Racial and Socioeconomic Disparities After Carotid Procedures
Todd R Vogel1, Robin L Kruse2, Ryan J Kim1
11 Division of Vascular Surgery, University of Missouri School of Medicine, Columbia, MO, USA.
Insights
Lower income and minority race are linked to worse outcomes, including stroke and mortality, after carotid procedures. Addressing these socioeconomic disparities is crucial for improving patient care.
Area of Science:
- Vascular Surgery
- Health Disparities
- Health Services Research
Background:
- Race is a known factor for poorer outcomes in various medical procedures.
- The impact of socioeconomic status (SES) on cerebrovascular disease interventions remains under-examined.
Purpose of the Study:
- To investigate the association between socioeconomic status and outcomes following carotid artery stenting (CAS) and carotid endarterectomy (CEA).
- To analyze the influence of race and income on the utilization and results of these cerebrovascular procedures.
Main Methods:
- Analysis of the National Inpatient Sample (2012-2014) for elective CAS and CEA procedures.
- Estimation of median household income using patient ZIP codes and assessment of outcomes via chi-square and multivariable logistic regression.
- Inclusion of covariates such as age, race, gender, comorbidities, insurance status, and hospital characteristics.
Main Results:
- Lowest quartile income patients (LQIP) were disproportionately Black and Hispanic, with lower private insurance rates and higher Medicaid use.
- LQIP, Black, and Hispanic patients were more likely to undergo CAS.
- Postoperative stroke was associated with LQIP, Black race, and Hispanic ethnicity. Whites in the lowest income quartile also had increased stroke risk.
- Mortality was linked to LQIP, Black race, and CAS. LQIP experienced longer hospital stays.
Conclusions:
- Race is associated with higher hospital mortality, stroke, and complications after carotid procedures.
- Lower income independently predicts increased stroke and mortality risk, regardless of race.
- Carotid procedure disparities stem from multiple factors, necessitating interventions targeting both race and socioeconomic status.
Background:
Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established.
Materials And Methods:
Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics.
Results:
We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001).
Conclusions:
Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.
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