Introduction: Safety-net hospitals (SNHs) serve a substantial share of vulnerable patient populations. Recent studies have documented inferior surgical outcomes at higher costs for procedures performed at SNHs. However, less is known about disparities in the utilization of surgical treatments at safety-net facilities. We analyzed the effect of hospital safety-net burden on the receipt of carotid revascularization (CR) and outcomes for carotid artery stenosis.
Methods: We conducted a retrospective analysis of the Nationwide Inpatient Sample (2005 to 2011) of adult cases with a primary diagnosis of carotid artery stenosis. Hospital safety-net burden was defined as the proportion of Medicaid/uninsured patients treated at each hospital and was categorized as low-burden (LBHs), medium-burden (MBHs), and high-burden hospitals (HBHs). Hierarchical regression methods were used to examine the effect of hospital safety-net burden on the likelihood of receiving any CR procedure, carotid endarterectomy (CEA), and carotid stenting (CAS). Outcomes analyzed were a composite outcome of mortality and/or post-operative neurological/cardiac complications, as well as hospital costs.
Results: A total of 175,239 patients met inclusion criteria. HBHs treated a greater proportion of black, Hispanic, Medicaid, and uninsured patients compared to LBHs (p <0.001). HBHs were also associated with higher rates of emergent and symptomatic admissions (p <0.001). On adjusted analysis, no differences in the utilization of any revascularization were observed. However, after stratifying by procedure, HBHs were associated with decreased utilization of CEA (OR 0.87, p=0.007) and increased utilization of CAS (OR 1.20, p=0.026) compared to LBHs. Among patients that underwent CR, no differences in outcomes were observed between high-burden and low-burden hospitals.
Conclusions: Differences in the utilization of carotid revascularization procedure were observed between level of safety-net burden. Despite this, equitable outcomes were achieved between safety-net and non-safety-net hospitals.
Patient Care: Despite their financial burden, safety-net hospitals provide equitable care for patients with carotid artery stenosis that undergo carotid revascularization. Policies that support the financial well-being of safety-net hospitals are critical in promoting quality surgical care for the communities they serve.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the effect of hospital safety-net burden on the utilization of carotid revascularization. 2) Determine the effect of hospital safety-net burden on outcomes and costs after carotid revascularization