title: Race, presenting signs and symptoms, use of carotid artery imaging, and appropriateness of carotid endarterectomy.
abstract: OBJECTIVE
  We sought to determine whether there are racial differences in use of carotid artery imaging after controlling for clinical factors and to ascertain racial differences in presenting signs and symptoms and overall appropriateness for carotid endarterectomy (CE).
  
  
  METHODS
  We performed a retrospective cohort study of 803 patients older than 45 years, hospitalized between 1991 and 1994 at any of 4 Veterans Affairs Medical Centers, with a discharge diagnosis of transient ischemic attack or ischemic stroke. Clinical data were abstracted from the medical record, including presenting symptoms, diagnostic test results, and use of surgical procedures. Appropriateness for CE was determined according to RAND criteria.
  
  
  RESULTS
  Black patients were more likely than white patients to present with stroke (78% versus 55%) but less likely to present with transient ischemic attack (22% versus 45%; P=0.001). There was no racial difference in medical comorbidity or preoperative risk. Black patients were less likely to have an imaging study of their carotid arteries (67% versus 79%; P=0.001). Race remained an independent predictor of imaging after adjustment for clinical factors (odds ratio=1.50; 95% CI, 1.06 to 2.13). Because of higher prevalence of significant carotid artery stenosis, whites were significantly more likely than blacks to be assessed as appropriate candidates for surgery with the use of RAND criteria (18% versus 4%; P=0.001).
  
  
  CONCLUSIONS
  Use of carotid artery imaging, a critical step in determining eligibility for CE, is influenced by the patient's race after controlling for clinical presentation. Adjustment for appropriateness of CE reduces but does not eliminate the importance of race.
authors.affiliation: Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC, USA. oddonOO1@mc.duke.edu
authors.forename: E Z
authors.initials: EZ
authors.lastname: Oddone
authors.forename: R D
authors.initials: RD
authors.lastname: Horner
authors.forename: R
authors.initials: R
authors.lastname: Sloane
authors.forename: L
authors.initials: L
authors.lastname: McIntyre
authors.forename: A
authors.initials: A
authors.lastname: Ward
authors.forename: J
authors.initials: J
authors.lastname: Whittle
authors.forename: L J
authors.initials: LJ
authors.lastname: Passman
authors.forename: L
authors.initials: L
authors.lastname: Kroupa
authors.forename: R
authors.initials: R
authors.lastname: Heaney
authors.forename: S
authors.initials: S
authors.lastname: Diem
authors.forename: D
authors.initials: D
authors.lastname: Matchar
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D002339:Carotid Arteries / Q000000981:diagnostic imaging* / Q000473:pathology*; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D002544:Cerebral Infarction / Q000209:etiology*; D003937:Diagnosis, Differential; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology*; D018810:Magnetic Resonance Angiography / Q000706:statistics & numerical data*; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D016017:Odds Ratio; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014728:Veterans; D044465:White People / Q000706:statistics & numerical data*