Socioeconomic Status Fails to Account for Worse Outcomes in Black Patients Undergoing Carotid Revascularization
Sanuja Bose1, Alana C. Keegan2, David S. Stonko3, Katie McDermott3, James H. Black, III1, Laura M. Drudi4, Ying-Wei Lum1, Devin S. Zarkowsky5, Caitlin W. Hicks1
1The Johns Hopkins University School of Medicine, Baltimore, MD;2Sinai Hospital of Baltimore, Baltimore, MD;3The Johns Hopkins Hospital, Baltimore, MD;4Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada5Scripps Vascular and Endovascular Surgery, La Jolla, CA
INTRODUCTION: There have been conflicting reports on race and carotid revascularization outcomes, often without an accompanying evaluation of socioeconomic status. We aimed to assess the association of race with in-hospital and long-term outcomes in patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR), while accounting for socioeconomic status. METHODS: We identified non-Hispanic Black and non-Hispanic white patients who underwent CEA, TFCAS, or TCAR between 2003-2022 in the Vascular Quality Initiative. Primary outcomes were in-hospital stroke and long-term stroke/death. Multivariable logistic and Cox regression models were used to assess the association of race with short- and long-term outcomes, respectively, after adjusting for baseline characteristics including area deprivation index (ADI), a validated composite marker of socioeconomic status. RESULTS: Of 201,405 patients, 5.1% (n=10,196) were non-Hispanic Black and 94.9% (n=191,209) were non-Hispanic white. Mean follow-up time was 13.2 ± 6.7 months. A disproportionately higher percentage of Black patients were living in more socioeconomically deprived neighborhoods relative to their white counterparts (ADI-3/4: 67.5% vs 54.2%, P<0.001). After adjustment, Black race was associated with greater odds of in-hospital stroke (aOR 1.25, 95% CI 1.09-1.43) and long-term stroke/death (aHR 1.10, 95% CI 1.04-1.18). Patients living in more deprived neighborhoods had greater risk of long-term stroke/death (aHR 1.06, 95% CI 1.05-1.08), but similar in-hospital outcomes (P>0.05; Figure). The risk-adjusted associations of race with in-hospital and long-term outcomes were not significantly different by procedure type (both, P>0.05 for interaction). CONCLUSIONS: Black race is associated with worse in-hospital and long-term outcomes after carotid revascularization, a relationship that cannot be explained by socioeconomic deprivation. Because patient comorbidities and socioeconomic status cannot explain the disparities in carotid revascularization outcomes, we must recognize the possibility of gaps in our care preventing Black patients from experiencing equitable outcomes. 
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