218 - Socioeconomic and Racial Disparities in Surgical Management of Adolescent Idiopathic Scoliosis: Vertebral Body Tethering Versus Posterior Spinal Fusion

Publication Number: 1207.218

Laurel E. Wong, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Ryan G.. Smolarsky, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Helen Xie, Icahn School of Medicine at Mount Sinai, New York City, NY, United States; Sheena Ranade, Icahn School of Medicine at Mount Sinai, New York, NY, United States

Background: Adolescent Idiopathic Scoliosis (AIS) affects 2-3% of children aged 10-18, and progressive cases often require surgery. Posterior spinal fusion (PSF) remains the standard treatment but restricts mobility, while vertebral body tethering (VBT) provides a motion-preserving alternative. However, VBT is costly, concentrated in specialized centers, and inconsistently reimbursed, raising concern that access is limited to higher socioeconomic status (SES), predominantly White populations. Despite increasing use, SES differences in VBT versus PSF remain poorly characterized.

Objective: To examine patterns of VBT utilization compared with PSF with respect to socioeconomic and hospital characteristics.

Design/Methods: A retrospective cross-sectional analysis of the 2022 Healthcare Cost and Utilization Project Kids' Inpatient Database identified patients aged≤18 years diagnosed with AIS undergoing elective PSF or VBT. Race, insurance, and ZIP-code income quartile served as SES proxies, while hospital characteristics represented institutional access. Weighted chi-squared and t-tests compared covariates. Multivariable logistic regression models identified independent predictors of VBT utilization, reporting adjusted odds ratios (OR) and 95% confidence intervals (CI), with p< 0.005 considered significant.

Results: Among 6,507 AIS patients, 259 (4.0%) underwent VBT and 6,248 (96.0%) PSF. VBT patients were younger (13.2 vs 14.3 years, p< 0.001) and incurred higher hospital charges ($301,050 vs 226,124, p< 0.001). VBT utilization was disproportionately higher among White (83.8% vs 60.8%, p< 0.001), privately insured patients (77.5% vs 58.2%, p< 0.001) residing in higher-income neighborhoods (42.1% vs 27.1%, p< 0.001), and at private (55.8% vs 38.6%, p< 0.001), urban hospitals (69.9% vs 50.1%, p< 0.001) in the Northeast (38.2% vs 17.9%, p< 0.001). These patterns persisted in the adjusted multivariable analysis, which showed significantly reduced odds of VBT among Black (OR 0.39, 95% CI 0.22-0.67) and Hispanic (OR 0.32, 95% CI 0.17-0.61) patients, those with Medicaid (OR 0.50, 95% CI 0.33-0.74), and those residing in the lowest-income neighborhoods (OR 0.51, 95% CI 0.31-0.87). Hospitals in the South (OR 0.16, 95% CI 0.10-0.24) and Midwest (OR 0.65, 95% CI 0.44-0.95) performed fewer VBTs.

Conclusion(s): VBT was predominantly performed in White, privately insured, higher-income patients at metropolitan hospitals, while minority and lower-SES groups had significantly lower utilization. These findings reveal persistent inequities in access to advanced surgical options for AIS.

Table 1. Individual characteristics of patients undergoing posterior spinal fusion (PSF) versus vertebral body tethering (VBT), 2022
*Quartiles were defined as $1-55,999 (0-25th percentile), $56,000-70,999 (26th-50th percentile), $71,000-93,999 (51st-75th percentile), 94,000+ (76th-100th percentile).

Table 2. Characteristics of hospitals performing posterior spinal fusion (PSF) versus vertebral body tethering (VBT), 2022


Table 3. Multivariable logistic regression model identifying socioeconomic and institutional predictors of vertebral body tethering (VBT) utilization versus posterior spinal fusion (PSF)
Covariates in the multivariable analysis included age, sex, LOS, and total hospital charges.
P value > 0.05 indicates statistical significance. Values with statistical significance are bolded.

a = Relative to White patients
b = Relative to private insurance
c = Relative to the 76th to 100th percentile ZIP income quartile
d = Relative to the Northeast hospital region
e = Relative to private, nonprofit hospital ownership
f = Relative to metropolitan hospitals with counties of metro areas of ≥1 million population
g = Too few VBT cases, variable was dropped from the analysis