age and tumor size, patients presenting to a public hospital were more likely to present with severe symptoms, wait longer for surgery, and had higher rates of post-operative complications than in a private hospital setting in the same region. These findings may reflect inability of patients to seek care early in their symptom course given lack of insurance, surgical proficiency in a high-volume center versus a low volume center and difficulty in following patients with many barriers in the social determinants of health. While many of these issues require change at a national, systemic level, providers working at safety net hospitals can develop protocols and designate staff who can longitudinally follow patients to ensure timely workup, diagnosis, operative scheduling and follow up care in addition to coordinating hearing, vestibular and facial nerve rehabilitation options. Heightened awareness of the vulnerability of these populations should direct efforts to support these patients more pro-actively

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Artikel online veröffentlicht:
15. Februar 2022