9. Demographic representation in the North American Spine Society Appropriate Use Criteria for Cervical Fusion and Degenerative Lumbar Spondylolisthesis

In the United States (US), there have been increasing efforts for diverse clinical trial recruitment with hopes of addressing inequities in health care and providing representative data for clinical decision-making. There has been no published evidence to analyze the current state of spine literature and representation among its studies. The primary aim of this study was to investigate the racial and ethnic representation in studies referenced in the North American Spine Society (NASS) 2022 Appropriate Use Criteria (AUC) for Cervical Fusion (CF) and 2020 AUC Degenerative Lumbar Spondylolisthesis for (LS) were analyzed. Review. Participants were pooled from studies included in the NASS CF and LS AUC. The primary outcome measure of this study was participation-to-prevalence ratio (PPR). The numerator (participation) was defined as the representation of a demographic group pooled across included studies. The PPR denominator (prevalence) was defined as the representation of a demographic group in the US population. Articles included in the NASS 2022 CF and 2020 DLS AUC were analyzed. Main study details and the demographic characteristics they reported were collected. US census data from 2020 was used to calculate the representation of each demographic group relative to their proportion in the US population, demonstrated as participation-to-prevalence ratio (PPR). PPR1.2 were classified as overrepresented. A total of 84 studies published from 1998 to 2020 were included, 44 of which were CF AUC references and 40 of which were DLS AUC references. Race was reported in 8 (9.5%) of the studies, ethnicity in 4 (4.7%) and gender in 63 (75%). There were 43 US-based studies (24 CF AUC, 19 DLS AUC), 7 reported race and of those 5 were published after 2014. Of the US-based studies 57% (4/7) reported race and ethnicity separately, three reported Asian participants and 2 reported American Indian/Alaska Native participants. Representation of White participants was calculated using pooled data from all 7 studies and revealed an overrepresentation when compared to the US population (PPR=1.52). When the 2 studies that reported all demographic groups were analyzed, an overrepresentation of White participants was again demonstrated (PPR=1.45), in addition to an underrepresentation of Black, Hispanic, and Asian participants (PPR=0.82, 0.39, 0.67 respectively). This study demonstrates a failure to consider race and ethnicity among t