Demystifying the outcome disparities in carotid revascularization: Utilization of experienced centers

Abstract

BackgroundThe present study examined race- and insurance-based disparities in utilization of high-volume centers for carotid revascularization. MethodsAdults (≥18 years) undergoing carotid endarterectomy or carotid artery stenting were identified in the 2012–2019 National Inpatient Sample. Annual, institutional volume of carotid endarterectomy and carotid artery stenting were tabulated, and hospitals in the highest and lowest quartiles were considered high-volume centers and low-volume centers, respectively. Multivariable logistic models were developed to evaluate the association of race and insurance status with high-volume center utilization. Logistic and linear regression was used to examine the association of high-volume centers with outcomes of interest. ResultsOf an estimated 583,200 eligible patients, 60.3% underwent carotid revascularization at high-volume centers. Treatment at high-volume centers was associated with improved outcomes, including decreased odds of mortality/stroke/myocardial infarction (adjusted odds ratio 0.76, 95% confidence interval: 0.60–0.96) and a decrement in length of stay (β: -0.19, 95% confidence interval: -0.25 to 0.12) and hospitalization costs by $2,000 (95% confidence interval: 1,800–2,300). After adjustment, Black (adjusted odds ratio 0.52, 95% confidence interval: 0.48–0.55), Hispanic (adjusted odds ratio 0.45, 95% confidence interval: 0.42–0.55), and other non-White patients (adjusted odds ratio 0.49, 95% confidence interval: 0.45–0.52) had lower odds of undergoing carotid revascularization at high-volume centers compared to White patients. Similarly, Medicaid (adjusted odds ratio 0.87, 95% confidence interval: 0.80–0.94) and lack of insurance (adjusted odds ratio 0.84, 95% confidence interval: 0.77–0.92) were associated with lower odds of high-volume center utilization relative to private insurance. ConclusionPatients of color and those with Medicaid or lack of insurance used high-volume centers at lower rates. Further systemic efforts to ensure equitable access to experienced centers may reduce observed disparities in carotid revascularization.