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  • Disparities in the Diagnosis and Management of Trigeminal Neuralgia

    Final Number:

    Azam Basheer MD; Kevin Reinard MD; Ellen L. Air MD, PhD; Ghaus M. Malik MD; Jason M. Schwalb MD , FAANS, FACS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: A number of studies have documented inequalities in care and outcomes for a variety of clinical conditions. We sought to identify potential racial and socioeconomic disparities in the diagnosis and treatment of trigeminal neuralgia (TN) that could serve as areas of focus for future quality improvement initiatives.

    Methods: Medical records of patients with an ICD-9 code of 350.1, signifying a diagnosis of TN, in the Henry Ford Medical Group (HFMG) from 2006 to 2012 were reviewed. The authors identified 652 such patients (Figure 1). Clinical and socioeconomic data were retrospectively reviewed on all patients (Table 1). Analyses were conducted to assess potential racial differences in subspecialty referral patterns and the specific type of treatment modality undertaken by patients with trigeminal neuralgia.

    Results: When compared to White patients, Black patients were less likely to undergo percutaneous ablative procedures, radiation therapy, or microvascular decompressions (p<0.001). However, there was no difference in likelihood of Blacks and Whites undergoing a procedure once they saw a neurosurgeon (67% vs. 70%, respectively; p = 0.712). Blacks and Whites were equally likely to be seen by a neurologist or neurosurgeon if they were seen in the ER (38% vs. 37%, p = 0.686) or Internal Medicine (48% vs. 50%, p = 0.743). For patients diagnosed after the publication of EFNS-AAN guidelines for medical therapy of TN in 2008 (n=293), fewer than 50% of patients were on medications sanctioned by the guidelines, without statistically significant racial disparities (p = 0.059) (Table 2).

    Conclusions: In a large retrospective database from one of the nation’s largest, comprehensive health systems, there were significant racial disparities in the likelihood of a patient undergoing a procedure for trigeminal neuralgia. This appeared to stem from a difference in referral patterns from outside that system.

    Patient Care: The Institute of Medicine report from 2002 on “Unequal Treatment” summarized a large of body of published literature on racial/ethnic inequalities in delivery and quality of health care.12 A large number of studies since then have continued to document disparities in various dimensions of medical care, including cancer care, myocardial infarction care, management of diabetes, and asthma care.13–15 The current study was launched after it was noted that a seemingly significant underrepresentation of Black patients were being referred for surgical management of TN, in spite of a large Black population in Southeast Michigan. It is worthwhile to point out, that while there is a disparity in referring black patients to see a neurosurgeon, there was no difference in likelihood of Blacks and Whites undergoing a procedure once they saw a neurosurgeon. The study can be applicable to many US urban settings and should highlight the need of a more aggressive referral pattern by primary care physicians and emergency departments in under-served areas.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Realize the existing racial disparities that exist among patients suffering from facial pain. 2) Once patients see a neurosurgeon, there was no difference in likelihood of Blacks and Whites undergoing a procedure 3) A good portion of this disparity stems from poor referral patterns that exist in under-served communities

    References: 1. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care [Internet]. Inst. Med. [cited 2014]. Available from: 2. Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol Off J Eur Fed Neurol Soc. 2008 Oct;15(10):1013–1028. 3. Van Hecke O, Austin SK, Khan RA, Smith BH, Torrance N. Neuropathic pain in the general population: A systematic review of epidemiological studies. Pain. 2013 Nov 26; 4. Hupp WS, Firriolo FJ. Cranial neuralgias. Dent Clin North Am. 2013 Jul;57(3):481–495. 5. Katusic S, Beard CM, Bergstralh E, Kurland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol. 1990 Jan;27(1):89–95. 6. Katusic S, Williams DB, Beard CM, Bergstralh EJ, Kurland LT. Epidemiology and clinical features of idiopathic trigeminal neuralgia and glossopharyngeal neuralgia: similarities and differences, Rochester, Minnesota, 1945-1984. Neuroepidemiology. 1991;10(5-6):276–281. 7. Siqueira SR, Teixeira MJ, Siqueira JT. Clinical characteristics of patients with trigeminal neuralgia referred to neurosurgery. Eur J Dent. 2009 Jul;3(3):207–212. 8. Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol Off J Eur Fed Neurol Soc. 2010 Sep;17(9):1113–e88. 9. Guardiani E, Sadoughi B, Blitzer A, Sirois D. A new treatment paradigm for trigeminal neuralgia using botulinum toxin type a. The Laryngoscope. 2014 Feb;124(2):413–417. 10. Kalkanis SN, Eskandar EN, Carter BS, Barker FG 2nd. Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes. Neurosurgery. 2003 Jun;52(6):1251–1261; discussion 1261–1262. 11. Wang DD, Ouyang D, Englot DJ, et al. Trends in surgical treatment for trigeminal neuralgia in the United States of America from 1988 to 2008. J Clin Neurosci Off J Neurosurg Soc Australas. 2013 Nov;20(11):1538–1545. 12. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care [Internet]. Inst. Med. [cited 2015]. Available from: 13. Drake BF, Keane TE, Mosley CM, et al. Prostate cancer disparities in South Carolina: early detection, special programs, and descriptive epidemiology. J S C Med Assoc 1975. 2006 Aug;102(7):241–249. 14. Gaskin DJ, Thorpe RJ Jr, McGinty EE, et al. Disparities in Diabetes: The Nexus of Race, Poverty, and Place. Am J Public Health. 2013 Nov 14; 15. Jean-Pierre P, Fiscella K, Griggs J, et al. Race/ethnicity-based concerns over understanding cancer diagnosis and treatment plan. J Natl Med Assoc. 2010 Mar;102(3):184–189. 16. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. J Natl Med Assoc. 2010 Apr;102(4):321–331.

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