Socioeconomic disparities in lumbar fusion rates were exacerbated during the COVID-19 pandemic

Background: The COVID-19 pandemic disrupted healthcare access and utilization throughout the US, with variable impact on patients of different socioeconomic status (SES) and race. We characterize pre-pandemic and pandemic demographic and SES trends of lumbar fusion patients in the US. Methods: Adults undergoing first-time lumbar fusion 1/1/2004-3/31/2021 were assessed in Clinformatics (R) Data Mart for patient age, geographical location, gender, race, education level, net worth, and Charlson Comorbidity Index (CCI). Multivariable regression models were used to evaluate the significance of trends over time, with a focus on pandemic trends 2020-2021 versus previous trends 2004-2019. Results: The total 217,204 patients underwent lumbar fusions, 1/1/2004-3/31/2021. The numbers and per capita rates of lumbar fusions increased 2004-2019 and decreased in 2020 (first year of COVID-19 pandemic), with large variation in geographic distribution. There was overall a significant decrease in proportion of White patients undergoing lumbar fusion over time (OR = 0.997, p < .001), though they were more likely to undergo surgery during the pandemic (OR = 1.016, p < .001). From 2004-2021, patients were more likely to be educated beyond high school. Additionally, patients in the highest ( > $500k) and lowest ( < $25k) net worth categories had significantly more fusions over time (p < .001). During the pandemic (2020-2021), patients in higher net worth groups were more likely to undergo lumbar fusions ($150k-249k & $250k-499k: p < .001) whereas patients in the lowest net worth group had decreased rate of surgeries (p < .001). Lastly, patients' CCI increased significantly from 2004 to 2021 (coefficient = 0.124, p < .001), and this trend held true during the pandemic (coefficient = 0.179, p < .001). Conclusions: To the best of our knowledge, our work represents the most comprehensive and recent characterization of SES variables in lumbar fusion rates. Unsurprisingly, lumbar fusions decreased overall with the onset of the COVID-19 pandemic. Importantly, disparities in fusion patients across patient race and wealth widened during the pandemic, reversing years of progress, a lesson we can learn for future public health emergencies.