Provider Bias Trumps Healthcare Access for Socioeconomic Disparities in Pain Management for Traumatic Spine Fractures

Introduction: Traumatic spine fractures are a leading cause of chronic pain and disability in the United States. Social and racial disparities in pain management influence long-term disability outcomes. To better develop strategies to limit disparities in pain outcomes, we must delineate confounding influences amongst social determinants, healthcare access, and provider biases.

Methods: This cohort included a retrospective review of opioid naïve patients presenting to a Level I trauma center with isolated, non-operative, spine fractures between 2013-2018. Injury characteristics and patient demographics were collected from electronic medical records. Area Deprivation Index (ADI) scores were derived from home zip code and used as a metric of socioeconomic disadvantage. 3-month follow-up appointments and insurance were used as surrogates for healthcare access. Physician Drug Monitoring Program data was used to determine provider prescribing patterns. Differences were considered significant if p≤0.05 in multivariable analysis.

Results: Of the 1,155 patients in this study, mean age was 59.05 years (SE:0.65), ADI was 14.55 (SE:0.54), with patients being predominantly male (53.68%), white (87.71%), and holding private insurance (57.92%). 141/1155 (12.2%) remained on a new opioid pain medication at ≥12months post-injury. Race and socioeconomic status influenced healthcare access with significantly lower 3-month follow-up rates amongst blacks (OR:0.564; CI:0.356–0.894; p=0.015) and disadvantaged individuals (high ADI; OR:0.99; CI:0.985–0.995; p< 0.001). After controlling for confounding factors through multivariable analysis, neither healthcare access (p=0.533), race (p=0.176) or insurance status (p>0.05) influenced prescribing patterns. Conversely, socioeconomic status independently influenced pain medication prescribing patterns, with disadvantaged individuals being less likely to receive prescriptions (OR:0.982; CI:0.965-0.995; p=0.019).

Conclusion : Within this cohort of 1,155 opioid naïve patients with new traumatic spine fractures, providers were less likely to prescribe pain medications for socioeconomically disadvantaged individuals – independent of healthcare access. Strategies targeting provider management decisions, and not healthcare system access, may improve disparities in pain management and disability amongst spine fracture patients.