The purpose of this article was to document the racial distribution of carotid endarterectomy in several patient populations in order to better understand the increased morbidity and mortality from stroke among blacks compared with whites. The study population consisted of patients discharged from eight hospitals (1982-1986), all of which have wide geographic distributions of patients throughout North Carolina. Demographic data were obtained for these patients, as well as for two comparison populations: (1) the general population in each hospital’s surrounding community based on 1980 census data and (2) the National Inpatient Profile, a national sample of patients for 1985-1986 with a primary or secondary procedure code for carotid endartectomy.

First, the authors compared the patient population with the general population from the surrounding North Carolina communities. Twenty-two percent of the population of North Carolina is black; 26% of all patients discharged from the eight study hospitals were black; and 4.6% of all carotid endarterectomies performed in the eight hospitals were for black patients. More thorough data were obtained from one hospital. In that hospital, 6.4% of the endarterectomies were performed on black patients, and 15% of the carotid/cerebral angiograms performed were performed on black patients. Thus blacks in North Carolina are underrepresented among patients receiving endarterectomies and having angiograms (a diagnostic procedure). The authors also noted that 9% of the blacks and 2% of the whites who underwent carotid endarterectomies were self-payers.

The patient population was then compared with the national population. Of the general population, 12.1% is black; 12% of those discharged from hospitals nationally were black; 10.7% of those having surgical procedures who were discharged from hospitals nationally were black; and 2.7% of all patients having carotid endarterectomies were black. Thus, blacks were even more highly underrepresented nationally than in North Carolina among patients having endarterectomies.

The authors conclude that, since blacks are underrepresented among patients having carotid endarterectomies, “the distribution of carotid atheromatous disease is a racial or genetic feature of this vascular area.” However, they then acknowledge that “intracranial versus extracranial disease distribution may not be the only explanation for this observation,” and suggested that blacks might not “find access to the surgical care system.” Nonetheless, they dismiss this explanation, as “the national data showed that the percentage of blacks among all patients discharged from hospitals is comparable to the percentage of blacks in the general population; and blacks are only slightly underrepresented among all surgical patients discharged.” They further note that the percentage of blacks among all patients discharged was equal to or greater than the hospital watershed’s general population, and that the percentage of blacks having no insurance among those receiving carotid endarterectomies was higher than the same percentage for whites. These observations indicated to the authors that pay status did not specifically limit access of blacks to carotid endarterectomy.

These data were limited in several ways. First, the authors used measures of the surgical treatment as indication of prevalence of disease and did not adequately acknowledge that treatment might be measuring many other factors in addition to disease incidence. Second, the North Carolina hospital data were not representative of the general North Carolina hospital population. Third, all data were unadjusted for age and other potentially confounding factors. Fourth, the fact that patients might receive repeat hospitalizations or procedures and the issue of survivorship were not fully accounted for in this analysis.