Date of Award

January 2026

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Michael DiLuna

Second Advisor

Aladine Elsamadicy

Abstract

Background: Insurance and racial disparities have been shown to influence patient outcomes in various disease states. However, few studies have investigated the impact of insurance and race/ethnic background on cervical spinal cord injury (SCI) outcomes, especially with the growing proportion of elderly patients presenting with acute SCI.

Research Aims: The aim of this study was to assess associations between age, race/ethnicity, insurance and adverse events (AEs), non-routine discharge, and in-hospital mortality in patients with acute cervical SCI.

Methods: We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Programs (TQP) database to compare outcomes for adult patients with acute cervical SCI based on age group (18-44 years, 45-65 years, and >65 years), insurance type (public, private, and other insurance), and race/ethnic group (non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic or Latino (HIS), and other (OTH) race). Patient demographics, comorbidities, type of injury, treatment modality, AEs, length of stay were assessed. Multivariate logistic regression was used to identify independent predictors of adverse events, non-routine discharge, and in-hospital mortality.

Results: A total of 71,048 patients were identified and included in analyses. On multivariate analysis, 45-65 years and >65 years age groups, respectively, significantly predicted any AE [Odds Ratio (OR):1.18, Confidence Interval (CI): 1.07-1.29, p<0.001; OR:1.27, CI: 1.15-1.41, p<0.001], non-routine discharge [OR:1.38, CI: 1.26-1.51, p<0.001; OR:3.24, CI: 2.87-3.65, p<0.001], and in-hospital mortality [OR:1.89, CI: 1.67-2.14, p<0.001; OR:4.80, CI: 4.20-5.48, p<0.001]. Insurance type did not significantly predict AEs [Private: p=0.835; Other: p=0.964]. Private insurance was significantly associated with decreased odds of non-routine discharge [OR: 0.84, CI: 0.77-0.92, p<0.001] and in-hospital mortality [OR: 0.81, CI: 0.74-0.89, p<0.001]. Conversely, Other coverage was significantly associated with decreased odds of non-routine discharge [OR: 0.52, CI: 0.47-0.58, p<0.001], but increased odds of in-hospital mortality [OR: 1.35, CI: 1.19-1.53, p<0.001]. Regarding the impact of race/ethnic background, only HIS [OR: 1.15, CI: 1.01-1.32, p=0.037] and OTH race [OR: 1.15, CI: 1.02-1.30, p=0.026] were significant predictors of AEs. NHB race was significantly associated with increased odds [OR: 1.25, CI: 1.13-1.38, p<0.001], while HIS race was significantly associated with decreased odds [OR: 0.77, CI: 0.67-0.89, p<0.001] of non-routine discharge. Only NHB race was significantly associated with decreased odds of in-hospital mortality [OR: 0.66, CI: 0.59-0.74, p<0.001].

Scientific Impact: Our study suggests that older age and non-private insurance coverage are associated with increased morbidity and mortality risk in patients with acute cervical SCI. Further, our findings suggest there are racial disparities in outcomes and discharge disposition of patients undergoing treatment for SCI. Additional research is needed to identify and address factors contributing to these disparities.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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