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January 14, 2014; 82 (2) Article

Disparities in deep brain stimulation surgery among insured elders with Parkinson disease

Allison W. Willis, Mario Schootman, Nathan Kung, Xiao-Yu Wang, Joel S. Perlmutter, Brad A. Racette
First published December 11, 2013, DOI: https://doi.org/10.1212/WNL.0000000000000017
Allison W. Willis
From the Departments of Neurology and Epidemiology and Biostatistics and the Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (X.-Y.W., J.S.P., N.K., B.A.R.), and Departments of Radiology and Neurobiology and Programs in Physical Therapy and Occupational Therapy (J.S.P.), Washington University School of Medicine, St. Louis; and Departments of Epidemiology and Health Services Research and Medicine (M.S.), St. Louis University, MO.
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Mario Schootman
From the Departments of Neurology and Epidemiology and Biostatistics and the Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (X.-Y.W., J.S.P., N.K., B.A.R.), and Departments of Radiology and Neurobiology and Programs in Physical Therapy and Occupational Therapy (J.S.P.), Washington University School of Medicine, St. Louis; and Departments of Epidemiology and Health Services Research and Medicine (M.S.), St. Louis University, MO.
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Nathan Kung
From the Departments of Neurology and Epidemiology and Biostatistics and the Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (X.-Y.W., J.S.P., N.K., B.A.R.), and Departments of Radiology and Neurobiology and Programs in Physical Therapy and Occupational Therapy (J.S.P.), Washington University School of Medicine, St. Louis; and Departments of Epidemiology and Health Services Research and Medicine (M.S.), St. Louis University, MO.
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Xiao-Yu Wang
From the Departments of Neurology and Epidemiology and Biostatistics and the Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (X.-Y.W., J.S.P., N.K., B.A.R.), and Departments of Radiology and Neurobiology and Programs in Physical Therapy and Occupational Therapy (J.S.P.), Washington University School of Medicine, St. Louis; and Departments of Epidemiology and Health Services Research and Medicine (M.S.), St. Louis University, MO.
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Joel S. Perlmutter
From the Departments of Neurology and Epidemiology and Biostatistics and the Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (X.-Y.W., J.S.P., N.K., B.A.R.), and Departments of Radiology and Neurobiology and Programs in Physical Therapy and Occupational Therapy (J.S.P.), Washington University School of Medicine, St. Louis; and Departments of Epidemiology and Health Services Research and Medicine (M.S.), St. Louis University, MO.
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Brad A. Racette
From the Departments of Neurology and Epidemiology and Biostatistics and the Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (X.-Y.W., J.S.P., N.K., B.A.R.), and Departments of Radiology and Neurobiology and Programs in Physical Therapy and Occupational Therapy (J.S.P.), Washington University School of Medicine, St. Louis; and Departments of Epidemiology and Health Services Research and Medicine (M.S.), St. Louis University, MO.
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Citation
Disparities in deep brain stimulation surgery among insured elders with Parkinson disease
Allison W. Willis, Mario Schootman, Nathan Kung, Xiao-Yu Wang, Joel S. Perlmutter, Brad A. Racette
Neurology Jan 2014, 82 (2) 163-171; DOI: 10.1212/WNL.0000000000000017

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Abstract

Objective: To identify sociodemographic, clinical, and physician/practice factors associated with deep brain stimulation (DBS). DBS is a proven surgical therapy for Parkinson disease (PD), but is recommended only for patients with excellent health, results in significant out-of-pocket costs, and requires substantial physician involvement.

Methods: Retrospective cohort study of more than 657,000 Medicare beneficiaries with PD. Multivariable logistic regression models examined the association between demographic, clinical, socioeconomic status (SES), and physician/practice factors, and DBS therapy.

Results: There were significant disparities in the use of DBS therapy among Medicare beneficiaries with PD. The greatest disparities were associated with race: black (adjusted odds ratio [AOR] 0.20, 95% confidence interval [CI] 0.16–0.25) and Asian (AOR 0.55, 95% CI 0.44–0.70) beneficiaries were considerably less likely to receive DBS than white beneficiaries. Women (AOR 0.79, 95% CI 0.75–0.83) also had lower odds of receiving DBS compared with men. Eighteen percent of procedures were performed on patients with PD who had cognitive impairment/dementia, a reported contraindication to DBS. Beneficiaries treated in minority-serving PD practices were less likely to receive DBS, regardless of individual race (AOR 0.76, 95% CI 0.66–0.87). Even after adjustment for demographic and clinical covariates, high neighborhood SES was associated with 1.4-fold higher odds of receiving DBS (AOR 1.42, 95% CI 1.33–1.53).

Conclusions: Among elderly Medicare beneficiaries with PD, race, sex, and neighborhood SES are strong independent predictors of DBS receipt. Racial disparities are amplified when adjusting for physician/clinic characteristics. Future investigations of the demographic differences in clinical need/usefulness of DBS, ease of DBS attainment, and actual/opportunity DBS costs are needed to inform policies to reduce DBS disparities and improve PD quality of care.

GLOSSARY

AOR=
adjusted odds ratio;
BASF=
Beneficiary Annual Summary File;
CI=
confidence interval;
CPT=
Current Procedural Terminology;
DBS=
deep brain stimulation;
ICD-9=
International Classification of Diseases, ninth revision;
OR=
odds ratio;
PD=
Parkinson disease;
RCT=
randomized controlled trial;
SES=
socioeconomic status;
ZCTA=
Zip Code Tract Area

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Received May 9, 2013.
  • Accepted in final form October 1, 2013.
  • © 2014 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Improving Inclusiveness in PD Research
    • Allison W. Willis, Assistant Professor, University of Pennsylvania School of MedicineAllison.Willis@uphs.upenn.edu
    Submitted August 06, 2014
  • Improving Group Homogeneity in PD Research
    • Matthew Barrett, Assistant Professor, University of Virginiamjbarrett@virginia.edu
    • Matthew James Barrett, Charlottesville, VA; Guofen Yan, Charlottesville, VA; Robert D. Abbott, Otsu, Shiga, Japan
    Submitted March 11, 2014
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