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

Background: The present study examined race- and insurance-based disparities in utilization of high-volume centers for carotid revascularization.

Methods: Adults (≥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.

Results: Of 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.

Conclusion: Patients 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.