种族对美国颈动脉内膜切除术结局的影响。
The impact of race on outcomes after carotid endarterectomy in the United States.
机构信息
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
出版信息
J Vasc Surg. 2018 Aug;68(2):426-435. doi: 10.1016/j.jvs.2017.11.087. Epub 2018 Feb 23.
OBJECTIVE
Black patients undergoing carotid endarterectomy (CEA) in the United States are more often symptomatic at presentation and have more comorbidities compared with white patients. However, the impact of race on outcomes after CEA is largely unknown.
METHODS
We identified CEA patients in the Vascular Quality Initiative registry (2012-2017) and compared them by race (black vs white). All other nonwhite races (891 [1.4%]) and Hispanics (2222 [3.4%]) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities. We assessed long-term survival using multivariable Cox regression. The primary outcome was perioperative stroke/death, with long-term survival as a secondary outcome.
RESULTS
We included 57,622 CEA patients; 2909 (5.0%) were black, of whom 983 (34%) were symptomatic. Of the 54,713 white patients, 16,132 (30%) were symptomatic. Black patients, compared with white patients, had a higher vascular disease burden and were less likely to be operated on in a high-volume hospital or by a high-volume surgeon. In addition, black symptomatic patients, compared with white symptomatic patients, were more often operated on <2 weeks after the index neurologic symptom (47% vs 40%; P < .001). Perioperative stroke/death was comparable between black and white patients (symptomatic, 2.8% vs 2.2% [P = .2]; asymptomatic, 1.6% vs 1.3% [P = .2]), as was unadjusted survival at 3 years (93% vs 93%; P = .7). However, after adjustment, black patients did experience better long-term survival compared with white patients (hazard ratio, 0.8; 95% confidence interval, 0.7-0.9; P = .01). On multilevel logistic regression, race was not associated with perioperative stroke/death (odds ratio, 1.0; 95% confidence interval, 0.8-1.3; P = .98).
CONCLUSIONS
Despite the greater prevalence of vascular risk factors in black patients and racial inequalities in surgical treatment, rates of perioperative stroke/death and unadjusted survival were similar between white and black patients. Moreover, black patients experienced better adjusted long-term survival after CEA.
目的
与白人患者相比，在美国接受颈动脉内膜切除术（CEA）的黑人患者在就诊时更常出现症状，且合并症更多。然而，种族对 CEA 后结果的影响在很大程度上尚不清楚。
方法
我们在血管质量倡议登记处（2012-2017 年）中确定了 CEA 患者，并按种族（黑人与白人）进行比较。所有其他非白人种族（891 例[1.4%]）和西班牙裔（2222 例[3.4%]）均被排除在外。我们使用多水平逻辑回归来考虑人口统计学和合并症的差异。我们使用多变量 Cox 回归评估长期生存率。主要结局是围手术期卒中/死亡，次要结局为长期生存率。
结果
我们纳入了 57622 例 CEA 患者；其中 2909 例（5.0%）为黑人，其中 983 例（34%）为有症状。在 54713 例白人患者中，有 16132 例（30%）为有症状。与白人患者相比，黑人患者的血管疾病负担更高，且更不可能在高容量医院或由高容量外科医生进行手术。此外，与白人有症状患者相比，黑人有症状患者在索引神经症状后更常在 2 周内进行手术（47% vs 40%；P<0.001）。黑人患者和白人患者的围手术期卒中/死亡率相当（有症状患者为 2.8% vs 2.2%[P=0.2]；无症状患者为 1.6% vs 1.3%[P=0.2]），3 年未调整生存率也相当（93% vs 93%；P=0.7）。然而，调整后，黑人患者的长期生存率确实优于白人患者（风险比为 0.8；95%置信区间为 0.7-0.9；P=0.01）。在多水平逻辑回归中，种族与围手术期卒中/死亡率无关（比值比为 1.0；95%置信区间为 0.8-1.3；P=0.98）。
结论
尽管黑人患者中血管危险因素更为普遍，且手术治疗存在种族不平等，但白人患者和黑人患者的围手术期卒中/死亡率和未调整生存率相似。此外，黑人患者在接受 CEA 后有更好的长期生存率。
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