Impact of health disparities on treatment for single-suture craniosynostosis in an era of multimodal care

Abstract

Craniosynostosis results in both cosmetic deformityand limitation in brain growth and development,requiring surgical intervention to avoid cognitiveimpairment and cosmetic dysmorphology. There are cur-rently two principal forms of treatment for single-suturesynostosis: open cranial vault remodeling and endoscopicsuturectomy with postoperative orthotic therapy. Opensurgery and endoscopic suturectomy are both effectivemeans of treating craniosynostosis; however, the endo-scopic approach is associated with decreased blood loss and transfusion risk, decreased dissection and postopera-tive swelling, shorter operative time, and shorter hospital-ization.1 Candidates for endoscopic treatment are typicallyyounger than 4 months of age at the time of surgery. Giventhe narrow age range for endoscopic treatment, early di-agnosis is therefore essential to provide this option. As aresult, for children with craniosynostosis to receive appro-priate treatment, access to care and facilitation of diagno-sis have been brought to the forefront.It is well established that underrepresented minority ABBREVIATIONS PCP = primary care physician. ACCOMPANYING EDITORIAL DOI: 10.3171/2021.1.FOCUS2124. SUBMITTED November 22, 2020. ACCEPTED January 6, 2021. INCLUDE WHEN CITING DOI: 10.3171/2021.1.FOCUS201000. * C.H. and A.B.V. contributed equally to this work. Impact of health disparities on treatment for single-suture craniosynostosis in an era of multimodal care *Caitlin Hoffman, MD,1 Alyssa B. Valenti, MD,2,3 Eseosa Odigie,1 Kwanza Warren, MD,4 Ishani D. Premaratne, BA,2 and Thomas A. Imahiyerobo, MD2,3 Departments of 1Neurosurgery and 2Plastic Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and Departments of 3Plastic Surgery and 4Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York Craniosynostosis is the premature fusion of the skull. There are two forms of treatment: open surgery and minimally in-vasive endoscope-assisted suturectomy. Candidates for endoscopic treatment are less than 6 months of age. The tech-niques are equally effective; however, endoscopic surgery is associated with less blood loss, minimal tissue disruption, shorter operative time, and shorter hospitalization. In this study, the authors aimed to evaluate the impact of race/ethnic-ity and insurance status on age of presentation/surgery in children with craniosynostosis to highlight potential disparities in healthcare access. Charts were reviewed for children with craniosynostosis at two tertiary care hospitals in New York City from January 1, 2014, to August 31, 2020. Clinical and demographic data were collected, including variables pertain-ing to family socioeconomic status, home address/zip code, insurance status (no insurance, Medicaid, or private), race/ ethnicity, age and date of presentation for initial consultation, type of surgery performed, and details of hospitalization. Children with unknown race/ethnicity and those with syndromic craniosynostosis were excluded. The data were analyzed via t-tests and chi-square tests for statistical significance (p <0.05). A total of 121 children were identified; 62 surgeries were performed open and 59 endoscopically. The mean age at initial presentation of the cohort was 6.68 months, and on the day of surgery it was 8.45 months. Age at presentation for the open surgery cohort compared with the endoscopic cohort achieved statistical significance at 11.33 months (SD 12.41) for the open cohort and 1.86 months (SD 1.1473) for the endoscopic cohort (p <0.0001). Age on the day of surgery for the open cohort versus the endoscopic cohort demon-strated statistical significance at 14.19 months (SD 15.05) and 2.58 months (SD 1.030), respectively. A statistically signifi-cant difference between the two groups was noted with regard to insurance status (p = 0.0044); the open surgical group comprised more patients without insurance and with Medicaid compared with the endoscopic group. The racial composi-tion of the two groups reached statistical significance when comparing proportions of White, Black, Hispanic, Asian, and other (p = 0.000815), with significantly more Black and Hispanic patients treated in the open surgical group. The results demonstrate a relationship between race and lack of insurance or Medicaid status, and type of surgery received; Black and Hispanic children and children with Medicaid were more likely to present later and undergo open surgery.