Patient risk perceptions for carotid endarterectomy: which patients are strongly averse to surgery?

Conceptualizing and Measuring Trust, Mistrust, and Distrust: Implications for Advancing Health Equity and Building Trustworthiness

Trust is vital to public confidence in health and science, yet there is no consensus on the most useful way to conceptualize, define, measure, or intervene on trust and its related constructs (e.g., mistrust, distrust, and trustworthiness). In this review, we synthesize literature from this wide-ranging field that has conceptual roots in racism, marginalization, and other forms of oppression. We summarize key definitions and conceptual frameworks and offer guidance to scholars aiming to measure these constructs. We also review how trust-related constructs are associated with health outcomes, describe interventions in this field, and provide recommendations for building trust and institutional trustworthiness and advancing health equity. We ultimately call for future efforts to focus on improving the trustworthiness of public health professionals, scientists, health care providers, and systems instead of aiming to increase trust in these entities as they currently exist and behave.

Psychological Determinants of Attitude to Surgery in Internal Carotid Artery Stenosis Patients

The basic way to prevent cerebral stroke in symptomatic 70–99% stenosis of internal carotid artery (ICA) is an open or endovascular surgical procedure. Psychological research done so far among ICA stenosis patients focused on cognitive functioning changes. The objective was to assess attitude to surgery in relation to self-efficacy, life quality perception, and health locus of control in ICA stenosis patients. Materials and Methods: The study involved 53 asymptomatic ICA stenosis patients, aged from 53 to 81. Four scales were applied: Generalized Self-Efficacy Scale (GSES); Satisfaction With Life Scale (SWLS); Multidimensional Health Locus of Control Scale (MHLC); and a simple scale to examine the attitude to surgery, where “−10” stands for the maximally negative attitude, “0”—neutral, and “+10”—maximally positive. The obtained results were put to statistical analysis. Results: It was found that women and men assessed their attitude to the surgery as positive (M = 7.92; SD = 3.094), though the men estimated it slightly higher (M = 8.03; SD = 3.02) than the women (M = 7.67; SD = 3.37). The mean value of self-efficacy was high (M = 32.53; SD = 6.231), and slightly higher for the men (M = 32.79; SD = 5.576) compared to the women (M = 31.87; SD = 7.836). The patients generally tended to manifest the external personal health locus of control (M = 28.62; SD = 3.17). The runner-up was internal health locus of control (M = 26.02; SD = 3.775), and the next one—external impersonal aspect (chance/luck) (M = 23.57; SD = 4.457). The mean assessment of the patients’ own life quality proved to be above average (M = 23.60) but varied (SD = 5.95). The women perceived the quality of their lives as better (M = 24.33; SD = 6.422) than the men (M = 23.32; SD = 5.818). Very strong positive correlations were found between self-efficacy and life quality assessment (p < 0.001) and between the internal and external personal aspects of health locus of control (p < 0.007) in the women, and positive correlations were found between the attitude to surgery and internal health locus of control (p < 0.021) in the men. Conclusions: When breaking the news of a need to have a surgical intervention due to ICA stenosis, the physician should strongly refer to the value of human life and health. The message should arise from external (in the case of women) or internal (in the case of men) motivation to undergo surgery, and enhance the patient’s conviction that the disease should be considered a challenge which must be taken to reverse their unfavorable situation and improve life quality.

Socioeconomic Disparities in Carotid Revascularization Procedures

OBJECTIVES

Several studies have demonstrated healthcare disparities in postoperative outcomes after carotid endarterectomy and carotid artery stenting, including increased hospital mortality, postoperative stroke, and readmission rates. The objective of the present study was to examine the intersectionality between race/ethnicity, insurance status, and postoperative outcomes in carotid procedures.

DESIGN

Records of adults from 2007 to 2014 were retrospectively identified, and patients with appropriate International Classification of Diseases Ninth Revision Clinical Modification codes for carotid endarterectomy or carotid artery stenting were identified. Primary outcomes were unadjusted rates and adjusted odds ratios (aORs) of postoperative in-hospital mortality, stroke, combined stroke/mortality, and cardiovascular complications.

SETTING

Data were sourced from the State Inpatient Databases data from California, Florida, Kentucky, Maryland, and New York during the years 2007 to 2014.

PARTICIPANTS

Patients undergoing carotid revascularization procedures.

INTERVENTIONS

The effects of race and insurance status as independent variables and as effect modifiers on postoperative outcomes.

MEASUREMENTS AND MAIN RESULTS

Multivariable logistic regression models were used to examine the associations between race and/or insurance status with respect to study outcomes. Race, but not payer status, was significantly associated with adverse outcomes after carotid artery procedures, with blacks, Hispanics, and other non-Caucasian races demonstrating a significantly greater risk of postoperative stroke and mortality (aOR range 1.24-1.59). This relationship persisted even when stratified by procedure type (aOR range 1.25-1.56) and symptomatology (aOR range 1.51-1.63).

CONCLUSIONS

These results suggest that disparities in postoperative outcomes after carotid artery procedures are associated with race but not with primary insurance status. Multiple contributing factors exist, including racial inequities in prevalence of comorbidities, health literacy, and procedure type performed.

Factors associated with influenza vaccination in Japanese elderly outpatients

BACKGROUND

Elderly patients benefit from influenza vaccination, but the number of Japanese elderly patients who are vaccinated is insufficient. Several factors are associated with influenza vaccination acceptance, but little is known about Japanese elderly outpatients. The purpose of this study was to examine factors associated with influenza vaccination in elderly outpatients in Japan.

METHODS

During the 2017-2018 influenza season, outpatients from one hospital and one clinic in Kitaibaraki City, Ibaraki, Japan, participated in this study. Patients answered a self-report questionnaire exploring factors such as their vaccination status during the 2017-2018 season, past influenza vaccination, perceived susceptibility to influenza and adverse events of the vaccine, perceived vaccine efficacy, physician recommendations. Multivariable logistic regression analyses were conducted to identify factors associated with vaccination.

RESULTS

Of 377 patients, 316 (83.8%) responded, and the vaccination rate was 57%. Eighty-three patients (27.0%) reported that their physician recommended the influenza vaccine. In multivariate analysis, influenza vaccination was associated with higher age (odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03-1.14), physician recommendations (OR 2.49, 95% CI 1.18-5.25), low perceived susceptibility to vaccine-related adverse events (OR 0.33, 95% CI 0.15-0.74), and belief in vaccine efficacy (OR 4.73, 95% CI 2.08-10.8).

CONCLUSIONS

Influenza vaccination was associated with belief in vaccine efficacy, perceived susceptibility to vaccine-related adverse events, physician recommendations, and older age. Increasing the frequency of physician recommendations may lead to increased vaccination coverage.

Visual Aids for Improving Patient Decision Making in Severe Symptomatic Carotid Stenosis

BACKGROUND

Because of the large amount of information to process and the limited time of a clinical consult, choosing between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) can be confusing for patients with severe symptomatic internal carotid stenosis (ICA).

GOAL

We aim to develop a visual aid tool to help clinicians and patients in the decision-making process of selecting between CEA and CAS.

MATERIALS AND METHODS

Based on pooled analysis from randomized controlled trials including patients with symptomatic and severe ICA (SSICA), we generated visual plots comparing CEA with CAS for 3 prespecified postprocedural time points: (1) any stroke or death at 4 months, and (2) any stroke or death in the first 30 days and ipsilateral stroke thereafter at 5 years and (3) at 10 years.

RESULTS

A total of 4574 participants (2393 assigned to CAS, and 2361 to CEA) were included in the analyses. For every 100 patients with SSICA, 6 would develop any stroke or death in the CEA group compared with 9 undergoing CAS at 4 months (hazard ratio [HR] 1.53; 95%CI 1.20-1.95). At 5 years, 7 patients in the CEA group would develop any periprocedural stroke or death and ipsilateral stroke thereafter versus 12 undergoing CAS (HR 1.72; 95%CI 1.24-2.39), compared with 10 patients in the CEA and 13 in the CAS groups at 10 years (HR 1.17; 95%CI 0.82-1.66).

CONCLUSION

Visual aids presented in this study could potentially help patients with severe symptomatic internal carotid stenosis to better weigh the risks and benefits of CEA versus CAS as a function of time, allowing for the prioritization of personal preferences, and should be prospectively assessed.

Racial differences and disparities in cancer care and outcomes: where's the rub?

Despite a profusion of studies over the past several years documenting racial differences in cancer outcomes, there is a paucity of data as to the root causes underlying these observations. This article reviews work to date focusing on black-white differences in cancer outcomes, explores potential mechanisms underlying these differences, and identifies patient, physician, and health care system factors that may account for persistent racial disparities in cancer care. Research strategies to elucidate the relative influence of these various factors and policy recommendations to reduce persistent disparities are also discussed.

Carotid endarterectomy and carotid artery stenting utilization trends over time

BACKGROUND

Carotid endarterectomy (CEA) has been the standard in atherosclerotic stroke prevention for over 2 decades. More recently, carotid artery stenting (CAS) has emerged as a less invasive alternative for revascularization. The purpose of this study was to investigate whether an increase in stenting parallels a decrease in endarterectomy, if there are specific patient factors that influence one intervention over the other, and how these factors may have changed over time.

METHODS

Using a nationally representative sample of US hospital discharge records, data on CEA and CAS procedures performed from 1998 to 2008 were obtained. In total, 253,651 cases of CEA and CAS were investigated for trends in utilization over time. The specific data elements of age, gender, payer source, and race were analyzed for change over the study period, and their association with type of intervention was examined by multiple logistic regression analysis.

RESULTS

Rates of intervention decreased from 1998 to 2008 (P < 0.0001). Throughout the study period, endarterectomy was the much more widely employed procedure. Its use displayed a significant downward trend (P < 0.0001), with the lowest rates of intervention occurring in 2007. In contrast, carotid artery stenting displayed a significant increase in use over the study period (P < 0.0001), with the highest intervention rates occurring in 2006. Among the specific patient factors analyzed that may have altered utilization of CEA and CAS over time, the proportion of white patients who received intervention decreased significantly (P < 0.0001). In multivariate modeling, increased age, male gender, white race, and earlier in the study period were significant positive predictors of CEA use.

CONCLUSIONS

Rates of carotid revascularization have decreased over time, although this has been the result of a reduction in CEA despite an overall increase in CAS. Among the specific patient factors analyzed, age, gender, race, and time were significantly associated with the utilization of these two interventions.

Comparing the use of diagnostic imaging and receipt of carotid endarterectomy in elderly black and white stroke patients

BACKGROUND

Previous studies show that black patients undergo carotid endarterectomy (CEA) less frequently than white patients. Diagnostic imaging is necessary to determine whether a patient is a candidate for the operation. We determined whether there were differences in the use of diagnostic carotid imaging and the frequency of CEA between elderly black and white ischemic stroke patients.

METHODS

Medicare fee-for-service beneficiaries with discharge diagnoses of ischemic stroke (International Classification of Diseases, 9th revision codes 433, 434, and 436) were randomly selected for inclusion in the National Stroke Project 1998-1999, 2000-2001. Receipt of at least one type of carotid imaging study was compared for black and white patients. Binomial logistic regression models were used to evaluate the associations between race and receipt of carotid imaging and CEA with adjustment for demographics, degree of carotid artery stenosis, and other clinical covariates.

RESULTS

Among 19,639 stroke patients (1974 black, 17,655 white), 69.6% received at least 1 diagnostic carotid imaging test (blacks 68.4%; whites 69.7%; P = .233). After risk adjustment, blacks were less likely to receive carotid imaging (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.78-0.97). There was no relationship between race and the receipt of CEA after adjustment for degree of carotid stenosis and other covariates (adjusted OR 1.14; 95% CI 0.66-1.96).

CONCLUSIONS

Black ischemic stroke patients were less likely to receive diagnostic carotid imaging than white patients, although the difference was small and only significant after risk adjustment. There was no difference in the proportion having CEA after adjustment for degree of carotid artery stenosis and other clinical factors.

Race differences in cardiac catheterization: the role of social contextual variables

BACKGROUND

Race differences in the receipt of invasive cardiac procedures are well-documented but the etiology remains poorly understood.

OBJECTIVE

We examined how social contextual variables were related to race differences in the likelihood of receiving cardiac catheterization in a sample of veterans who were recommended to undergo the procedure by a physician.

DESIGN

Prospective observational cohort study.

PARTICIPANTS

A subsample from a study examining race disparities in cardiac catheterization of 48 Black/African American and 189 White veterans who were recommended by a physician to undergo cardiac catheterization.

MEASURES

We assessed social contextual variables (e.g., knowing somebody who had the procedure, being encouraged by family or friends), clinical variables (e.g., hypertension, maximal medical therapy), and if participants received cardiac catheterization at any point during the study.

KEY RESULTS

Blacks/African Americans were less likely to undergo cardiac catheterization compared to Whites even after controlling for age, education, and clinical variables (OR = 0.31; 95% CI, 0.13, 0.75). After controlling for demographic and clinical variables, three social contextual variables were significantly related to increased likelihood of receiving catheterization: knowing someone who had undergone the procedure (OR = 3.14; 95% CI, 1.70, 8.74), social support (OR = 2.05; 95% CI, 1.17, 2.78), and being encouraged by family to have procedure (OR = 1.45; 95% CI, 1.08, 1.90). After adding the social contextual variables, race was no longer significantly related to the likelihood of receiving catheterization, thus suggesting that social context plays an important role in the relationship between race and cardiac catheterization.

CONCLUSIONS

Our results suggest that social contextual factors are related to the likelihood of receiving recommended care. In addition, accounting for these relationships attenuated the observed race disparities between Whites and Blacks/African Americans who were recommended to undergo cardiac catheterization by their physicians.

Racial and ethnic disparities in the VA health care system: a systematic review

OBJECTIVES

To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system.

METHODS

We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.

RESULTS

Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.

CONCLUSIONS

Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.

Racial/ethnic and educational-level differences in diabetes care experiences in primary care

AIMS

To assess potential racial/ethnic and educational-level differences in the degree to which patients with diabetes who receive primary care from a Veterans Affairs Medical Center report that experiences with the diabetes care system are consistent with the Chronic Care Model (CCM).

METHODS

A cross-sectional mailed survey of 296 patients included the Patient Assessment of Chronic Illness Care (PACIC), which measures components of the care system suggested by the CCM.

RESULTS

Among 189 patients with complete information, non-white veterans had more than twice the odds of indicating that their diabetes care experience is in line with the CCM [measured by overall PACIC score > or =3.5] (OR 2.3; 95% CI 1.3-4.1). Non-white veterans were more likely to report high levels of assistance with problem solving and follow-up. Patients not completing high school had three times the odds of reporting care in line with the CCM (OR 3.0; 95% CI 1.2-7.6). Associations were also seen with implementation of the CCM in the areas of patient activation, perceived care teams, collaborative goal setting, and collaborative problem solving.

CONCLUSIONS

Non-white patients and those with less than a high school education had more than twice the odds of reporting that the diabetes care system is in line with the CCM.

The influence of race and socioeconomic factors on patient acceptance of perioperative epidural analgesia

BACKGROUND

Ethnic minorities and patients of lower socioeconomic status may be more averse to the acceptance of epidural analgesia than nonminority counterparts and those of higher socioeconomic status, despite evidence for substantial benefit to the patient.

METHODS

A scripted telephone survey was developed from the 2000 United States Census by a panel of experts. Contact was attempted at least twice for all patients listed for surgery at the Hospital of the University of Pennsylvania over a 4-mo period.

RESULTS

Three thousand seven hundred thirty-nine patients were called and 1265 subjects were successfully contacted and 1193 consented, whereas 72 refused to participate. Seven hundred sixty-two subjects (64%) would accept an epidural if recommended by an anesthesiologist and 425 (36%) would refuse. If the epidural was recommended by both the anesthesiologist and surgeon acceptance increased to 932 (78.5%). The univariate predictor of refusal of perioperative epidural analgesia was African American race. Univariate predictors of acceptance include full- or part-time employment, total household income >$50,001/yr, college graduate, prior epidural treatment, and knowledge of what an epidural is. When the potential confounders of race, total household income, employment, and education were included in a multivariate logistic regression model, African American race predicted refusal (odds ratio [OR], 0.58; P < 0.006; confidence interval [CI], 0.41-0.81) and was the only factor that predicted refusal or acceptance of epidural analgesia.

CONCLUSIONS

Acceptance of perioperative epidural analgesia is strongly affected by race and socioeconomic status. Anesthesiologists need to recognize this potential barrier when trying to maximize patient comfort and outcome.

Racial disparities in the filling of warfarin prescriptions for nonvalvular atrial fibrillation

BACKGROUND

Warfarin has been shown to decrease the rate of thromboembolic events in patients with nonvalvular atrial fibrillation, but it is frequently underprescribed. Our goal was to establish whether there have been racial disparities in the filling of warfarin prescriptions for patients with newly incident nonvalvular atrial fibrillation.

METHODS

We conducted a retrospective analysis of Ohio Medicaid claims between January 1, 1997 and May 31, 2002, for recipients with newly incident nonvalvular atrial fibrillation. Race was identified from the demographic information in the database, and the analysis was limited to white and African-American patients. The main outcome measure was the filling of a prescription for warfarin at any time between 7 days prior to the initial diagnosis of atrial fibrillation and 30 days after the initial diagnosis. To evaluate the independent role of race in the filling of warfarin prescriptions, we created a multivariable logistic regression model incorporating predictors significant at P < 0.10 in the univariate model.

RESULTS

A total of 6283 patients were identified as having newly incident nonvalvular atrial fibrillation, 18.5% of whom were African-American. In general, African-American patients had a higher rate of comorbid illness. Warfarin prescriptions were filled for 9.4% of white patients and 7.6% of African-American patients. When controlling for significant confounders in the multivariable logistic regression model, African-American patients had an adjusted odds ratio for receiving warfarin of 0.76 (95% CI, 0.60-0.98) when compared with white patients.

CONCLUSION

African-American patients in the Ohio Medicaid population between 1998 and 2002 were significantly less likely than white patients to fill a warfarin prescription for newly incident nonvalvular atrial fibrillation.

Factors associated with a provider's recommendation of carotid endarterectomy: implications for understanding disparities in the use of invasive procedures

OBJECTIVE

This study assessed the relative importance of clinical and nonclinical factors in a provider's decision to recommend carotid endarterectomy (CEA) for a patient, with emphasis on the role of the patient's race in the provider's assessment of the risks and benefits of the procedure.

METHODS

The study was a secondary analysis of data on the use of CEA conducted in a patient sample of 355 white and black patients who were referred for evaluation for CEA and were adjudicated preoperatively as appropriate candidates for the procedure by objective criteria. The patients were from five VA medical centers nationally. The primary outcome was the provider's recommendation that the patient receive CEA. Patient factors included age, race, the degree of carotid artery stenosis, clinical status, trust in the provider, and aversion to surgery. Provider factors were assessment of the patient's risks and benefits from CEA, including perceived efficacy of the surgery, perceived risk of stroke < or =1 year without the surgery, and perceived risk of stroke < or =30 days from the surgery.

RESULTS

The primary factor associated with a provider's decision to recommend CEA was his or her assessment of the patient's risk of stroke without the surgery. The patient's race was not associated with the provider's assessments of the patient's risks or benefits from CEA.

CONCLUSION

A major determinant of a provider's recommendation for a patient to receive CEA endarterectomy is the assessment of the patient's likely future risk of stroke, regardless of the patient's race.

Age-related differences in invasive treatment of peripheral arterial disease: disease severity versus social support as determinants

OBJECTIVE

Social support may influence the seeking of appropriate treatment. We examined social support and peripheral arterial disease (PAD) severity as determinants of treatment for PAD in younger and older patients.

METHODS

Consecutive PAD patients (N=203) completed the Perceived Social Support Scale. Treadmill-walking distance and ankle-brachial pressure index (ABPI) were measured. The main outcome was invasive treatment for PAD in the year following diagnosis.

RESULTS

During follow-up, 48% of the patients underwent invasive treatment for PAD. Younger patients (<or=64 years) tended to be more often invasively treated as compared to older patients. In younger patients, a high level of social support predicted invasive treatment above and beyond PAD severity. In older patients, low ABPI predicted invasive treatment.

CONCLUSION

Younger patients with inadequate social support may fail to seek appropriate treatment, suggesting the need to consider psychosocial factors in optimizing treatment of atherosclerotic vascular disease in this high-risk group.

Racial differences in blood pressure control: potential explanatory factors

PURPOSE

Poor blood pressure control remains a common problem that contributes to significant cardiovascular morbidity and mortality, particularly among African Americans. We explored antihypertensive medication adherence and other factors that may explain racial differences in blood pressure control.

METHODS

Baseline data were obtained from the Veteran's Study to Improve The Control of Hypertension, a randomized controlled trial designed to improve blood pressure control. Clinical, demographic, and psychosocial factors relating to blood pressure control were examined.

RESULTS

A total of 569 patients who were African American (41%) or white (59%) were enrolled in the study. African Americans were more likely to have inadequate baseline blood pressure control than whites (63% vs 50%; odds ratio = 1.70; 95% confidence interval [CI] 1.20-2.41). Among 20 factors related to blood pressure control, African Americans also had a higher odds ratio of being nonadherent to their medication, being more functionally illiterate, and having a family member with hypertension compared with whites. Compared with whites, African Americans also were more likely to perceive high blood pressure as serious and to experience the side effect of increased urination compared with whites. Adjusting for these differences reduced the odds ratio of African Americans having adequate blood pressure control to 1.59 (95% confidence interval 1.09-2.29).

CONCLUSIONS

In this sample of hypertensive patients who have good access to health care and medication benefits, African Americans continued to have lower levels of blood pressure control despite considering more than 20 factors related to blood pressure control. Interventions designed to improve medication adherence need to take race into account. Patients' self-reports of failure to take medications provide an opportunity for clinicians to explore reasons for medication nonadherence, thereby improving adherence and potentially blood pressure control.

Attitudes, psychology, and risk taking of potential live kidney donors: strangers, relatives, and the general public

It is unclear whether potential living kidney donors and the general public differ in attitudes and psychological characteristics. We performed a case-control study to explore differences in these groups using a standardized questionnaire (analyzed using conditional logistic regression). Strangers (N = 42) were more willing than controls (N = 126) to incur risks: 64% strangers versus 35% controls accepting >50% medical complications (MC) risk; 90% strangers versus 61% controls accepting >8 days hospitalization; 71% strangers versus 43% controls accepting >3 months unpaid; 55% strangers versus 16% controls accepting 100% kidney failure (KF) risk; 70% strangers versus 34% controls accepting < or =10% likelihood of successful transplant (all p < 0.01). Relatives (N = 251) were also more willing than controls (N = 251) to incur risks. Strangers were most willing to incur MC, KF and transplant failure. Groups did not differ in attitudes, depression or anxiety. Potential stranger and related donors are willing to undergo greater risks with donation than the general public, but do not differ in other attitudes, depression or anxiety. This should help reassure transplant centers and the public that both forms of live donation do not necessarily involve increased ethical risks of donor coercion or irrational thought processes. Still, careful attention to communication of all risks of donation is warranted.