择期及单纯颈动脉内膜切除术：利用情况和结局方面的健康差异，但再入院情况无差异。
Elective and isolated carotid endarterectomy: health disparities in utilization and outcomes, but not readmission.
作者信息
Kennedy Byron S, Fortmann Stephen P, Stafford Randall S
机构信息
Department of Family Medicine, Georgetown University School of Medicine, Washington, DC 20011, USA.
出版信息
J Natl Med Assoc. 2007 May;99(5):480-8.
BACKGROUND
Carotid endarterectomy (CEA) has been shown to decrease future ischemic stroke risk in selected patients. However, clinical trials did not examine the risk-benefit ratio for nonwhites, who have a greater ischemic stroke risk than whites. In general, few studies have examined the effects of race on CEA use and complications, and data on race and CEA readmission are lacking.
METHODS
This study used administrative data for patients discharged from California hospitals between January 1 and December 31, 2000. Selection criteria of cases included: ICD-9 principal procedure code 38.12, principal diagnostic code 433 and diagnosis-related group 5. There were 8,080 white and 1196 nonwhite patients (228 blacks, 643 Hispanics, 325 Asians/Pacific Islanders) identified that underwent an elective and isolated CEA. For both groups, CEA rates were compared. Logistic regression was used to examine the independent effects of race on in-hospital death and stroke, as well as CEA readmission.
RESULTS
Rates of CEA use were more than three times greater for whites than nonwhites, although nonwhites were more likely to have symptomatic disease. For all patients, the complication rate was 1.9%. However, the odds of in-hospital death and stroke were greater for nonwhites than whites, but after adjustment for patient and hospital factors, these differences were only significant for stroke (OR = 1.7, P = 0.013). For both outcomes, the final models had good predictive accuracy. Overall, CEA readmission risk was 7%, and no significant racial differences were observed (P = 0.110).
CONCLUSIONS
The data suggest that CEA is performed safely in California. However, nonwhites had lower rates of initial CEA use but higher rates of in-hospital death and stroke than whites. Racial differences in stroke risk persisted after adjustment for patient and hospital factors. Finally, this study found that despite significant racial disparities in initial CEA use, whites and nonwhites were similar in their CEA readmission rates. These findings may suggest that screening initiatives are lacking for nonwhites, which may increase their risk for poorer outcomes.
背景
颈动脉内膜切除术（CEA）已被证明可降低特定患者未来发生缺血性中风的风险。然而，临床试验并未研究非白人患者的风险效益比，非白人发生缺血性中风的风险高于白人。总体而言，很少有研究探讨种族对CEA使用和并发症的影响，且缺乏关于种族与CEA再入院的数据。
方法
本研究使用了2000年1月1日至12月31日期间从加利福尼亚州医院出院患者的管理数据。病例选择标准包括：ICD-9主要手术代码38.12、主要诊断代码433和诊断相关组5。共识别出8080名白人患者和1196名非白人患者（228名黑人、643名西班牙裔、325名亚裔/太平洋岛民）接受了择期孤立性CEA手术。对两组患者的CEA手术率进行了比较。采用逻辑回归分析来研究种族对住院期间死亡和中风以及CEA再入院的独立影响。
结果
白人的CEA使用率是非白人的三倍多，尽管非白人更有可能患有症状性疾病。所有患者的并发症发生率为1.9%。然而，非白人患者住院期间死亡和中风的几率高于白人，但在对患者和医院因素进行调整后，这些差异仅在中风方面具有统计学意义（OR = 1.7，P = 0.013）。对于这两个结果，最终模型具有良好的预测准确性。总体而言，CEA再入院风险为7%，未观察到显著的种族差异（P = 0.110）。
结论
数据表明，在加利福尼亚州，CEA手术的实施是安全的。然而，非白人的初始CEA使用率低于白人，但住院期间死亡和中风的发生率高于白人。在对患者和医院因素进行调整后，中风风险的种族差异仍然存在。最后，本研究发现，尽管在初始CEA使用方面存在显著的种族差异，但白人和非白人的CEA再入院率相似。这些发现可能表明，针对非白人缺乏筛查措施，这可能会增加他们出现较差预后的风险。
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