Akbari Syed Hassan A, Oates Gabriela R, Gonzalez-Sigler Irina, Arynchyna Anastasia A, McCroskey Justin, Alford Elizabeth N, Leon Tofey J, Rutland Sarah, Johnston James M, Blount Jeffrey P, Rozzelle Curtis J, Rocque Brandon G
1Department of Neurosurgery.
2Department of Pediatrics, and.
J Neurosurg Pediatr. 2021 Nov 26;29(3):305-311. doi: 10.3171/2021.9.PEDS21258. Print 2022 Mar 1.
There is little research on the effect of social determinants of health on Chiari malformation type I (CM-I). The authors analyzed data on all children evaluated for CM-I at a single institution to assess how socioeconomic factors and race affect the surgical treatment of this population.
Medical records of patients treated for CM-I at the authors' institution between 1992 and 2017 were reviewed. Area Deprivation Index (ADI) and Rural-Urban Commuting Area (RUCA) codes for each patient were used to measure neighborhood disadvantage. Non-Hispanic White patients were compared to non-White patients and Hispanic patients of any race (grouped together as non-White in this study) in terms of insurance status, ADI, and RUCA. Patients with initially benign CM-I, defined as not having undergone surgery within 9 months of their initial visit, were then stratified by having delayed symptom presentation or not, and compared on these same measures.
The sample included 665 patients with CM-I: 82% non-Hispanic White and 18% non-White. The non-White patients were more likely to reside in disadvantaged (OR 3.4, p < 0.001) and urban (OR 4.66, p < 0.001) neighborhoods and to have public health insurance (OR 3.11, p < 0.001). More than one-quarter (29%) of patients underwent surgery. The non-White and non-Hispanic White patients had similar surgery rates (29.5% vs 28.9%, p = 0.895) at similar ages (8.8 vs 9.7 years, p = 0.406). There were no differences by race/ethnicity for symptoms at presentation. Surgical and nonsurgical patients had similar ADI scores (3.9 vs 4.2, p = 0.194), RUCA scores (2.1 vs 2.3, p = 0.252), and private health insurance rates (73.6% vs 74.2%, p = 0.878). A total of 153 patients underwent surgery within 9 months of their initial visit. The remaining 512 were deemed to have benign CM-I. Of these, 40 (7.8%) underwent decompression surgery for delayed symptom presentation. Patients with delayed symptom presentation were from less disadvantaged (ADI 3.2 vs 4.2; p = 0.025) and less rural (RUCA 1.8 vs 2.3; p = 0.023) areas than those who never underwent surgery.
Although non-White patients were more likely to be socioeconomically disadvantaged, race and socioeconomic disadvantage were not associated with undergoing surgical treatment. However, among patients with benign CM-I, those undergoing decompression for delayed symptom presentation resided in more affluent and urban areas.
关于健康的社会决定因素对Ⅰ型Chiari畸形（CM-Ⅰ）影响的研究较少。作者分析了在单一机构接受CM-Ⅰ评估的所有儿童的数据，以评估社会经济因素和种族如何影响该人群的手术治疗。
回顾了1992年至2017年在作者所在机构接受CM-Ⅰ治疗的患者的病历。使用每个患者的区域剥夺指数（ADI）和城乡通勤区域（RUCA）代码来衡量邻里劣势。将非西班牙裔白人患者与非白人患者以及任何种族的西班牙裔患者（在本研究中归为非白人组）在保险状况、ADI和RUCA方面进行比较。最初被定义为在初次就诊后9个月内未接受手术的良性CM-Ⅰ患者，再根据是否有延迟症状出现进行分层，并在这些相同指标上进行比较。
样本包括665例CM-Ⅰ患者：82%为非西班牙裔白人，18%为非白人。非白人患者更有可能居住在弱势社区（比值比[OR]3.4，p<0.001）和城市社区（OR 4.66，p<0.001），并且拥有公共医疗保险（OR 3.11，p<0.001）。超过四分之一（29%）的患者接受了手术。非白人和非西班牙裔白人患者在相似年龄（8.8岁对9.7岁，p = 0.406）时的手术率相似（29.5%对28.9%，p = 0.895）。就诊时的症状在种族/族裔方面没有差异。手术和非手术患者的ADI评分（3.9对4.2，p = 0.194）、RUCA评分（2.1对2.3，p = 0.252）以及私人医疗保险费率（73.6%对74.2%，p = 0.878）相似。共有153例患者在初次就诊后9个月内接受了手术。其余512例被认为患有良性CM-Ⅰ。其中，40例（7.8%）因出现延迟症状而接受了减压手术。出现延迟症状的患者所在地区的弱势程度（ADI 3.2对4.2；p = 0.025）和农村程度（RUCA 1.8对2.3；p = 0.023）均低于从未接受手术的患者。
尽管非白人患者在社会经济方面更有可能处于弱势，但种族和社会经济劣势与接受手术治疗无关。然而，在患有良性CM-Ⅰ的患者中，因延迟症状出现而接受减压手术的患者居住在更富裕和城市地区。
