This Article Full Text Full Text (PDF) All Versions of this Article: 40/7/2493    most recent STROKEAHA.108.544866v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Halm, E. A. Articles by Chassin, M. R. PubMed PubMed Citation Articles by Halm, E. A. Articles by Chassin, M. R. Related Collections Health policy and outcome research Carotid endarterectomy

(Stroke. 2009;40:2493.)
© 2009 American Heart Association, Inc.

Original Contributions

Racial and Ethnic Disparities in Outcomes and Appropriateness of Carotid Endarterectomy

Impact of Patient and Provider Factors

Ethan A. Halm, MD, MPH; Stanley Tuhrim, MD; Jason J. Wang, PhD; Mary Rojas, PhD; Caron Rockman, MD; Thomas S. Riles, MD Mark R. Chassin, MD, MPP, MPH

From the Departments of Internal Medicine and Clinical Sciences (E.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas; the Departments of Neurology (S.T.), Health Policy (J.J.W., M.R.), and Pediatrics (M.R.), Mount Sinai School of Medicine, New York, NY; the Department of Surgery (C.R., T.S.R.), New York University School of Medicine, New York, NY; and The Joint Commission on Accreditation of Healthcare Organizations (M.R.C.), Oakbrook Terrace, Ill.

Correspondence to Ethan A. Halm, MD, MPH, Division of General Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8889. E-mail Ethan.Halm{at}UTsouthwestern.edu

Background and Purpose— Prior work documented racial and ethnic disparities in incidence of stroke, stroke risk factors, and use of carotid endarterectomy. Less is known about disparities in outcomes and appropriateness of carotid endarterectomy or reasons for such inequalities.

Methods— This was a population-based cohort of carotid endarterectomy performed in Medicare beneficiaries in New York. Clinical data were abstracted from medical charts to assess sociodemographics, clinical indication for carotid endarterectomy, disease severity, comorbidities, and deaths and strokes within 30 days of surgery. Appropriateness was based on validated criteria from a national expert panel. Differences in patients, providers, outcomes, and appropriateness were compared using ² tests. Differences in risk-adjusted rates of death or nonfatal stroke were compared using multiple logistic regression accounting for patient, physician, and hospital-level risk factors.

Results— Overall, 95.3% of patients undergoing carotid endarterectomy were white, 2.5% black, and 2.2% Hispanic (N=9093). Minorities had more severe neurological disease and more comorbidities and were more likely to be cared for by lower-volume surgeons and hospitals (P<0.0001). Rates of 30-day death/stroke were higher in Hispanics (9.5%) and blacks (6.9%) than whites (3.8%; P<0.0001). Multivariable analyses that adjusted for presurgical patient risk and provider characteristics found that blacks no longer had significantly worse outcomes (OR=1.37; CI, 0.78 to 2.40), although the higher risk of death/stroke in Hispanics persisted (OR=1.87; CI, 1.09 to 3.19). Minorities had higher rates of inappropriate surgery (Hispanics 17.6%, black 13.0%, white 7.9%; P<0.0001) largely due to higher comorbidity.

Conclusions— Minorities had worse outcomes and higher rates of inappropriate surgery. Differences in underlying presurgical risk factors and provider characteristics explained the higher risk of complications in blacks, but not Hispanics.

Key Words: appropriateness • carotid endarterectomy • complications • outcomes • racial and ethnic disparities