Socioeconomic disparities in first stroke incidence, quality of care, and survival: a nationwide registry-based cohort study of 44 million adults in England

Relative and absolute inequalities in cerebrovascular disease mortality rates: exploring the influence of socioeconomic status and urbanization levels in Taiwan

BACKGROUND/OBJECTIVE

Limited evidence exists regarding the socioeconomic inequalities in cerebrovascular disease (CBD) mortality at different urbanization levels. Therefore, this study was conducted to assess the socioeconomic inequalities and urbanization levels in township-based CBD mortality in Taiwan.

METHODS

Socioeconomic variables, including the percentages of low-income households, individuals with a university education and above, and tax payments, were measured at the township level from 2011 to 2020. Urbanization was also determined by the national survey and divided into seven levels. Age-standardized mortality rate (ASMR) of CBD was calculated using a Geographic Information System (GIS) in 358 townships. The effects of socioeconomic variables and urbanization levels on relative and absolute inequalities in township-based CBD mortality rates were examined.

RESULTS

Significant differences in ASMR of CBD were observed across all socioeconomic status indicators over the years. Higher proportions of low-income households were associated with higher ASMR of CBD. Conversely, there were negative correlations between higher proportions of individuals with a university education and above and tax payments with ASMR of CBD. The regression analysis indicated significant impacts of relative and absolute socioeconomic inequalities on ASMR of CBD. Additionally, a moderation effect of socioeconomic variables and urbanization on CBD mortality rates was observed, with rural areas showing sensitivity to these factors.

CONCLUSION

Although ASMR of CBD showed significant decreases over time, socioeconomic inequalities in CBD mortality rates persist. Interventions targeting socioeconomic inequalities in health outcomes, especially in rural areas, are needed to address this issue.

Stroke incidence, mortality, subtypes in rural and urban populations in five geographic areas of India (2018-2019): results from the National Stroke Registry Programme

Background

Increasing stroke burden in India demands a long-term stroke surveillance framework. Earlier studies in India were urban-based, short term and provided limited data on stroke incidence and its outcomes. This gap is addressed by the establishment of five population-based stroke registries (PBSRs) of the National Stroke Registry Programme, India. This paper describes stroke incidence, mortality and age, sex, and subtypes distribution in the five PBSRs with urban and rural populations.

Methods

First-ever incident stroke patients in age group ≥18 years, resident for at least one year in the defined geographic area, identified from health facilities were registered. Death records with stroke as the cause of death from the Civil Registration System (CRS) were included. Transient ischemic attack (TIA) was excluded. Three PBSRs (Cuttack, Tirunelveli, Cachar) included urban and rural populations. PBSRs in Kota and Varanasi were urban areas. The crude and age-standardized incidence rate (ASR) by age, sex, and residence (urban and rural), rate ratios of ASR, case fatality proportions and rates at day 28 after onset of stroke were calculated for years 2018-2019.

Findings

A total of 13,820 registered first-ever stroke cases that included 985 death certificate-only cases (DCOs) were analysed. The pooled crude incidence rate was 138.1 per 100,000 population with an age-standardized incidence rate (ASR) of 103.4 (both sexes), 125.7 (males) and 80.8 (females). The risk of stroke among rural residents was one in seven (Cuttack), one in nine (Tirunelveli), and one in 15 (Cachar). Ischemic stroke was the most common type in all PBSRs. Age-standardized case fatality rates (ASCFR) per 100,000 population for pooled PBSRs was 30.0 (males) and 18.8 (females), and the rate ratio (M/F) ranged from 1.2 (Cuttack) to 2.0 (Cachar).

Interpretation

Population-based registries have provided a comprehensive stroke surveillance platform to measure stroke burden and outcomes by age, sex, residence and subtype across India. The rural-urban pattern of stroke incidence and mortality shall guide health policy and programme planning to strengthen stroke prevention and treatment measures in India.

Funding

The National Stroke Registry Programme is funded through the intramural funding of the Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, India.

Association of neighborhood deprivation and hypertension: A systematic review and meta-analysis

BACKGROUND

Hypertension impacts nearly one billion individuals and is a primary health challenge. While traditional perspectives have focused on individual behavior and genetics as principal risk factors, recent research underscores the profound influence of socioeconomic factors within neighborhoods on the risk of hypertension. This systematic review and meta-analysis is aimed to elucidate the association between neighborhood deprivation and the risk of hypertension.

METHODS

A comprehensive literature search was conducted across PubMed, Embase, and Web of Science from inception until December 25, 2023. Observational studies defining neighborhood deprivation and reporting hypertension incidence were included. Nested Knowledge software was used for screening and data extraction, with study quality assessed using the Newcastle-Ottawa Scale. Statistical analysis was performed with R software (V 4.3), using a random-effects model to calculate the pooled relative risk (RR).

RESULTS

Twenty-six studies were included in the qualitative analysis and 22 in the meta-analysis, covering over 62 million participants. The pooled RR was 1.139 (95% CI: 1.006 - 1.290), p=0.04, indicating a higher hypertension risk in deprived neighborhoods. Subgroup analyses showed variability by country and deprivation assessment methods. RR varied from 1.00 in Japan (95% CI: 0.93-1.08) to 1.60 (95% CI: 1.07-2.39) in France and 1.57 (95% CI: 0.67-3.70) in Germany, with significant heterogeneity observed in measures of neighborhood deprivation.

CONCLUSION

Our analysis confirms a significant association between neighborhood deprivation and hypertension, underscoring the importance of socioeconomic factors in public health. It highlights the need for targeted local assessments and interventions. Future research should explore the causal mechanisms and effectiveness of interventions addressing neighborhood deprivation.

A Scoping Review of Possible Solutions for Decreasing Socioeconomic Inequalities in Type 2 Diabetes Mellitus

Background

As socioeconomic inequalities are key factors in access and utilization of type 2 diabetes (T2D) services, the purpose of this scoping review was to identify solutions for decreasing socioeconomic inequalities in T2D.

Methods

A scoping review of scientific articles from 2000 and later was conducted using PubMed, Web of Science (WOS), Scopus, Embase, and ProQuest databases. Using the Arksey and O'Malley framework for scoping review, articles were extracted, meticulously read, and thematically analyzed.

Results

A total of 7204 articles were identified from the reviewed databases. After removing duplicate and nonrelevant articles, 117 articles were finally included and analyzed. A number of solutions and passways were extracted from the final articles. Solutions for decreasing socioeconomic inequalities in T2D were categorized into 12 main solutions and 63 passways.

Conclusions

Applying identified solutions in diabetes policies and interventions would be recommended for decreasing socioeconomic inequalities in T2D. Also, the passways could be addressed as entry points to help better implementation of diabetic policies.

Social and clinical vulnerability in stroke and STEMI management during the COVID-19 pandemic: a registry-based study

OBJECTIVE

This study aims to evaluate whether the first wave of the COVID-19 pandemic resulted in a deterioration in the quality of care for socially and/or clinically vulnerable stroke and ST-segment elevation myocardial infarction (STEMI) patients.

DESIGN

Two cohorts of STEMI and stroke patients in the Aquitaine neurocardiovascular registry.

SETTING

Six emergency medical services, 30 emergency units, 14 hospitalisation units and 11 catheterisation laboratories in the Aquitaine region in France.

PARTICIPANTS

This study involved 9218 patients (6436 stroke and 2782 STEMI patients) in the neurocardiovascular registry from January 2019 to August 2020.

PRIMARY OUTCOME MEASURES

Care management times in both cohorts: first medical contact-to-procedure time for the STEMI cohort and emergency unit admission-to-imaging time for the stroke cohort. Associations between social (deprivation index) and clinical (age >65 years, neurocardiovascular history) vulnerabilities and care management times were analysed using multivariate linear mixed models, with an interaction on the time period (pre-wave, per-wave and post-first COVID-19 wave).

RESULTS

The first medical contact procedure time was longer for elderly (p<0.001) and 'very socially disadvantaged' (p=0.003) STEMI patients, with no interaction regarding the COVID-19 period (age, p=0.54; neurocardiovascular history, p=0.70; deprivation, p=0.64). We found no significant association between vulnerabilities and the admission imaging time for stroke patients, and no interaction with respect to the COVID-19 period (age, p=0.81; neurocardiovascular history, p=0.34; deprivation, p=0.95).

CONCLUSIONS

This study revealed pre-existing inequalities in care management times for vulnerable STEMI and stroke patients; however, these inequalities were neither accentuated nor reduced during the first COVID-19 wave. Measures implemented during the crisis did not alter the structured emergency pathway for these patients.

TRIAL REGISTRATION NUMBER

NCT04979208.

Mediation Analyses of the Mechanisms by Which Socioeconomic Status, Comorbidity, Stroke Severity, and Acute Care Influence Stroke Outcome

BACKGROUND AND OBJECTIVES

Low socioeconomic status (SES) is associated with increased risk of death and disability after stroke, but interventional targets to minimize disparities remain unclear. We aim to assess the extent to which SES-based disparities in the association between low SES and death and dependency at 3 months after stroke could be eliminated by offsetting differences in comorbidity, stroke severity, and acute care.

METHODS

This nationwide register-based cohort study included all 72 hospitals caring for patients with acute stroke in Sweden. All patients registered with an acute ischemic stroke in the Swedish Stroke Register in 2015-2016 who were independent in activities of daily living (ADL) during stroke were included. Data on survival and SES the year before stroke were retrieved by cross-linkage with other national registers. SES was defined by education and income and categorized into low, mid, and high. Causal mediation analysis was used to study the absolute risk of death and ADL dependency at 3 months depending on SES and to what extent hypothetical interventions on comorbidities, stroke severity, and acute care would equalize outcomes.

RESULTS

Of the 25,846 patients in the study, 6,798 (26.3%) were dead or ADL dependent 3 months after stroke. Adjusted for sex and age, low SES was associated with an increased absolute risk of 5.4% (95% CI 3.9%-6.9%; p < 0.001) compared with mid SES and 10.1% (95% CI 8.1%-12.2%; p < 0.001) compared with high SES. Intervening to shift the distribution of all mediators among patients with low SES to those of the more privileged groups would result in absolute reductions of these effects by 2.2% (95% CI 1.2%-3.2%; p < 0.001) and 4.0% (95% CI 2.6%-5.5%; p < 0.001), respectively, with the largest reduction accomplished by equalizing stroke severity.

DISCUSSION

Low SES patients have substantially increased risks of death and ADL dependency 3 months after stroke compared with more privileged patient groups. This study suggests that if we could intervene to equalize SES-related differences in the distributions of comorbidity, acute care, and stroke severity, up to 40 of every 1,000 patients with low SES could be prevented from dying or becoming ADL dependent.

A systematic review of ambulance service-based randomised controlled trials in stroke

BACKGROUND

Treatment for stroke is time-dependent, and ambulance services play a vital role in the early recognition, assessment and transportation of stroke patients. Innovations which begin in ambulance services to expedite delivery of treatments for stroke are developing. However, research delivery in ambulance services is novel, developing and not fully understood.

AIMS

To synthesise literature encompassing ambulance service-based randomised controlled interventions for acute stroke with consideration to the characteristics of the type of intervention, consent modality, time intervals and issues unique to research delivery in ambulance services. Online searches of MEDLINE, EMBASE, Web of Science, CENTRAL and WHO IRCTP databases and hand searches identified 15 eligible studies from 538. Articles were heterogeneous in nature and meta-analysis was partially available as 13 studies reported key time intervals, but terminology varied. Randomised interventions were evident across all points of contact with ambulance services: identification of stroke during the call for help, higher dispatch priority assigned to stroke, on-scene assessment and clinical interventions, direct referral to comprehensive stroke centres and definitive care delivery at scene. Consent methods ranged between informed patient, waiver and proxy modalities with country-specific variation. Challenges unique to the prehospital setting comprise the geographical distribution of ambulance resources, low recruitment rates, prolonged recruitment phases, management of investigational medicinal product and incomplete datasets.

CONCLUSION

Research opportunities exist across all points of contact between stroke patients and ambulance services, but randomisation and consent remain novel. Early collaboration and engagement between trialists and ambulance services will alleviate some of the complexities reported.

REGISTRATION NUMBER

PROSPERO 2018CRD42018075803.

Influence of social deprivation on morbidity and all-cause mortality of cardiometabolic multi-morbidity: a cohort analysis of the UK Biobank cohort

BACKGROUND

The relation of social deprivation with single cardiometabolic disease (CMD) was widely investigated, whereas the association with cardiometabolic multi-morbidity (CMM), defined as experiencing more than two CMDs during the lifetime, is poorly understood.

METHODS

We analyzed 345,417 UK Biobank participants without any CMDs at recruitment to study the relation between social deprivation and four CMDs including type II diabetes (T2D), coronary artery disease (CAD), stroke and hypertension. Social deprivation was measured by Townsend deprivation index (TDI), and CMM was defined as occurrence of two or more of the above four diseases. Multivariable Cox models were performed to estimate hazard ratios (HRs) per one standard deviation (SD) change and in quartile (Q1-Q4, with Q1 as reference), as well as 95% confidence intervals (95% CIs).

RESULTS

During the follow up, 68,338 participants developed at least one CMD (median follow up of 13.2 years), 16,225 further developed CMM (median follow up of 13.4 years), and 18,876 ultimately died from all causes (median follow up of 13.4 years). Compared to Q1 of TDI (lowest deprivation), the multivariable adjusted HR (95%CIs) of Q4 (highest deprivation) among participants free of any CMDs was 1.23 (1.20 ~ 1.26) for developing one CMD, 1.42 (1.35 ~ 1.48) for developing CMM, and 1.34 (1.27 ~ 1.41) for all-cause mortality. Among participants with one CMD, the adjusted HR (95%CIs) of Q4 was 1.30 (1.27 ~ 1.33) for developing CMM and 1.34 (1.27 ~ 1.41) for all-cause mortality, with HR (95%CIs) = 1.11 (1.06 ~ 1.16) for T2D patients, 1.07 (1.03 ~ 1.11) for CAD patients, 1.07 (1.00 ~ 1.15) for stroke patients, and 1.24 (1.21 ~ 1.28) for hypertension patients. Among participants with CMM, TDI was also related to the risk of all-cause mortality (HR of Q4 = 1.35, 95%CIs 1.28 ~ 1.43).

CONCLUSIONS

We revealed that people living with high deprived conditions would suffer from higher hazard of CMD, CMM and all-cause mortality.

Fatigue, Depression and Health-Related Quality of Life in Patients with Post-Myocardial Infarction during the COVID-19 Pandemic: Results from the Augsburg Myocardial Infarction Registry

The interplay between fatigue and depression and their association with health-related quality of life (HRQoL) after acute myocardial infarction (AMI) has received little attention during the COVID-19 pandemic. Therefore, this study evaluated the frequency of fatigue and depression in post-AMI patients during the COVID-19 pandemic and investigated the cross-sectional associations between fatigue, depression and HRQoL.

METHODS

The analysis was based on population-based Myocardial Infarction Registry Augsburg data. All survivors of AMI between 1 June 2020 and 15 September 2021 were included (n = 882) and received a postal questionnaire containing questions about fatigue (Fatigue Assessment Scale), depression (Patient Health Questionnaire), and HRQoL (MacNew Heart Disease HRQoL questionnaire) on 17 November 2021. The questionnaire was returned by 592 patients (67.1%), and 574 participants could be included in the analysis. Multivariable linear regression models were performed to investigate the associations between fatigue and depression (both exposures) and HRQoL (outcome).

RESULTS

Altogether, 273 (47.6%) participants met the criteria for the presence of fatigue, about 16% showed signs of moderate to severe depression. Both fatigue and depression were significantly associated with a decreased HRQoL (total score and emotional, social, and physical subscales; all p-values < 0.0001). In particular, a combined occurrence of fatigue and depression was associated with a significantly reduced HRQoL.

CONCLUSIONS

It seems necessary to screen post-MI patients for the presence of fatigue and depression in clinical practice on a routine basis to provide them with adequate support and treatment and thus also to improve their HRQoL.

Impact of the COVID-19 pandemic on CVD prevention between different socioeconomic groups in Switzerland

BACKGROUND

The COVID-19 pandemic disrupted the continuing management of cardiovascular disease (CVD) risk factors in the population. Socioeconomic status (SES) is a major determinant of health. Whether the COVID-19 pandemic increased, the SES gap in CVD risk factors is unknown.

AIMS

To compare the management of CVD risk factors and the SES gap before and during the pandemic.

METHODS

Cross-sectional study conducted between 2018 and 2021 in Lausanne, Switzerland. Prevalence, awareness, treatment and control rates of hypertension, dyslipidaemia and diabetes were compared between the periods before (N=2416, 45.2% men, 65.3±9.8 years) and during (N=776, 44.5% men, 63.9±9.1 years) the COVID-19 pandemic. SES was defined by education and categorised as low (compulsory or apprenticeship), middle (high school) and high (university).

RESULTS

After multivariable analysis, the prevalence of hypertension increased, and awareness decreased during the pandemic: OR and (95% CI) 1.26 (1.04 to 1.53) and 0.70 (0.53 to 0.94), respectively. For dyslipidaemia, prevalence decreased during the pandemic 0.82 (95% CI 0.69 to 0.98); awareness did not change. For diabetes, prevalence did not change but awareness increased 5.76 (95% CI 1.23 to 27.04). No differences were found before and during the pandemic regarding treatment and control for all CVD risk factors. Relative to high SES, a decrease in hypertension awareness among middle SES categories was observed during the pandemic (OR and 95% CI 1.11 (0.73 to 1.69) before and 0.45 (95% CI 0.23 to 0.85) during, p for interaction<0.05), while no other changes were found.

CONCLUSION

Prevalence and management of CVD risk factors changed little during the pandemic. The SES gap did not increase except for hypertension awareness.

Are relative educational inequalities in multiple health behaviors widening? A longitudinal study of middle-aged adults in Northern Norway

Introduction

Educational inequality in multiple health behaviors is rarely monitored using data from the same individuals as they age. The aim of this study is to research changes in relative educational inequality in multiple variables related to health behavior (smoking, physical activity, alcohol intake, and body mass index), separately and collectively (healthy lifestyle), among middle-aged adults living in Northern Norway.

Methods

Data from adult respondents aged 32-87 in 2008 with repeated measurements in 2016 (N = 8,906) were drawn from the sixth and seventh waves of the Tromsø Study. Logistic regression was used to assess the relative educational inequality in the variables related to health behavior. The analyses were performed for the total sample and separately for women and men at both baseline and follow-up.

Results

Educational inequality was observed in all the variables related to health behavior at baseline and follow-up, in both men and women. Higher levels of educational attainment were associated with healthier categories (non-daily smoking, physical activity, normal body mass index, and a healthy lifestyle), but also with high alcohol intake. The prevalence of daily smoking and physical inactivity decreased during the surveyed period, while high alcohol intake, having a body mass index outside of the normal range and adhering to multiple health recommendations simultaneously increased. The magnitude of relative educational inequality measured at baseline increased at the follow-up in all the variables related to health behavior. Differences were larger among women when compared to men, except in physical inactivity.

Conclusion

Persistent and increasing relative disparities in health behavior between the highest education level and lower education levels are found in countries with well-established and comprehensive welfare systems like Norway. Addressing these inequalities is essential for reducing both the chronic disease burden and educational disparities in health.

Palliative care interventions and end-of-life care as reported by patients' post-stroke and their families: a systematic review

AIMS

Internationally, there is an urgent need to implement guidelines supporting integration of palliative care into stroke clinical practice. Despite considerable advances in acute stroke management, ∼20% of all acute stroke patients die within the first 30 days. Palliative care is well established in diseases such as cancer or advanced heart failure, but evidence-based interventions of high quality are limited in stroke populations. This systematic review aims to identify and evaluate quantitative studies that describe palliative care interventions and end-of-life care as reported by patient's post-stroke and their families.

METHODS AND RESULTS

A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted in Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane, Embase, Ovid, Proquest, and Scopus from 1990 to April 2021. The National Heart, Lung and Blood Institute standardized quality rating tools for quality assessment were used. Seven studies were identified, and all used descriptive quantitative designs. There were no interventional studies. The results were synthesized narratively according to the elements of palliative care interventions and end-of-life care: symptom burden and satisfaction, loss of autonomy at the end of life, and acknowledging uncertainty.

CONCLUSION

This review highlights the limited empirical evidence that describes palliative care interventions and end-of-life care as reported by patient's post-stroke and their families. Most of the current evidence focuses on the provision of care during the final days and hours of life, or end-of-life care, with little evidence to guide the integration of palliative care into post-stroke clinical care, especially for patients with an uncertain prognosis. Acute stroke is sudden, unexpected, and life-changing, and patients and families would benefit from well-designed targeted interventions to determine strategies that address the diverse palliative needs of this patient population.

REGISTRATION

PROSPERO CRD42021254536.

Effect of Primary Care Center Characteristics, Healthcare Worker Vaccination Status and Patient Economic Setting on Patient Influenza Vaccination Coverage Rates

BACKGROUND

Reaching the public health organizations targets of influenza vaccination in at-risk patient groups remains a challenge worldwide. Recognizing the relationship between the healthcare system characteristics and the economic environment of the population with vaccination uptake can be of great importance to improve.

METHODS

Several characteristics were correlated in this retrospective ecological study with data from 6.8 million citizens, 15,812 healthcare workers across 258 primary care health centers, and average income by area of the care center in Spain.

RESULTS

No correlation between HCW vaccination status and patient vaccination was found. A weak negative significant correlation between the size of the population the care center covers and their vaccination status did exist (6 mo.-59 yr., r = 0.19, p = 0.002; 60-64 yr., r = 0.23, p < 0.001; ≥65 yr., r = 0.23, p ≥ 0.001). The primary care centers with fewer HCWs had better uptake in the at-risk groups in the age groups of 60-64 yr. (r = 0.20, p = 0.002) and ≥65 (r = 0.023, p ≥ 0.001). A negative correlation was found regarding workload in the 6 mo.-59 yr. age group (r = 0.18, p = 0.004), which showed the at-risk groups that lived in the most economically deprived areas were more likely to be vaccinated.

CONCLUSIONS

This study reveals that the confounding variables that determine influenza vaccination in a population and in HCWs are complex. Future influenza campaigns should address these especially considering the possibility of combining influenza and SARS-CoV-2 vaccines each year.

Processes of Care and Associated Factors in Patients With Stroke by Immigration Status

BACKGROUND

Receiving evidence-based stroke care processes is associated with good clinical outcome. However, data on early stroke care among immigrants are scarce.

OBJECTIVE

We investigated whether guideline-recommended acute stroke care and associated factors differ between immigrants and Danish-born residents.

DESIGN

Patients admitted with ischemic and hemorrhagic stroke diagnoses (n=129,724) between 2005 and 2018 were identified from the Danish Stroke Registry.

RESULTS

We included 123,928 Danish-born residents and 5796 immigrants with stroke. Compared with Danish-born residents, immigrants were less likely to be admitted to a stroke unit within 24 hours after stroke onset (81.5% vs. 83.9%, P <0.001) and had lower odds of early stroke care including dysphagia screening, physiotherapy, occupational therapy, and nutritional assessment. After adjustment for age, sex, clinical, and sociodemographic factors, immigrants had lower odds of early stroke unit admission (odds ratio [OR]: 0.97; 95% CI, 0.94-0.99), early dysphagia screening (OR: 0.96; 95% CI, 0.93-0.98), early physiotherapy (OR: 0.96; 95% CI, 0.94-0.99), and early occupational therapy (OR: 0.96; 95% CI, 0.93-0.98) than Danish-born residents. Small absolute differences in overall quality of stroke care were found when comparing immigrants and Danish-born residents. Significant factors associated with greater likelihood of stroke care included high income, high education, and cohabitation.

CONCLUSIONS

Immigrants had lower chances of early stroke unit admission and received fewer individual early stroke care processes such as dysphagia screening, physiotherapy and occupational therapy than Danish-born residents. However, the absolute disparities were in general minor and largely influenced by socioeconomic status and cohabitation.

The impact of regional deprivation on stroke incidence, treatment, and mortality in Germany

BACKGROUND

Regional deprivation has been shown to be an influential factor in stroke incidence risk. However, there is a paucity of knowledge on regional differences in stroke incidence and mortality in Germany.

METHODS

We assessed data from the Diagnosis Related Groups statistics (2016-2019) and the German Federal Registry of Physicians (2019). Negative binomial regression analysis was used to examine the association between the German Index of Multiple Deprivation 2015 covering 401 districts and district-free cities in Germany and stroke incidence, treatment, and mortality.

RESULTS

The adjusted rate ratios of stroke incidence and mortality with the highest deprivation level compared with the least deprived area were 1.161 (95% CI [1.143, 1.179]) and 1.193 (95% CI [1.148, 1.239]), respectively. Moreover, this study revealed that physician density was higher in district-free cities compared to districts.

CONCLUSIONS

Our results indicate that regional deprivation is associated with incident and mortality cases of stroke, necessitating a more targeted approach to stroke prevention in deprived regions.

Kenton Award Lecture-Stroke Disparities Research: Learning From the Past, Planning for the Future

Inequities in stroke care and outcomes have been documented both within and among countries based on factors, such as race, geography, and socioeconomic status. Research can help us to identify, understand, and address inequities, and this article offers considerations for scientists working in this area. These include designing research aimed at identifying the underlying causes of inequities, recognizing the importance of the social determinants of health, considering interventions that go beyond the individual patient and provider to include policies and systems, acknowledging the role of structural racism, performing community-engaged participatory research, considering intersecting social identities, learning from cross-national comparisons, maintaining the data sources needed for inequities research, using terminology that advances health equity, and improving diversity across the research enterprise.

Is the socioeconomic inequality in stroke prognosis changing over time and does quality of care play a role?

Introduction:

In a publicly financed healthcare system we aimed to study the development in socioeconomic disparity in ischemic stroke outcomes over time. In addition, we study whether the healthcare system affects these outcomes through the quality of early stroke care when adjustments are made for various patient characteristics incl. comorbidity and stroke severity.

Patients and methods:

Using nationwide, detailed individual-level register-data we analysed how income-related and education-related inequality in 30-day mortality and 30-day readmission risk developed between 2003 and 2018. In addition, focusing on income-related inequality, we applied mediation analyses to estimate the mediating role of quality of acute stroke care on 30-day mortality and 30-day readmission.

Results:

A total of 97,779 individual ischemic stroke patients were registered in Denmark with a first ever stroke in the study period. Three-point-seven percent died within 30 days of their index-admission and 11.5% were readmitted within 30 days of discharge. The income-related inequality in mortality remained virtually unchanged over time from an RR of 0.53 (95% CI: 0.38; 0.74) in 2003–06 to RR 0.69 (95% CI: 0.53; 0.89)) in 2015–18 when high income was compared to low income (Family income-time interaction: RR 1.00 (95% CI: 0.98–1.03)). A similar but less uniform trend was found for the education-related inequality in mortality (Education-time interaction: RR 1.00 (95% CI: 0.97–1.04)). The income-related disparity in 30-day readmission was smaller than in 30-day mortality and it diminished over time from 0.70 (95% CI: 0.58; 0.83) to 0.97 (95% CI: 0.87; 1.10). The mediation analysis showed no systematic mediating effect of quality of care on neither mortality nor readmission. However, it cannot be ruled out that residual confounding may have washed out some mediating effects.

Discussion and Conclusion:

The socioeconomic inequality in stroke mortality and re-admission risk has yet to be eliminated. Additional studies from different settings are warranted in order to clarify the impact of socioeconomic inequality of quality of acute stroke care.

The relevance of social and commercial determinants for neurological health

A disconnect has developed over the past two decades between neurological and neuroscientific research, which have seen notable innovation and development, and our increasing understanding of the role of social and commercial determinants of health, including the health of the nervous system. Over the next two decades, grounding neurological research in public health and epidemiological principles can bring about a paradigm shift, away from reductionism, over-medicalisation, and health inequities towards neurological research that reduces inequalities and has true relevance to the populations it aims to serve. People who are involved in neurological and neuroscientific research and practice, as clinicians, researchers, publishers, and funders, can create change by being more aware of the social and commercial determinants of health, reprioritising research funding, and advocating for greater neurological health equity.

Stroke-related length of hospitalization trends and in-hospital mortality in Peru

Background

Peru faces challenges to provide adequate care to stroke patients. Length of hospitalization and in-hospital mortality are two well-known indicators of stroke care. We aimed to describe the length of stay (LOS) of stroke in Peru, and to assess in-hospital mortality risk due to stroke, and subtypes.

Methods

This retrospective cohort study used hospitalization registries coding with ICD-10 from 2002 to 2017 (N = 98,605) provided by the Ministry of Health; in-hospital mortality was available for 2016-2017 (N = 6,566). Stroke cases aged ≥35 years were divided into subarachnoid hemorrhage (I60), intracerebral hemorrhage (I61), cerebral infarction (I63), and stroke not specified as hemorrhage or infarction (I64). Data included stroke LOS and in-hospital mortality; socio-demographic and clinical variables. We fitted a region- and hospital level-stratified Weibull proportional hazard model to assess the in-hospital mortality.

Results

The median LOS was 7 days (IQR: 4-13). Hemorrhagic strokes had median LOS longer than ischemic strokes and stroke not specified as hemorrhage or infarction (P = <0.001). The case fatality rate (CFR) of patients with stroke was 11.5% (95% CI [10-12%]). Subarachnoid hemorrhage (HR = 2.45; 95% CI [1.91-3.14]), intracerebral hemorrhage (HR = 1.95; 95% CI [1.55-2.46]), and stroke not specified as hemorrhage or infarction (HR = 1.45; 95% CI [1.16-1.81]) were associated with higher in-hospital mortality risk in comparison to ischemic strokes.

Discussion

Between 2002 and 2017, LOS due to stroke has not changed in Peru in stroke patients discharged alive. Hemorrhagic cases had the longest LOS and highest in-hospital mortality risk during 2016 and 2017. The findings of our study seem to be consistent with a previous study carried out in Peru and similar to that of HIC and LMIC, also there is an increased median LOS in stroke cases managed in specialized centers. Likewise, LOS seems to depend on the type of stroke, where ischemic stroke cases have the lowest LOS. Peru needs to improve access to stroke care.

Cardiovascular-related conditions and risk factors in primary care for deprived communities before and during the COVID-19 pandemic: an observational study in Northern England

OBJECTIVES

The North East of England, ranked as having the highest poverty levels and the lowest health outcomes, has the highest cardiovascular disease (CVD) premature mortality. This study aimed to compare CVD-related conditions and risk factors for deprived practice populations with other general practice (GP) populations in Northern England to England overall, before and during COVID-19 to identify changes in recorded CVD-related risk factors and conditions and evidence-based lipid prescribing behaviour.

DESIGN

A population-based observational study of aggregated practice-level data obtained from publicly accessible data sets.

SETTING

34 practices that fall into the 15% most deprived practice populations in England were identified as the most deprived communities in the North East and North Cumbria (Deep End).

PARTICIPANTS

Patients aged ≥16 registered with GP and diagnosed with any form of CVD.

PRIMARY AND SECONDARY OUTCOME MEASURES

CVD-related conditions and risk factors, statin prescribing.

RESULTS

Deep End (n=263 830) had a smaller, younger and more deprived population with lower levels of employment and full-time education and higher smoking prevalence. They had some higher recorded CVD-related conditions than England but lower than the non-Deep End. Atrial fibrillation (-0.9, -0.5), hypertension (-3.7, -1.3) and stroke and transient ischaemic attack rates (-0.5, -0.1) appeared to be lower in the Deep End than in the non-Deep End but the optimal statin prescribing rate was higher (3.1, 8.2) than in England.

CONCLUSION

Recorded CVD-related risk factors and conditions remained comparable before and during COVID-19. These are higher in the Deep End than in England and similar or lower than the non-Deep End, with a higher optimal statin prescribing rate. However, it was not possible to control for age and sex. More work is needed to estimate the consequences of the pandemic on disadvantaged communities and to compare whether the findings are replicated in other areas of deprivation.

Rural-urban differences in the initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study

AIMS

Little is known about rural-urban differences in the treatment and outcomes in patients with atrial fibrillation (AF). We aimed to assess whether the initiation of oral anticoagulant (OAC) therapy in patients with AF differs between those with rural and urban residence.

METHODS

The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The outcome was the first redeemed OAC prescription.

RESULTS

We identified 222 419 patients (50.1% female; mean age 72.8 (SD 13.2) years) with incident AF during 2007-2018. Urban residence was associated with a lower rate of OAC therapy initiation (adjusted subdistribution hazard ratio (SHR) (95% CI) 0.96 (0.95-0.97)). Correspondingly, an inverse graded dose-response relationship was observed between higher urbanization degree tertile and OAC initiation rate (highest tertile compared to lowest: adjusted SHR (95% CI) 0.94 (0.93-0.95)). The adoption of direct oral anticoagulants for stroke prevention was faster among patients with urban residence.

CONCLUSION

This nationwide cohort study documented that urban residence is associated with a slightly lower rate of OAC therapy initiation in patients with incident AF, but faster adoption of direct oral anticoagulant use.

Commissioning [Integrated] Care in England: An Analysis of the Current Decision Context

Background:

Methods:

Results:

Conclusion:

Rural-Urban differences in Use of Rhythm Control Therapies in Patients with Incident Atrial Fibrillation: A Finnish Nationwide Cohort Study

Background: Rural-urban disparities have been reported in the access, utilization, and quality of healthcare. We aimed to assess whether use of antiarrhythmic therapies (AATs) in patients with atrial fibrillation (AF) differs between those with rural and urban residence. Methods: The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The primary outcome was the use of any AAT, including cardioversion, catheter ablation, and fulfilled antiarrhythmic drug (AAD) prescription. Results: We identified 177,529 patients (49.9% female, mean age 73.0 (SD13.0) years) with incident AF during 2010-2018. Except for AADs, the differences in AAT use were nonsignificant when patients were stratified according to the rural-urban classification system (urban vs. rural adjusted incidence rate ratios (aIRRs) with 95% CIs for any AAT 1.01 (0.99-1.03), AADs 1.11 (1.07-1.15), cardioversion 1.01 (0.98-1.03), catheter ablation 1.05 (0.98-1.12)). However, slightly higher use of all rhythm control modalities was observed in the highest urbanization degree tertile when compared to the lowest tertile (aIRRs with 95% Cis for any AAT 1.06 (1.03-1.08), AADs 1.18 (1.14-1.23), cardioversion 1.05 (1.02-1.08), catheter ablation 1.10 (1.02-1.19)). Conclusions: This nationwide retrospective cohort study observed that urban residence is associated with higher use of AADs in patients with incident AF. Otherwise, the observed disparities were only marginal, suggesting that in the use of rhythm control therapies, no large rural-urban inequity exists in Finland.

The individual and combined associations of depression and socioeconomic status with risk of major cardiovascular events: A prospective cohort study

OBJECTIVE

We aimed to investigate the individual and combined associations of depression and low socioeconomic status (SES) with risk of major cardiovascular events (MCVE), defined as first-ever fatal or non-fatal stroke or myocardial infarction, in a large prospective cohort study.

METHODS

We used data from 466,238 UK Biobank participants, aged 40-69 years without cardiovascular disease, bipolar disorder or schizophrenia at baseline. We performed Cox proportional hazard models to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the individual and combined associations of depression and each of educational attainment, area-based deprivation and income with risk of MCVE. We assessed effect modification and explored interaction on the additive and multiplicative scale.

RESULTS

Depression, low education, high area-based deprivation and low income were individually associated with increased risks of MCVE (adjusted HR, 95% CI: 1.28, 1.19-1.38; 1.20, 1.14-1.27; 1.17, 1.11-1.23; and 1.22, 1.16-1.29, respectively). Depression was associated with increased risks of MCVE among individuals with high and low SES. Individuals with depression and each of low education, high area-based deprivation and low income were at particularly high risk of MCVE (HR, 95% CI: 1.50, 1.38-1.63; 1.63, 1.46-1.82; 1.31, 1.23-1.40, respectively). There was interaction between depression and area-based deprivation on multiplicative and additive scales but no interaction with education or income.

CONCLUSION

Depression was associated with increased risks of MCVE among individuals with high and low SES, with particularly high risks among those living in areas of high deprivation.

Temporal trend of first-ever ischaemic stroke incidence from 2010 to 2019 in South Korea: a nationwide retrospective cohort study

OBJECTIVE

Ischaemic stroke incidence is on the decline globally, but the trend in South Korea is unknown. In this study, the 10-year incidence trends of first-ever ischaemic stroke in South Korea were evaluated.

DESIGN, SETTING AND PARTICIPANTS

The National Health Insurance Services medical claim data were used to construct 10 annual cohorts of adults aged 20 years and older, who had not been diagnosed with stroke, to find out the incidence trends of first-ever ischaemic stroke from 2010 to 2019.

OUTCOME MEASURES

The primary outcomes were crude and age-adjusted incidence rates for 10 years. Crude incidence rates of the age groups and incidence age statistics were calculated. For comparison among the income groups, age-adjusted incidence rates were used. Incidence rates in all the groups were analysed separately by sex.

RESULTS

Age-standardised incidence rates of ischaemic stroke per 100 000 were 101.0 in men, and 67.6 in women in 2010; and 92.2 in men, and 55.0 in women in 2019. By age group, there was a decrease in women over 40 years of age, and men over 60 years of age. The relative difference in stroke incidence rates between medical aid beneficiaries and the highest income group increased from 1.5 to 1.87 over 10 years.

CONCLUSIONS

Age-standardised incidence rate of ischaemic stroke has decreased from 2010 to 2019 for both man and women. The incidence rate was stable in the younger age groups and decreased in the older age groups, and the disparities between income groups have widened over the past decade. Stroke prevention strategies are needed for the younger age group and the low-income group. Further research is needed to study the risk factors contributing to the incidence of ischaemic stroke in different groups.

Socioeconomic status and stroke severity: Understanding indirect effects via risk factors and stroke prevention using innovative statistical methods for mediation analysis

Background

Those with low socioeconomic status have an increased risk of stroke, more severe strokes, reduced access to treatment, and more adverse outcomes after stroke. The question is why these differences are present. In this study we investigate to which extent the association between low socioeconomic status and stroke severity can be explained by differences in risk factors and stroke prevention drugs.

Methods

The study included 86 316 patients registered with an ischemic stroke in the Swedish Stroke Register (Riksstroke) 2012–2016. Data on socioeconomic status was retrieved from the Longitudinal integrated database for health insurance and labour market studies (LISA) by individual linkage. We used education level as proxy for socioeconomic status, with primary school education classified as low education. Stroke severity was measured using the Reaction Level Scale, with values above 1 classified as severe strokes. To investigate the pathways via risk factors and stroke prevention drugs we performed a mediation analysis estimating indirect and direct effects.

Results

Low education was associated with an excess risk of a severe stroke compared to mid/high education (absolute risk difference 1.4%, 95% CI: 1.0%-1.8%), adjusting for confounders. Of this association 28.5% was an indirect effect via risk factors (absolute risk difference 0.4%, 95% CI: 0.3%-0.5%), while the indirect effect via stroke prevention drugs was negligible.

Conclusion

Almost one third of the association between low education and severe stroke was explained by risk factors, and clinical effort should be taken to reduce these risk factors to decrease stroke severity among those with low socioeconomic status.

Macrostructural Aspects in Oral Narratives in Brazilian Portuguese by Left and Right Hemisphere Stroke Patients With Low Education and Low Socioeconomic Status

OBJECTIVE

Individuals with a stroke in either the left hemisphere (LH) or the right hemisphere (RH) often present macrostructural impairments in narrative abilities. Understanding the potential influence of low education and low socioeconomic status (SES) is critical to a more effective assessment of poststroke language. The first aim was to investigate macrostructural processing in low-education and low-SES individuals with stroke in the LH or RH or without brain damage. The second aim was to verify the relationships between macrolinguistic, neuropsychological, and sociodemographic variables.

METHOD

Forty-seven adults with LH (n = 15) or RH (n = 16) chronic ischemic stroke and 16 matched (age, education, and SES) healthy controls produced three oral picture-sequence narratives. The macrostructural aspects analyzed were cohesion, coherence, narrativity, macropropositions, and index of lexical informativeness and were compared among the three groups. Then, exploratory correlations were performed to assess associations between sociodemographic (such as SES), neuropsychological, and macrostructural variables.

RESULTS

Both the LH and the RH presented impairments in the local macrostructural aspect (cohesion), whereas the RH also presented impairments in more global aspects (global coherence and macropropositions). All five macrostructural variables correlated with each other, with higher correlations with narrativity. Naming was correlated with all macrostructural variables, as well as prestroke reading and writing habits (RWH), showing that higher naming accuracy and higher RWH are associated with better macrostructural skills.

CONCLUSIONS

The present results corroborate the role of the LH in more local processing and that of the RH in more global aspects of discourse. Moreover, this study highlights the importance of investigating discourse processing in healthy and clinical populations of understudied languages such as Brazilian Portuguese, with various levels of education, SES, and RWH.

The Effect of Neighborhood Deprivation on Mortality in Newly Diagnosed Diabetes Patients: A Countrywide Population-Based Korean Retrospective Cohort Study, 2002-2013

Background: Neighborhood environmental factors along with individual factors are beginning to make a mark as factors which influence individual health outcomes. The goal of this study is to look at the combined impact of individual and neighborhood socioeconomic status on all-cause mortality in diabetic patients who have just been diagnosed. Methods: The Korean National Health Insurance (2002–2013) was employed in this cohort research, which used a stratified random sample. During the years 2003–2006, a total of 15,882 individuals who were newly diagnosed with diabetes and using oral disease-controlling medication were included in the study. Individual income and neighborhood deprivation index were used to examine the combined effect on all-cause mortality. The frailty model was performed using Cox’s proportional hazard regression. Results: During the study period, 28.3 percent (n = 4493) of the 15,882 eligible individuals died. In a Cox regression analysis after adjusting for all covariates, with advantaged and disadvantaged neighborhoods classified according to individual household income, the adjusted HR for patients living in a disadvantaged area was higher compared to patients living in an advantaged area in patients with middle income, compared to the reference group (a high income within an advantaged neighborhood) (HR, 1.22; 95% CI, 1.09–1.35; HR, 1.13; 95% CI, 1.02–1.25, respectively). The adjusted HR for patients with low income who lived in a disadvantaged location was greater than for patients who lived in an advantaged area (HR, 1.34; 95% CI, 1.18–1.53 vs. HR, 1.28; 95% CI, 1.14–1.49). Conclusions: Individual SES has a greater impact on all-cause mortality among diabetic patients when they live in a low-income neighborhood.

The impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in Ireland: a cross-sectional nationally representative study

Background

Cognitive impairment after stroke is associated with poorer health outcomes and increased need for long-term care. The aim of this study was to determine the impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in older adults in Ireland.

Methods

This cross-sectional study involved secondary data analysis of 8,175 community-dwelling adults (50 + years), from wave 1 of The Irish Longitudinal Study on Ageing (TILDA). Participants who had been diagnosed with stroke by a doctor were identified through self-report in wave 1. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). The main outcome of the study was healthcare utilisation, including General Practitioner (GP) visits, emergency department visits, outpatient clinic visits, number of nights admitted to hospital, and use of rehabilitation services. The data were analysed using multivariate adjusted negative binomial regression and logistic regression. Incidence-rate ratios (IRR), odds ratios (OR) and 95% confidence intervals (CI) are presented.

Results

The adjusted regression analyses were based on 5,859 participants who completed a cognitive assessment. After adjusting for demographic and clinical covariates, stroke was independently associated with an increase in GP visits [IRR (95% CI): 1.27 (1.07, 1.50)], and outpatient service utilisation [IRR: 1.49 (1.05, 2.12)]. Although participants with poor cognitive function also visited the GP more frequently than participants with normal cognitive function [IRR: 1.07 (1.04, 1.09)], utilisation of outpatient services was lower in this population [IRR: 0.92 (0.88, 0.97)]. PSCI was also associated with a significant decrease in outpatient service utilisation [IRR: 0.75 (0.57, 0.99)].

Conclusions

Stroke was associated with higher utilisation of GP and outpatient services. While poor cognitive function was also associated with more frequent GP visits, outpatient service utilisation was lower in participants with poor cognitive function, indicating that cognitive impairment may be a barrier to outpatient care. In Ireland, the lack of appropriate neurological or cognitive rehabilitation services appears to result in significant unaddressed need among individuals with cognitive impairment, regardless of stroke status.

Disparities in the quality of care for chronic hepatitis C among Medicare beneficiaries

Purpose

Chronic hepatitis C virus (HCV) infection is an important public health concern. Limited information exists on disparities in the quality of HCV care. We examine disparities in genotype or quantitative HCV ribonucleic acid testing before and after starting HCV treatment, and screening for hepatocellular carcinoma (HCC) in HCV patients with cirrhosis.

Methods

This national study included Medicare beneficiaries with HCV between 2014 and 2017. We used bivariate probit to estimate the probability of receiving recommended tests before and after HCV treatment by patient race/ethnicity, urban/rural residence, and socioeconomic status. We used multivariate logistic regression to estimate adjusted odds ratios (aOR) of HCC screening among beneficiaries with cirrhosis by patient factors.

Findings

Of 41,800 Medicare patients with HCV treatment, 93.47% and 84.99% received pre- and post-treatment testing. Patients in racial minority groups had lower probabilities of pre- and post-treatment testing than whites. Rural residents were less likely to receive a post-treatment test (Coef. = -0.06, 95% CI: -0.11, -0.01). Among HCV patients with cirrhosis, 40% (24,021) received at least one semi-annual HCC screening during the study period. The odds of HCC screening were 14% lower in rural than in urban patients (aOR = 0.86, 95% CI: 0.80, 0.92), lower in African Americans (aOR = 0.93, 95% CI: 0.90, 0.96), but higher among Hispanics than in whites (aOR = 1.09, 95% CI: 1.04, 1.15). There was no significant association between ZIP-level income or education and HCC screening.

Conclusions

Disparities in the quality of HCV care existed by patient race/ethnicity, urban/rural residence, and socioeconomic status. Continued efforts are needed to improve the quality of care for all HCV patients—especially rural patients and racial/ethnic minorities.

Sex and Economic Disparity Related to Reperfusion Therapies for Patients with Acute Ischemic Stroke in South Korea across a 10-Year Period: A Nationwide Population-Based Study Using the National Health Insurance Database

A complete enumeration study was conducted to evaluate trends related to reperfusion therapies (intravenous thrombolysis (IVT) and endovascular treatment (EVT)) in acute ischemic stroke (AIS) in South Korea, according to sex, economic status, and age, over a 10-year period retrospectively, using the National Health Information Database (NHIS-2020-1-481). This study included AIS patients aged ≥20 years who were hospitalized in a general hospital or tertiary hospital for ≥4 days and underwent brain imaging during the same period. Study participants were classified by sex, economic status (Medical Aid beneficiaries and National Health Insurance beneficiaries) and age (20-44, 45-64, 65-79, and ≥80 years). Women showed a significantly lower OR (Odds ratio) than men in IVT (OR: 0.75; 95% CI: 0.73-0.77), EVT (OR: 0.96; 95% CI: 0.93-0.99), and any therapy (OR: 0.82; 95% CI: 0.80-0.84). The Medical Aid beneficiaries showed significantly lower OR in IVT (OR 0.91, 95% CI 0.88-0.95), EVT (OR 0.93, 95% CI 0.89-0.98), and either therapy (OR 0.92, 95% CI 0.90-0.95) than the National Health Insurance beneficiaries. This study showed sex and economic disparity related to reperfusion therapies in patients with AIS in Korea.

Reduced cardiovascular morbidity in patients with hemophilia: results of a 5-year multinational prospective study

In this prospective study, PWH have a lower-than-predicted incidence of CVD.

The QRISK-2011 risk predictor is not valid for PWH.

Hemophilia is a congenital bleeding disorder caused by low levels of clotting factor VIII or IX. The life expectancy of people with hemophilia (PWH) has increased with the availability of clotting factor concentrates. At the same time, the incidence of cardiovascular disease (CVD) has increased; in retrospective studies, there are conflicting data regarding if, despite this increase, the incidence is still lower than in the general population. We prospectively compared the incidence of CVD in PWH vs the predicted incidence. This prospective, multicenter, observational study included adult PWH (aged >30 years) from The Netherlands and United Kingdom. They were followed up for a 5-year period, and CVD incidence was compared with a predicted event rate based on the QRISK2-2011 CVD risk model. The primary end point was the observed fatal and nonfatal CVD incidence after 5 years compared with the estimated events and in relation to severity of hemophilia. The study included 709 patients, of whom 687 (96.9%) completed 5 years’ follow-up or reached an end point. For 108 patients, the QRISK score could not be calculated at inclusion. For the remaining 579, fewer CVD events were observed than predicted: 9 vs 24 (relative risk, 0.38; 95% confidence interval, 0.18-0.80; P = .01), corresponding with an absolute risk reduction of 2.4%. Severe hemophilia treated on demand had the highest risk reduction. There was no statistically significant relation between severity of hemophilia and incidence of CVD. In hemophilia, a lower-than-predicted CVD incidence was found, supporting the theory that hemophilia protects against CVD. The study is registered at www.clinicaltrials.gov as #NCT01303900.

Using Artificial Intelligence With Natural Language Processing to Combine Electronic Health Record's Structured and Free Text Data to Identify Nonvalvular Atrial Fibrillation to Decrease Strokes and Death: Evaluation and Case-Control Study

BACKGROUND

Nonvalvular atrial fibrillation (NVAF) affects almost 6 million Americans and is a major contributor to stroke but is significantly undiagnosed and undertreated despite explicit guidelines for oral anticoagulation.

OBJECTIVE

The aim of this study is to investigate whether the use of semisupervised natural language processing (NLP) of electronic health record's (EHR) free-text information combined with structured EHR data improves NVAF discovery and treatment and perhaps offers a method to prevent thousands of deaths and save billions of dollars.

METHODS

We abstracted 96,681 participants from the University of Buffalo faculty practice's EHR. NLP was used to index the notes and compare the ability to identify NVAF, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category (CHA₂DS₂-VASc), and Hypertension, Abnormal liver/renal function, Stroke history, Bleeding history or predisposition, Labile INR, Elderly, Drug/alcohol usage (HAS-BLED) scores using unstructured data (International Classification of Diseases codes) versus structured and unstructured data from clinical notes. In addition, we analyzed data from 63,296,120 participants in the Optum and Truven databases to determine the NVAF frequency, rates of CHA₂DS₂‑VASc ≥2, and no contraindications to oral anticoagulants, rates of stroke and death in the untreated population, and first year's costs after stroke.

RESULTS

The structured-plus-unstructured method would have identified 3,976,056 additional true NVAF cases (P<.001) and improved sensitivity for CHA₂DS₂-VASc and HAS-BLED scores compared with the structured data alone (P=.002 and P<.001, respectively), causing a 32.1% improvement. For the United States, this method would prevent an estimated 176,537 strokes, save 10,575 lives, and save >US $13.5 billion.

CONCLUSIONS

Artificial intelligence-informed bio-surveillance combining NLP of free-text information with structured EHR data improves data completeness, prevents thousands of strokes, and saves lives and funds. This method is applicable to many disorders with profound public health consequences.

The impact of the UK COVID-19 pandemic on patient-reported health outcomes after stroke: a retrospective sequential comparison

Background and purpose

The COVID-19 pandemic and related social isolation measures are likely to have adverse consequences on community healthcare provision and outcome after acute illnesses treated in hospital, including stroke. We aimed to evaluate the impact of the COVID-19 pandemic on patient-reported health outcomes after hospital admission for acute stroke.

Methods

This retrospective study included adults with acute stroke admitted to the University College Hospital NHS Foundation Trust Hyperacute Stroke Unit. We included two separate cohorts of consecutively enrolled patients from the same geographical population at two time points: 16th March–16th May 2018 (pre-COVID-19 pandemic); and 16th March–16th May 2020 (during the COVID-19 pandemic). Patients in both cohorts completed the validated Patient Reported Outcomes Measurement Information System–29 (PROMIS-29 version 2.0) at 30 days after stroke.

Results

We included 205 patients who were alive at 30 days (106 admitted before and 99 admitted during the COVID-19 pandemic), of whom 201/205 (98%) provided patient-reported health outcomes. After adjustment for confounding factors, admission with acute stroke during the COVID-19 pandemic was independently associated with increased anxiety (β = 28.0, p < 0.001), fatigue (β = 9.3, p < 0.001), depression (β = 4.5, p = 0.002), sleep disturbance (β = 2.3, p = 0.018), pain interference (β = 10.8, p < 0.001); and reduced physical function (β = 5.2, p < 0.001) and participation in social roles and activities (β = 6.9, p < 0.001).

Conclusion

Compared with the pre-pandemic cohort, patients admitted with acute stroke during the first wave of the COVID-19 pandemic reported poorer health outcomes at 30 day follow-up in all domains. Stroke service planning for any future pandemic should include measures to mitigate this major adverse impact on patient health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10819-9.

Association of Neighborhood-Level Material Deprivation With Health Care Costs and Outcome After Stroke

BACKGROUND AND OBJECTIVES

To determine the association between material deprivation and direct health care costs and clinical outcomes following stroke in the context of a publicly funded universal health care system.

METHODS

In this population-based cohort study of patients with ischemic and hemorrhagic stroke admitted to the hospital between 2008 and 2017 in Ontario, Canada, we used linked administrative data to identify the cohort, predictor variables, and outcomes. The exposure was a 5-level neighborhood material deprivation index. The primary outcome was direct health care costs incurred by the public payer in the first year. Secondary outcomes were death and admission to long-term care.

RESULTS

Among 90,289 patients with stroke, the mean (SD) per-person costs increased with increasing material deprivation, from $50,602 ($55,582) in the least deprived quintile to $56,292 ($59,721) in the most deprived quintile (unadjusted relative cost ratio and 95% confidence interval 1.11 [1.08, 1.13] and adjusted relative cost ratio 1.07 [1.05, 1.10] for least compared to most deprived quintile). People in the most deprived quintile had higher mortality within 1 year compared to the least deprived quintile (adjusted hazard ratio [HR] 1.07 [1.03, 1.12]) as well as within 3 years (adjusted HR 1.09 [1.05, 1.13]). Admission to long-term care increased incrementally with material deprivation and those in the most deprived quintile had an adjusted HR of 1.33 (1.24, 1.43) compared to those in the least deprived quintile.

DISCUSSION

Material deprivation is a risk factor for increased costs and poor outcomes after stroke. Interventions targeting health inequities due to social determinants of health are needed.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that the neighborhood-level material deprivation predicts direct health care costs.

The effects of computer-assisted cognitive rehabilitation on cognitive impairment after stroke: A systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of computer-assisted cognitive rehabilitation in improving cognitive function in patients with post-stroke cognitive impairment.

BACKGROUND

In recent years, computer-assisted cognitive rehabilitation has been accepted as a good substitute or supplement for traditional cognitive rehabilitation. Some clinical randomised controlled trials have been carried out, but no relevant systematic evaluations have been performed. Therefore, we conducted a systematic review of studies involving computer-assisted cognitive rehabilitation to provide evidence-based data for its promotion and application.

METHODS

Nine databases (Cochrane Library, PubMed, Web of Science, Embase, OVID, Wanfang Data, CNKI, VIP and SinoMed databases) were systematically searched. Randomised controlled trials that assessed computer-assisted cognitive rehabilitation for patients with post-stroke cognitive impairment were included. Two reviewers appraised the risks of bias through the Cochrane Collaboration's tool and performed the meta-analysis, including the assessment of heterogeneity. We follow the PRISMA 2020 guidelines.

RESULTS

Thirty-two studies comprising 1837 participants were included. Compared with conventional therapy alone, the addition of computer-assisted cognitive rehabilitation significantly improved the global cognition of patients, evaluated using the Montreal cognitive assessment, mini-mental state examination and Loewenstein occupational therapy cognitive assessment (p < .01 for all tests). The therapy also significantly improved activities of daily living, assessed using the Barthel index, modified Barthel index and functional independence measure (p < .05 for all tests).

CONCLUSION

Computer-assisted cognitive rehabilitation significantly improved the cognitive function and activities of daily living of patients with post-stroke cognitive impairment.

RELEVANCE TO CLINICAL PRACTICE

Computer-assisted cognitive rehabilitation can be a valuable technique for cognitive rehabilitation after stroke. It is advantageous for improving patient cognition and restoring the overall functional state of patients. Moreover, the research findings can provide suggestions and inspiration for researchers to implement the proposal, which is conducive to the design of more rigorous and high-quality randomised controlled trials.

Regional Deprivation, Stroke Incidence, and Stroke Care

BACKGROUND

Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes.

METHODS

We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses.

RESULTS

The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile.

CONCLUSION

These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Effects of acupuncture on clinical outcome and helper T cell distribution and abundance in patients with convalescent ischemic stroke

OBJECTIVE

To study the effects of acupuncture on clinical outcomes and helper T cell levels in patients with convalescent ischemic stroke.

METHODS

One hundred and thirty-six patients with cerebral ischemic stroke were selected for this prospective study. Patients in the control group were treated with routine therapy, and patients in the observation group were treated with acupuncture for 30 minutes once a day for 14 days plus the treatment of the control group. The clinical efficacy, cognitive function, T cell subsets distribution and inflammatory factors of patients in both groups were recorded before and after treatment.

RESULTS

Total effectiveness rate of the observation group was significantly higher than that of the control group (P<0.05). After treatment, CD3⁺ cell percentage, CD4⁺ cell percentage and CD4⁺ cell percentage/CD8⁺ cell percentage of patients in both groups were significantly increased (P<0.05), while CD8⁺ cell percentage in both groups was significantly decreased (P<0.05). Compared to those in the control group, the overall response rate as well as CD3⁺ cell percentage, CD4⁺ cell percentage and CD4⁺/CD8⁺ of patients after treatment in the observation group were higher (P<0.001), while CD8⁺ cell percentage was lower (all P<0.001). Moreover, the improvement in inflammatory factors as well as scores of Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) in observation group were better than those of the control group (P<0.001) respectively.

CONCLUSION

Treatment of cerebral ischemic stroke by acupuncture can improve clinical outcome and cognitive function, which may be related to its regulation of immune response and reduction of inflammation in vivo.

Are there socio-economic inequities in access to reperfusion therapy: The stroke 69 cohort

BACKGROUND AND PURPOSE

Low socio-economic status of individuals has been reported to be associated with a higher incidence of stroke and influence the diagnosis after revascularization. However, whether it is associated with poorer acute stroke management is less clear. To determine whether social deprivation was associated with a poorer access to reperfusion therapy, either intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) in a population-based cohort.

METHODS

Over a 14-month period, all consecutive adult patients admitted to any emergency department or a comprehensive or primary stroke center (CSC/PSC) of the Rhône county with a confirmed ischemic stroke were included. The socioeconomic status of each patient was measured using the European Deprivation Index (EDI). The association between EDI and access to reperfusion therapy was assessed in univariate and multivariate logistic regression analyses.

RESULTS

Among the 1226 consecutive IS patients, 316 (25%) were admitted directly in a PSC or CSC, 241 (19.7%) received a reperfusion therapy; 155 IVT alone, 20 EVT alone, and 66 both therapies. Median age was 79 years, 1030 patients had an EDI level of 1 to 4, and 196 an EDI of 5 (the most deprived group). The most deprived patients (EDI level 5) did not have a poorer access to reperfusion therapy compared to all other patients in univariate (OR 1.22, 95%CI [0.85; 1.77]) nor in multivariate analyses (adjOR 0.97, 95%CI [0.57; 1.66]).

CONCLUSIONS

We did not find any significant association between socioeconomic deprivation and access to reperfusion therapy. This suggests that the implementation of EVT was not associated with increased access inequities.

Neighborhood Socioeconomic Status and Stroke Incidence: A Systematic Review

OBJECTIVE

To summarize overall patterns of the impact of neighborhood socioeconomic status (nSES) on stroke incidence and uncover potential gaps in the literature, we conducted a systematic review of studies examining the association between nSES and stroke incidence, independent of individual SES.

METHODS

Four electronic databases and reference lists of included articles were searched, and corresponding authors were contacted to locate additional studies. A keyword search strategy included the 3 broad domains of neighborhood, SES, and stroke. Eight studies met our inclusion criteria (e.g., nSES as an exposure, individual SES as a covariate, and stroke incidence as an outcome). We coded study methodology and findings across the 8 studies.

RESULTS

The results provide evidence for the overall nSES and stroke incidence association in Sweden and Japan, but not within the United States. Findings were inconclusive when examining the nSES-stroke incidence association stratified by race. We found evidence for the mediating role of biological factors in the nSES-stroke incidence association.

CONCLUSIONS

Higher neighborhood disadvantage was found to be associated with higher stroke risk, but it was not significant in all the studies. The relationship between nSES and stroke risk within different racial groups in the United States was inconclusive. Inconsistencies may be driven by differences in covariate adjustment (e.g., individual-level sociodemographic characteristics and neighborhood-level racial composition). Additional research is needed to investigate potential intermediate and modifiable factors of the association between nSES and stroke incidence, which could serve as intervention points.

The CASSIOPEA Study (Economic Crisis and Adherence to the Mediterranean diet: poSSIble impact on biOmarkers of inflammation and metabolic PhEnotypes in the cohort of the Moli-sAni Study): Rationale, design and characteristics of participants

BACKGROUND AND AIMS

The CASSIOPEA Study was designed to evaluate whether the economic downturn during the late 2000s was a contributing factor to the observed decrease in adherence to Mediterranean diet (MD).

METHODS AND RESULTS

The study protocol consists of two steps: A) recall of 7406 men and women who, between 2005 and 2006, had been randomly recruited in the Moli-sani Study from the general population of Molise, to assess possible economic hardship (EH) related to the economic crisis initiated in 2007; B) re-examination, between 2017 and 2020, of available subjects identified in Step 1 as poorly or harder hit by EH to test the hypothesis that EH is associated with a decrease in MD adherence, possibly resulting in increased inflammation. The results of Step 1 are reported here. From the initial sample of individuals re-examined after 12.6 years (median; IQR = 12.1-13.0 y), 3646 were finally analysed. An Economic Hardship Score (EHS; range 0-14) was obtained by scoring three domains: 1) change in employment status; 2) financial hardship and 3) financial hardship for health expenditures. Overall, 37.8% of the sample reported high EHS (≥3), whilst 32% scored 0 (no EH). Those with high EHS were prevalently women and younger, with low socioeconomic status.

CONCLUSIONS

High economic hardship was prevalently reported by weaker socioeconomic groups. Longitudinal analysis (step 2) will examine whether the economic crisis had an effect on adherence to Mediterranean diet with consequent potential impact on inflammation, one of the main biological pathways linking MD to health outcomes. CLINICALTRIALS.

GOV IDENTIFIER

NCT03119142.

Health care utilization for patients with stroke: a 3-year cross-sectional study of China's two urban health insurance schemes across four cities

Background

Stroke is a devastating disease and a major cause of death and disability in China. While existing studies focused mainly on differences in stroke patients’ health care utilization by insurance type, this study assesses whether health utilization and medical costs differed by insurance type across four cities in China.

Methods

A 5% random sample from the 2014–2016 China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) claims data were collected across four cities, Beijing, Shanghai, Tianjin, and Chongqing. Descriptive statistics and ordinary least squares regression were employed to analyze the data.

Results

We found that differences in healthcare utilization and inpatient and outpatient medical expenses varied more by city-specific insurance type than they did between the UEBMI and URBMI schemes. For example, the median UEBMI medical outpatient costs in Beijing (RMB500.2) were significantly higher than UEBMI patients in Shanghai (RMB260.8), Tianjin (RMB240.8), and Chongqing (RMB293.0), and Beijing URBMI patients had significantly higher outpatient medical costs (RMB356.9) than URBMI patients in Shanghai (RMB233.4) and Chongqing (RMB211.0), which were significantly higher than Tianjin (RMB156.2). Patients in Chongqing had 66.4% (95% CI: − 0.672, − 0.649) fewer outpatient visits, 13.0% (95% CI: − 0.144, − 0.115) fewer inpatient visits, and 34.2% (95% CI: − 0.366, − 0.318) shorter length of stay than patients in Beijing. The divergence of average length of stay and out-of-pocket (OOP) expenses by insurance type was also greater between cities than the UEMBI-URBMI mean difference.

Conclusions

Significant city-specific differences in stroke patients’ healthcare utilization and medical costs reflected inequalities in health care access. The fragmented social health insurance schemes in China should be consolidated to provide patients in different cities equal financial protection and benefit packages and to improve the equity of stroke patient access to health care.

Disparities in Mortality and Cardiovascular Events by Income and Blood Pressure Levels Among Patients With Hypertension in South Korea

Background

Socioeconomic status is associated with differences in risk factors of cardiovascular disease and increased risks of cardiovascular disease and mortality. However, it is unclear whether an association exists between cardiovascular disease and income, a common measure of socioeconomic status, among patients with hypertension.

Methods and Results

This population‐based longitudinal study comprised 479 359 patients aged ≥19 years diagnosed with essential hypertension. Participants were categorized by income and blood pressure levels. Primary end point was all‐cause and cardiovascular mortality and secondary end points were cardiovascular events, a composite of cardiovascular death, myocardial infarction, and stroke. Low income was significantly associated with high all‐cause (hazard ratio [HR], 1.26; 95% CI, 1.23–1.29, lowest versus highest income) and cardiovascular mortality (HR, 1.31; 95% CI, 1.25–1.38) as well as cardiovascular events (HR, 1.07; 95% CI, 1.05–1.10) in patients with hypertension after adjusting for age, sex, systolic blood pressure, body mass index, smoking status, alcohol consumption, physical activity, fasting glucose, total cholesterol, and the use of aspirin or statins. In each blood pressure category, low‐income levels were associated with high all‐cause and cardiovascular mortality and cardiovascular events. The excess risks of all‐cause and cardiovascular mortality and cardiovascular events associated with uncontrolled blood pressure were more prominent in the lowest income group.

Conclusions

Low income and uncontrolled blood pressure are associated with increased all‐cause and cardiovascular mortality and cardiovascular events in patients with hypertension. These findings suggest that income is an important aspect of social determinants of health that has an impact on cardiovascular outcomes in the care of hypertension.

Sex, Age, and Socioeconomic Differences in Nonfatal Stroke Incidence and Subsequent Major Adverse Outcomes

Supplemental Digital Content is available in the text.

Data about variations in stroke incidence and subsequent major adverse outcomes are essential to inform secondary prevention and prioritizing resources to those at the greatest risk of major adverse end points. We aimed to describe the age, sex, and socioeconomic differences in the rates of first nonfatal stroke and subsequent major adverse outcomes.

Gender difference of geographic distribution of the stroke incidence affected by socioeconomic, clinical and urban-rural factors: an ecological study based on data from the Brest stroke registry in France

Background

Mapping the spatial distribution of disease occurrence is a strategy to identify contextual factors that could be useful for public health policies. The purpose of this ecological study was to examine to which extent the socioeconomic deprivation and the urbanization level can explain gender difference of geographic distribution in stroke incidence in Pays de Brest, France between 2008 and 2013.

Methods

Stroke cases aged 60 years or more were extracted from the Brest stroke registry and combined at the census block level. Contextual socioeconomic, demographic, and geographic variables at the census block level come from the 2013 national census. We used spatial and non-spatial regression models to study the geographic correlation between socioeconomic deprivation, degree or urbanization and stroke incidence. We generated maps using spatial geographically weighted models, after longitude and latitude smoothing and adjustment for covariates.

Results

Stroke incidence was comparable in women and men (6.26 ± 3.5 vs 6.91 ± 3.3 per 1000 inhabitants-year, respectively). Results showed different patterns of the distribution of stroke risk and its association with deprivation or urbanisation across gender. For women, stroke incidence was spatially homogeneous over the entire study area, but was associated with deprivation level in urban census blocks: age adjusted risk ratio of high versus low deprivation = 1.24, [95%CI 1.04–1.46]. For men, three geographic clusters were identified. One located in the northern rural and deprived census blocks with a 9–14% increase in the risk of stroke. Two others clusters located in the south-eastern (mostly urban part) and south-western (suburban and rural part) with low deprivation level and associated with higher risk of stroke incidence between (3 and 8%) and (8.5 and 19%) respectively. There were no differences in profile of cardiovascular risk factors, stroke type and stroke severity between clusters, or when comparing clusters cases to the rest of the study population.

Conclusions

Understanding whether and how neighborhood and patient’s characteristics influence stroke risk may be useful for both epidemiological research and healthcare service planning.

Social deprivation and 1-year survival after stroke: a prospective cohort study

BACKGROUND

Social deprivation may have a deleterious influence on post-stroke outcomes, but available data in the literature are mixed.

AIM

The aim of this cohort study was to evaluate the impact of social deprivation on 1-year survival in patients with first-ever stroke.

METHODS

Social deprivation was assessed at individual level with the EPICES score, a validated multidimensional questionnaire, in 1312 patients with ischemic stroke and 228 patients with spontaneous intracerebral hemorrhage, who were prospectively enrolled in six French study centers. Baseline characteristics including stroke severity and pre-stroke functional status were collected. Multivariable Cox models were generated to evaluate the associations between social deprivation and survival at 12 months in ischemic stroke and intracerebral hemorrhage separately.

RESULTS

A total of 819 patients (53.2%) were socially deprived (EPICES score ≥ 30.17). In ischemic stroke, mortality at 12 months was higher in deprived than in non-deprived patients (16% vs. 11%, p = 0.006). In multivariable analyses, there was no association between deprivation and death occurring within the first 90 days following ischemic stroke (adjusted hazard ratio [aHR] 0.81, 95% CI 0.54-1.22, p = 0.32). In contrast, an excess in mortality was observed between 90 days and 12 months in deprived compared with non-deprived patients (aHR 1.97, 95% CI 1.14-3.42, p = 0.016). In patients with intracerebral hemorrhage, mortality at 12 months did not significantly differ according to deprivation status.

CONCLUSIONS

Social deprivation was associated with delayed mortality in ischemic stroke patients only and, although the exact underlying mechanisms are still to be identified, our findings suggest that deprived patients in particular may benefit from an optimization of post-stroke care.

Long-Term Effect of Income Level on Mortality after Stroke: A Nationwide Cohort Study in South Korea

We investigated whether income level has long-term effects on mortality rate in stroke patients and whether this varies with time after the first stroke event, using the National Health Insurance Service National Sample Cohort data from 2002 to 2015 in South Korea. The study population was new-onset stroke patients ≥18 years of age. Patients were categorized into Category (1) insured employees and Category (2) insured self-employed/Medical Aid beneficiaries. Each category was divided into three and four income level groups, retrospectively. The study population comprised of 11,668 patients. Among the Category 1 patients (n = 7720), the low-income group's post-stroke mortality was 1.15-fold higher than the high-income group. Among the Category 2 patients (n = 3948), the lower income groups had higher post-stroke mortality than the high-income group (middle-income, aOR (adjusted odds ratio) 1.29; low-income, aOR 1.70; Medical Aid beneficiaries, aOR 2.19). In this category, the lower income groups' post-stroke mortality risks compared to the high-income group were highest at 13-36 months after the first stroke event(middle-income, aOR 1.52; low-income, aOR 2.31; Medical Aid beneficiaries, aOR 2.53). Medical Aid beneficiaries had a significantly higher post-stroke mortality risk than the high-income group at all time points.