Racial disparities in carotid revascularization following stroke in minority-serving hospitals

Beyond patient factors, recent evidence has suggested that institutional characteristics may contribute to persistent racial disparities in carotid revascularization following acute ischemic stroke. Minority-serving hospitals (MSHs) care for a disproportionately high number of historically underserved populations and thus may contribute to observed disparities.

All adults (≥18 years) admitted for acute ischemic stroke owing to carotid artery stenosis were identified in the 2016-2021 Nationwide Inpatient Sample. Patients with missing key data, elective status, or admitted to hospitals performing five or fewer carotid revascularization procedures per year (≤5th percentile) were excluded. Carotid revascularization composed of endarterectomy or stenting. The outcomes of interest were receipt of carotid revascularization, in-hospital mortality, myocardial infarction (MI), and a composite of both measures (death/MI), along with postoperative length of stay, hospitalization costs, and nonhome discharge. Multivariable regression models were developed to evaluate the association of MSH with outcomes of interest.

Of the hospitals included in the analysis, 28.9% were classified as MSHs. Revascularization rate for these patients significantly increased for both MSH (2016: 16.5%, 2021: 20.5%, nP_trend = 0.02) and non-MSH (2016: 20.1%, 2021: 22.0%, nP_trend <0.01), over the study period. After risk adjustment, treatment at MSH was associated with a significantly lower odds of receiving revascularization (AOR, 0.80; 95% CI, 0.74-0.87), relative to others. MSH status was linked with similar in-hospital mortality (AOR, 1.15; 95% CI, 0.96-1.22), but increased odds of MI (AOR, 1.17; 95% CI, 1.02-1.34) and death/MI (AOR, 1.14; 95% CI, 1.04-1.25). Treatment at these centers was associated with prolonged LOS (β +0.45 days; 95% CI, 0.14-0.76) and hospitalization expenditures (β +$5800; 95% CI, 4510-7080), along with increased relative risk of nonhome discharge (AOR, 1.10; 95% CI, 1.05-1.18) compared with non-MSH. Despite decreased revascularization use for Black and Asian patients across all centers, Hispanic race was linked with lower odds of revascularization solely at MSH.

Providing increased resources to support MSH may be an effective strategy to ensure equal health access to racial/ethnic minority patients. Future studies incorporating hospital quality initiatives targeted for MSH are warranted.