Socioeconomic variations in the course of stroke: unequal health outcomes, equal care?

Influence of Socioeconomic Status on Functional Outcomes After Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

This review aimed to quantify the impact of socioeconomic status on functional outcomes from stroke and identify the socioeconomic status indicators that exhibit the highest magnitude of association.

METHODS AND RESULTS

We performed a systematic literature search across Medline and Embase from inception to May 2022, to identify observational studies (n≥100, and in English). Risk of bias was assessed using the modified Newcastle Ottawa Scale. Random effects meta-analysis was used to pool data. We included 19 studies (157 715 patients, 47.7% women) reporting functional outcomes measured with modified Rankin Scale or Barthel index, with 10 assessed as low risk of bias. Measures of socioeconomic status reported were education (11 studies), income (8), occupation (4), health insurance status (3), and neighborhood socioeconomic deprivation (3). Pooled data suggested that low socioeconomic status was significantly associated with poor functional outcomes, including incomplete education or below high school level versus high school attainment and above (odds ratio [OR], 1.66 [95% CI, 1.40-1.95]), lowest income versus highest income (OR, 1.36 [95% CI, 1.02-1.83]), a manual job/being unemployed versus a nonmanual job/working (OR, 1.62 [95% CI, 1.29-2.02]), and living in the most disadvantaged socioeconomic neighborhood versus the least disadvantaged (OR, 1.55 [95% CI, 1.25-1.92]). Low health insurance status was also associated with an increased risk of poor functional outcomes (OR, 1.32 [95% CI, 0.95-1.84]), although this was association was not statistically significant.

CONCLUSIONS

Despite great strides in stroke treatment in the past decades, social disadvantage remains a risk factor for poor functional outcome after an acute stroke. Further research is needed to better understand causal mechanisms and disparities.

Socioeconomic Inequalities in Functional Outcome After Reperfusion-Treated Ischemic Stroke

BACKGROUND

We aimed to investigate whether socioeconomic status (SES) was associated with functional outcome in patients with ischemic stroke treated with reperfusion therapy (intravenous thrombolysis and/or thrombectomy).

METHODS

This nationwide cohort study included reperfusion-treated patients with ischemic stroke ≥18 years registered in the Danish Stroke Registry between 2015 and 2018. Functional outcome was determined by the modified Rankin Scale score 90 days after stroke. SES was defined by educational attainment, family income, and employment status before stroke. SES data were available from Statistics Denmark and linked on the individual level with data from the Danish Stroke Registry. Uni- and multivariable ordinal logistic regression was performed for each socioeconomic parameter individually (education, income, and employment) to estimate the common odds ratios (cORs) for lower 90-day modified Rankin Scale scores.

RESULTS

A total of 5666 patients were included. Mean age was 68.7 years (95% CI, 68.3-69.0), and 38.4% were female. Low SES was associated with lower odds for achieving lower 90-day modified Rankin Scale score: Low versus high education, cOR, 0.69 (95% CI, 0.61-0.79), low versus high income, cOR, 0.59 (95% CI, 0.53-0.67), and unemployed versus employed, cOR, 0.70 (95% CI, 0.58-0.83). Inequalities were reduced after adjusting for age, sex, and immigrant status, except for unemployed versus employed patients, adjusted cOR, 0.66 (95% CI, 0.54-0.80). No statistically significant differences remained after adjusting for potentially mediating variables (eg, stroke severity, prestroke modified Rankin Scale, and smoking).

CONCLUSIONS

Socioeconomic inequalities were observed in functional outcome after reperfusion treated ischemic stroke. In particular, prestroke unemployment was negatively associated with good functional outcome. A more adverse prognostic profile among patients with low SES appeared to explain the majority of these inequalities.

Accessibility for Rehabilitation Therapy According to Socioeconomic Status in Patients With Stroke: A Population-Based Retrospective Cohort Study

This study aimed to investigate accessibility for rehabilitation therapy according to socioeconomic status (SES) after stroke using nationwide population-based cohort data. We selected patients with a diagnosis with stroke (International Classification of Diseases, 10th Revision code: I60-64) and SES including residential area, income level, and insurance type were also assessed. Receiving continuous rehabilitation therapy was defined as accumulation of "Rehabilitative developmental therapy for disorder of central nervous system (claim code: MM105)" more than 41 times. Logistic regression analyses were performed to investigate the association between SES and rehabilitation therapy using odds ratios (ORs) and 95% confidence intervals (CIs). A total of 18,842 patients with stroke were enrolled. Rural area (OR, 0.745; 95% CI, 0.664-0.836) and medical aid (OR, 0.605; 95% CI, 0.494-0.741) were associated with lower rate of receiving rehabilitation therapy. As for income level, when lowest income group was used as a reference group, low-middle group showed an increased rate of receiving rehabilitation therapy (OR, 1.206; 95% CI, 1.020-1.426). Although rehabilitation therapy after stroke is covered with national health insurance program in Korea, there still existed disparities of accessibility for rehabilitation therapy according to SES. Our results would suggest helpful information for health policy in patients with stroke.

Life and Leisure Activities following Stroke or Transient Ischaemic Attack (TIA): An Observational, Multi-Centre, 6-Month Follow-Up Study

OBJECTIVE

To examine changes in leisure participation following stroke/transient ischaemic attack (TIA) and explore its relationship to modifiable and non-modifiable participant characteristics.

DESIGN

An observational study design with self-report questionnaires collected at two time points (baseline and 6-months).

SETTING

The study was conducted across 21 hospital sites in England, Wales, and Northern Ireland.

PARTICIPANTS

Participants were aged 18+ and had experienced a first or recurrent stroke or TIA and had a post-stroke/TIA modified Rankin score (mRS) of ≤3.

PROCEDURE

Research practitioners at each site approached potential participants. Individuals who agreed to participate completed a baseline questionnaire whilst an inpatient or at a first post-stroke/TIA clinic appointment. A follow-up questionnaire was posted to participants with a freepost return envelope. Two questionnaires were developed that collected demographic information, pre-stroke/TIA mRS, social circumstances (e.g., employment situation) and incorporated the shortened Nottingham Leisure Questionnaire (sNLQ).

RESULTS

The study recruited eligible participants (N = 3295); 2000 participants returned questionnaires at follow-up. Data showed three participant variables were significant predictors of engagement in leisure activities post-stroke/TIA: age, sex, and deprivation decile. There was an overall decline in the number and variety of leisure activities, with an average loss of 2.2 activities following stroke/TIA. Only one activity, "exercise/fitness" saw an increase in engagement from baseline to follow-up; watching TV remained stable, whilst participation in all other activities reduced between 10% and 40% with an average activity engagement reduction of 22%.

CONCLUSIONS

Some groups experienced a greater reduction in activities than others-notably older participants, female participants, and those living in a low socioeconomic area.

REGISTRATION

researchregistry4607.

STRENGTHS AND LIMITATIONS OF THIS STUDY

1. This is the largest-ever study to survey life and leisure activity engagement following stroke/TIA. 2. Survey responses were self-reported retrospectively and, therefore, may have been misreported, or misremembered. 3. Despite the large cohort, there were few participants, and so respondents, from ethnic minority groups.

Association of material deprivation with discharge location and length of stay after inpatient stroke rehabilitation in Ontario: a retrospective, population-based cohort study

BACKGROUND

Low socioeconomic status is associated with increased risk of stroke and worse poststroke functional status. The aim of this study was to determine whether socioeconomic status, as measured by material deprivation, is associated with direct discharge to long-term care or length of stay after inpatient stroke rehabilitation.

METHODS

We performed a retrospective, population-based cohort study of people admitted to inpatient rehabilitation in Ontario, Canada, after stroke. Community-dwelling adults (aged 19-100 yr) discharged from acute care with a most responsible diagnosis of stroke between Sept. 1, 2012, and Aug. 31, 2017, and subsequently admitted to an inpatient rehabilitation bed were included. We used a multivariable logistic regression model to examine the association between material deprivation quintile (from the Ontario Marginalization Index) and discharge to long-term care, and a multivariable negative binomial regression model to examine the association between material deprivation quintile and rehabilitation length of stay.

RESULTS

A total of 18 736 people were included. There was no association between material deprivation and direct discharge to long-term care (most v. least deprived: odds ratio [OR] 1.07, 95% confidence interval [CI] 0.89-1.28); however, people living in the most deprived areas had a mean length of stay 1.7 days longer than that of people in the least deprived areas (p = 0.004). This difference was not significant after adjustment for other baseline differences (relative change in mean 1.02, 95% CI 0.99-1.04).

INTERPRETATION

People admitted to inpatient stroke rehabilitation in Ontario had similar discharge destinations and lengths of stay regardless of their socioeconomic status. In future studies, investigators should consider further examining the associations of material deprivation with upstream factors as well as potential mitigation strategies.

The Association between Education and Rehabilitation Outcomes: a Population Retrospective Observational Study

OBJECTIVES

Retrospective observational study aiming at testing whether different education levels in older adults are associated with the rehabilitation outcome.

STUDY DESIGN

The study planned to cover all patients of over 65 rehabilitated from 2015 to 2017 at Golgi-Redaelli, a large government-funded rehabilitation Institute in Northern Italy comprising of three centers. Different administrative datasets were linked to investigate the factors associated with the functional outcome. The cohort resulted in 2,486 older adults for whom information on education and rehabilitation outcome was available.

MAIN OUTCOME MEASURES

Rehabilitation outcome was measured with the Barthel Index testing the ability in basic activities of daily living and the Tinetti Performance Oriented Mobility Assessment measuring stability and walking. Multiple linear and logistic regression models were run controlling for rehabilitation setting and center of care, age, gender, cognitive functioning and comorbidity.

RESULTS

Education resulted negatively associated with functional recovery. Patients with at least 8 years of education improved 2.24 point less in Barthel Index (out of100) and 0.70 points less in Tinetti Performance Oriented Mobility Assessment (out of 28) than the less educated patients. Results confirmed the importance of cognitive functioning in predicting rehabilitation outcome in older patients.

CONCLUSIONS

Different mechanisms can explain an unexpected negative association between education and rehabilitation outcome, when possible inequalities in access to care are controlled for by study design (the cohort was admitted to a NHS-funded institute). Additional studies are needed to confirm our results and to test more specific hypotheses about the degree of effectiveness of rehabilitation across socio-economic groups.

Girls' Empowerment and Adolescent Pregnancy: A Systematic Review

Background: 21 million girls get pregnant every year. Many initiatives are empowering girls. Various studies have looked at girl empowerment, however, there is contradicting evidence, and even less literature from developing countries. Methods: We searched articles published between January 2000 to January 2019. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered our protocol on the International Prospective Register of Systematic Reviews PROSPERO (CRD42019117414). Nine articles were selected for review. Quality appraisal was done using separate tools for qualitative studies, cohort and cross-sectional studies and randomized control trials. Results: Eight studies included educational empowerment, four studies included community empowerment, three studies included economic empowerment, while two studies discussed policy empowerment. Three studies were of fair quality; two qualitative and one cross-sectional study were of high quality, while three studies had low quality. Discussion. Studies showed a favorable impact of girl empowerment on adolescent pregnancies and risky sexual behaviors. Education empowerment came through formal education or health systems such as in family planning clinics. Community empowerment was seen as crucial in girls' development, from interactions with parents to cultural practices. Economic empowerment was direct like cash transfer programs or indirect through benefits of economic growth. Policies such as contraceptive availability or compulsory school helped reduce pregnancies.

The Dutch version of the Oxford Cognitive Screen (OCS-NL): normative data and their association with age and socio-economic status

The Oxford Cognitive Screen (OCS) is a screening tool designed for stroke patients, assessing attention, executive functions, language, praxis, numeric cognition and memory. Here we present norms for the two parallel versions of the Dutch OCS (OCS-NL, acquired in 246 participants for version A and a subset of 179 participants for version B. We evaluated the association of age and socio-economic status (i.e. education, income, occupation) with OCS-NL performance There were no systematic performance differences between income groups, nor between manual and non-manual workers. There were small differences between education groups. The association of education and performance did not vary across subtests. The association of age and performance varied across subtests, with the strongest associations for the naming, praxis, verbal memory and executive task. Thus, OCS-NL norms do not need to be stratified on income and occupation and age-specific norms are recommended for some subtests.

Robot-assisted gait training for balance and lower extremity function in patients with infratentorial stroke: a single-blinded randomized controlled trial

Background

Balance impairments are common in patients with infratentorial stroke. Although robot-assisted gait training (RAGT) exerts positive effects on balance among patients with stroke, it remains unclear whether such training is superior to conventional physical therapy (CPT). Therefore, we aimed to investigate the effects of RAGT combined with CPT and compared them with the effects of CPT only on balance and lower extremity function among survivors of infratentorial stroke.

Methods

This study was a single-blinded, randomized controlled trial with a crossover design conducted at a single rehabilitation hospital. Patients (n = 19; 16 men, three women; mean age: 47.4 ± 11.6 years) with infratentorial stroke were randomly allocated to either group A (4 weeks of RAGT+CPT, followed by 4 weeks of CPT+CPT) or group B (4 weeks of CPT+CPT followed by 4 weeks of RAGT+CPT). Changes in dynamic and static balance as indicated by Berg Balance Scale scores were regarded as the primary outcome measure. Outcome measures were evaluated for each participant at baseline and after each 4-week intervention period.

Results

No significant differences in outcome-related variables were observed between group A and B at baseline. In addition, no significant time-by-group interactions were observed for any variables, indicating that intervention order had no effect on lower extremity function or balance. Significantly greater improvements in secondary functional outcomes such as lower extremity Fugl-Meyer assessment (FMA-LE) and scale for the assessment and rating of ataxia (SARA) were observed following the RAGT+CPT intervention than following the CPT+CPT intervention.

Conclusion

RAGT produces clinically significant improvements in balance and lower extremity function in individuals with infratentorial stroke. Thus, RAGT may be useful for patients with balance impairments secondary to other pathologies.

Trial registration

ClinicalTrials.gov Identifier NCT02680691. Registered 09 February 2016; retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12984-019-0553-5) contains supplementary material, which is available to authorized users.

Socioeconomic class and universal healthcare: Analysis of stroke cost and outcomes in US military healthcare

OBJECTIVE

Do socioeconomic disparities exist in the US military healthcare system with ischemic stroke admissions?

METHODS

Civilian healthcare in the United States is paid for by a variety of payers. Significant disparities exist in this system based upon socioeconomic status (SES). In contrast, the military healthcare system (MHS) is a universal healthcare system. Military rank is a SES surrogate. Data was collected from the MHS database for years 2010 through 2015. All admissions to military health care facilities with a primary diagnosis of ischemic stroke were reviewed. Military rank was compared for primary outcomes of: Disposition (In-hospital mortality and discharge destination setting) and IV tPA administration and for secondary outcomes of: Total cost of hospitalization and Length of hospital stay (LoS). All adjusted for relevant demographics and co-morbidities.

RESULTS

Military rank was identified with 1895 (52.3%) of the 3623 admissions. The ranks identified were: Junior Enlisted 100 (2.7%), Senior Enlisted/Warrant Officers 1390 (38.4%), Junior Officers 59 (1.6%) and Senior Officers 346 (9.6%). Statistically significant results included: Lower SES group/ranks were more likely to have poor discharge destination setting while the highest SES group/ranks and had lower rates of in-hospital mortality, shorter lengths of stay and higher hospitalization costs after controlling for relevant variables.

CONCLUSION

Higher military ranks (Higher SES) had shorter hospitalization stays, higher costs and less in-hospital mortality in the military's universal healthcare system. This suggests aggregate characteristics of SES plays a large role in the outcomes among SES groups.

Association between socioeconomic status and post-stroke functional outcome in deprived rural southern China: a population-based study

BACKGROUND

Data on the association between socioeconomic status and post-stroke functional outcome in developing countries is lacking. We aimed to evaluate the association in stroke survivors in deprived rural Southern China.

METHODS

We conducted door-to-door interviews and collected data using a structured questionnaire in stroke survivors from five fourth-class rural areas of Guangdong Province through a non-government initiated registry from August 2014 to March 2015. Descriptive statistics were used to provide information on the demographic, socioeconomic and clinical characteristics of the selected population. Univariate and multivariate logistic regression were used to examine the relationship of socioeconomic status indexed by self-reported average family income and functional impairment defined as a modified Rankin Scale of 3 to 5.

RESULTS

Among the 425 stroke survivors, 52.7% lived below the poverty line set by the local government. About 50% of patients suffered from functional impairment and required assistance in their daily life. Compared with their wealthier counterpart, stroke survivors with lower income were more likely to have functional impairment (OR 2.85, 95% CI 1.93-4.23). The effect size increased and remained significant after adjusting for possible confounding factors (OR 3.17, 95% CI 2.04-4.91).

CONCLUSIONS

Poorer patients tend to have poorer post-stroke functional outcome. Primary and secondary strategies targeting underprivileged populations in less-developed areas are thus urgently needed in China.

The prognosis of stroke survivors primarily discharged to their homes

OBJECTIVES

Stroke is one of the leading causes for nursing home placement (NHP). We have studied the prognosis and risk factors regarding NHP for stroke patients initially discharged to their homes.

MATERIALS AND METHODS

All stroke patients in the municipality of Stavanger, Norway, between January 1, 1996, and March 31, 2004, were included and followed until death or May 31, 2012. Time intervals for NHP and death were compared to an age- and sex-matched, stroke-free control cohort. Logistic regression analysis was used to assess risk factors for NHP.

RESULTS

A total of 452 patients were included. A total of 48 patients (10.6%) were directly placed in a nursing home, while 401 patients (88.7%) were discharged to their homes; 180 patients (44.7%) directly and 221 patients (55.3%) after temporary rehabilitation. Of the patients discharged to their homes, 29.7% needed NHP at a later time point as compared to 19.9% of the controls (P<.001). Logistic regression analysis showed that only age (P<.001) was a risk factor for NHP. Stroke patients discharged home and stroke patients admitted directly to nursing home were significantly younger at time of NHP; stroke patients discharged home died significantly earlier than the controls.

CONCLUSIONS

Almost 90% of the stroke patients could be discharged to their homes, but they needed more often NHP in the long run than the stroke-free controls. Stroke patients discharged to their homes were younger at the time of NHP and death indicating that the stroke deficit may contribute to increased morbidity and mortality in this patient group.

Occupational class inequalities in disability retirement after hospitalisation

AIMS

This study aimed to investigate whether hospitalisation is associated with increased risk of disability retirement differently across four occupational classes.

METHODS

170,510 employees of the City of Helsinki, Finland were followed from 1990 to 2013 using national registers for hospitalisations and disability retirement. Increases in the risk of disability retirement after hospitalisation for any cause, cardiovascular diseases, musculoskeletal disorders, mental disorders, malignant neoplasms, respiratory diseases and injuries were assessed across four occupational classes: professional, semi-professional, routine non-manual and manual, using competing risks models.

RESULTS

In general, hospitalisation showed a slightly more increased risk of disability retirement in the lower ranking occupational classes. Hospitalisation among women for mental disorders showed a more increased risk in the professional class (hazard ratio 14.73, 95% confidence interval 12.67 to 17.12) compared to the routine manual class (hazard ratio 7.27, 95% confidence interval 6.60 to 8.02). Occupational class differences were similar for men and women. The risk of disability retirement among women increased most in the routine non-manual class after hospitalisation for musculoskeletal disorders and injuries, and most in the professional class after hospitalisation for cardiovascular diseases. The corresponding risks among men increased most in the two lowest ranking classes after hospitalisation for injuries.

CONCLUSIONS

Ill-health as measured by hospitalisation affected disability retirement in four occupational classes differently, and the effects also varied by the diagnostic group of hospitalisation. Interventions that tackle work disability should consider the impact of ill-health on functioning while taking into account working conditions in each occupational class.

Is there a correlation between socioeconomic disparity and functional outcome after acute ischemic stroke?

BACKGROUND

To investigate the impact of low socioeconomic status (SES), indicated by low level of education, occupation and income, on 3 months functional outcome after ischemic stroke.

METHODS

We analyzed data from the China National Stroke Registry (CNSR), a multicenter and prospective registry of consecutive patients with acute cerebrovascular events occurred between September 2007 and August 2008. 11226 patients with ischemic stroke had SES and clinical characteristics data collected at baseline and mRS measured as indicator of functional outcome in 3 months follow up. Multinomial and ordinal logistic regression models were performed to examine associations between SES and the functional outcome.

RESULTS

At 3 months after stroke, 5.3% of total patients had mRS scored at 5, 11.3% at score 4, 11.1% at score 3, 14.4% at score 2, 34.2% at score 1 and 23.7% at score 0. Compared to patients with educational level of ≥ 6 years and non-manual laboring, those < 6 years and manual laboring tended to have higher mRS score (P<0.001). Multinomial adjusted odds ratios (ORs) of outcome in manual workers were significantly increased (ORs from1.38 to 1.87), but OR in patients with less income was not significant. There were similar patterns of association The impact may be stronger in patients aged <65 years (P = 0.003, P<0.001 respectively) and being male (P = 0.001, P<0.001 respectively).

CONCLUSIONS

Our study provides evidence that people who are relatively more deprived in socioeconomic status suffer poorer outcome after ischemic stroke. The influence of low educational level and manual laboring can be more intensive than low income level on 3-month outcome. Health policy and service should target the deprived populations to reduce the public health burden in the society.

Oro-facial impairment in stroke patients

Stroke is considered one of the leading causes of death and acquired disability with a peak prevalence over the age of 80 years. Stroke may cause debilitating neurological deficiencies that frequently result in sensory deficits, motor impairment, muscular atrophy, cognitive deficits and psychosocial impairment. Oro-facial impairment may occur due to the frequent involvement of the cranial nerves' cortical representation areas, central nervous system pathways or motoneuron pools. The aim of this narrative, non-systematic review was to discuss the implications of stroke on oro-facial functions and oral health-related quality of life (OHRQoL). Stroke patients demonstrate an impaired masticatory performance, possibly due to reduced tongue forces and disturbed oral sensitivity. Furthermore, facial asymmetry is common, but mostly discrete and lip restraining forces are reduced. Bite force is not different between the ipsi- and contra-lesional side. In contrast, the contra-lesional handgrip strength and tongue-palate contact during swallowing are significantly impaired. OHRQoL is significantly reduced mainly because of the functional impairment. It can be concluded that impaired chewing efficiency, dysphagia, facial asymmetry, reduced lip force and OHRQoL are quantifiable symptoms of oro-facial impairment following a stroke. In the absence of functional rehabilitation, these symptoms seem not to improve. Furthermore, stroke affects the upper limb and the masseter muscle differently, both, at a functional and a morphological level. The rehabilitation of stroke survivors should, therefore, also seek to improve the strength and co-ordination of the oro-facial musculature. This would in turn help improve OHRQoL and the masticatory function, subsequently preventing weight loss and malnutrition.

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study

Background

Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD.

Methods

We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients.

Results

During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care.

Conclusions

Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

The influence of individual socioeconomic status on the clinical outcomes in ischemic stroke patients with different neighborhood status in Shanghai, China

Objective: Socioeconomic status (SES) is being recognized as an important factor in both social and medical problems. The aim of present study is to examine the relationship between SES and ischemic stroke and investigate whether SES is a predictor of clinical outcomes among patients with different neighborhood status from Shanghai, China. Methods: A total of 471 first-ever ischemic stroke patients aged 18-80 years were enrolled in this retrospective study. The personal SES of each patient was evaluated using a summed score derived from his or her educational level, household income, occupation, and medical reimbursement rate. Clinical adverse events and all-cause mortality were analyzed to determine whether SES was a prognostic factor, its prognostic impact was then assessed based on different neighborhood status using multivariable Cox proportional hazard models after adjusting for other covariates. Results: The individual SES showed a significant positive correlation with neighborhood status (r = 0.370; P < 0.001). The incidence of clinical adverse events and mortality were significantly higher in low SES patients compared with middle and high SES patients (P = 0.001 and P = 0.037, respectively). After adjusting other risk factors and neighborhood status, Kaplan-Meier analysis showed clinical adverse events and deaths were still higher in the low SES patients (all P < 0.05). Multivariate Cox regression analysis demonstrated that both personal SES and neighborhood status are independent prognostic factors for ischemic stroke (all P < 0.05). Besides, among patients with low and middle neighborhood status, lower individual SES was significantly associated with clinical adverse events and mortality (all P < 0.05). Conclusion: Both individual SES and neighborhood status are significantly associated with the prognosis after ischemic stroke. A lower personal SES as well as poorer neighborhood status may significantly increase risk for adverse clinical outcomes among ischemic stroke patients.

Identifying Treatment Effect Modifiers in the STarT Back Trial: A Secondary Analysis

Identification of patient characteristics influencing treatment outcomes is a top low back pain (LBP) research priority. Results from the STarT Back trial support the effectiveness of prognostic stratified care for LBP compared with current best care, however, patient characteristics associated with treatment response have not yet been explored. The purpose of this secondary analysis was to identify treatment effect modifiers within the STarT Back trial at 4-month follow-up (n = 688). Treatment response was dichotomized using back-specific physical disability measured using the Roland-Morris Disability Questionnaire (≥7). Candidate modifiers were identified using previous literature and evaluated using logistic regression with statistical interaction terms to provide preliminary evidence of treatment effect modification. Socioeconomic status (SES) was identified as an effect modifier for disability outcomes (odds ratio [OR] = 1.71, P = .028). High SES patients receiving prognostic stratified care were 2.5 times less likely to have a poor outcome compared with low SES patients receiving best current care (OR = .40, P = .006). Education level (OR = 1.33, P = .109) and number of pain medications (OR = .64, P = .140) met our criteria for effect modification with weaker evidence (.20 > P ≥ .05). These findings provide preliminary evidence for SES, education, and number of pain medications as treatment effect modifiers of prognostic stratified care delivered in the STarT Back Trial.

PERSPECTIVE

This analysis provides preliminary exploratory findings about the characteristics of patients who might least likely benefit from targeted treatment using prognostic stratified care for LBP.

Socioeconomic Status and the Quality of Acute Stroke Care: The China National Stroke Registry

BACKGROUND AND PURPOSE

The association of socioeconomic status (SES) with quality of stroke care is not well understood, and few studies have examined the association with different indicators of SES simultaneously. We assessed the impacts of low levels of education, occupation, and income on the quality of stroke care.

METHODS

We examined data from the China National Stroke Registry recording consecutive stroke patients between September 2007 and August 2008. Baseline low SES was measured using educational level <6 years, occupation as manual workers or no job, and average family income per capita at ≤¥1000 per month. Compliance with 11 performances was summarized in a composite score defined as the proportion of all needed care given. Poor quality of care was defined as having a composite score of 0.71 or less.

RESULTS

Among 12 270 patients with ischemic stroke, 38.6% had <6 educational years, 37.6% had manual workers/no job, and 34.7% had income ≤¥1000 per month. There was an increased chance of receiving poor quality of care in patients with low education (adjusted odds ratio 1.15, 95% confidence interval 1.03-1.28), low occupation (adjusted odds ratio 1.16, 95% confidence interval 1.01-1.32), and low income (adjusted odds ratio 1.18, 95% confidence interval 1.06-1.30), respectively. People with low SES had poor performances on some aspects of care quality. Combined effects existed among these SES indicators; those with low SES from all 3 indicators had the poorest quality of care.

CONCLUSIONS

There was a social gradient in the quality of stroke care. Continuous efforts of socioeconomic improvement will increase the quality of acute stroke care.

Moving Toward an Understanding of Disability in Older U.S. Stroke Survivors

OBJECTIVES

We test a comprehensive model of disability in older stroke survivors and determine the relative contribution of neighborhood, economic, psychological, and medical factors to disability.

METHOD

The sample consisted of 728 stroke survivors from the National Health and Aging Trends Study (NHATS), who were 65 years and older living in community settings or residential care. Confirmatory factor analysis and structural equation modeling were used to test relationships between neighborhood, socioeconomic, psychological, and medical factors, and disability.

RESULTS

Economic and medical context were associated with disability directly and indirectly through physical impairment. Neighborhood context was associated with disability, but was only marginally statistically significant ( p = .05). The effect of economic and neighborhood factors was small compared with that of medical factors.

DISCUSSION

Neighborhood and economic factors account for a portion of the variance in disability among older stroke survivors beyond that of medical factors.

Predictors of functional level and quality of life at 6 months after a first-ever stroke: the KOSCO study

Predicting functional outcome and quality of life (QOL) is critical to the treatment of patients with stroke. The purpose of this study was to analyze the factors influencing functional status and QOL of stroke patients 6 months after a first-ever stroke. This study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation Study, designed to include 10 years of follow-up for first-ever stroke patients. This study analyzed data from 2857 patients who completed face-to-face assessments with the functional independence measurement (FIM) and Euro Quality of Life-5D (EQ-5D) at 6 months after stroke onset. A multivariate regression analysis was used to analyze factors that potentially influenced FIM and EQ-5D results at 6 months after stroke. Of the patients in this study, 80.1 % suffered from ischemic stroke and 19.9 % experienced hemorrhagic stroke. The independent predictors of functional independency measured by FIM at 6 months after stroke were age, initial stroke severity, duration of hospitalization, and functional level at discharge in terms of motor, ambulation, and language. For QOL measured by EQ-5D at 6 months after stroke, age, duration of hospitalization, and motor function at discharge were significant predictors. In conclusion, proper treatment to achieve maximal functional gain at discharge may be an important factor in improving functional independency and QOL in chronic stage stroke survivors. These results provide useful information for establishing comprehensive and systematic care for stroke patients.

Association between socioeconomic deprivation and functional impairment after stroke: the South London Stroke Register

BACKGROUND AND PURPOSE

Previous findings of the association between socioeconomic deprivation and functional impairment after stroke are inconsistent. There is a lack of data on long-term association. We assessed the association and differences by age, sex, prestroke comorbidities, and stroke phenotypes.

METHODS

We examined data from the South London Stroke Register cohort of 1995 to 2011, recording all first-ever strokes in patients of all ages in South London. A total of 2104 patients were alive at 3 months after stroke. Socioeconomic deprivation was measured using the index of multiple deprivation based on patient postcodes, and functional impairment after stroke was defined as a Barthel index of <15.

RESULTS

At 3 months after stroke, 643 patients had functional impairment (30.6%; 95% confidence interval, 28.6%-32.5%). Compared with the first quartile of index of multiple deprivation (the least deprived), multivariate-adjusted odds ratios for functional impairment in patients with the second, third, and fourth quartiles were 1.29 (95% confidence interval, 0.94-1.76), 1.33 (0.97-1.82), and 1.78 (1.31-2.43), overall P=0.004. The association was significant in patients aged ≥65 years (corresponding odds ratios were 1.49 [1.02-2.17], 1.21 [0.83-1.75], and 1.94 [1.34-2.81]; P=0.003); in women, P=0.008, in patients who do not have prestroke comorbidities, P=0.009, and in patients with ischemic stroke, P<0.001, but not significant in their counterpart patients. There were similar patterns of the associations of socioeconomic deprivation with impairment at 3 years after stroke.

CONCLUSIONS

There are significant inequalities in short- and long-term functional recovery after stroke. General socioeconomic improvement, targeting groups at high risk of functional impairment is likely to reduce inequality in functional recovery after stroke.

Mortality following stroke during and after acute care according to neighbourhood deprivation: a disease registry study

BACKGROUND

Neighbourhood deprivation has been shown to be inversely associated with mortality 1 month after stroke. Whether this disadvantage begins while patients are still receiving acute care is unclear. We aimed to study mortality after stroke specifically in the period while patients are under acute care and the ensuing period when they are discharged to home or other care settings.

METHODS

Our sample includes 1760 incident strokes (mean age 75, 48% men, 86% ischaemic) identified between 1998 and 2010 by the population-based stroke registry of Dijon (France). We used Cox regression to study all-cause mortality up to 90 days after stroke occurrence.

RESULTS

Overall, 284 (16.1%) patients died during the 90 days following stroke. Prior to stroke, risk factors prevalence (eg, high blood pressure and diabetes) and acute care management did not vary across deprivation levels. There was no association between deprivation and mortality while patients were in acute care (HR comparing the highest to the lowest tertiles of deprivation: 1.01, 95% CI 0.71 to 1.43). After discharge, however, age and gender adjusted mortality gradually increased with deprivation (HR 2.08, 95% CI 1.07 to 4.02). This association was not modified when stroke type and severity were accounted for.

CONCLUSIONS

The gradient of higher poststroke mortality with increasing neighbourhood deprivation was noticeable only after acute hospital discharge. Quality of postacute care and social support are potential determinants of these variations.

Does pain severity guide selection to multimodal pain rehabilitation across gender?

BACKGROUND

Studies have addressed the effect of multimodal pain rehabilitation (MMR), whereas criteria for selection are sparse. This study examines whether higher scores on musculoskeletal pain measures are associated with selection to MMR, and whether this differs across gender.

METHOD

A clinical population of 262 male and 589 female patients was recruited consecutively during 3 years, 2007-2010. The patients were referred from primary care to a pain rehabilitation clinic in Northern Sweden for assessment and selection to MMR. Register-based data on self-reported pain were linked to patients' records where outcome (MMR or not) was stated. We modelled odds ratios for selection to MMR by higher scores on validated pain measures (pain severity, interference with daily life, pain sites and localized pain vs. varying pain location). Covariates were age, educational level and multiple pain measures. Anxiety and depression (Hospital, Anxiety and Depression Scale) and working status were used in sensitivity tests.

RESULTS

Higher scores of self-reported pain were not associated with selection to MMR in multivariate models. Among women, higher scores on pain severity, pain sites and varying pain location (localized pain = reference) were negatively associated with selection to MMR. After adjustment for multiple pain measures, the negative odds ratio for varying location persisted (OR = 0.59, 95% CI = 0.39-0.89).

CONCLUSION

Higher scores on self-reported pain did not guide selection to MMR and a negative trend was found among women. Studies of referral patterns and decision processes may contribute to a better understanding of the clinical practice that decides selection to MMR.

Impact of living and socioeconomic characteristics on cardiovascular risk in ischemic stroke patients

OBJECTIVE

We aimed to stratify the risk of vascular event recurrence in patients with cerebral infarction according to living and socioeconomic characteristics and geographic region.

METHOD

The Outcomes in Patients with TIA and Cerebrovascular Disease (OPTIC) study is an international prospective study of patients aged 45 years or older who required secondary prevention of stroke [following either an acute transient ischemic attack, minor ischemic strokes, or recent (less than six-months previous), stable, first-ever, nondisabling ischemic stroke]. A total 3635 patients from 245 centers in 17 countries in four regions (Latin America, Middle East, North Africa, South Africa) were enrolled between 2007 and 2008. The outcome measure was the two-year rate of a composite of major vascular events (vascular death, myocardial infarction and stroke).

RESULTS

During the two-year follow-up period, 516 patients experienced at least one major cardiovascular event, resulting in an event rate of 15·6% (95% confidence interval 14·4-16·9%). Event rates varied across geographical region (P < 0·001), ranging from 13·0% in Latin America to 20·7% in North Africa. Unemployment status, living in a rural area, not living in fully serviced accommodation (i.e., house or apartment with its own electricity, toilet and water supply), no health insurance coverage, and low educational level (less than two-years of schooling) were predictors of major vascular events. Major vascular event rates steeply increased with the number of low-quality living/socioeconomic conditions (from 13·4% to 47·9%, adjusted P value for trend <0·001).

CONCLUSION

Vascular risk in stroke patients in low- and middle-income countries varies not only with the number of arterial beds involved but also with socioeconomic variables.

Low-educated women with chronic pain were less often selected to multidisciplinary rehabilitation programs

Background

There is a lack of research about a potential education-related bias in assessment of patients with chronic pain. The aim of this study was to analyze whether low-educated men and women with chronic pain were less often selected to multidisciplinary rehabilitation than those with high education.

Methods

The population consisted of consecutive patients (n = 595 women, 266 men) referred during a three-year period from mainly primary health care centers for a multidisciplinary team assessment at a pain rehabilitation clinic at a university hospital in Northern Sweden. Patient data were collected from the Swedish Quality Registry for Pain Rehabilitation National Pain Register. The outcome variable was being selected by the multidisciplinary team assessment to a multidisciplinary rehabilitation program. The independent variables were: sex, age, born outside Sweden, education, pain severity as well as the hospital, anxiety and depression scale (HADS).

Results

Low-educated women were less often selected to multidisciplinary rehabilitation programs than high-educated women (OR 0.55, CI 0.30–0.98), even after control for age, being born outside Sweden, pain intensity and HADS. No significant findings were found when comparing the results between high- and low-educated men.

Conclusion

Our findings can be interpreted as possible discrimination against low-educated women with chronic pain in hospital referrals to pain rehabilitation. There is a need for more gender-theoretical research emphasizing the importance of taking several power dimensions into account when analyzing possible bias in health care.

The association between socioeconomic status and disability after stroke: findings from the Adherence eValuation After Ischemic stroke Longitudinal (AVAIL) registry

Background

Stroke is the leading cause of disability among adults in the United States. The association of patients’ pre-event socioeconomic status (SES) with post-stroke disability is not well understood. We examined the association of three indicators of SES—educational attainment, working status, and perceived adequacy of household income—with disability 3-months following an acute ischemic stroke.

Methods

We conducted retrospective analyses of a prospective cohort of 1965 ischemic stroke patients who survived to 3 months in the Adherence eValuation After Ischemic stroke – Longitudinal (AVAIL) study. Multivariable logistic regression was used to examine the relationship of level of education, pre-stroke work status, and perceived adequacy of household income with disability (defined as a modified Rankin Scale of 3–5 indicating activities of daily living limitations or constant care required).

Results

Overall, 58% of AVAIL stroke patients had a high school or less education, 61% were not working, and 27% perceived their household income as inadequate prior to their stroke. Thirty five percent of patients were disabled at 3-months. After adjusting for demographic and clinical factors, stroke survivors who were unemployed or homemakers, disabled and not-working, retired, less educated, or reported to have inadequate income prior to their stroke had a significantly higher odds of post-stroke disability.

Conclusions

In this cohort of stroke survivors, socioeconomic status was associated with disability following acute ischemic stroke. The results may have implications for public health and health service interventions targeting stroke survivors at risk of poor outcomes.

Implementation of telephone-based secondary preventive intervention after stroke and transient ischemic attack - participation rate, reasons for nonparticipation and one-year mortality

Background and Purpose

Patients who experience a stroke or transient ischemic attack (TIA) are known to be at high risk of subsequent vascular events, underscoring the need for secondary preventive intervention. However, previous studies have indicated insufficiency in the implementation of secondary prevention, emphasizing the need to develop effective methods of follow-up. In the present study, we examined the potential of implementing a telephone-based, nurse-led, secondary preventive follow-up in stroke and TIA patients on a population level by analyzing the participation rate, reasons for nonparticipation, and one-year mortality.

Methods

Between January 1, 2010 and December 31, 2011, all patients admitted to Östersund hospital, Sweden, and diagnosed with either stroke or TIA were considered for inclusion into the secondary preventive follow-up. Baseline data were collected at the hospital, and reasons for nonparticipation were documented. Multivariate logistic regression was performed to identify predictors of the patient decision not to participate and to explore independent associations between baseline characteristics and exclusion. A one-year follow-up of mortality was also performed; the survival functions of the three groups (included, excluded, declining participation) was calculated using the Kaplan-Meier estimator.

Results

From a total of 810 identified patients, 430 (53.1%) were included in the secondary preventive follow-up, 289 (35.7%) were excluded mainly due to physical or cognitive disability, and 91 (11.2%) declined participation. Age ≥85 years, ischemic and hemorrhagic stroke, modified Rankin scale score >3, body mass index ≥25, congestive heart failure, and lower education level were independently associated with exclusion, whereas lower education level was the only factor independently associated with the patient decision not to participate. Exclusion was associated with a more than 12 times higher risk of mortality within the first year after discharge.

Conclusion

Population-based implementation of secondary prevention in stroke and TIA patients is limited by the high prevalence of comorbidity and a considerable degree of disability. In our study, a large proportion of patients were unable to participate even in this simple form of secondary preventive follow-up. Exclusion was associated with substantially higher one-year mortality, and education level was independently associated with physical ability as well as the motivation to participate in the secondary preventive follow-up program.

Reduced inequality in access to stroke unit care over time: a 15-year follow-up of socioeconomic disparities in Sweden

BACKGROUND

Despite the compelling scientific evidence on the superiority of stroke unit care, far from all acute stroke patients have access to stroke unit care. In congruence with what has been observed when other new methods are introduced in health care, we hypothesized that there has been an inequality in the buildup phase of stroke units but that the gradients between patient groups have decreased as the total capacity of stroke unit care has increased. The purpose of this study was to explore if patients in a national sample who were socioeconomically disadvantaged (low education or low income) had reduced access to stroke unit care and if differences varied over time.

METHODS

All patients 18-74 years of age registered between 1995 and 2009 in Riks-Stroke, the Swedish stroke register, were included. The Stroke Unit Trialists' definition of a stroke unit has been adopted by Riks-Stroke and hospitals participating in the registry. Basic patient characteristics, stroke risk factors, process and outcome variables are recorded in Riks-Stroke. Socioeconomic data were accessed from Statistics Sweden. Multiple logistic regression analyses were used to calculate odds ratios (ORs) for stroke unit care between prespecified patient subgroups.

RESULTS

A total of 319,240 stroke patients were included in Riks-Stroke during the years 1995-2009, and 124,173 were aged between 18 and 74 years; they were included in the final analyses. After adjustment for confounders in a multiple regression model, women were treated in stroke units slightly less often [OR 0.97, 95% confidence interval (CI) 0.95-0.99]. There were no statistically significant associations between stroke unit care and age or between stroke unit care and cohabiting or living alone. The highest level of education predicted access to stroke unit care (secondary vs. primary school: OR 1.04, 95% CI 1.01-1.07; university vs. primary school: OR 1.06, 95% CI 1.02-1.10). Differences according to level of education diminished over time (p = 0.001). Income was not independently associated with stroke unit care, and over time the proportion of patients treated in stroke units increased at a similar rate in all income groups (p = 0.12).

CONCLUSIONS

Even in a country with modest socioeconomic differences in the general population and public financing of all acute hospital care, socioeconomic inequalities in access to stroke unit care were evident during the early years, but they diminished as the total capacity for stroke unit care increased.

Socioeconomic Status and Care After Stroke

Background and Purpose—

Socioeconomic status is inversely associated with mortality after stroke; however, the reasons behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and medication adherence vary with neighborhood income.

Methods—

We conducted a cohort study of 11 050 patients with ischemic stroke or transient ischemic attack admitted to any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We used multivariable analyses to assess whether differences in stroke care and medication adherence existed across income groups after adjustment for age, sex, stroke severity, and comorbid conditions.

Results—

Higher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates were small. There was no difference across income quintiles in the use of postdischarge homecare services or in adherence to antihypertensive, antithrombotic, or lipid-lowering medications.

Conclusions—

Higher income is associated with improvements in some aspects of stroke care delivery. However, the magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed association between socioeconomic status and survival after stroke.

The Tinker Toy Test as a Measure of the Dysexecutive Syndrome in Those from Differing Socio-Economic Backgrounds

We investigated the impact of socio-economic status (SES) on executive functioning in a group of participants who were at least six months post Acquired Brain Injury (ABI). Challenges exist when measuring executive function in a developing country: norms developed in the country of test origin are rarely transferable to other populations and cultural differences require local test-item adaptation. Furthermore, SES has a graded impact upon cognitive functioning: those from lower socio-economic circumstances tend to produce inferior test scores to those from more affluent backgrounds. Not controlling for these effects may induce diagnostic errors. Three measures of executive functioning, the Wisconsin Card Sorting Test, the Iowa Gambling Test, and the Tinker Toy Test (TTT) were administered to 25 participants who were drawn from a South African Welfare organisation dedicated to supporting and assisting those with acquired brain injury. Sensitivity to race (as a possible measure of SES) was only elicited using the TTT. This test which is simple to administer, ecologically appropriate, and non-language based appears to be a useful adjunct as a measure of executive function in those with ABI from varying SES backgrounds.

Neighborhood income and stroke care and outcomes

OBJECTIVE

To evaluate factors that may contribute to the increased stroke case fatality rates observed in individuals from low-income areas.

METHODS

We conducted a cohort study on a population-based sample of all patients with stroke or TIA seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2002, and March 31, 2003, and April 1, 2004, and March 31, 2005. Socioeconomic status measured as income quintiles was imputed from median neighborhood income. In the study sample of 7,816 patients we determined 1-year mortality by grouped income quintile and used multivariable analyses to assess whether differences in survival were explained by cardiovascular risk factors, stroke severity, stroke management, or other prognostic factors.

RESULTS

There was no significant gradient across income groups for stroke severity or stroke management. However, 1-year mortality rates were higher in those from the lowest income group compared to those from the highest income group, even after adjustment for age, sex, stroke type and severity, comorbid conditions, hospital and physician characteristics, and processes of care (adjusted hazard ratio for low- vs high-income groups, 1.18; 95 confidence interval 1.03 to 1.29).

CONCLUSIONS

In Ontario, 1-year survival rates after an index stroke are higher for those from the richest compared to the least wealthy areas, and this is only partly explained by age, sex, comorbid conditions, and other baseline risk factors.

Confiabilidade do Perfil de Saúde de Nottingham após acidente vascular encefálico

O artigo tem o objetivo de avaliar a confiabilidade, a consistência interna e a concordância do instrumento de qualidade de vida (QV) Perfil de Saúde de Nottingham (PSN) em indivíduos após Acidente Vascular Encefálico (AVE). Estudo do tipo transversal realizado em comunidades da Cidade do Recife-PE. A amostra foi composta por 53 indivíduos na fase crônica do AVE. Após verificação do estado cognitivo foi aplicado o PSN. Utilizou-se estatística descritiva para caracterizar a amostra; a consistência interna foi medida através do alfa (α) de Cronbach; a confiabilidade com o coeficiente de correlação intraclasse (CCI) e a concordância pelo teste de plotagem Bland and Altman, com nível de significância de 5%. A percepção dos indivíduos sobre suas saúdes teve uma tendência positiva em 83,3% dos domínios do PSN (média > 50 pontos), exceto para o domínio "habilidades físicas" que variou entre 41,5 e 50 pontos. O instrumento obteve boa consistência interna, com α entre 0,81 e 0,87; excelente confiabilidade nos domínios "dor" e "habilidades físicas", ICC >0,90 (p <0,01); e concordância em 95% das ocasiões. O PSN, além de ser um instrumento simples e de fácil aplicação, apresentou propriedades clinimétricas adequadas para avaliar a QV de indivíduos pós-AVE na fase crônica.

Income and education as predictors of stroke mortality after the survival of a first stroke

Background. It is well known that socioeconomic indicators, such as income and education, predict both stroke incidence and stroke mortality. This means that persons in lower socioeconomic positions are less likely to survive their stroke, and there will be a selective survival in the group discharged from hospital after their first stroke. Question. Does socioeconomic position continue to predict mortality, stroke specific, or from other causes, among patients surviving their first stroke in spite of this selective survival? Methods. All persons in Sweden aged 40–59 years who were discharged after a first hospitalization for stroke in 1996–2000 were included (n = 10,487), then followed up until the end of the fourth calendar year after discharge. Data were analysed with Cox regressions controlling for age, sex, and stroke type. Results. Persons with high socioeconomic position, measured by education and income, have lower mortality than those of low position. Education was not significant when adjusted for income, however. The risk of dying was similar for stroke-specific mortality and all-cause mortality, for those with cerebral infarction as well as for all patients. Conclusions. Socioeconomic position predicted stroke-specific mortality also in the selective group of persons who survived their first stroke.

Ambient experience in restitutive treatment of aphasia

One of the greatest challenges to language rehabilitation is reconciling the fact that the same therapeutic intervention, provided to different individuals with similar types of stroke-induced aphasia, may result in divergent outcomes. In this paper, the authors reviewed existing literature to identify relevant ambient factors – those outside the control of the clinician – that may potentially influence functional language recovery in aphasia and response to treatment. The goal was to develop a clinical history-taking tool to assist clinicians in gathering information germane to each individual's unique circumstances and environment, elements that may have previously been underestimated, to provide a complete inventory of potentially potent prognostic factors. First, two of the authors, speech–language pathologists experienced in aphasia rehabilitation, identified and categorized factors that seemed likely to influence aphasia outcomes. Then, a wide range of literature was reviewed in an effort to identify factors empirically found to be potent influences on aphasia recovery. Where studies relating these factors to aphasia were not found, relevant research from allied fields that examined recovery from brain injury is reported. Moreover, some factors thought to be potentially potent have yet to be examined. Finally, the ambient factors supported by evidence were categorized as facilitators or barriers to functional improvement, and the Ambient Influences on Outcome Checklist (AOC) was developed, including only those factors shown to be potent in the recovery process. It is hoped that this checklist can be used to more broadly assess potential prognostic influences in aphasia restitution, as well as spawn further research.

Quality of life declines after first ischemic stroke. The Northern Manhattan Study

OBJECTIVES

Quality of life (QOL) after stroke is poorly characterized. We sought to determine long-term natural history and predictors of QOL among first ischemic stroke survivors without stroke recurrence or myocardial infarction (MI).

METHODS

In the population-based, multiethnic Northern Manhattan Study, QOL was prospectively assessed at 6 months and annually for 5 years using the Spitzer QOL index (QLI), a 10-point scale. Functional status was assessed using the Barthel Index (BI) at regular intervals, and cognition using the Mini-Mental State Examination at 1 year. Generalized estimating equations estimated the association between patient characteristics and repeated QOL measures over 5 years. Follow-up was censored at death, recurrent stroke, or MI.

RESULTS

There were 525 incident ischemic stroke patients >/=40 years (mean age 68.6 +/- 12.4 years). QLI declined after stroke (annual change -0.10, 95% confidence interval -0.17 to -0.04), after adjusting for age, sex, race-ethnicity, education, insurance, depressed mood, stroke severity, bladder continence, and stroke laterality. This decline remained when BI >/=95 was added to the model as a time-dependent covariate, and functional status also predicted QLI. Changes in QLI over time differed by insurance status (p for interaction = 0.0017), with a decline for those with Medicaid/no insurance (p < 0.0001) but not Medicare/private insurance (p = 0.98).

CONCLUSIONS

In this population-based study, QOL declined annually up to 5 years after stroke among survivors free of recurrence or MI and independently of other risk factors. QLI declined more among Medicaid patients and was associated with age, mood, stroke severity, urinary incontinence, functional status, cognition, and stroke laterality.

A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area

PURPOSE

To compare a group exercise programme known as the Back to Fitness programme with individual physiotherapy for patients with non-specific low back pain from a materially deprived area.

METHOD

This was a randomized controlled trial including 237 physiotherapy patients with back pain lasting more than six weeks. Participants were allocated to either the Back to Fitness programme or to individual physiotherapy, and followed up at three months and 12 months after randomization. The main outcome measure was the Roland Disability Questionnaire. Secondary measures were: SF12, EQ5D, Pain Self-Efficacy Scale. Health care diaries recording patients' use of health care resources were also collected over a 12-month period.

RESULTS

There were no statistically significant differences in change scores between groups on the primary outcome measure at three months (CI - 2.24 to 0.49) and at 12 months (CI - 1.68 to 1.39). Only minor improvements in disability scores were observed in the Back to Fitness group at three months and 12 months respectively (mean change scores; - 0.89, - 0.77) and in the individual physiotherapy arm (mean change scores; - 0.02, - 0.63). Further analysis showed that patients from the most severely deprived areas were marginally worse at three month follow-up whereas those from more affluent areas tended to improve (CI 0.43 to 3.15).

Predictors of resuming therapy within four weeks after discharge from inpatient rehabilitation

PURPOSE

To identify the percentage of persons with stroke resuming therapy within 4 weeks of inpatient rehabilitation discharge, to compare the characteristics of those who did and did not resume therapy, and to determine the predictors of resuming physical (PT), occupational (OT), and speech (ST) therapy.

METHOD

Sociodemographic, stroke-related, and therapy data for persons with stroke (N = 131) were abstracted from inpatient rehabilitation charts. FIM, Stroke Impact Scale, Geriatric Depression Scale, and data on therapy received after discharge were also collected.

RESULTS

Logistic regression models demonstrated that minorities were less likely to resume PT (odds ratio [OR] = 0.30) and OT (OR = 0.25). Survivors with neglect/visual-field cut/spatial-perceptual loss were 2-3 times more likely to resume PT, OT, and ST. Survivors with higher scores on the SIS Physical domain subscale were less likely to resume PT (OR = 0.98) and OT (OR = 0.97). Men were 3.3 times more likely to have OT than women. Those with comprehensive health insurance were 11.2 times more likely to receive ST.

CONCLUSIONS

The benefits of outpatient therapy are not universally available to all persons with stroke. Further research needs to explore the factors that hinder the prompt resumption of therapy for minority and female persons with stroke and to test appropriate interventions.

Stroke Outcome in Clinical Trial Patients Deriving From Different Countries

Background and Purpose— Stroke incidence and outcome vary widely within and across geographical locations. We examined whether differences in index stroke severity, stroke risk factors, mortality, and stroke outcome across geographical locations remain after adjusting for case mix.

Methods— We analyzed 3284 patients from the Virtual International Stroke Trials Archive (VISTA). We used logistic regression to examine the incidence of mild index stroke, functional, and neurological outcomes after accounting for age, medical history, year of trial recruitment, and initial stroke severity in the functional and neurological outcome analyses. We examined mortality between geographical regions using a Cox proportional hazards model, accounting for age, initial stroke severity, medical history, and year of trial recruitment.

Results— Patients enrolled in the USA and Canada had the most severe index strokes. Those recruited in Austria and Switzerland had the best functional and neurological outcomes at 90 days ( P <0.05), whereas those enrolled in Germany had the worst functional outcome at 90 days ( P =0.013). Patients enrolled in Austria, Switzerland, Belgium, Netherlands, Finland, Germany, Greece, Israel, Spain, and Portugal had a significantly better survival rate when compared with those enrolled in USA and Canada. Patients enrolled in trials after 1998 had more severe index strokes, with no significant difference in outcome compared with those enrolled before 1998.

Conclusion— We identified regional variations in index stroke severity, outcome, and mortality for patients enrolled in ischemic stroke clinical trials over the past 13 years that were not fully explained by case mix. Index stroke severity was greater in patients enrolled after 1998, with no significant improvement in outcomes compared to those enrolled before 1998.

Rehabilitative outcome in supratentorial and infratentorial stroke: the role of motor deficits

BACKGROUND AND AIMS

There are few studies on the functional outcome of patients with supratentorial (STS) and infratentorial stroke (ITS). They lead to conflicting conclusions and do not define the role of motor deficits on functional recovery of STS and ITS patients. We wished to investigate this.

METHODS

The study was carried out on 90 consecutive patients admitted to our Rehabilitation Department with clinical evidence of acute cerebrovascular accident. Neuroimaging data, clinical evidence, and the National Institute of Health Stroke Scale (NIH) were used to select two groups of patients: 1) 45 patients with supratentorial stroke lesion (STS group), 2) 45 patients with infratentorial stroke lesion (ITS group). The STS group included patients with hemiparesis, and the ITS group patients with ataxia. Patients were evaluated through the NIH, Fugl-Meyer scale, Klockgether score, CIRS, Trunk Control Test (TCT), Lindmark scale, Barthel index, and Katz index, at both admission and discharge.

RESULTS

At admission, there were no differences between the STS and ITS groups in disability or average Barthel, Lindmark and Katz scores. At discharge, the Katz index average scores were significantly higher (p=0.000) and disability was lower (p=0.002) in ITS patients. The efficiency in Lindmark, Barthel and Katz scores of group ITS was significantly greater than that of STS patients (p=0.003, p=0.030 and p=0.000, respectively). The final Katz score was correlated (Spearman rank method) with initial TCT (p=0.000), onset to admission interval (p=0.019) and initial NIH (p=0.044) in the STS group. Final BADL score was correlated only with initial TCT (p=0.000) in the ITS group.

CONCLUSIONS

Our data seem to indicate that STS has a worse rehabilitative prognosis than ITS, and that hemiparesis is more difficult to rehabilitate than ataxia.

Impact of socio-economic factors on stroke prevalence among urban and rural residents in Mainland China

Background

An inverse relationship between better socioeconomic status (total household income, education or occupation) and stroke has been established in developed communities, but family size has generally not been considered in the use of socioeconomic status indices. We explored the utility of Family Average Income (FAI) as a single index of socioeconomic status to examine the association with stroke prevalence in a region of China, and we also compared its performance as a single index of socioeconomic status with that of education and occupation.

Methods

A population-based cross-sectional study was conducted in Nanjing municipality of China during the period between October 2000 and March 2001. A total of 45 administrative villages were randomly selected using a multi-stage sampling approach and all regular local residents aged 35 years or above were included. Descriptive statistics and logistic regression models were used in analysis.

Results

The overall prevalence of diagnosed stroke was 1.54% in all 29,340 eligible participants. An elevated prevalence of stroke was associated with increasing levels of FAI. After adjustment for basic demographic variables (age, urban/rural area and gender) and a group of defined conventional risk factors, this gradient still remained significant, with participants in the highest (OR = 1.94, 95% CI = 1.40, 2.70) and middle (OR = 1.43, 95% CI = 1.01, 2.02) categories of FAI having higher risks compared with the lowest category. A significantly elevated OR of stroke prevalence was found in white collar workers compared to blue collar workers, while no significant relationship was observed with education.

Conclusion

Our study consistently revealed that the prevalence of stroke was associated with increasing levels of all SES indices, including FAI, education, and occupation. However, a significant gradient was only observed with FAI after controlling for important confounding factors. The findings suggested that, compared with occupation and education, FAI could be used as a more sensitive index of socio-economic status for public health studies in China.

A prospective study on educational level and adaptation to cancer, within one year after the diagnosis, in an older population

Socio-economic status (SES) has often been associated with health disparities and mortality in cancer patients, yet systematic research into the role of SES in the course of the disease is lacking. This prospective study intends to examine the role of SES (i.e. educational level in this study) in psychological and physical adaptation to cancer. Ninety-nine cancer patients were followed from a community-based survey. Pre- and post-morbid data on patients' quality of life (QoL) were available. Adaptation was defined by looking at the level and pattern of scores on QoL scales from pre- to post-disease assessments. Results show some non-significant trends that more high-educated patients managed to adapt completely to cancer in relation to role and physical functioning when compared with low-educated participants. Furthermore, the greater part of high-educated patients who completely adapted in physical functioning achieved this result more rapidly without an initial deterioration. Unexpectedly, these differences were not significant when tested in a regression model. Hence, although there are some indications for differences in adaptation to role and physical functioning between educational groups, we did not find any evidence that proved such a relation. For the group as a whole, it is very interesting to see that based on our operationalization of adaptation, only a small percentage of patients deteriorated from pre- to post-disease assessments.

Social determinants of discharge destination for patients after stroke with low admission FIM instrument scores

OBJECTIVE

To investigate the effects of immigrant status (via country of birth), marital status, and area-based socioeconomic status (SES) on discharge destination after stroke for those with low admission scores on the FIM instrument.

DESIGN

Cross-sectional study.

SETTING

Inpatient rehabilitation ward at an urban community hospital in Australia.

PARTICIPANTS

A total of 326 inpatients admitted for rehabilitation poststroke.

INTERVENTION

Multidisciplinary rehabilitation.

MAIN OUTCOME MEASURE

Discharge home versus nursing home.

RESULTS

A total admission FIM score of 75 or lower was associated with a higher probability of nursing home discharge. Married patients with a total FIM admission score of 75 or lower were significantly more likely to be discharged home, after adjusting for immigrant status, type and side of stroke, sex, and age (odds ratio, 6.07; 95% confidence interval, 1.65-22.40; P<.01). This effect was also observed for low motor and cognition components of FIM admission score. The effect of immigrant status did not remain significant after adjusting for marital status. Area-based SES and stroke characteristics did not substantially attenuate the relationship between immigrant status, marital status, and discharge location.

CONCLUSIONS

Marital status is a significant determinant of discharge destination. Immigrant status and area-based SES were not significant predictors of discharge disposition.

Prevention of Transient Ischemic Attack and Stroke in Older Adults: Implementing Evidence-Based Interventions

By the year 2030, it is estimated there will be more than 70 million adults age 55 and older. Despite the increased risk of transient ischemic attack and stroke after age 55, multiple evidence-based preventive actions can be taken to specifically target manageable health conditions and other modifiable factors that can substantially reduce their likelihood. The purpose of this article is to describe the essential elements in the transient ischemic attack and stroke risk assessment for older adults and the major evidence-based pharmacological and lifestyle stroke-prevention interventions for first ischemic strokes, transient ischemic attacks, and subsequent events.