Racial and Ethnic Disparities in Outcomes and Appropriateness of Carotid Endarterectomy

Abstract

Background and Purpose-Prior work documented racial and ethnic disparities in incidence of stroke, stroke risk factors, and use of carotid endarterectomy. Less is known about disparities in outcomes and appropriateness of carotid endarterectomy or reasons for such inequalities. Methods-This was a population-based cohort of carotid endarterectomy performed in Medicare beneficiaries in New York. Clinical data were abstracted from medical charts to assess sociodemographics, clinical indication for carotid endarterectomy, disease severity, comorbidities, and deaths and strokes within 30 days of surgery. Appropriateness was based on validated criteria from a national expert panel. Differences in patients, providers, outcomes, and appropriateness were compared using 2 tests. Differences in risk-adjusted rates of death or nonfatal stroke were compared using multiple logistic regression accounting for patient, physician, and hospital-level risk factors. Results-Overall, 95.3% of patients undergoing carotid endarterectomy were white, 2.5% black, and 2.2% Hispanic (Nϭ9093). Minorities had more severe neurological disease and more comorbidities and were more likely to be cared for by lower-volume surgeons and hospitals (PϽ0.0001). Rates of 30-day death/stroke were higher in Hispanics (9.5%) and blacks (6.9%) than whites (3.8%; PϽ0.0001). Multivariable analyses that adjusted for presurgical patient risk and provider characteristics found that blacks no longer had significantly worse outcomes (ORϭ1.

The Impact of Socioeconomic Status on Presentation and Treatment of Diverticular Disease

“…16 This increase in emergent presentations is undesirable for both the patient and the health care system, as it may contribute to higher overall health care cost and resource utilization. Becker 17 showed in a 10-year analysis of patients with uterine fibroids that patients of non-white race/ethnicity had higher total cost and length of stay compared to white patients.…”

“…Low SES patients were treated at hospitals with less experience with the disease than high SES patients (mean 61 vs. 70, p<0.0001). The mean number of cases of diverticular disease treated by an individual attending physician was 3.3 (median, 2; range, [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Low SES patients were also treated by attending physicians with less experience than high SES patients (mean, 3 …”

Racial/Ethnic Variation in Carotid Artery Revascularization Utilization and Outcomes

“…[7][8][9][10][11] Although these studies identify differences in postprocedural outcomes related to race and ethnicity, they do not provide information about other racial groups, such as Asians and American Indians. In addition, these studies do not provide important information on medication use, carotid lesion anatomic factors, or recurrent stenosis, which are factors known to have significant impact on clinical outcomes after carotid revascularization.…”

“…3 Although some studies have identified disparate patterns of utilization of carotid imaging and surgical revascularization between patients from different racial or ethnic backgrounds, [3][4][5][6] other studies have not confirmed these findings. 7 The studies that did demonstrate racial differences also found higher mortality rates after CEA in blacks and Hispanics; 4,[8][9][10][11][12] and some studies showed a relative increase in the incidence of postprocedural stroke and myocardial infarction (MI) in blacks after CEA. 9,13 In a recent study analyzing a nationwide inpatient sample (NIS) from 2005 to 2008, postprocedural mortality was significantly higher in Hispanic and blacks than in whites after CEA but not after CAS.…”

Race as a predictor of delay from diagnosis to endarterectomy in clinically significant carotid stenosis

“…2 Explanations for these outcomes disparities have included increased comorbidities preoperatively, poor patient selection, confounding by socioeconomic status and other non-medical factors, and increased proportion of CEA operations on black patients performed at low volume institutions, by less experienced surgeons. 2, 6, 9, 11, 15 …”