A Comparative Analysis of Stroke Presentation, Severity of Carotid Stenosis, and Need for Reoperation between African American and White Women Undergoing Carotid Endarterectomy.

Abstract

Background: Racial and gender disparities in healthcare outcomes including surgery is a well-known phenomenon. Some of these disparities have been attributed to social determinants of health which affect access to quality care and preventative medicine. In this study, we analyze differences in outcomes by race and gender following carotid endarterectomy (CEA) for carotid stenosis.

Methods: Adult females undergoing CEA for an indication of carotid stenosis in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2012 and 2021 were stratified between white females (Group I) and African American females (Group II). Primary outcomes include 30-day mortality, stroke and return to the operating room (ROR). Secondary outcomes included length of stay (LOS), discharge destination, operative time and being in hospital >30days.

Results: The study population included 8,773 patients, of which 8,165 (93.1%) in Group I and 608 (6.9%) in Group II. Of these, 5,334(60.8%) were asymptomatic (6.62% African American females and 93.38% White females). Patients in Group II were more likely to present with ipsilateral stroke (16.8% vs 23.2%, p<0.001), as well as severe ipsilateral stenosis (80-99%) (66.8% vs 72.1%; p-value < 0.005) and contralateral stenosis (6.93% vs 10.2%; p-value < 0.026) as compared to Group I. Group II was also observed to less likely to be on aspirin (89.3% vs 84.7%, p<0.001) and less likely to undergo an elective procedure (84.5% vs 80.6%, p<0.001). For post-operative outcomes, patients in Group II had higher risk of return to the OR (2.19% vs 3.45%, p=0.044), longer operative time [Mean:110.8 mins (SD- ± 44.0) vs 123.8 mins (± 43.2), p<0.001], longer LOS [2.6days (±4.8) vs 3.8 days (± 6.5), p<0.001] and were more likely to be discharged to a non-home location (14.1% vs 18.5, p=0.003). There were no statistically significant differences in post-operative 30-day mortality (p=0.290) and stroke (p=0.210) between the two groups. Risk-adjusted model also showed a 42% increased risk for patients in Group II for preoperative stroke compared to patients in Group I.

Conclusion: African American females tend to present symptomatic with more severe forms of carotid disease with poorer outcomes. After adjusting for associated risk factors, they were still found to be at a higher risk for pre-operative stroke. This study highlights disparities in healthcare, its effect on clinical outcomes and the importance of early access to quality preventative care along with healthcare education and access for minorities including early referrals for vascular care.