Medicare Patients with Symptomatic Carotid Disease Requiring Carotid Revascularization Are Likely to Have Delayed Access: An Analysis of a Multicenter Surgical Data

Abstract

The Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease recommends carotid revascularization as soon as the patient is neurologically stable after 48 hours and before 14 days of symptom onset in patients with recent stroke. In the United States, insurance status has been demonstrated to play a role in wait times for surgical care. There are no large-scale studies that assess the effect of patient primary insurance status on time to surgery in patients with symptomatic carotid disease. We utilized the Vascular Quality Initiative (VQI) database to evaluate our hypothesis that insurance status is associated with waiting times before surgery in patients with symptomatic carotid disease. All patients who underwent carotid revascularization in the VQI dataset from 2010 to 2022 were included. Patients with incomplete or missing outcomes data, Modified Rankin score of >2 and asymptomatic were excluded. Primary outcome was time between onset of symptomatic carotid disease and intervention. Categorical variables were compared using χ2 test and one-way analysis of variance for continuous variables. Multivariable logistic regression was used to assess the association between insurance status and waiting time to surgery while adjusting for potential confounders. The study consisted of 11,973 patients who had carotid revascularization within 14 days of symptoms (early cohort) and 21,253 patients in the late cohort (after 14 days). Patients in the late cohort were older (70.1 ± 9.8 vs 69.8 ± 10.5; P = .02), less likely to undergo carotid endarterectomy (85.9% vs 88.4%; P < .01), and more likely to have an elective procedure (90.3% vs 44.3%; P < .01). Fig 1 shows the distribution of insurance coverage among the study cohort. After adjusting for potential confounders, compared to Medicare, recipients of other insurer types had lower odds of experiencing delayed surgery: Medicare Advantage (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.80-0.99; P = .03), commercial (aOR, 0.84; 95% CI, 0.78-0.90; P < .001), military/Department of Veterans Affairs (aOR, 0.67; 95% CI, 0.54-0.84; P < .001), and self-pay (aOR, 0.54; 95% CI, 0.45-0.65; P < .001). Medicaid patients had similar delay (aOR, 0.90; 95% CI, 0.78-1.03; P = .14) and non-US insurance had longer delay to surgery (aOR, 1.48; 95% CI, 1.13-1.95; P = .005), in comparison to Medicare patients (Fig 2). Symptomatic carotid patients on Medicare and Medicaid are more likely to receive delayed revascularization procedures compared to patient with commercial insurance. Future studies are needed to investigate and potentially mitigate the underlying causes for the delay and the overall health implications of such a delay on the long-term outcomes of these patients.Fig 2Adjusted odds of receiving late carotid revascularization in symptomatic patients requiring surgery: comparing other major insurance providers with Medicare. *Model adjusted for urgency of procedure, prior coronary artery disease, prior carotid endarterectomy/coronary artery stenting, preoperative beta-blocker use, prior congestive heart failure, type of procedure (carotid endarterectomy, transcarotid artery revascularization, transfemoral carotid artery stenting), age, race, body mass index, preoperative creatinine levels, preoperative hemoglobin concentration, preoperative dysrhythmia, previous major amputation, preoperative functional status, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, and degree of stenosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)