Racial and Socioeconomic Disparities After Carotid Procedures

Abstract

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.