Disparities in Access to Vascular Stroke Imaging and Carotid Revascularization: A Population Study
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Background
CT angiography (CTA), MR angiography (MRA), and ultrasound are noninvasive vascular imaging modalities used in the investigation of stroke or transient ischemic attack (TIA). Imaging decisions may be influenced by factors ranging from location-based resource considerations to patient characteristics. The aim of this study was to investigate disparities in vascular imaging utilization and subsequent carotid revascularization over 7 years in a Canadian province (Alberta, population:4.4 million).
Methods
We used provincial administrative data encompassing patients presenting to hospital or emergency/urgent-care facilities with a diagnosis of TIA or ischemic stroke from 1-April-2016 to 31-Mar-2023 and related the vascular imaging received (CTA/MRA/ultrasound/none) to age, sex, region (rural vs urban), diagnosis (ischemic stroke vs minor stroke/TIA), comorbidities, center type, and year using multivariable logistic regressions. We explored whether these variations persisted in recurrent events and investigated the odds of carotid endarterectomy/stenting using similar regression models.
Results
Among 47,963 patients (median age: 72, interquartile range: 21, 47.6% female) with TIA/stroke, those older than seventy-one, with minor stroke/TIA, and with specific comorbidities had significantly lower odds of receiving CTA or any neurovascular imaging, as were those in rural sites or hospitals not designated as Comprehensive Stroke Centers (CSCs, e.g. aOR-CTA [stroke unit-equivalent care vs CSC]: 0.20, 95%CI:0.13-0.30). Female patients were less likely to undergo CTA or any vascular imaging (66.4% female vs 71.1% male, aOR:0.84, 95%CI:0.81-0.88). Those presenting in more recent years had higher odds of receiving CTA (aOR-per-additional-year:1.15, 95%CI:1.14-1.17) or any neurovascular imaging (aOR:1.13, 95%CI:1.11-1.14). Female sex was associated with lower odds of carotid revascularization, as were patients with minor stroke/TIA, atrial fibrillation, care at non-CSC centers, and absence of vascular imaging (e.g. aOR[female vs male]:0.57, 95%CI:0.51-0.64).
Conclusions
We found important demographic and geographic disparities in vascular imaging utilization despite increasing utilization over time; similar disparities were also seen in carotid revascularization.
