Racial and Insurance Based Disparities in the Treatment of Carotid Artery Stenosis: a Study of the Nationwide Inpatient Sample

Background And Purpose: Minorities and uninsured/underinsured patients have poorer access to healthcare system resources, especially preventative treatments. We sought to determine whether racial and insurance based disparities existed in the treatment of carotid artery stenosis.

Methods: Using the Nationwide Inpatient Sample, hospitalizations for carotid artery stenting and carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis from 2005 to 2011 were identified. We calculated χ(2) tests, and bivariate and multivariable logistic regression models were fit to assess differences in the characteristics of patients receiving carotid revascularization for asymptomatic compared with symptomatic carotid artery stenosis. Demographic characteristics studied included race/ethnicity (white, black, Hispanic, Asian/Pacific Islander) and primary payer status (Medicare, Medicaid, private insurance, self-pay and no charge).

Results: Between 2005 and 2011, 890 680 patients underwent carotid revascularization for the treatment of carotid artery stenosis (92.1% asymptomatic and 7.9% symptomatic). Multivariate logistic regression analysis demonstrated that Medicaid (OR=0.87, 95% CI 0.83 to 0.92, p<0.0001) and self-pay patients (OR=0.48, 95% CI 0.45 to 0.51, p<0.0001) had a lower odds of being revascularized for asymptomatic carotid artery stenosis compared with private insurance patients. Black (OR=0.81, 95% CI -0.77 to 0.84, p<0.0001) and Hispanic (OR=0.86, 95% CI -0.83 to 0.90, p<0.0001) patients had significantly lower odds of revascularization for asymptomatic carotid artery stenosis compared with white patients.

Conclusions: Minorities and self-pay/Medicaid patients were less likely to receive carotid revascularization when asymptomatic-rather they were more likely to have treatment only after symptoms had developed. These findings suggest possible disparities in the degree of morbidity related to carotid artery stenosis, the likelihood of early detection, and/or the likelihood of treatment conditional on indication.