During a presentation at the North American Neuromodulation Society (NANS) virtual meeting (15–16 January) entitled “Outcomes and Access to Neuromodulation for Women and Underrepresented Minorities: A Call to Action”, speakers discussed a range of factors that may contribute to a reported disparity in the access to and outcomes after neuromodulation-based procedures for women and minorities. Factors discussed included implicit bias, cultural differences, and lack of representation of women and minorities in neuromodulation-related specialties, medical societies, and academic leadership. NeuroNews conducted exclusive interviews with two speakers from this presentation—Myrdalis Diaz-Ramirez (Sarasota Pain Relief Centers, Sarasota, USA), who discussed disparities in neuromodulation access and outcomes, and Stephanie Vanterpool (University of Tennessee Medical Center Department of Anaesthesiology, Knoxville, USA), who detailed how outreach can improve access.
“The tendency is for neuromodulation therapies to be offered or more accessible to Caucasian men, with private insurance, fewer comorbidities, seen at higher volume hospitals, and with higher income households,” comments Diaz-Ramirez regarding her research into the disparities in access to pain treatment. “For deep brain stimulation (DBS), the access is over 90% to those able to reach a large academic centre in metropolitan areas. Despite this, African American patients who met characteristics for DBS received the procedure much less frequently than non-African Americans. DBS seems to be also received more frequently by Caucasian men. The racial disparities are amplified when adjusting for physician and clinic characteristics.”
Diaz-Ramirez and colleagues conducted a search across a number of academic libraries, including PubMed and the Florida State University library, and were only able to find eight articles relating to disparities in access to neuromodulation. Diaz-Ramirez says, “The data we have available from specific research about disparities in neuromodulation, including access and outcomes, are very limited.” She continues: “Most of the articles are retrospective, with data over 10 years old. They do not take into account the shift of using a great part of the technology, mainly for pain management, into the outpatient setting. The data also focuses on only three examples of neuromodulation: spinal cord stimulation for pain, deep brain stimulation for Parkinson’s disease, and vagal nerve stimulation for pain.”
Vanterpool details: “In one of the largest national surveys of disparities in neuromodulation, Mark Jones [Weil Cornell Medical College, Department of Anaesthesiology, New York, USA] and colleagues reviewed the Center for Medicare services database of over 1.2 million patients who had the diagnosis of post-laminectomy pain syndrome or chronic pain syndrome, two of the primary diagnoses that we use for neuromodulation. In that study, only 4.8% of those patients received spinal cord stimulation (SCS) as a treatment option, and of those, we found that Black, Hispanic, Asian, and North American Native patients were significantly less likely to receive SCS compared to patients who were white. This also held true when adjusted for socio-economic status, and for other clinical factors. Additionally, it was also found in that paper patients of lower socio-economic status across the board had less access to SCS.”
When asked about differences in outcome for minority group patients, Diaz-Ramirez notes: “In a study where they compared Medicaid patients to patients with private insurance, they found no difference in complications, nor two-year re-operation for spinal cord stimulator surgery.” However, these findings were not the same for women, as she further comments, “They found women would have more subsequent examinations in a particular clinic with less pain relief and more findings of depression after permanent implants had been implanted.”
Vanterpool explains what the aim of outreach can be for these patients: “To inform patients that the treatment option is available to them is really one of the main goals of patient outreach.”
Vanterpool goes on to explain how clinicians can play a role in improving these disparities: “When it comes to engaging with patients from other backgrounds, I think it really starts with a conscious intention to do that, and then also setting an example. As a senior clinician, you want to ensure that any unconscious biases or conscious biases that you have are appropriately addressed and not interfering with your patient interactions. The best way to do this is to make sure that you are making an accurate diagnosis for any patient that comes in front of you, regardless of their race, ethnicity, or socioeconomic status.”
Vanterpool advises: “Different diagnoses or causes of pain have evidence-based treatments. We need to focus on making sure that we have accurately identified the diagnosis as clearly and closely as possible, and then equally and across the board apply evidence-based treatments. In that one way we would ensure that we are not allowing race and ethnicity to cloud our treatment options for these patients. It sounds a little bit easier than it is to just focus on the diagnosis, but that really is one of the foundations of it.”
Diaz-Ramirez notes limitations in her research due to the data available: “Hispanics and Asian/Pacific Islanders are mentioned without a significant specific conclusion drawn. They do not mention North American Native patients, for example, nor other groups. There are no studies that mention [the] LGBTQ+ [community].” She ultimately concludes: “We are at the beginnings of studying disparities in neuromodulation.”
In concluding, Vanterpool states: “Outreach is really a combination of three things: awareness, advocacy, and application. By applying those three things, to ensure that socio-economic disparities or racial disparities do not factor into evidence-based treatment options for patients, we can increase awareness and access to our patients for these life-saving and life-changing neuromodulation therapies.”
