Demystifying the outcome disparities in carotid revascularization: Utilization of experienced centers
Russyan Mark Mabeza1, Nikhil Chervu1, Yas Sanaiha1
1Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Insights
Racial and insurance disparities limit access to high-volume centers for carotid revascularization. Ensuring equitable access to experienced centers is crucial for improving patient outcomes and reducing disparities.
Area of Science:
- Vascular Surgery
- Health Services Research
- Health Equity
Background:
- Examined race- and insurance-based disparities in the utilization of high-volume centers for carotid revascularization procedures.
- Investigated potential inequities in access to specialized care for carotid artery disease.
Purpose of the Study:
- To determine if race and insurance status are associated with lower utilization of high-volume centers for carotid revascularization.
- To identify disparities in access to experienced centers for carotid endarterectomy and stenting.
Main Methods:
- Utilized data from the 2012-2019 National Inpatient Sample for adults undergoing carotid endarterectomy or stenting.
- Defined high-volume centers based on institutional procedure volume quartiles.
- Employed multivariable logistic regression to analyze associations between race, insurance, and high-volume center utilization.
Main Results:
- High-volume center utilization was associated with improved outcomes, including reduced mortality/stroke/myocardial infarction rates and shorter hospital stays.
- Black, Hispanic, and other non-White patients had significantly lower odds of receiving care at high-volume centers compared to White patients.
- Medicaid and uninsured patients also demonstrated lower utilization rates of high-volume centers compared to privately insured patients.
Conclusions:
- Patients of color and those with public or no insurance are disproportionately underserved by high-volume centers for carotid revascularization.
- Systemic interventions are needed to promote equitable access to experienced centers, thereby mitigating disparities in care and improving patient outcomes.
Background:
The present study examined race- and insurance-based disparities in utilization of high-volume centers for carotid revascularization.
Methods:
Adults (≥18 years) undergoing carotid endarterectomy or carotid artery stenting were identified in the 2012-2019 National Inpatient Sample. Annual, institutional volume of carotid endarterectomy and carotid artery stenting were tabulated, and hospitals in the highest and lowest quartiles were considered high-volume centers and low-volume centers, respectively. Multivariable logistic models were developed to evaluate the association of race and insurance status with high-volume center utilization. Logistic and linear regression was used to examine the association of high-volume centers with outcomes of interest.
Results:
Of an estimated 583,200 eligible patients, 60.3% underwent carotid revascularization at high-volume centers. Treatment at high-volume centers was associated with improved outcomes, including decreased odds of mortality/stroke/myocardial infarction (adjusted odds ratio 0.76, 95% confidence interval: 0.60-0.96) and a decrement in length of stay (β: -0.19, 95% confidence interval: -0.25 to 0.12) and hospitalization costs by $2,000 (95% confidence interval: 1,800-2,300). After adjustment, Black (adjusted odds ratio 0.52, 95% confidence interval: 0.48-0.55), Hispanic (adjusted odds ratio 0.45, 95% confidence interval: 0.42-0.55), and other non-White patients (adjusted odds ratio 0.49, 95% confidence interval: 0.45-0.52) had lower odds of undergoing carotid revascularization at high-volume centers compared to White patients. Similarly, Medicaid (adjusted odds ratio 0.87, 95% confidence interval: 0.80-0.94) and lack of insurance (adjusted odds ratio 0.84, 95% confidence interval: 0.77-0.92) were associated with lower odds of high-volume center utilization relative to private insurance.
Conclusion:
Patients of color and those with Medicaid or lack of insurance used high-volume centers at lower rates. Further systemic efforts to ensure equitable access to experienced centers may reduce observed disparities in carotid revascularization.
