(74) How Do Socioeconomic Factors and Unconscious Bias Influence the Probability of Operative Management of Nasal Bone Fractures?

Abstract: Purpose and problem: Often, the decision as to whether nasal bone fractures will require surgical intervention involves waiting for edema to subside over 1 to 2 weeks before re-evaluating a patient’s function and cosmesis. Therefore, the patient’s ability to reliably present to clinic for outpatient follow-up is an important factor influencing if surgical treatment is performed. There also may be an element of unconscious bias, which plays a role in a practitioner’s decision to offer surgical intervention or in the way treatment options are discussed with the patient. We seek to scrutinize the role that socioeconomic factors and unconscious bias play in the management of nasal bone fractures, particularly which patients ultimately undergo surgical intervention. Materials and methods: We performed a retrospective cohort study of 511 patients who presented to John H. Stroger Jr. Hospital of Cook County from 2016 to 2024 with a diagnosis of nasal bone fractures. Fifty-five patients were excluded, leaving 456 patients included for analysis. Patient demographic information was collected from the electronic health record including age at presentation, sex, ZIP code, race, ethnicity, preferred language, incarceration status, and insurance type. Using each patient’s ZIP code and data from the American Community Survey provided by the Chicago Health Atlas, the patients were grouped into quartiles based on median household income. Additionally, the following study variables were collected including scheduling and attendance of preoperative follow-up, and surgical intervention, either as an outpatient or on initial admission. Methods of data analysis: Discrepancies in study variables were compared using odds ratios (OR).

Results: Out of 456 patients, 368 were male. The average age at the time of injury was 40.74 years. Two-hundred forty-three people identified as African American/Black, 93 as White/non-Hispanic, and 95 as Hispanic. Seventy-eight patients were incarcerated. Overall, 80.9% of patients were offered follow-up, 42% attended, and 10.5% underwent surgery. Prisoners were offered and attended follow-up and underwent surgery at a higher rate overall (87.2%, 60.3%, and 14.1%, respectively). Excluding prisoners, investigated sub-groups were offered and attended follow-up at a similar rate. However, African American/Black (8.63% vs 16.42%, OR 0.48) and Hispanic (8.51% vs 16.42%, OR 0.47) patients underwent surgery less often than White/non-Hispanic patients. Non-English-speaking patients also underwent surgical intervention less often than English-speaking patients (7.69% vs 10.03%, OR 0.75). Finally, patients in the lowest quartile of median household income underwent surgery less often than those in the highest quartile (5% vs 13.64%, OR 0.34). Outcomes of data: Overall, minority groups including people of color, non-English speakers, and patients from areas with the lowest median household income underwent surgical intervention for nasal bone fractures less often as compared to White/non-Hispanic and English-speaking patients and those from wealthier areas of the city.

Conclusions: Our study suggests that several socioeconomic factors, including race/ethnicity, preferred language, and ZIP code, may contribute to the probability that a patient will ultimately undergo surgical intervention for treatment of nasal bone fractures. Physicians treating these patients should recognize how these factors and their own unconscious bias can influence treatment and may lead some patients to receive sub-par care. References 1. de Jager E, Ho YH. Socioeconomic disparities in rates of facial fracture surgeries for women and men at a regional tertiary care centre in Australia. ANZ J Surg. 2022 Jul;92(7-8):1700-1705. doi: 10.1111/ans.17763. Epub 2022 May 9. PMID: 35531884.2. Chicago Department of Public Health. Median household income. Chicago Health Atlas. https://chicagohealthatlas.org

Table 1. Effect of socioeconomic factors on follow-up and surgical intervention