Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Depatment of Surgery, Harbor-UCLA Medical Center, Torrance, CA.
Surgery. 2022 Aug;172(2):766-771. doi: 10.1016/j.surg.2022.03.043. Epub 2022 May 14.
The present study examined race- and insurance-based disparities in utilization of high-volume centers for carotid revascularization.
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.
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.
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.
本研究旨在探讨种族和保险因素对颈动脉血运重建术高容量中心利用的影响。
在 2012-2019 年全国住院患者样本中，确定了接受颈动脉内膜切除术或颈动脉血管成形术的成年人（≥18 岁）。每年对颈动脉内膜切除术和颈动脉血管成形术的机构容量进行了分类，将容量最高和最低四分位数的医院分别视为高容量中心和低容量中心。采用多变量逻辑模型评估种族和保险状况与高容量中心利用的关联。采用逻辑和线性回归检验高容量中心与感兴趣结局的关系。
在估计的 583200 名合格患者中，60.3%在高容量中心接受颈动脉血运重建术。在高容量中心治疗与改善结局相关，包括降低死亡率/中风/心肌梗死的几率（校正比值比 0.76，95%置信区间：0.60-0.96）和住院时间缩短（β：-0.19，95%置信区间：-0.25 至 0.12）和住院费用减少 2000 美元（95%置信区间：1800-2300 美元）。调整后，黑人（校正比值比 0.52，95%置信区间：0.48-0.55）、西班牙裔（校正比值比 0.45，95%置信区间：0.42-0.55）和其他非白人患者（校正比值比 0.49，95%置信区间：0.45-0.52）在高容量中心进行颈动脉血运重建术的几率低于白人患者。同样，医疗补助（校正比值比 0.87，95%置信区间：0.80-0.94）和无保险（校正比值比 0.84，95%置信区间：0.77-0.92）与私人保险相比，利用高容量中心的几率较低。
有色人种患者和有医疗补助或无保险的患者利用高容量中心的比例较低。进一步系统地努力确保公平获得经验丰富的中心可能会减少颈动脉血运重建术方面观察到的差异。
