Cite as: Pan W, Hussain A, Tolba R. Disparities in access to neuromodulation therapies: what factors are at play?. ASRA Pain Medicine News 2022;47. https://doi.org/10.52211/asra020122.007. 

According to the Center for Disease Control and Prevention, chronic pain is one of the most common reasons adults seek medical care in the United States, with an estimated 11%–40% of U.S. adults experiencing chronic pain.¹ For many patients, the typical medical and interventional therapies eventually lose efficacy, especially for those with longstanding chronic pain. Neuromodulation can offer relief by modifying how the body processes pain, but it is not widely accessible. In this article, we discuss the factors that may contribute to disparities in certain U.S. populations’ access to neuromodulation as a treatment modality, including insurance, socioeconomic status, and race. We will also comment briefly on specific challenges faced by patients internationally.

How can neuromodulation be considered a treatment option if entire subsets of the patient population have difficulty obtaining it? 

How can neuromodulation be considered a treatment option if entire subsets of the patient population have difficulty obtaining it? A review of the ambulatory surgery databases in four major U.S. states revealed that ambulatory spinal cord stimulator (SCS) placement is significantly more common in patients with private insurance than publicly insured patients.² Furthermore, patients with Medicare or Medicaid are significantly more likely to have procedures performed in an urgent inpatient setting as compared to privately insured patients, possibly because publicly insured patients tend to be “older and sicker,” leading to later diagnosis and treatment, longer inpatient hospital stays, more frequent discharges to higher level of care, and higher overall costs.³

Socioeconomic status is closely interwoven with insurance status in affecting access to neuromodulation, as evidenced by analyses from large cohorts and datasets. Patients who are dual eligible for Medicare and Medicaid, a marker for lower socioeconomic status, are significantly less likely to receive SCS therapy than those eligible for Medicare only, according to data from the Centers for Medicare and Medicaid Services Claims Limited Dataset.⁴ Additionally, two major neuromodulation device companies reported that U.S. counties with any device implants have a statistically higher average household income ($49,663) than counties with no device implants ($41,314).⁵

Racial disparities exist in many areas of medicine and pain management, and they have a complex interplay when it comes to access to neuromodulation. In the Medicare dataset, after adjusting for comorbidities, Black, Asian, Hispanic, and North American Native patients were significantly less likely to receive SCS than White patients.⁴ A retrospective cohort study of data in ambulatory surgery databases from four large U.S. states found that among higher-volume hospitals, ambulatory SCS access was more common for Caucasians, males, and those with private insurance or fewer comorbidities.²

Although most SCS procedures are performed in the outpatient setting, some are performed in the inpatient setting. In the National Inpatient Sample, Black and Hispanic patients were more likely to receive SCS therapy,⁶ suggesting that the outpatient setting is a disparity for minority patients—but it is the predominant setting in which SCS is performed. The reasons for those differences are unclear, but it may be related to higher comorbidities, similar to the disparities for publicly insured patients.

International patients face different challenges in access to SCS therapy. Developing countries with limited resources have limited access to SCS because of the high cost of implants and lack of insurance coverage. Solutions such as more affordable out-of-pocket bundle pricing should be offered, although it will still come at a steep price, or some nongovernmental organizations can help raise capital to fund the procedures. Finally, many providers in certain countries simply lack awareness of SCS, leading to inappropriate access despite its availability. Proper community outreach and provider education is crucial to raise awareness.

Equitable access is paramount to effective health care delivery. Multiple factors, including race, socioeconomic status, insurance status, comorbidities, gender, access to high-volume hospitals, and geographic factors are at play. Further research and understanding are needed to elucidate the complex etiology of inequitable access to pain neuromodulation therapies.

Wenyu Pan, MD, is an anesthesiology resident physician at the University of Chicago School of Medicine in Chicago, IL.

Abrar Hussain, DO, is an anesthesiology resident physician at the University of Texas Medical Branch in Galveston.

Reda Tolba, MD, is chair of the Pain Management Department at Cleveland Clinic Abu Dhabi in the United Arab Emirates.

References

1. Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67:1001–6. http://dx.doi.org/10/15585/mmwr.mm6736a2
2. Missios S, Rahmani R, Bekelis K. Spinal cord stimulators: socioeconomic disparities in four US states. Neuromodulation. 2014;17(5):451–5; discussion 455–6. https://doi.org/10.1111/ner.12101   
3. Burton BN, Barboza J, Angerstein A, et al. The association of insurance status with non-routine hospital discharge after placement of spinal cord stimulators. J Clin Anesth. 2019;57:17–9. https://doi.org/10.1016/j.jclinane.2019.02.024  
4. Jones MR, Orhurhu V, O'Gara B, et al. Racial and socioeconomic disparities in spinal cord stimulation among the Medicare population. Neuromodulation. 2021;24(3):434–40. https://doi.org/10.1111/ner.13373 
5. Leiphart J, Barrett M, Shenai MB. Economic inequities in the application of neuromodulation devices. Cureus. 2019;11(9):e5685. https://doi.org/10.7759/cureus.5685 
6. Orhurhu V, Gao C, Agudile E, et al. Socioeconomic disparities in the utilization of spinal cord stimulation therapy in patients with chronic pain. Pain Pract. 2021;21:75-82. https://doi.org/10.1111/papr.12936