INTRODUCTION
There are marked differences in the prevalence of carotid artery stenosis (CAS) and revascularization among underrepresented groups defined by race and ethnicity.1–2 It is increasingly recognized that underrepresented groups defined by factors other than race and ethnicity also carry a disproportionate burden of cardiovascular disease.3 We used the All of Us Research Program4 to test the hypothesis that the burden of CAS and the proportion of persons who undergo carotid revascularization differ in broadly defined underrepresented groups.
METHODS
All data are publicly available at www.allofus.nih.gov. We performed a cross-sectional study including All of Us participants with available electronic health records (EHR) data. We used a novel conceptual framework proposed by All of Us to study not only race/ethnic minorities, but also other underrepresented groups defined by education (less than high school degree); income (<= 35k USD); and gender identity/sexual orientation. Outcomes were ascertained using validated EHR codes (Table S1). We used logistic regression to model adjusted associations between underrepresented group status and outcomes, adjusting for age, sex, and cardiovascular risk factors. All of Us is approved and monitored by the dedicated All of Us IRB. All participants provided consent.
RESULTS
The study included 203,813 patients with EHR data (mean age 51.5 [SD 17] years, 124,735 [61%] female, Table S2). The prevalence of CAS was 2.7% (n=5,420). The proportion of patients who underwent carotid revascularization was 7.3% (n=395). Income<35K USD was associated with higher odds of CAS (OR 1.15, 95%CI 1.07–1.24; p<0.001) and carotid revascularization (OR 1.38, 95%CI 1.04–1.83; p=0.024). Black (OR 0.87; 95%CI 0.78–0.96; p=0.006) and Hispanic participants (OR 0.83; 95%CI 0.73–0.94; p=0.004) had lower odds of CAS while Black participants (OR 0.41; 95%IC 0.24–0.68; p=0.001) were less likely to receive any carotid revascularization (Table 1).
Table 1.
Results from multivariable logistic regression models.
| Underrepresented groups | Outcomes | |
|---|---|---|
| Carotid Artery Stenosis | Carotid Revascularization | |
| OR (multivariable) | ||
| Ancestry/ethnicity (n, %) | ||
| White | REFERENCE | |
| Black | 0.87 (0.79–0.96, p=0.006) | 0.41 (0.24–0.68, p=0.001) |
| Hispanic/Latino/a/x | 0.83 (0.73–0.94, p=0.004) | 1.02 (0.62–1.64, p=0.922) |
| Asian | 1.11 (0.86–1.41, p=0.397) | 0.87 (0.21–2.45, p=0.821) |
| Other/>1 | 0.93 (0.75–1.15, p=0.525) | 0.56 (0.17–1.37, p=0.265) |
| Sexual Diversity (n, %) | ||
| Non-LGBTQIA+ | REFERENCE | |
| LGBTQIA+ | 0.99 (0.88–1.12, p=0.933) | 0.95 (0.58–1.49, p=0.839) |
| Education (n, %) | ||
| High school completed | REFERENCE | |
| Less than high school degree | 0.86 (0.75–1.00, p=0.046) | 0.90 (0.49–1.54, p=0.703) |
| Household income (n, %) | ||
| >35K | REFERENCE | |
| <35K | 1.15 (1.07–1.24, p<0.001) | 1.38 (1.04–1.83, p=0.024) |
Abbreviations:
OR=Odds Ratio.
LGBTQIA+=lesbian, gay, bisexual, transgender, queer, intersex, asexual, other.
DISCUSSION
When considering underrepresented groups defined by factors other than race and ethnicity, persons with income <35k USD were more likely to both have CAS and undergo revascularization. People with lower income have worse profiles of cardiovascular health,3 which could explain these findings. Consistent with prior reports, when evaluating underrepresented groups defined by race/ethnicity, we found that Black and Hispanic participants had a lower prevalence of CAS.1–2 Moreover, Black participants had lower estimates of carotid revascularization, which could be explained by lower rates of high-grade stenosis1, but other factors should be explored further, including the potential presence of care access bias. Of note, our study may be subject to “volunteer bias,” leading to an increased number of healthy people enrolled. Additionally, not all the participants chose to share their EHR. These results highlight the need to extend cerebrovascular health disparities research beyond groups defined by race/ethnicity, a goal that will be significantly facilitated by the newly established All of Us research program.
Supplementary Material
Acknowledgments
SOURCES OF FUNDING
JNA, KNS and GJF are supported by the American Heart Association. KNS, CCM and GJF are supported by the National Institutes of Health.
DISCLOSURES
KNS reports grants from BARD; grants from Biogen; a patent pending for Stroke wearables licensed to Alva Health; grants from Novartis; and grants from Hyperfine. CCM reports compensation from Silk Road Medical, Inc. for consultant services.
Non-standard Abbreviations and Acronyms
- CAS
Carotid Artery Stenosis
- EHR
Electronic Health Records
- OR
Odds ratio
References
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