Discussion: Scoping Review of Healthcare Disparities in Treatment of Craniosynostosis: Assessing Impacts of Race,Insurance,and Socioeconomic Status

In the treatment of craniosynostosis, early diagnosis is becoming increasingly important. This is due to the advent of minimally-invasive techniques, which require patients to be younger than a certain age at the time of surgery (approximately 3 months for suturectomy and helmet therapy, and approximately 6 months for spring-assisted cranioplasty). There is no question that these minimally-invasive techniques have certain advantages over open remodeling techniques, namely lower transfusion rates, shorter operative times, shorter length of hospital stay, and lower cost.^1-3 In addition, for unilateral coronal craniosynostosis, minimally-invasive techniques are thought to result in superior ophthalmic outcomes, compared to open remodeling techniques. ⁴ When it comes to open calvarial vault remodeling surgery, there is plenty of evidence that delaying surgery past 18 months of age can have deleterious long-term neurocognitive outcomes.^5,6

Sadly, the findings by Gregory Pearson et al are predictable and disheartening. They utilized sound systematic review principles to demonstrate that nonwhite patients, those with Medicaid or no insurance, and those with lower income, had delayed referrals, longer wait times between referral and surgery, and delayed surgery, with trends for higher complication rates and higher costs of care.

The goal of the craniofacial surgeon should be to consistently see infants with craniosynostosis at an early age, when all surgical options, including minimally-invasive techniques, are still available. There are 2 types of variables that affect this goal, some of which are partially within the surgeon’s control, and some of which are outside the surgeon’s control. The authors do a nice job of exploring demographic causes of delays in diagnosis and treatment that are largely outside the surgeon’s control: language other than English, negative perception/lack of trust in the medical field, lack of access to transportation, difficulty taking time off work to attend medical appointments, and lack of adequate health insurance, among others. There is, however, an additional element that is partially within the surgeon’s control: education and outreach. Surgeons should dedicate some of their time to educating pediatricians and families in the community about craniosynostosis, minimally-invasive techniques, and the importance of early diagnosis and treatment. Many pediatricians have never seen a child with craniosynostosis, and may not be able to detect a mild unicoronal or sagittal craniosynostosis case. It is our job as surgeons to visit these pediatricians, and teach them what to look for and when/how to refer patients. Even better, we can target our outreach visits to pediatricians who treat a high proportion of underserved families that, according to Gregory Pearson et al, are at the highest risk of delayed diagnosis and treatment.

We all strive to achieve more equitable access to craniofacial surgery. We hope that readers who may feel disheartened by the findings of this study will instead feel motivated to address the root of the problem.