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Socioeconomics
Original research
Provider care segregation and hospital-region racial disparities for carotid interventions in the USA
  1. David Daniel1,
  2. Luke Maillie2,
  3. Mandip Dhamoon1
  1. 1 Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  2. 2 Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Dr Mandip Dhamoon; mandip.dhamoon{at}mssm.edu

Abstract

Background Reasons for racial disparities in the utilization and outcomes of carotid interventions (carotid endarterectomy (CEA) and carotid artery stenting (CAS)) are not well understood, especially segregation of care associated with carotid intervention. We examined patterns of geographic and provider care segregation in carotid interventions and outcomes.

Method We used de-identified Medicare datasets to identify CEA and CAS interventions between January 1, 2016 and December 31, 2019 using validated ICD-10 codes. For patients who underwent carotid intervention, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for carotid intervention cases. We examined associations between measures of segregation and outcomes.

Results Despite higher proportions of Black patients in counties with hospitals that provide carotid intervention, lower proportions of Black patients received intervention. The difference in the proportion of White patients comparing CEA patients to the county race distribution was 0.143 (SD 0.297) at the hospital level (for CAS, 0.174 (0.315)). The dissimilarity index for CEA providers was high, with mean (SD) 0.387 (0.274) averaged across all hospitals and higher among CAS providers at 0.472 (0.288). Black patients receiving CEA and CAS (compared with Whites) had reduced odds of discharge home. Better outcomes (inpatient mortality and 30-day mortality) were independently associated with higher proportion of White CAS patients.

Conclusion In this national study with contemporary data on carotid intervention, we found evidence for segregation of care of both CEA and CAS.

  • Stroke
  • Intervention

Data availability statement

Data may be obtained from a third party and are not publicly available. The data used in this analysis are available upon application from Medicare.

https://doi.org/10.1136/jnis-2023-020656

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    Data availability statement

    Data may be obtained from a third party and are not publicly available. The data used in this analysis are available upon application from Medicare.

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    Footnotes

    • Contributors DD had substantial contributions to the conception or design of the work; and interpretation of data for the work; AND · Drafting the work or revising it critically for important intellectual content; AND · Final approval of the version to be published; AND · Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. LM had substantial contributions to interpretation of data for the work; AND · Drafting the work or revising it critically for important intellectual content; AND · Final approval of the version to be published; AND · Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MD had substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND · Drafting the work or revising it critically for important intellectual content; AND · Final approval of the version to be published; AND · Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MSD is the guarantor of the study.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.