African Americans who undergo the most frequently performed blood vessel operation, carotid endarterectomy (CEA), have worse outcomes than whites, according to a new study by Johns Hopkins researchers. The study, reported in the November issue of Annals of Surgery, blames the discrepancy, in part, on the fact that African Americans tend to be operated on by less experienced surgeons than whites.
"In Maryland, at least, African Americans undergoing elective CEA do not do as well as whites because their care is more likely to be delivered in hospitals where fewer CEAs are performed and by surgeons who are less experienced," says Bruce Perler, M.D., professor of surgery at Johns Hopkins. "We believe this situation may be linked to socioeconomic and health insurance status."
For the study, Hopkins investigators reviewed the Maryland Health Services Cost Review Commission database to identify all elective CEA procedures performed in all non-federal acute care hospitals in Maryland from 1990 to 1995. They then examined the influence of race and other factors on the rates of in-hospital mortality, in-hospital stroke, length of stay and total hospital charges.
Although African Americans have been known for years to experience a higher stroke rate and stroke death rate than whites, and although carotid endarterectomy has been proven in multiple studies to be an effective stroke-preventing operation, the researchers found that African Americans made up only 6 percent of the CEA procedures. Only 623 African Americans underwent the operation in the study period, compared to 9,219 whites.
The researchers found that the in-hospital stroke rate was 3.1 percent among African Americans and 1.6 percent among white patients. Although African American race was an independent risk factor for in-hospital stroke, they also discovered that patients operated on by surgeons who performed a high volume of procedures were less likely to have a stroke during surgery, and that whites were twice as likely to undergo the operation by a high-volume surgeon than African Americans. In addition, operative strokes occurred much more often in hospitals where the procedure was performed infrequently, and African Americans were four times more likely than whites to undergo the surgery in these facilities.
Nationally, physicians perform more than 130,000 CEAs annually to clear plaque from the inner lining of the carotid artery, one of the main arteries supplying blood to the brain. Blocked carotid arteries are one of the most common causes of stroke.
"Previous studies have shown that CEA is performed less frequently in African Americans. And some researchers hypothesize that there is a perception that African Americans don't do as well with the surgery, so doctors are less likely to recommend the operation," says Perler. "But until now, community-wide studies have not investigated the influence of race on the outcome of surgery. This study suggests that it is not necessarily genetic, but socioeconomic factors that are influential in determining surgical outcome."
"There is no question that surgeons and hospitals that do the most procedures get the best results, and we found that African Americans are going to different hospitals as a group than whites," continues Perler. "African Americans are more likely to undergo surgery in low-volume hospitals and are less likely to have the operation performed by the most experienced surgeons. African Americans tend not to get optimal medical care in terms of this operation, and we think it is an important social issue."
The researchers say the question of unequal access to optimal surgical care is particularly concerning in view of the infrequency with which CEA is performed on African Americans. The researchers say the current study supports the hypothesis that some doctors may not recommend CEA to African Americans because they are at an increased risk for complications of the procedure. While race was an independent risk factor for stroke, it was not an independent factor in all bad outcomes. Heart disease and diabetes, independent of race, were found to be predictive of in-hospital mortality, and African Americans have higher rates of both.
Other authors of the study are Toby Gordon, Sc.D.; Alan Dardik, M.D., Ph.D.; Helen Bowman; and Ginny Hsieh from Johns Hopkins.
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Journal
Annals of Surgery