Racial and ethnic disparities in outcomes and appropriateness of carotid endarterectomy: impact of patient and provider factors.
Racial and ethnic disparities in outcomes and appropriateness of carotid endarterectomy: impact of patient and provider factors.
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DOI：
10.1161/strokeaha.108.544866
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发表时间：
2009-07
期刊：
影响因子：
8.3
通讯作者：
Chassin MR
中科院分区：
文献类型：
--
作者：
Halm EA;Tuhrim S;Wang JJ;Rojas M;Rockman C;Riles TS;Chassin MR
先前的工作记录了中风发病率、中风危险因素和颈动脉内膜切除术（CEA）使用方面的种族和民族差异。人们对 CEA 的结果差异和适当性以及造成这种不平等的原因知之甚少。这是在纽约州医疗保险受益人中进行的基于人群的 CEA 队列。从医学图表中提取临床数据，以评估社会人口统计学、CEA 的临床指征、疾病严重程度、合并症以及手术后 30 天内的死亡和中风。适当性基于国家专家小组的验证标准。使用卡方检验比较患者、提供者、结果和适当性的差异。使用多元逻辑回归对患者、医生和医院层面的风险因素进行比较，比较风险调整后的死亡率或非致命性卒中发生率的差异。总体而言，95.3% 的 CEA 患者是白人，2.5% 是黑人，2.2% 是西班牙裔 (N=9093)。少数族裔患有更严重的神经系统疾病和更多的合并症，并且更有可能接受较少量的外科医生和医院的护理（p<.0001）。西班牙裔 (9.5%) 和黑人 (6.9%) 的 30 天死亡率/中风率高于白人 (3.8%；p<.0001)。根据术前患者风险和提供者特征进行调整的多变量分析发现，黑人的结果不再明显较差（OR=1.37；CI，0.78-2.40），尽管西班牙裔的死亡/中风风险仍然较高（OR=1.87；CI，1.09-3.19）。少数族裔的不适当手术率较高（西班牙裔 17.6%，黑人 13.0%，白人 7.9%，P<.0001），这主要是由于较高的合并症。少数族裔的结果更差，不适当手术的发生率更高。潜在的术前风险因素和提供者特征的差异解释了黑人而非西班牙裔并发症风险较高的原因。
Prior work documented racial and ethnic disparities in incidence of stroke, stroke risk factors, and use of carotid endarterectomy(CEA). Less is known about disparities in outcomes and appropriateness of CEA, or reasons for such inequalities. This was a population-based cohort of CEA performed in Medicare beneficiaries in NY. Clinical data were abstracted from medical charts to assess sociodemographics, clinical indication for CEA, 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 chi square tests. Differences in risk-adjusted rates of death or non-fatal stroke were compared using multiple logistic regression accounting for patient, physician, and hospital level risk factors. Overall, 95.3% of CEA patients 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<.0001). Rates of 30 day death/stroke were higher in Hispanics(9.5%) and Blacks(6.9%) than Whites(3.8%;p<.0001). Multivariable analyses which adjusted for pre-surgical patient risk and provider characteristics found that Blacks no longer had significantly worse outcomes(OR=1.37;CI, 0.78-2.40), though the higher risk of death/stroke in Hispanics persisted(OR=1.87; CI,1.09-3.19). Minorities had higher rates of inappropriate surgery (Hispanics 17.6%, Black 13.0%, and White 7.9%,P<.0001) largely due to higher comorbidity. Minorities had worse outcomes and higher rates of inappropriate surgery. Differences in underlying pre-surgical risk factors and provider characteristics explained the higher risk of complications in Blacks, but not Hispanics.