Racial Differences in Perioperative Complications, Readmissions, and Mortalities after Elective Spine Surgery: A Systematic Review using AI-Assisted Bibliometric Analysis

Introduction: A growing body of evidence has reported on the prevalence of systemic racial and socioeconomic disparities in the United States healthcare system. Race has been identified as a primary predictor of clinical care and outcomes across nearly every field of medicine. Among racial minorities, African American (AA) patients specifically have been shown to experience worse health outcomes, including chronic disease and mortality, compared with matched white cohorts. A growing number of studies have shown that race is a significant predictor of operative outcomes after oncologic, transplant, and orthopedic surgeries. These racial disparities have been attributed to many factors, including patient factors (such as comorbidities and socioeconomic status), use of care, and quality of care. Furthermore, racial minorities oftentimes encounter racial bias from the provider, cultural barriers, and a lack of insurance coverage. While previous meta-analyses have established that there are racial disparities in complications following spine surgeries, data granularity and restrictive sample sizes have largely forced such works to group complications broadly into medical or surgical perioperative categories.

Objectives: 1) To use AI-assisted bibliometric analysis perform a comprehensive literature evaluation to identify the specific medical and surgical 90-day peri-operative events that most contributed to the increased post-operative morbidity of African American (AA) vs. White patients; 2) Identify outcomes that had the greatest literature volume within these complication groups.

Methods: PUBMED, MEDLINE(R), ERIC, and EMBASE were searched for studies documenting peri-operative events for white and AA patients following elective spine surgery. Pooled incidence rates and odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events (re-admission, non-routine discharge, re-operation, mortality) and 7 complication categories (cardiovascular, respiratory, genitourinary, neurologic, DVT/PE, wound related) based on literature volume. Sub analyses were performed for each outcome by running the same calculations on subsets of studies based on sample acquisition: single institution (SI) and works that included >100,000 patients.

Results: Seventy-three studies (5,589,069 patients, 9.8% AA) were included. Eleven had samples >100,000. AA patients had increased rates of 90-day readmission (OR 1.33, p=0.0001), non-routine discharge (OR 1.71, p=0.0001), and mortality (OR 1.66, p=0.0003), but not re-operation (OR 1.16, p=.1354). AA patients were more likely to have a medical complication (OR 1.35, p=0.0006), in particular cardiovascular (OR 1.33, p=0.0126), DVT/PE (OR 2.22, p =0.0188) and genitourinary (OR 1.17, p=0.0343). Respiratory (OR 1.40, p=0.0632), neurologic (OR 1.39, p=0.2244), or wound related complications (OR 1.47, p=0.0001) were equivocal. SI studies were only able to detect racial differences in re-admission and non-routine discharge. Studies with < 100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when including all studies.

Conclusions: AA patients face a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.