(10) Referral Patterns for Craniosynostosis Surgical Consultation: A Retrospective Review

Abstract:

Purpose: Delays in the presentation of craniosynostosis impede timely surgical intervention and can be detrimental to patient outcomes. Disparities in accessing care may influence referral time and hinder access to providers who can provide swift and accurate diagnoses. Furthermore, an initial evaluation by a provider unfamiliar with the diagnosis might prolong referral to a neurosurgeon or craniofacial surgeon. This study aimed to explore referral patterns associated with surgical consultation for craniosynostosis.

Methods: A retrospective review of California-based craniosynostosis patients at a tertiary children's hospital between 2014 and 2024 was performed. The demographic variables collected included patient sex, age, race/ethnicity, median household income, and patient ZIP code. Patient ZIP codes were used to calculate state-specific Area Deprivation Index (ADI), a measure of socioeconomic disadvantage in deciles from least (1) to most (10) disadvantaged based on income, education, employment, and housing quality. ADI scores of (5) and greater were considered to have higher disadvantages. Referral-related information was abstracted, including the type of provider, the ZIP code of the referring institution, and the referral date. Patient age at presentation and craniosynostosis surgery also were recorded. Descriptive statistics, chi-squared tests, and independent t-tests were used for the statistical analysis.

Results: In total, 278 patients with craniosynostosis were evaluated. There were 126 (43.9%) Hispanic/Latinx, 76 (26.5%) White, 10 (3.5%) Asian, 3 (1.0%) Black/African American, and 56 (19.5%) other unknown patients. More than half (57.5%) of the patients had public insurance and a median household income of $81,559 ± $29,293. The mean ADI was 5.48 ± 2.25. The mean age at referral was 4.38 ± 4.56 months, and the mean age at presentation for surgical consultation was 5.49 ± 4.54 months. The mean time from referral to presentation was 43.10 ± 79.50 days. Across racial groups, significant differences were observed in the age at presentation (P < .001). The majority of referrals were from pediatricians (n = 222, 74.4%), followed by outside craniofacial/neurosurgeons (n = 26, 8.6%), self-referrals (n = 12, 4.0%), neonatologists (n = 10, 3.4%), and unknown (n = 2, 0.1%). Patients referred from mid-level providers had the oldest age at referral (6.73 ± 6.47 months), followed by patients referred from outside hospital craniofacial/neurosurgeons (6.34 ±5.18 months), pediatricians (4.14 ± 4.21 months), self-referrals (4.15 ± 5.91 months) and neonatologists (​​0.82 ± 1.20 months), P = .0147.

Conclusion: This study highlights significant differences in the age of referral for patients with craniosynostosis depending on provider type and patient race. Education and awareness of craniosynostosis at the community and provider levels may affect referral timing. Initiatives should be taken to address these disparities, promote equitable access to all craniosynostosis surgical options, and improve patient outcomes.

References
1. Hauc SC, Junn A, Dinis J, Phillips S, Alperovich M. Disparities in Craniosynostosis Outcomes by Race and Insurance Status. J Craniofac Surg. 2022;33(1):121-124.
2. Akbari SHA, Mooney J, Lepard J, et al. Racial differences in the care of pediatric sagittal craniosynostosis: a single-institution cohort study affecting state Medicaid policy. J Neurosurg Pediatr. 2023;32(4):464-471.