Impact of Socioeconomic Status on Treatment Decisions and Health Outcomes in Rathke’s Cleft Cyst Patients

Introduction: Rathke’s cleft cysts (RCCs) are benign sellar lesions that can impart significant endocrine and mass effect symptoms. While socioeconomic status (SES) is recognized to influence health outcomes, its role in RCC presentation and management is not well-defined. This study aims to explore the association between SES—particularly estimated income, insurance status, and primary care provider (PCP) access—and the presentation, management, and outcomes of patients with RCCs.

Methods: A retrospective review of 484 RCC patients referred to our center from 2000 to 2022 was performed. Data were collected on demographics, estimated income (2021 U.S. census data), and clinical variables. Patients were categorized by surgery, PCP, and insurance (private, public, uninsured) status. Statistical analyses included Wilcoxon’s rank-sum tests for continuous data, Pearson’s chi-squared and Fisher’s exact tests for categorical data, and univariate and multivariate logistic regression to adjust for potential confounders.

Results: Of 484 RCC patients (median age = 44 years, 72% female), 234 (48%) patients underwent surgery. The frequency of headaches (74 vs. 56%, p < 0.001) and visual symptoms (43 vs. 22%, p < 0.001, [Table 1]) was higher among surgical patients. There was no significant difference in median household income between operated and observed patients ($93,995 vs. $100,718, p = 0.2, [Fig. 1A]). Surgery rates varied by insurance type and PCP status (p = 0.020, [Fig. 1B]). Among surgical patients, public insurance (59%) was most common, followed by private (44%), then uninsured (38%) (p = 0.003, [Table 2A]). Preoperative visual dysfunction was most prevalent in those with public insurance (43%) followed by uninsured (28%) and private insurance (26%) patients (p = 0.002). Hispanic/Latino patients were more likely to undergo surgery compared to non-Hispanic/Latino patients (56 vs. 48%, p = 0.033). On logistic regression analyses ([Table 3]), we found significant predictors of surgery included public insurance (univariate OR = 1.81, p = 0.003; multivariate OR = 1.99, p = 0.009), and larger cyst size (univariate and multivariate OR = 1.23, p < 0.001). On logistic regression analyses, English proficiency was associated with smaller cyst size at diagnosis (univariate beta = −3.0, p = 0.002; multivariate beta = −2.3, p = 0.043). Postoperatively, resolution of visual symptoms was lower among uninsured patients (22%) compared to public (39%) and private (29%) insurance patients (p = 0.006, [Table 2B]). The median follow-up period for all patients was 2.4 years. A positive correlation was observed between follow-up and median income (p = 0.013, [Fig. 1C]). Longer follow-up was noted in patients with PCPs (3.0 vs. 1.4 years, p = 0.049) and those undergoing surgery (4.7 vs. 1.1 years, p < 0.001). Median follow-up also varied by insurance status (3.8 years for public vs. 2.0 years for private vs. 0.5 years for uninsured, p < 0.001). Insurance status was not associated with time to surgery (p = 0.2655, [Fig. 1D]).

Conclusion: RCC patients with public insurance and larger cysts have higher rates of surgery on multivariate regression analyses. English proficiency was associated with smaller RCC size. Resolution of preoperative visual dysfunction was lowest among uninsured patients. Follow-up duration was correlated with income and associated with PCP status, surgery, and insurance type. Further studies are needed to understand the underlying mechanisms and develop strategies to ensure equitable access to timely diagnosis, treatment, and follow-up.