Elective and isolated carotid endarterectomy: health disparities in utilization and outcomes, but not readmission.
BACKGROUND
Carotid endarterectomy (CEA) has been shown to decrease future ischemic stroke risk in selected patients. However, clinical trials did not examine the risk-benefit ratio for nonwhites, who have a greater ischemic stroke risk than whites. In general, few studies have examined the effects of race on CEA use and complications, and data on race and CEA readmission are lacking.


METHODS
This study used administrative data for patients discharged from California hospitals between January 1 and December 31, 2000. Selection criteria of cases included: ICD-9 principal procedure code 38.12, principal diagnostic code 433 and diagnosis-related group 5. There were 8,080 white and 1196 nonwhite patients (228 blacks, 643 Hispanics, 325 Asians/Pacific Islanders) identified that underwent an elective and isolated CEA. For both groups, CEA rates were compared. Logistic regression was used to examine the independent effects of race on in-hospital death and stroke, as well as CEA readmission.


RESULTS
Rates of CEA use were more than three times greater for whites than nonwhites, although nonwhites were more likely to have symptomatic disease. For all patients, the complication rate was 1.9%. However, the odds of in-hospital death and stroke were greater for nonwhites than whites, but after adjustment for patient and hospital factors, these differences were only significant for stroke (OR = 1.7, P = 0.013). For both outcomes, the final models had good predictive accuracy. Overall, CEA readmission risk was 7%, and no significant racial differences were observed (P = 0.110).


CONCLUSIONS
The data suggest that CEA is performed safely in California. However, nonwhites had lower rates of initial CEA use but higher rates of in-hospital death and stroke than whites. Racial differences in stroke risk persisted after adjustment for patient and hospital factors. Finally, this study found that despite significant racial disparities in initial CEA use, whites and nonwhites were similar in their CEA readmission rates. These findings may suggest that screening initiatives are lacking for nonwhites, which may increase their risk for poorer outcomes.
Kennedy
Byron S
BS
Department of Family Medicine, Georgetown University School of Medicine, Washington, DC 20011, USA. bsk33@georgetown.edu
Fortmann
Stephen P
SP
Stafford
Randall S
RS
D000293:Adolescent; D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D001213:Asian / Q000706:statistics & numerical data; D002545:Brain Ischemia / Q000208:ethnology / Q000517:prevention & control; D002140:California / Q000453:epidemiology; D002340:Carotid Artery Diseases / Q000208:ethnology / Q000601:surgery*; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data* / Q000639:trends; D044469:Racial Groups / Q000208:ethnology / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D014600:Utilization Review; D044465:White People / Q000706:statistics & numerical data