Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.
J Vasc Surg. 2023 Jun;77(6):1700-1709.e2. doi: 10.1016/j.jvs.2023.01.204. Epub 2023 Feb 12.
Recent studies have highlighted that race and socioeconomic status serve as important determinants of disease presentation and perioperative outcomes in carotid artery disease. However, these investigations only focus on individual factors of social disadvantage, and fail to account for community factors that may drive disparities. Area Deprivation Index (ADI) is a validated measure of neighborhood adversity that offers a more comprehensive assessment of social disadvantage. We examined the impact of ADI ranking on carotid artery disease severity, management, and postoperative outcomes.
We identified patients who underwent carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR) in the Vascular Quality Initiative registry between 2016 and 2020. Patients were assigned ADI scores of 1 to 100 based on zip codes and grouped into quintiles, with higher quintiles reflecting increasing adversity. Outcomes assessed included disease presentation, intervention type, and discharge patterns. Logistic regression was used to evaluate independent associations between ADI quintiles and these outcomes.
Among 91,904 patients undergoing carotid revascularization, 9811 (10.7%) were in the lowest ADI quintile (Q1), 18,905 (20.6%) in Q2, 25,442 (27.7%) in Q3, 26,099 (28.4%) in Q4, and 11,647 (12.7%) in Q5. With increasing ADI quintiles, patients were more likely to present with symptomatic disease (Q5, 52.1% vs Q1, 46.6%; P < .001), and stroke vs transient ischemic attack (Q5, 63.1% vs Q1, 53.5%; P < .001); they also more frequently underwent CAS vs CEA (Q5, 46.4% vs Q1, 33.9%; P < .001), and specifically tfCAS vs TCAR (Q5, 54.2% vs Q1, 33.9%; P < .001). In adjusted analyses, higher ADI quintiles remained as independent risk factors for presenting with symptomatic disease and stroke and undergoing CAS and tfCAS. Across ADI quintiles, patients were more likely to experience death (Q5, 0.8% vs Q1, 0.4%; P < .001), stroke/death (Q5, 2.1% vs Q1, 1.6%; P = .001), failure to discharge home (Q5, 11.5% vs Q1, 8.0%; P < .001) and length of stay >2 days (Q5, 33.3% vs Q1, 26.3%; P < .001) following revascularization.
Among carotid revascularization patients, those with greater neighborhood social disadvantage had greater disease severity and more frequently underwent tfCAS. These patients also had higher rates of death and stroke/death, were less frequently discharged home, and had prolonged hospital stays. Greater efforts are needed to ensure that patients in higher ADI quintiles undergo better carotid surveillance and are treated appropriately for their carotid artery disease.
最近的研究强调，种族和社会经济地位是颈动脉疾病表现和围手术期结果的重要决定因素。然而，这些研究仅关注社会劣势的个体因素，而没有考虑可能导致差异的社区因素。区域剥夺指数（ADI）是一种经过验证的衡量邻里逆境的指标，它提供了对社会劣势的更全面评估。我们研究了 ADI 排名对颈动脉疾病严重程度、管理和术后结果的影响。
我们在 2016 年至 2020 年期间在血管质量倡议登记处确定了接受颈动脉内膜切除术（CEA）、经股颈动脉血管成形术（tfCAS）和经颈动脉血管重建术（TCAR）的患者。根据邮政编码将患者分配 1 到 100 的 ADI 评分，并分为五分位数，较高的五分位数反映了越来越多的逆境。评估的结果包括疾病表现、干预类型和出院模式。使用逻辑回归评估 ADI 五分位数与这些结果之间的独立关联。
在 91904 例接受颈动脉血运重建的患者中，9811 例（10.7%）处于最低 ADI 五分位数（Q1），18905 例（20.6%）处于 Q2，25442 例（27.7%）处于 Q3，26099 例（28.4%）处于 Q4，11647 例（12.7%）处于 Q5。随着 ADI 五分位数的增加，患者更有可能出现症状性疾病（Q5，52.1% vs Q1，46.6%；P<0.001）和中风与短暂性脑缺血发作（Q5，63.1% vs Q1，53.5%；P<0.001）；他们也更频繁地接受 CAS 而不是 CEA（Q5，46.4% vs Q1，33.9%；P<0.001），特别是 tfCAS 而不是 TCAR（Q5，54.2% vs Q1，33.9%；P<0.001）。在调整分析中，较高的 ADI 五分位数仍然是出现症状性疾病和中风以及接受 CAS 和 tfCAS 的独立危险因素。在 ADI 五分位数中，患者更有可能经历死亡（Q5，0.8% vs Q1，0.4%；P<0.001）、中风/死亡（Q5，2.1% vs Q1，1.6%；P=0.001）、未能出院回家（Q5，11.5% vs Q1，8.0%；P<0.001）和住院时间>2 天（Q5，33.3% vs Q1，26.3%；P<0.001）。
在颈动脉血运重建患者中，那些邻里社会劣势较大的患者疾病严重程度更高，更常接受 tfCAS。这些患者的死亡率和中风/死亡率更高，出院回家的比例更低，住院时间更长。需要做出更大的努力，以确保处于较高 ADI 五分位数的患者接受更好的颈动脉监测，并为其颈动脉疾病进行适当治疗。
