Title : Racial disparities in access to deep brain stimulation surgery
Abstract:
Deep brain stimulation (DBS) surgery is an elective surgery offered to Parkinson disease (PD) patients who meet certain symptom criteria. Despite the success of DBS and increasing use, racial disparities in utilization are prevalent [1, 2]. To date, no study has carefully examined the wide range of factors potentially contributing to observed disparities in DBS use. Therefore, the goals of this study are to a) identify patient predictors for referral for DBS surgery using a large database and b) explore patients’ perception of key factors that drive the acceptance of DBS and determine the specific factors that differ by race.
Methods: This study utilizes a mixed quantitative-qualitative design. For Aim 1, several demographic and disease severity variables and whether or not they were referred for DBS evaluation were collected from the medical charts of 537 participants in the patient research database of a Parkinson Center of Excellence. The milestone reached in the DBS receipt process (referral, multidisciplinary evaluation, approval for surgery, and receipt of surgery) were collected for each patient. Logistic regressions were run to investigate racial differences in the filtering of potential DBS candidates at each milestone to identify clinical procedural sources of inequity.
For Aim 2, 17 participants were recruited from the participant pool studied in Aim 1 belonging to four groups: white participants with (n=5) and without DBS (n=5) and black participants with (n=2) and without (n=5) DBS. Participants participated in a semi-structured online interview over Zoom.
Thematic analysis and cognitive mapping of the healthcare decision making process were conducted on responses to build comparative conceptual frameworks of the primary influences on the decision to receive DBS between participants of black and white race.
Results: Holding all other predictor variables constant, the odds of being counseled on DBS by a medical provider decreased by 80% when a participant was Black compared to White (95% CI 0.12, 0.37), decreased by 58% when a participant was Hispanic versus White (95% CI 0.23, 0.75), decreased by 8% for every 1 year increase in age (0.91, 0.96), and increased two-fold when the participant had private health insurance (1.29, 4.00).
The odds of being referred for multidisciplinary evaluation decreased by 96% when a participant was Black versus White(95% CI 0.014, 0.12), decreased by 84% when a participant was Hispanic versus White (95% CI 0.07, 0.38), and decreased by 11% for every 1 year increase in age (95% CI 0.87, 0.91).
After the second filter, there were too few non-White cases to continue the analyses. Thematic analysis of participant responses during semi-structured interviews revealed principle themes of trust in medical team, personal communal support, and belief in potential benefit outweighing risk of surgery as primary holders of decision-making power, independent of participant race. Black participants expressed enhanced caution towards neurosurgery and higher tolerance of Parkinson symptoms.
