Carotid endarterectomy and race: do clinical indications and patient preferences account for differences?

BACKGROUND AND PURPOSE Carotid endarterectomy (CE) has been proved to reduce the risk of stroke for certain patients, but black patients are less likely than whites to receive CE. The purpose of this work was to determine the importance of clinical indications and patient preferences in predicting the use of carotid angiography and CE in a racially stratified sample of patients. METHODS Between 1997 and 1999, 708 patients with at least 1 carotid artery containing a >/=50% stenosis were enrolled (617 whites, 91 blacks) from 5 Veteran Affairs Medical Centers. Patient interviews were conducted at the time of the index carotid ultrasound, and each patient was followed up for 6 months to determine clinical events and receipt of carotid angiography or CE. RESULTS Black and white patients were similar in terms of age, sex, education level, and social support. More black than white patients received ultrasound for a completed stroke (36% versus 13%), and fewer black patients were classified as asymptomatic (56% versus 70%) or as having had a TIA (8% versus 17%; P<0.001). Health-related quality of life scores, trust in physician, and medical comorbidity scores were similar for black and white patients. Black patients expressed higher aversion to CE than white patients (31% versus 15% in the highest aversion quartile for blacks and whites, respectively; P=0.01). During follow-up, 20% of white patients and 14% of black patients received CE (P=0.19). In adjusted analyses, only patient clinical status as it relates to the indication for CE and site were associated with receipt of CE. CONCLUSIONS Contrary to prior research, patient's race was not associated with receipt of invasive carotid imaging or CE for older male veterans. These findings persist after controlling for patient preferences, comorbid illness, and quality of life. For patients enrolled in an equal-access health care system, clinical status was the primary determinant of the receipt of CE.