Lack of diversity in patients undergoing carotid artery stenting: Implications for the Distressed Community Index.

Introduction: As the role of social determinants in carotid artery stenting (CAS) outcomes remains unclear, we investigated the association between the Distressed Community Index (DCI) (zip-code based) and post-CAS mortality/stroke outcomes.

Methods: We analyzed patients undergoing CAS from 2015 to 2019 using the Medicare claims-linked Vascular Quality Initiative database. Patients were grouped based on high (DCI ⩾ 60) and low (DCI < 60) community distress. We analyzed 36-month mortality using Kaplan-Meier survival curves and hierarchical Cox regression, and 36-month stroke using cumulative incidence function curves and Fine-Gray models.

Results: The final cohort included 8717 patients (3032 DCI ⩾ 60), with a mean DCI score of 46.2 (± 28.5) and mean age of 74.7 (± 7.8) years. Most participants were men (64.3%), White (92.7%), and non-Hispanic/Latino (97.7%). There was no significant difference in the 36-month mortality incidence between high and low community distress groups (25.6% vs 23.5%, p = 0.22), and no significant association between high community distress and mortality (unadjusted HR: 1.04; 95% CI 0.90-1.21; adjusted HR: 1.02; 95% CI 0.89-1.17). The high community distress group experienced an elevated 36-month stroke incidence (26.8% vs 22.4%, p = 0.048), but no significant association with stroke was observed (unadjusted sub-HR: 1.12; 95% CI 1.00-1.24; adjusted sub-HR: 1.03; 95% CI 0.92-1.16).

Conclusion: Our cohort showed underrepresentation in terms of sex, race, and ethnicity, with a skewed DCI distribution towards lower community distress. Contrary to what we know about community distress, no independent association between higher community distress and post-CAS stroke/mortality risk was found. Future work must examine whether accessibility barriers and selective CAS allocation explain our results.