Disparities and institutional variation in time to surgery for traumatic cervical spinal cord injury: a multicenter cohort study.

OBJECTIVE

Early access to surgical care is increasingly recognized as an important principle in the management of traumatic spinal cord injury (SCI); however, systems-level barriers that hinder delivery of care exist. Therefore, the aim of this study was to evaluate the associations of race, insurance status, and frailty with the time to surgical intervention in patients with traumatic SCI, and to quantify institutional variation in surgical timing across North American trauma centers.

METHODS

A multicenter retrospective cohort study was conducted using the American College of Surgeons Trauma Quality Improvement Program database (2010-2020). Adult patients (age ≥ 16 years) with blunt traumatic cervical SCI who underwent surgical decompression were included. A mixed-effects regression model was used to identify independent predictors of the time to surgery and to assess variation between and within trauma centers. Variance components from a null model (intercept only) and full model (case-mix adjusted) were compared, and the proportional change in variance at the hospital and individual levels was calculated to quantify the explanatory value of hospital- and patient-level characteristics, respectively.

RESULTS

The cohort included 20,566 patients (15,977 male, mean age 53 years) from 503 trauma centers. The mean time to surgery was 30 hours (SD 28 hours), and 57% of patients underwent decompression within 24 hours of presentation. Black race, lack of insurance, and increasing frailty were independently associated with delayed surgery. Patients categorized as frail experienced a 3.4-hour longer delay in time to surgery (95% CI 2.03-4.63, p < 0.001). Uninsured patients waited 1.6 hours longer (95% CI 0.24-2.94, p = 0.023). Black patients experienced a 1.4-hour delay (95% CI 0.81-2.80, p = 0.005) compared with White patients. Observed case-mix and hospital-level characteristics did not account for between-hospital variability in surgical timing (proportional change in variance of -5.3%). Only 8.6% of the individual-level proportional change in variance was explained by these factors. The adjusted intraclass correlation coefficient was 8%, indicating low correlation in surgical timing for patients with similar characteristics treated at the same center.

CONCLUSIONS

Delays in surgical treatment for cervical SCI persist, particularly among patients categorized as frail, those who were uninsured, and Black patients. Institutional variation remains substantial and largely unexplained by case-mix or hospital-level characteristics. These findings highlight the need for equity-focused quality improvement efforts and system-level interventions to improve timely care for individuals with SCI.