Racial and insurance based disparities in the treatment of carotid artery stenosis: a study of the Nationwide Inpatient Sample

Brinjikji, Waleed; El-Sayed, Abdulrahman M.; Kallmes, David F.; Lanzino, Giuseppe; Cloft, Harry J.

doi:10.1136/neurintsurg-2014-011294

Cited by 35 publications

(17 citation statements)

References 32 publications

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“…5, 24-27 To date, it has been reported using the Nationwide Inpatient Sample database that asymptomatic self-pay/Medicaid patients are less likely to receive carotid revascularization, often waiting until becoming symptomatic. 28 One additional confounder might be an increased aversion to surgery among black patients, manifesting in a delay to surgery attributable to operative hesitancy. 29-31 These patients were cared for by the same group of surgeons, and received preoperative medical optimization similarly, supported by similar rates of treatment with at least one anti-platelet agent (78% vs. 88% for white and black patients, respectively; P =.45), in accordance with recommended management guildelines 32, 33 , and a statin (48% vs. 41% for white and black patients, respectively; P =.56).…”

Section: Discussionmentioning

confidence: 99%

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

Wise

Ladner

Song

et al. 2015

Journal of Vascular Surgery

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Objective Prompt carotid endarterectomy (CEA) in clinically significant carotid stenosis is important in the prevention of neurologic sequelae. The greatest benefit from surgery is obtained by prompt revascularization upon diagnosis. It has been demonstrated that black patients both receive CEA less frequently than white patients and experience worse postoperative outcomes. We sought to test our hypothesis that black race is an independent risk factor for a prolonged time from sonographic diagnosis of carotid stenosis warranting surgery to the day of operation (TDO). Methods 166 CEA patients from 1998-2013 at a single institution were retrospectively reviewed using Synthetic Derivative, a de-identified electronic medical record. Factors potentially affecting TDO, including demographics, preoperative cardiac stress testing (CST), degree of stenosis, smoking status and comorbidities, were noted. Multivariate analysis was performed on variables that trended with prolonged TDO on univariate analysis (P<.10) to determine independent (P<.05) predictors of TDO. Subgroup analyses were further performed on the symptomatic and asymptomatic stenosis cohorts. Results 32 black patients and 134 white patients and were studied; the mean TDO was 78±17 days vs. 33±3 days, respectively (P<.001). In addition to the need for preoperative CST, black race was the only variable that demonstrated a trend with (P<.10), or was an independent risk factor (P<.05) for prolonged TDO among all patients (B=42 days; P<.001) and within the symptomatic (B=35 days; P=.08) and asymptomatic cohorts (B=35 days; P=.003). On Kaplan-Meier analysis, black patients in each strata of symptomatology (all, symptomatic and asymptomatic patients) experienced prolonged TDO (log-rank P<.03 for all three groups). Conclusions Black race is a risk factor for a temporal delay in CEA for carotid stenosis. Awareness of this disparity may help surgeons avoid undesirable delays in operation for their black patients.

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Section: Discussionmentioning

confidence: 99%

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

Wise

Ladner

Song

et al. 2015

Journal of Vascular Surgery

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“…had symptoms attributable to their carotid disease) was identified using the following ICD-9-CM codes previously reported in literature: 362.3(0–7), 362.84, 433.11, 433.31, 434.01, 434.91, 435. (0–3,8,9), and 781.4 (2,4,5). The primary outcome of interest was hospital readmission within 30-days of discharge from a hospitalization during which a carotid revascularization procedure had been performed.…”

Section: Methodsmentioning

confidence: 99%

Readmissions After Carotid Artery Revascularization in the Medicare Population

Al‐Damluji

Dharmarajan

Zhang

et al. 2015

Journal of the American College of Cardiology

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Background In appropriately selected patients with severe carotid stenosis, carotid revascularization reduces ischemic stroke. Prior clinical research has focused on the efficacy and safety of carotid revascularization, but few investigators have considered readmission as a clinically important outcome. Objectives To examine frequency, timing, and diagnoses of 30-day readmission following carotid revascularization; to assess differences in 30-day readmission between patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS); to describe hospital variation in risk-standardized readmission rates (RSRR); and to examine whether hospital variation in procedural choice (CEA vs. CAS) was associated with differences in RSRRs. Methods We used Medicare fee-for-service administrative claims data to identify acute care hospitalizations for CEA and CAS from 2009–2011. We calculated crude 30-day all-cause hospital readmissions following carotid revascularization. To assess differences in readmission after CAS compared with CEA, we used Kaplan-Meier survival curves and fitted mixed-effect logistic regression. We estimated hospital RSRRs using hierarchical generalized logistic regression. We stratified hospitals into 5 groups by their proportional CAS use and compared hospital group median RSRRs. Results Of 180,059 revascularizations from 2,287 hospitals, CEA and CAS were performed in 81.5% and 18.5% of cases, respectively. The unadjusted 30-day readmission rate following carotid revascularization was 9.6%. Readmission risk after CAS was higher than after CEA. There was modest hospital-level variation in 30-day RSRRs (Median: 9.5%, Range: 7.5%–12.5%). Variation in proportional use of CAS was not associated with differences in hospital RSRR (range of median RSRR across hospital quartiles: 9.49%–9.55%, P 0.771). Conclusions Almost 10% of Medicare patients undergoing carotid revascularization were readmitted within 30-days of discharge. Compared with CEA, CAS was associated with higher readmission risk. However, hospitals’ RSRR did not differ by their proportional CAS use.

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“…Socioeconomic and racial status and type of insurance has consistently been a predictor in the rendering of medical care [4][5][6]. The Provider Utilization and Payment Data Inpatient Public Use File database can be utilized to study disparities in care of patients with…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, the 2013 Centers for Disease Control Health Disparities and Inequalities Report notes that minorities continue to be of lower socioeconomic status, resulting in greater barriers to health care access and increased burden of disease [7]. Specifically, Brijinki, et al [5] showed that minorities were less likely to receive carotid revascularization when asymptomatic and Kao et al [4] demonstrated lower DES usage in patients with government insurance and the uninsured population.…”

Section: Study Cohortmentioning

confidence: 99%

Novel methodology using publicly reported data to study percutaneous coronary stent utilization in the United States: Linking centres for medicare medicaid services provider analysis and review inpatient data with hospital and community characteristics

Tuliani¹,

Shenoy²,

Parikh³

et al. 2017

Cardiovasc Disord Med

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Racial and insurance based disparities in the treatment of carotid artery stenosis: a study of the Nationwide Inpatient Sample

Cited by 35 publications

References 32 publications

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

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

Readmissions After Carotid Artery Revascularization in the Medicare Population

Novel methodology using publicly reported data to study percutaneous coronary stent utilization in the United States: Linking centres for medicare medicaid services provider analysis and review inpatient data with hospital and community characteristics

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