The need for accuracy in neurovascular examinations of the extremities of trauma patients is well... more The need for accuracy in neurovascular examinations of the extremities of trauma patients is well recognized. The goals of this study were to (a) evaluate the completeness of orthopedic house staff documentation of the neurovascular status of adult patients with extremity trauma, (b) identify the frequency of individual element documentation, and (c) determine if completeness was related to experience. The trauma center's database was reviewed for patients with extremity injuries (June 2006 through January 2008). For 114 patients, the authors assessed the neurovascular examination documentation for completeness (sensory, motor function, and vascular elements) and "perfection" (complete bilateral elements), identified the frequency of individual element documentation, and determined the relationship of completeness to experience (Pearson correlation coefficients; significance, P ≤ .05). There was no complete (all elements) or perfect (complete bilateral) documentation. The element most often documented completely was the sensory examination. Increased examiner experience was significantly associated with decreased sensory and vascular documentation.
Retrospective analysis. To determine the association of hospital and patient population character... more Retrospective analysis. To determine the association of hospital and patient population characteristics with charges and payments for Medicare patients undergoing cervical spine surgery. Third-party payers, such as Medicare, pay negotiated rates for health care services that represent a substantial savings from hospitals' list prices. Previous research has shown geographical variation in hospital charges. However, the association with other hospital and patient population characteristics is poorly understood. We determined the association of hospital characteristics (bed size, ownership, location, teaching status, procedure volume, and geographical region) and patient population characteristics (proportion female, nonwhite, or with ≥1 comorbid condition) with excess charges (difference between hospital charges and payments) and cost-to-charge ratio (ratio of payments to hospital charges) for Medicare patients undergoing cervical spine fusion without complication (MS-DRG 473). Si...
The spine journal : official journal of the North American Spine Society
The Cervical Spine Outcomes Questionnaire (CSOQ), a disease-specific outcomes instrument, has not... more The Cervical Spine Outcomes Questionnaire (CSOQ), a disease-specific outcomes instrument, has not been systematically compared with the Short Form-36 (SF-36) or the Neck Disability Index (NDI). To examine the psychometric properties of the CSOQ and to compare them with those of the SF-36 and NDI. Prospective analysis of outcomes data in patients undergoing surgery. We used telephone surveys (CSOQ) and clinical assessments (SF-36 and NDI) to evaluate 534 patients undergoing anterior cervical decompression and fusion at 23 nationwide sites. The psychometric properties of the CSOQ were analyzed for floor/ceiling effect, internal consistency of items within the CSOQ, and concurrent validity with the SF-36 and NDI. The CSOQ domain scores showed good psychometric properties (Cronbach's alpha >0.70). Only physical symptoms (other than pain) showed a ceiling effect. The CSOQ domain scores had good concurrent validity (Spearman rank correlation coefficient >0.70) with the mental he...
Prospective multicenter cohort study. To assess the: (1) agreement between surgeon and independen... more Prospective multicenter cohort study. To assess the: (1) agreement between surgeon and independent review of fusion after single-level anterior cervical decompression and fusion, and (2) influence of surgeon impression of patient status on agreement. Failure to achieve fusion can lead to poor functional outcome. Visual inspection of plain radiographs is used to assess fusion, but this assessment's reliability is not well understood. Of 668 participants in the Cervical Spine Research Society Outcomes Study, 181 underwent single-level procedures. Three independent reviewers and each surgeon assessed fusion (i.e., radiographic trabecular bridging of the graft-vertebral body gap and absence of spinous process motion) on plain radiographs at 3 and 6 months after surgery. Agreement was evaluated with an intraclass correlation coefficient (ICC). The influence of surgeon impression of patient status on agreement was assessed with logistic regression analysis. Agreement was high among re...
Retrospective analysis, survey. To describe a cohort of individuals with achondroplasia undergoin... more Retrospective analysis, survey. To describe a cohort of individuals with achondroplasia undergoing thoracolumbar laminectomy and to examine if shorter time to surgery was related to improvement in long-term functional outcome. Data on the long-term benefits of laminectomy are mixed for such patients. Earlier intervention may be associated with greater likelihood of long-term benefit, but quantified data are lacking. We retrospectively studied 49 patients with achondroplasia who underwent primary laminectomy for spinal stenosis. Patients completed a questionnaire to assess symptoms, walking distance, and independence (per Modified Rankin Scale), before surgery and currently. Responses were analyzed for the likelihood of improved walking distance or Rankin level. Our patients had the following mean values: age, 37.7 ± 10.6 years; body mass index, 31.8 ± 5.5; symptom duration, 74.0 ± 100.1 months; preoperative symptom severity score, 2.7 ± 1.0 points; mean changes in blocks walked, +0.39 ± 2.0; and Rankin level, +0.08 ± 1.47. Patients with a time-to-surgery interval of <6 months were 7.13 times (95% confidence interval [CI], 1.39-36.66) more likely to experience improvement in walking distance and 4.00 times (95% CI, 1.05-15.21) more likely to experience Rankin level improvement than patients whose interval was >6 months. Intervals of up to 12 and 24 months were associated with increased likelihoods of 4.95 (95% CI, 1.41-17.41) and 3.43 (95% CI, 1.05-11.22), respectively, of improved walking distance compared with those with longer time-to surgery intervals, but those Rankin level improvements were not statistically significant. Time from symptom onset to surgery in patients with achondroplasia is an important predictor of long-term functional outcome. For sustained long-term postsurgical improvement, the window of opportunity might be relatively narrow. Patients with achondroplasia should seek medical advice for spinal stenotic symptoms as soon as possible.
Insulin resistance occurs in HIV-infected individuals and is associated with HIV-associated neuro... more Insulin resistance occurs in HIV-infected individuals and is associated with HIV-associated neurocognitive disorders (HAND). However, the mechanisms involved are not well understood. Previously, we showed a correlation between soluble insulin receptor (sIR) and HAND. Here, we investigated if binding of free insulin to sIR and soluble insulin-like growth factor-1 receptor (sIGF1-R) levels are associated with sIR in HAND. Thirty-four (34) HIV-seropositive women stratified by cognitive status and five HIV-seronegative women were evaluated. In a subgroup of 20 HIV positive and 5 donors, binding of plasma insulin to sIR was determined by ELISA assay of residual insulin levels in plasma immuno-depleted with anti-IR-monoclonal antibody-Sepharose beads. sIR and sIGF1-R levels were determined by ELISA. Nonparametric statistics were used. Higher percentages of insulin bound to sIR significantly correlated with sIR levels and were associated with HAND status. Higher levels of plasma sIGF1-R had a positive correlation with sIR levels (p = 0.011) and were associated with HAND (p = 0.006). No correlations were observed with age, viral-immune profile, antiretroviral therapy, or TNF. This study suggests that changes in sIGF1-R levels and insulin binding to sIR may contribute to HAND.
Satisfaction is a key indicator of how health care has met patient expectations. To examine relat... more Satisfaction is a key indicator of how health care has met patient expectations. To examine relationship between clinical and functional outcome and patient satisfaction. Prospective analysis of outcomes. A total of 428 patients undergoing cervical spine surgery consecutively enrolled at 23 nationwide sites. Cervical Spine Outcomes Questionnaire (CSOQ). We used the CSOQ to evaluate 428 patients undergoing cervical spine surgery at 23 nationwide sites. Satisfaction was assessed at 3 months by self-report. Clinical improvement was defined at 3 months as decreased postoperative CSOQ domain scores. Principal components analysis (PCA) was used to demonstrate adherence of the CSOQ to domains of clinical and functional recovery and to identify items measuring patient satisfaction. Psychometric properties of items measuring patient satisfaction were examined. The association between patient satisfaction and 3 month clinical and functional outcome was tested. On repeat administration in a subset of 50 patients, these four items demonstrated good test-retest reliability (Cronbach's alpha=0.784). PCA extracted factors adhering to the domain structure of the CSOQ. A unique factor was characterized by the following: recommend to friend (loading=0.658), compare favorably with others (loading=0.525) and with expectations (loading=0.701), and show overall satisfaction (loading=0.513). Structural equation models revealed influence of CSOQ domain scores and socioeconomic status on patient satisfaction. All reported comparisons were significant at p<.001. Satisfaction is unobservable, but can be assessed through self-report. Clinical improvement, especially in neck pain, after surgery is associated with improved patient satisfaction.
Retrospective national database analysis. Our goal was to estimate racial and ethnic differences ... more Retrospective national database analysis. Our goal was to estimate racial and ethnic differences in in-hospital complication and mortality rates associated with cervical spine surgery. The impact of observed racial and ethnic disparities in orthopedic spine care use on morbidity and mortality is not well understood. On the basis of the Nationwide Inpatient Sample, there were 983,420 adult nontrauma hospital discharges from 2000 through 2009. In-hospital complications and mortality were the outcome variables. The primary independent variable was race/ethnicity (defined as non-Hispanic white [white], non-Hispanic black [black], and Hispanic). Covariates were age, sex, household income, insurance status, geographical location, hospital volume, and comorbidities. Multivariable regression models were used to determine the association between race/ethnicity and in-hospital complication and mortality. Significance was set at a P value less than 0.05. The overall rates of an in-hospital complication or mortality were 4.09% and 0.42%, respectively. There were no differences in the rates of in-hospital complications or mortality between Hispanics and Caucasians. Compared with Caucasians, African Americans had higher odds of experiencing an in-hospital complication (odds ratio, 1.37; 95% confidence interval, 1.27-1.48) and higher odds of dying during hospitalization (odds ratio, 1.59; 95% confidence interval, 1.30-1.96). Although there were no differences between Caucasians and Hispanics, African Americans had significantly higher rates of in-hospital complications and mortality associated with cervical spine surgery than did Caucasians. These differences persisted after adjusting for known risk factors for complications and mortality. 3.
Prospective cohort study. To examine the relationship between improvement in pain intensity and s... more Prospective cohort study. To examine the relationship between improvement in pain intensity and subsequent improvement in physical function and disability during the first 12 months after lumbar spine surgery. Little is known about how reduction of pain intensity after surgery may predict improvements in physical function and disability. We prospectively enrolled 260 individuals undergoing elective surgery for degenerative lumbar spine conditions from August 2005 through August 2011. Preoperative and postoperative (3, 6, and 12 mo) assessment tools were numeric pain rating scale, Short Form 12 version 2 physical component score (physical function), and Oswestry Disability Index (disability). Changes were defined using minimum clinically important differences. The association between improvement in pain intensity and subsequent improvement in physical function and disability during the first 12 postoperative months was assessed using standard regression methods. Significance was set at a P value less than 0.05. Preoperatively, mean pain intensity was 5.2 (standard deviation, 2.4), physical function was 27.9 (standard deviation, 9.2), and disability was 40.1% (standard deviation, 16.8%). Pain intensity had improved in 164 (63.1%) patients by 3 and 6 months and in 184 (70.8%) by 12 months. Patients with improvement in pain postoperatively were more likely to have subsequent improvement in physical function (odds ratio, 2.11; 95% confidence interval, 1.10-3.16) during the course of 12 postoperative months. The association between postoperative pain reduction and reduced disability was similar (odds ratio, 1.61; confidence interval, 1.12-2.33). Most patients experienced clinically important postsurgical reductions in pain intensity by 3 months after surgery. Those patients were more likely to have clinically important improvement in physical function and reduction in disability during the first postoperative year. 1.
Retrospective analysis of Nationwide Inpatient Sample and US Census data. To (1) document nationa... more Retrospective analysis of Nationwide Inpatient Sample and US Census data. To (1) document national trends in surgical hospitalizations with the primary diagnosis of lumbar spinal stenosis from 2000 through 2009; and (2) evaluate how those trends relate to race and ethnicity. In the United States, the rate of lumbar spinal stenosis surgery is increasing, and understanding how changing demographic trends impact hospitalization rates for this surgery is important. Multivariable regression models were used to determine associations between race and ethnicity and the rates of surgical hospitalization for lumbar spinal stenosis. All models were adjusted for age, sex, insurance, income status, geographical location, and comorbidities. From 2000 through 2009, the overall surgical hospitalization rate increased by 30%. Surgical hospitalization rates for lumbar spinal stenosis in the United States varied substantially across racial and ethnic groups. In 2009, white, non-Hispanics had the highest rate (1.074 per 1000) compared with black, non-Hispanics (0.558 per 1000; P< 0.001), and Hispanics (0.339 per 1000; P< 0.001). The relative differences persisted across time. There were substantial differences in rates of surgical hospitalization among individuals of different racial and ethnic groups. Possible causes were (1) differences in clinical decision making among spine care providers with regard to offering surgical care to minority populations; (2) differences in access to care because of financial, educational, or geographical barriers; and (3) differences in attitudes toward surgical care among those of different racial and ethnic groups. 3.
The need for accuracy in neurovascular examinations of the extremities of trauma patients is well... more The need for accuracy in neurovascular examinations of the extremities of trauma patients is well recognized. The goals of this study were to (a) evaluate the completeness of orthopedic house staff documentation of the neurovascular status of adult patients with extremity trauma, (b) identify the frequency of individual element documentation, and (c) determine if completeness was related to experience. The trauma center's database was reviewed for patients with extremity injuries (June 2006 through January 2008). For 114 patients, the authors assessed the neurovascular examination documentation for completeness (sensory, motor function, and vascular elements) and "perfection" (complete bilateral elements), identified the frequency of individual element documentation, and determined the relationship of completeness to experience (Pearson correlation coefficients; significance, P ≤ .05). There was no complete (all elements) or perfect (complete bilateral) documentation. The element most often documented completely was the sensory examination. Increased examiner experience was significantly associated with decreased sensory and vascular documentation.
Retrospective analysis. To determine the association of hospital and patient population character... more Retrospective analysis. To determine the association of hospital and patient population characteristics with charges and payments for Medicare patients undergoing cervical spine surgery. Third-party payers, such as Medicare, pay negotiated rates for health care services that represent a substantial savings from hospitals' list prices. Previous research has shown geographical variation in hospital charges. However, the association with other hospital and patient population characteristics is poorly understood. We determined the association of hospital characteristics (bed size, ownership, location, teaching status, procedure volume, and geographical region) and patient population characteristics (proportion female, nonwhite, or with ≥1 comorbid condition) with excess charges (difference between hospital charges and payments) and cost-to-charge ratio (ratio of payments to hospital charges) for Medicare patients undergoing cervical spine fusion without complication (MS-DRG 473). Si...
The spine journal : official journal of the North American Spine Society
The Cervical Spine Outcomes Questionnaire (CSOQ), a disease-specific outcomes instrument, has not... more The Cervical Spine Outcomes Questionnaire (CSOQ), a disease-specific outcomes instrument, has not been systematically compared with the Short Form-36 (SF-36) or the Neck Disability Index (NDI). To examine the psychometric properties of the CSOQ and to compare them with those of the SF-36 and NDI. Prospective analysis of outcomes data in patients undergoing surgery. We used telephone surveys (CSOQ) and clinical assessments (SF-36 and NDI) to evaluate 534 patients undergoing anterior cervical decompression and fusion at 23 nationwide sites. The psychometric properties of the CSOQ were analyzed for floor/ceiling effect, internal consistency of items within the CSOQ, and concurrent validity with the SF-36 and NDI. The CSOQ domain scores showed good psychometric properties (Cronbach's alpha >0.70). Only physical symptoms (other than pain) showed a ceiling effect. The CSOQ domain scores had good concurrent validity (Spearman rank correlation coefficient >0.70) with the mental he...
Prospective multicenter cohort study. To assess the: (1) agreement between surgeon and independen... more Prospective multicenter cohort study. To assess the: (1) agreement between surgeon and independent review of fusion after single-level anterior cervical decompression and fusion, and (2) influence of surgeon impression of patient status on agreement. Failure to achieve fusion can lead to poor functional outcome. Visual inspection of plain radiographs is used to assess fusion, but this assessment's reliability is not well understood. Of 668 participants in the Cervical Spine Research Society Outcomes Study, 181 underwent single-level procedures. Three independent reviewers and each surgeon assessed fusion (i.e., radiographic trabecular bridging of the graft-vertebral body gap and absence of spinous process motion) on plain radiographs at 3 and 6 months after surgery. Agreement was evaluated with an intraclass correlation coefficient (ICC). The influence of surgeon impression of patient status on agreement was assessed with logistic regression analysis. Agreement was high among re...
Retrospective analysis, survey. To describe a cohort of individuals with achondroplasia undergoin... more Retrospective analysis, survey. To describe a cohort of individuals with achondroplasia undergoing thoracolumbar laminectomy and to examine if shorter time to surgery was related to improvement in long-term functional outcome. Data on the long-term benefits of laminectomy are mixed for such patients. Earlier intervention may be associated with greater likelihood of long-term benefit, but quantified data are lacking. We retrospectively studied 49 patients with achondroplasia who underwent primary laminectomy for spinal stenosis. Patients completed a questionnaire to assess symptoms, walking distance, and independence (per Modified Rankin Scale), before surgery and currently. Responses were analyzed for the likelihood of improved walking distance or Rankin level. Our patients had the following mean values: age, 37.7 ± 10.6 years; body mass index, 31.8 ± 5.5; symptom duration, 74.0 ± 100.1 months; preoperative symptom severity score, 2.7 ± 1.0 points; mean changes in blocks walked, +0.39 ± 2.0; and Rankin level, +0.08 ± 1.47. Patients with a time-to-surgery interval of <6 months were 7.13 times (95% confidence interval [CI], 1.39-36.66) more likely to experience improvement in walking distance and 4.00 times (95% CI, 1.05-15.21) more likely to experience Rankin level improvement than patients whose interval was >6 months. Intervals of up to 12 and 24 months were associated with increased likelihoods of 4.95 (95% CI, 1.41-17.41) and 3.43 (95% CI, 1.05-11.22), respectively, of improved walking distance compared with those with longer time-to surgery intervals, but those Rankin level improvements were not statistically significant. Time from symptom onset to surgery in patients with achondroplasia is an important predictor of long-term functional outcome. For sustained long-term postsurgical improvement, the window of opportunity might be relatively narrow. Patients with achondroplasia should seek medical advice for spinal stenotic symptoms as soon as possible.
Insulin resistance occurs in HIV-infected individuals and is associated with HIV-associated neuro... more Insulin resistance occurs in HIV-infected individuals and is associated with HIV-associated neurocognitive disorders (HAND). However, the mechanisms involved are not well understood. Previously, we showed a correlation between soluble insulin receptor (sIR) and HAND. Here, we investigated if binding of free insulin to sIR and soluble insulin-like growth factor-1 receptor (sIGF1-R) levels are associated with sIR in HAND. Thirty-four (34) HIV-seropositive women stratified by cognitive status and five HIV-seronegative women were evaluated. In a subgroup of 20 HIV positive and 5 donors, binding of plasma insulin to sIR was determined by ELISA assay of residual insulin levels in plasma immuno-depleted with anti-IR-monoclonal antibody-Sepharose beads. sIR and sIGF1-R levels were determined by ELISA. Nonparametric statistics were used. Higher percentages of insulin bound to sIR significantly correlated with sIR levels and were associated with HAND status. Higher levels of plasma sIGF1-R had a positive correlation with sIR levels (p = 0.011) and were associated with HAND (p = 0.006). No correlations were observed with age, viral-immune profile, antiretroviral therapy, or TNF. This study suggests that changes in sIGF1-R levels and insulin binding to sIR may contribute to HAND.
Satisfaction is a key indicator of how health care has met patient expectations. To examine relat... more Satisfaction is a key indicator of how health care has met patient expectations. To examine relationship between clinical and functional outcome and patient satisfaction. Prospective analysis of outcomes. A total of 428 patients undergoing cervical spine surgery consecutively enrolled at 23 nationwide sites. Cervical Spine Outcomes Questionnaire (CSOQ). We used the CSOQ to evaluate 428 patients undergoing cervical spine surgery at 23 nationwide sites. Satisfaction was assessed at 3 months by self-report. Clinical improvement was defined at 3 months as decreased postoperative CSOQ domain scores. Principal components analysis (PCA) was used to demonstrate adherence of the CSOQ to domains of clinical and functional recovery and to identify items measuring patient satisfaction. Psychometric properties of items measuring patient satisfaction were examined. The association between patient satisfaction and 3 month clinical and functional outcome was tested. On repeat administration in a subset of 50 patients, these four items demonstrated good test-retest reliability (Cronbach's alpha=0.784). PCA extracted factors adhering to the domain structure of the CSOQ. A unique factor was characterized by the following: recommend to friend (loading=0.658), compare favorably with others (loading=0.525) and with expectations (loading=0.701), and show overall satisfaction (loading=0.513). Structural equation models revealed influence of CSOQ domain scores and socioeconomic status on patient satisfaction. All reported comparisons were significant at p<.001. Satisfaction is unobservable, but can be assessed through self-report. Clinical improvement, especially in neck pain, after surgery is associated with improved patient satisfaction.
Retrospective national database analysis. Our goal was to estimate racial and ethnic differences ... more Retrospective national database analysis. Our goal was to estimate racial and ethnic differences in in-hospital complication and mortality rates associated with cervical spine surgery. The impact of observed racial and ethnic disparities in orthopedic spine care use on morbidity and mortality is not well understood. On the basis of the Nationwide Inpatient Sample, there were 983,420 adult nontrauma hospital discharges from 2000 through 2009. In-hospital complications and mortality were the outcome variables. The primary independent variable was race/ethnicity (defined as non-Hispanic white [white], non-Hispanic black [black], and Hispanic). Covariates were age, sex, household income, insurance status, geographical location, hospital volume, and comorbidities. Multivariable regression models were used to determine the association between race/ethnicity and in-hospital complication and mortality. Significance was set at a P value less than 0.05. The overall rates of an in-hospital complication or mortality were 4.09% and 0.42%, respectively. There were no differences in the rates of in-hospital complications or mortality between Hispanics and Caucasians. Compared with Caucasians, African Americans had higher odds of experiencing an in-hospital complication (odds ratio, 1.37; 95% confidence interval, 1.27-1.48) and higher odds of dying during hospitalization (odds ratio, 1.59; 95% confidence interval, 1.30-1.96). Although there were no differences between Caucasians and Hispanics, African Americans had significantly higher rates of in-hospital complications and mortality associated with cervical spine surgery than did Caucasians. These differences persisted after adjusting for known risk factors for complications and mortality. 3.
Prospective cohort study. To examine the relationship between improvement in pain intensity and s... more Prospective cohort study. To examine the relationship between improvement in pain intensity and subsequent improvement in physical function and disability during the first 12 months after lumbar spine surgery. Little is known about how reduction of pain intensity after surgery may predict improvements in physical function and disability. We prospectively enrolled 260 individuals undergoing elective surgery for degenerative lumbar spine conditions from August 2005 through August 2011. Preoperative and postoperative (3, 6, and 12 mo) assessment tools were numeric pain rating scale, Short Form 12 version 2 physical component score (physical function), and Oswestry Disability Index (disability). Changes were defined using minimum clinically important differences. The association between improvement in pain intensity and subsequent improvement in physical function and disability during the first 12 postoperative months was assessed using standard regression methods. Significance was set at a P value less than 0.05. Preoperatively, mean pain intensity was 5.2 (standard deviation, 2.4), physical function was 27.9 (standard deviation, 9.2), and disability was 40.1% (standard deviation, 16.8%). Pain intensity had improved in 164 (63.1%) patients by 3 and 6 months and in 184 (70.8%) by 12 months. Patients with improvement in pain postoperatively were more likely to have subsequent improvement in physical function (odds ratio, 2.11; 95% confidence interval, 1.10-3.16) during the course of 12 postoperative months. The association between postoperative pain reduction and reduced disability was similar (odds ratio, 1.61; confidence interval, 1.12-2.33). Most patients experienced clinically important postsurgical reductions in pain intensity by 3 months after surgery. Those patients were more likely to have clinically important improvement in physical function and reduction in disability during the first postoperative year. 1.
Retrospective analysis of Nationwide Inpatient Sample and US Census data. To (1) document nationa... more Retrospective analysis of Nationwide Inpatient Sample and US Census data. To (1) document national trends in surgical hospitalizations with the primary diagnosis of lumbar spinal stenosis from 2000 through 2009; and (2) evaluate how those trends relate to race and ethnicity. In the United States, the rate of lumbar spinal stenosis surgery is increasing, and understanding how changing demographic trends impact hospitalization rates for this surgery is important. Multivariable regression models were used to determine associations between race and ethnicity and the rates of surgical hospitalization for lumbar spinal stenosis. All models were adjusted for age, sex, insurance, income status, geographical location, and comorbidities. From 2000 through 2009, the overall surgical hospitalization rate increased by 30%. Surgical hospitalization rates for lumbar spinal stenosis in the United States varied substantially across racial and ethnic groups. In 2009, white, non-Hispanics had the highest rate (1.074 per 1000) compared with black, non-Hispanics (0.558 per 1000; P< 0.001), and Hispanics (0.339 per 1000; P< 0.001). The relative differences persisted across time. There were substantial differences in rates of surgical hospitalization among individuals of different racial and ethnic groups. Possible causes were (1) differences in clinical decision making among spine care providers with regard to offering surgical care to minority populations; (2) differences in access to care because of financial, educational, or geographical barriers; and (3) differences in attitudes toward surgical care among those of different racial and ethnic groups. 3.
Uploads
Papers by Richard Skolasky