Racial/Ethnic Variation in Carotid Artery Revascularization Utilization and Outcomes

Abstract

Background and Purpose— It is not known whether racial or ethnic disparities observed with other revascularization procedures are also seen with carotid artery stenting (CAS) and endarterectomy (CEA). Methods— We compared the utilization and outcomes of CAS and CEA across racial/ethnic groups within the CARE Registry between May 2007 and December 2012. Results— Between 2007 and 2012, of the 13 129 patients who underwent CAS, majority were non-Hispanic whites (89.3%), followed by blacks (4.4%), Hispanics (4.3%), and other groups (2.0%). A similar distribution was observed among the 10 953 patients undergoing CEA (non-Hispanic whites, 92.6%; blacks, 3.5%; Hispanics, 2.8%; and other groups, 1.1%). During this time period, a trend toward proportionate increase in CAS utilization was observed in non-Hispanic whites and other groups, whereas the opposite was observed among Hispanics and blacks. This trend persisted even when hospitals performing both CAS and CEA were exclusively analyzed. Adherence to antiplatelet and statin therapy was significantly lower among blacks post CEA. In-hospital major adverse cardiac and cerebrovascular events remained comparable across groups post CAS and CEA. At 30 days, the incidence of stroke (7.2%) and major adverse cardiac and cerebrovascular events (8.8%) was higher among blacks post CEA ( P <0.05), after risk adjustment. Conclusion— During the study period, utilization of CAS and CEA was highest among non-Hispanic whites. There was a trend toward increased CAS utilization over time among non-Hispanic whites and other groups, and a trend toward increased CEA utilization among Hispanics and blacks. In-hospital major adverse cardiac and cerebrovascular events remained comparable between groups, whereas 30-day major adverse cardiac and cerebrovascular events were significantly higher in blacks.

Fixed and variable cost of carotid endarterectomy and stenting in the United States: A comparative study

“…This racial disparity may reflect an underlying difference in socioeconomic factors, which have been shown to be associated with delayed access to healthcare. [19][20][21] Baseline comorbidities in patients who underwent carotid revascularization showed some distinctions between patients who underwent CEA vs CAS. The majority of patients understudy were hypertensive.…”

The impact of race on outcomes after carotid endarterectomy in the United States

“…20,21 However, more worrisome, they differed in their identified effect of race on outcomes after CEA, as two found no association between race and stroke or death, 8,21 whereas one did find an association between Black race and 30-day mortality. 18 Despite comparable perioperative complication rates between Black and White patients in our study, Black patients experienced longer LOS and more failed discharges to home, which might reflect differences in socioeconomic factors and social networks, in combination with their overall higher disease burden.…”

“…Overall, most were limited by a small sample of Black patients, with very small event numbers. 5,6,8,17,18 Additionally, those using administrative or Medicare data lacked information on preprocedural stroke or TIA laterality, impeding a reliable classification of symptomatic patients. 5,7,9 This could result in biased racial comparisons among CEA patients, as Black patients are more likely symptomatic and more often have an ipsilateral stroke as their presenting symptom.…”

Challenge and Yield of Enrolling Racially and Ethnically Diverse Patient Populations in Low Event Rate Clinical Trials

“…18, 19 For carotid artery stenting (CAS), the CARE Registry showed that the risk of perioperative stroke did not differ by race for CAS, though the risk for stroke or major adverse cardiac or cerebrovascular events was significantly higher in blacks for CEA. 20…”