Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Carlos Mena-Hurtado

Second Advisor

Kim Smolderen


IntroductionThe association between community socioeconomic distress and carotid endarterectomy (CEA) outcomes is understudied. We therefore analyzed the association between the Distressed Community Index (DCI), a zip-code level measure of community distress, with 36-month post-CEA mortality and readmission.

MethodsWe thus examined patients undergoing CEA between 2015-2019 in the Vascular Quality Initiative database linked with Medicare claims outcomes data. Patients’ DCI ranged from 0 (not distressed) to 100 (distressed). The 36-month mortality was assessed by DCI quintiles using the Kaplan-Meir cumulative incidence function (CIF) and for linear DCI, using Cox regression stratified on site. For 90-day readmission, we used CIF curves and Fine-Gray models accounting for death as competing risk. Models were adjusted for patient and procedural characteristics.

Results The cohort included 33,593 patients with a mean DCI of 43.1 ±28.0, a mean age of 74.1 ±7.3 years, and 92.6% were White. The 36-month CIF of mortality varied from 16.4% in the “prosperous” to 20.8% in the “distressed” DCI quintiles (p<0.001). The mortality risk increased with a 10-point increase in DCI (unadjusted HR: 1.04; 95% CI 1.02-1.05 and adjusted HR: 1.03; 95% CI 1.02-1.04). The 90-day readmission CIF ranged from 18.1% in the “prosperous” to 19.4% in the “distressed” DCI quintiles (p=0.018).

ConclusionUltimately, this real-world CEA cohort demonstrates an increased 36-month mortality for high community distress groups.


This is an Open Access Thesis.

Open Access

This Article is Open Access