Socioeconomic Deprivation and Survival After Stroke: Findings From the Prospective South London Stroke Register of 1995 to 2011

Health Inequity and Time From Pediatric Stroke Onset to Arrival

BACKGROUND

Time from stroke onset to hospital arrival determines treatment and impacts outcome. Structural, socioeconomic, and environmental factors are associated with health inequity and onset-to-arrival in adult stroke. We aimed to assess the association between health inequity and onset-to-arrival in a pediatric comprehensive stroke center.

METHODS

A retrospective observational study was conducted on a consecutive cohort of children (>28 days-18 years) diagnosed with acute arterial ischemic stroke (AIS) between 2004 and 2019. Neighborhood-level material deprivation was derived from residential postal codes and used as a proxy measure for health inequity. Patients were stratified by level of neighborhood-level material deprivation, and onset-to-arrival was categorized into 3 groups: <6, 6 to 24, and >24 hours. Association between neighborhood-level material deprivation and onset-to-arrival was assessed in multivariable ordinal logistic regression analyses adjusting for sociodemographic and clinical factors.

RESULTS

Two hundred and twenty-nine children were included (61% male; median age [interquartile range] at stroke diagnosis 5.8-years [1.1-11.3]). Over the 16-year study period, there was an increase in proportion of children diagnosed with AIS living in the most deprived neighborhoods and arriving at the emergency room within 6 hours (P=0.01). Among Asian patients, a higher proportion lived in the most deprived neighborhoods (P=0.02) and level of material deprivation was associated with AIS risk factors (P=0.001).

CONCLUSIONS

Our study suggests an increase in pediatric stroke in deprived neighborhoods and certain communities, and earlier arrival times to the emergency room over time. However, whether these changes are due to an increase in incidence of childhood AIS or increased awareness and diagnosis is yet to be determined. The association between AIS risk factors and material deprivation highlights the intersectionality of clinical factors and social determinants of health. Finally, whether material deprivation impacts onset-to-arrival is likely complex and requires further examination.

Cohort profile: The South London Stroke Register - a population-based register measuring the incidence and outcomes of stroke

PURPOSE

The South London Stroke Register (SLSR) is a population-based cohort study, which was established in 1995 to study the causes, incidence, and outcomes of stroke. The SLSR aims to estimate incidence, and acute and long term needs in a multi-ethnic inner-city population, with follow-up durations for some participants exceeding 20 years.

PARTICIPANTS

The SLSR aims to recruit residents of a defined area within Lambeth and Southwark who experience a first stroke. More than 7700 people have been registered since inception, and >2750 people continue to be followed up. At the 2011 census, the source population was 357,308.

FINDINGS TO DATE

The SLSR was instrumental in highlighting the inequalities in risk and outcomes in the UK, and demonstrating the dramatic improvements in care quality and outcomes in recent decades. Data from the SLSR informed the UK National Audit Office in its 2005 report criticising the poor state of stroke care in England. For people living in the SLSR area the likelihood of being treated in a stroke unit increased from 19% in 1995-7 to 75% in 2007-9. The SLSR has investigated health inequalities in stroke incidence and outcome. SLSR analyses have demonstrated that lower socioeconomic status was associated with poorer outcome, and that Black people and younger people have not experienced the same improvements in stroke incidence as other groups.

FUTURE PLANS

As part of an NIHR Programme Grant for Applied Research, from April 2022 the SLSR has expanded to recruit ICD-11 defined stroke (including those with <24 h symptoms where there are neuroimaging findings), and have expanded the follow up interviews to collect more detailed information on quality of life, cognition, and care needs. Additional data items will be added over the Programme based on feedback from patients and other stakeholders.

Association Between Neighborhood Socioeconomic Status and 30-Day Mortality and Readmission for Patients With Common Neurologic Conditions

BACKGROUND AND OBJECTIVES

Patients of low individual socioeconomic status (SES) are at a greater risk of unfavorable health outcomes. However, the association between neighborhood socioeconomic deprivation and health outcomes for patients with neurologic disorders has not been studied at the population level. Our objective was to determine the association between neighborhood socioeconomic deprivation and 30-day mortality and readmission after hospitalization for various neurologic conditions.

METHODS

This was a retrospective study of nationwide Medicare claims from 2017 to 2019. We included patients older than 65 years hospitalized for the following broad categories based on diagnosis-related groups (DRGs): multiple sclerosis and cerebellar ataxia (DRG 058-060); stroke (061-072); degenerative nervous system disorders (056-057); epilepsy (100-101); traumatic coma (082-087), and nontraumatic coma (080-081). The exposure of interest was neighborhood SES, measured by the area deprivation index (ADI), which uses socioeconomic indicators, such as educational attainment, unemployment, infrastructure access, and income, to estimate area-level socioeconomic deprivation at the level of census block groups. Patients were grouped into high, middle, and low neighborhood-level SES based on ADI percentiles. Adjustment covariates included age, comorbidity burden, race/ethnicity, individual SES, and sex.

RESULTS

After exclusions, 905,784 patients were included in the mortality analysis and 915,993 were included in the readmission analysis. After adjustment for age, sex, race/ethnicity, comorbidity burden, and individual SES, patients from low SES neighborhoods had higher 30-day mortality rates compared with patients from high SES neighborhoods for all disease categories except for multiple sclerosis: magnitudes of the effect ranged from an adjusted odds ratio of 2.46 (95% CI 1.60-3.78) for the nontraumatic coma group to 1.23 (95% CI 1.19-1.28) for the stroke group. After adjustment, no significant differences in readmission rates were observed for any of the groups.

DISCUSSION

Neighborhood SES is strongly associated with 30-day mortality for many common neurologic conditions even after accounting for baseline comorbidity burden and individual SES. Strategies to improve health equity should explicitly consider the effect of neighborhood environments on health outcomes.

Race as a factor in adverse outcomes following unruptured aneurysm surgery

INTRODUCTION

Strong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States.

METHODS

Data from the 2012-2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type.

RESULTS

7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07-1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients.

CONCLUSION

Our nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.

A case control study of occupation and cardiovascular disease risk in Japanese men and women

We aimed to investigate the risks of cardiovascular diseases associated with specific occupations, using a nation-wide, multicentre, hospital-based registry data from the Inpatient Clinico-Occupational Survey. The analysis included 539,110 controls (non-circulatory disease) and 23,792 cases (cerebral infarction, intracerebral/subarachnoid hemorrhage, acute myocardial infarction) aged ≥ 20 years who were initially hospitalized during 2005–2015. The participants’ occupational and clinical histories were collected by interviewers and medical doctors. Occupations were coded into 81 categories according to the Japanese standard occupation classification. Multivariable logistic regression analysis adjusted for age, admission year and hospital, smoking, alcohol consumption, hypertension, and shift-work was conducted by sex using general clerical workers as the reference. Increased risks of cerebral infarction, intracerebral hemorrhage, subarachnoid hemorrhage, and acute myocardial infarction, were observed in 15, 20, 25, and 1 occupation(s) in men, and 9, 2, 2, and 10 occupations in women. Motor vehicle drivers, food and drink preparatory workers, fishery workers, cargo workers, civil engineer workers, and other manual workers in men and other manual workers in women faced increased risks of all three stroke subtypes. Our findings demonstrate associations between specific occupations and the risk of cardiovascular disease incidence and suggest that the risk may vary by occupation.

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Socioeconomic deprivation and long-term outcomes after elective surgery: analysis of prospective data from two observational studies

BACKGROUND

Socioeconomic deprivation is associated with health inequalities. We explored relationships between socioeconomic group and outcomes after elective surgery in the UK National Health Service (NHS).

METHODS

We combined data from two observational studies in 115 NHS hospitals and determined socioeconomic group using the Index of Multiple Deprivation (IMD) quintiles based on place of residence. Postoperative complications and 3-yr survival were assessed using logistic and Cox regression. Univariate analyses were adjusted for age differences between IMD quintiles. Multivariable analyses were used to account for other baseline risk factors including sex and comorbid disease. Results are reported as n (%), hazard ratios (HR) or odds ratios (OR) with 95% confidence intervals.

RESULTS

Postoperative complications developed in 971/9051 patients (10.7%) and 1597/9043 patients (17.7%) died within 3 yr. Complication rates increased with deprivation (reference group least-deprived IMD5): IMD1 (OR=1.44 [1.17-1.78]; P<0.001), IMD2 (OR=1.38 [1.12-1.70]; P<0.01), IMD3 (OR=1.09 [0.88-1.35]: P=0.44), IMD4 (OR=0.89 [0.71-1.11]; P=0.30). More patients from the most deprived quintile died (IMD1) (n=349, 18.8%) compared with the least deprived (IMD5) (n=297, 15.9%) with a trend across the socioeconomic spectrum (P=0.01). After age adjustment, patients in the most deprived areas experienced reduced 3-yr survival: IMD1 (HR=1.43 [1.23-1.67]; P<0.0001), IMD2 (HR=1.35 [1.15-1.57]; P<0.001), IMD3 (HR=1.04 [0.89-1.23]; P=0.60), and IMD4 (HR=1.11 [0.95-1.30]; P=0.19). This finding persisted in risk-adjusted analyses. Increased complication rates only partially explained this reduced survival.

CONCLUSIONS

Socioeconomic deprivation is associated with worse long-term outcomes after elective surgery. This risk factor should be considered when planning perioperative care for patients from deprived areas.

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.

Socioeconomic status predicts the risk of stroke death: A systematic review and meta-analysis

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Low socioeconomic status influence on the risk of stroke mortality.

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Low income and ocuption for stroke mortality is higher than education.

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The heterogeneity of the study was mainly from different SES indicator.

Low socioeconomic status appears to be an independent risk factor for stroke mortality in epidemiology studies, but there has been no systematic assessment of this association. We performed a systematic review and meta-analysis evaluating the association between low socioeconomic status and stroke mortality. A systematic review of MEDLINE, EMBASE, and Web of Science for cohort studies that reported low socioeconomic status and stroke mortality was conducted from inception until July 2017. Research information, adjusted risk ratio (RR) estimates and 95% confidence intervals (Cls) were extracted. Estimates were pooled using a random-effects model. Heterogeneity was examined using the Q statistic and I². Twenty-seven prospective cohort studies (471,354,852 subjects; 429,886 deaths) assessing stroke mortality with low socioeconomic status were identified. Compared with the highest socioeconomic status, overall RR of stroke mortality was 1.39 (95% CI, 1.31–1.48) for those with the lowest after adjustment for confounding factors, but there was substantial heterogeneity between studies (I² = 89.9%, P = 0.001). Significant relationships were observed between risk of stroke mortality and the lowest education (RR = 1.21, 95% CI 1.11–1.33; I² = 70.9%, P < 0.001), income (RR = 1.54, 95% CI 1.30–1.82; I² = 91.6%, P < 0.001), occupation (RR = 1.54, 95% CI 1.35–1.75; I² = 78.3%, P < 0.001), composite socioeconomic status (RR = 1.37, 95% CI 1.25–1.51; I² = 69.5%, P = 0.001). After subgroup analysis, it was found that the heterogeneity of each SES indicator mainly came from the follow-up time, study population, stroke type, study area. Patients with low socioeconomic status had a higher risk of stroke mortality. The heterogeneity of income and occupation is larger, and the education and composite SES is smaller.

Socioeconomic Status And Acute Stroke Care: Has The Inequality Gap Been Closed?

Purpose

Socioeconomic inequality in stroke care occurs even in countries with free access to health care. We aimed to investigate the association between socioeconomic status and guideline-recommended acute care in Denmark during the last decade.

Design

We conducted a nationwide, population-based study. We used household income, employment status, and education as markers of socioeconomic status and adjusted the results for relevant clinical covariates. We used weighted linear regression models to analyse empirical log odds of performance measure fulfillment at patient level.

Setting

Public hospitals in Denmark.

Participants

A total of 110,848 consecutive stroke patients discharged between 2004 and 2014.

Intervention(s)

Acute stroke care according to clinical guidelines.

Main outcome measure(s)

Guideline-recommended care was defined in two ways based on clinical performance measures: the percentage of fulfilled measures used throughout the study period (m=8) (model 1) and the percentage of fulfilled measures used at the time of discharge (m=8 to 16) (model 2).

Results

Compared with high family income, low income was negatively associated with the guideline-recommended care; odds ratios (95% CI) were 0.89 (0.85–0.93) in model 1 and 0.81 (0.77–0.85) in model 2. Low family income was negatively associated with fulfillment of 14 of the 16 performance measures. In general, the percentage of performance measures fulfilled increased over time from 70% (95% CI 63–76) to 85% (95% CI 83–87).

Conclusion

Socioeconomic inequality in guideline-recommended stroke care remains despite overall improvements in a setting with free access to care and systematic monitoring of health care quality.

Association of Socioeconomic Status With Ischemic Stroke Survival

Background and Purpose- The aim of the study was to determine the impact of individuals' socioeconomic status and their Primary Care Service Area Socioeconomic Index on survival after ischemic stroke. Methods- We conducted a nationwide population-based cohort study in Catalonia, Spain. We included all patients with first ischemic stroke admitted to a public hospital between January 1, 2015, and December 31, 2016. We measured both individual socioeconomic status (categorized as exempts, <€18 000 [$US 20 468] income per year, and >€18 000 income per year) and Primary Care Service Area Socioeconomic Index (from 0 to 100 categorized in quartiles). We used mixed-effects logistic and survival models to estimate odds ratios and hazard ratios for the short- (30 days) and the long-term (3 years) all-cause case fatality rates by individuals' socioeconomic status groups. Results- The cohort consisted of 16 344 ischemic stroke patients with 24 638 person-years of follow-up. We did not find an association between the lowest socioeconomic individual status and short-term survival (odds ratio, 1.03; 95% CI, 0.76-1.40), although we found it in patients with <€18 000 income/year (odds ratio, 1.26; 95% CI, 1.10-1.45). At long-term, after adjustment, we observed a gradient in mortality risk with decreasing individual socioeconomic status (hazard ratio, 1.52; 95% CI, 1.30-1.77). The Primary Care Service Area Socioeconomic Index had only an influence on short-term survival (odds ratio, 1.19; 95% CI, 1.03-1.37). Conclusions- Individuals' socioeconomic status was associated with short- and long-term survival in patients with ischemic stroke. Conversely, Primary Care Service Area Socioeconomic Index measures had an influence only in short-term survival. A small fraction of this association is due to differences in comorbidity and cardiovascular risk factors. Interventions addressing both individuals' and primary care service socioeconomic aspects might eventually affect differently short- and long-term survival.

Association between socioeconomic status and prognosis after ischemic stroke in South China

Background: Previous studies have conflicting results on the association between socioeconomic status and stroke outcomes. Thus, this study aimed to investigate whether socioeconomic status is associated with the prognosis of ischemic stroke in Guangzhou, South China. Methods: A total of 622 patients with ischemic stroke who were admitted in the neurology department of five general hospitals in Guangzhou from May 2014 to October 2014 were included in the study. Socioeconomic status was measured based on education, income, caregiver, and insurance. The modified Rankin scale was used to evaluate the two years prognosis of patients with stroke. A multivariate logistic regression model was performed to determine the association between socioeconomic status and ischemic stroke prognosis. Results: In 2 years follow-up, 542 ischemic stroke patients were interviewed by telephone. Age ranged from 31 to 96 years, 65.5% of the patients were male. 33.9% of patients with ischemic stroke had a poor prognosis. After adjustment for age, sex, cardiovascular disease, behavior lifestyle, and severity of stroke, odds ratio for poor prognosis in patients with low income was 1.84 (95%CI 1.05-3.22), family caregiver 3.19 (95%CI 1.05-9.70), and no insurance 1.68 (95%CI 1.02-2.77). Conclusions: Patients with low income, family caregiver, and no insurance have a poorer prognosis after ischemic stroke that can be partly explained by intermediate variable in the patients' demographic characteristics, cardiovascular disease, behavior lifestyle, and stroke severity. Abbreviations: DALYs: disability-adjusted life years; SES: socioeconomic status; FMC: free medical care; MIUR: medical insurance for urban residents; MIUE: medical insurance for urban employees; NCMS: new rural cooperative medical scheme ; NIHSS: National Institute of Health Stroke Scale ; mRS: modified Rankin scale; OR: odds ratios; CI: confidence interval.

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.

Socioeconomic disparities in prehospital stroke care

Background and purpose

Recent studies have revealed socioeconomic disparities in stroke outcomes. Here, we investigated whether prehospital stroke care differs with respect to socioeconomic status (SES).

Methods

Consecutive stroke and TIA patients (n = 3006) admitted to stroke units at Sahlgrenska University Hospital, Gothenburg, Sweden, from 1 November 2014 to 31 July 2016, were included. Data on prehospital care were obtained from a local stroke register. Socioeconomic status was classified according to the average level of income and education within each patient’s neighbourhood (postcode area).

Results

The median system delay from calling the emergency medical communication centre (EMCC) to start of brain computed tomography on hospital arrival was 3 h 47 min (95% confidence interval (CI) 3 h 30 min to 4 h 05 min) for patients within the lowest SES tertile and 3 h 17 min (95% CI 3 h 00 min to 3 h 37 min) for the highest tertile (p < 0.05). Patients with a lower SES were less likely to receive the highest priority in the ambulance (p < 0.05) and had lower rates of prehospital recognition of stroke/TIA (p < 0.05) than those with a high SES. No inequities were found concerning EMCC prioritisation or the probability of ambulance transport.

Conclusions

We found socioeconomic inequities in prehospital stroke care which could affect the efficacy of acute stroke treatment. The ambulance nurses’ ability to recognise stroke/TIA may partly explain the observed inequities.

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

BACKGROUND

We aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England.

METHODS

In this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards).

FINDINGS

Of the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7-2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3-1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07-1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20-1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05-1·17).

INTERPRETATION

Wide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke.

FUNDING

NHS England and the Welsh Government.

The Development of Psychiatric Services Providing an Alternative to Full-Time Hospitalization Is Associated with Shorter Length of Stay in French Public Psychiatry

International recommendations for mental health care have advocated for a reduction in the length of stay (LOS) in full-time hospitalization and the development of alternatives to full-time hospitalizations (AFTH) could facilitate alignment with those recommendations. Our objective was therefore to assess whether the development of AFTH in French psychiatric sectors was associated with a reduction in the LOS in full-time hospitalization. Using data from the French national discharge database of psychiatric care, we computed the LOS of patients admitted for full-time hospitalization. The level of development of AFTH was estimated by the share of human resources allocated to those alternatives in the hospital enrolling the staff of each sector. Multi-level modelling was carried out to adjust the analysis on other factors potentially associated with the LOS (patients', psychiatric sectors' and environmental characteristics). We observed considerable variations in the LOS between sectors. Although the majority of these variations resulted from patients' characteristics, a significant negative association was found between the LOS and the development of AFTH, after adjusting for other factors. Our results provide first evidence of the impact of the development of AFTH on mental health care and will provide a lever for policy makers to further develop these alternatives.

Analysis of cerebrovascular disease mortality trends in Andalusia (1980-2014)

INTRODUCTION

In recent decades, mortality rates for cerebrovascular diseases (CVD) have decreased significantly in many countries. This study analyses recent tendencies in CVD mortality rates in Andalusia (1980-2014) to identify any changes in previously observed sex and age trends.

PATIENTS AND METHODS

CVD mortality and population data were obtained from Spain's National Statistics Institute database. We calculated age-specific and age-standardised mortality rates using the direct method (European standard population). Joinpoint regression analysis was used to estimate the annual percentage change in rates and identify significant changes in mortality trends. We also estimated rate ratios between Andalusia and Spain.

RESULTS

Standardised rates for both males and females showed 3 periods in joinpoint regression analysis: an initial period of significant decline (1980-1997), a period of rate stabilisation (1997-2003), and another period of significant decline (2003-2014).

CONCLUSIONS

Between 1997 and 2003, age-standardised rates stabilised in Andalusia but continued to decrease in Spain as a whole. This increased in the gap between CVD mortality rates in Andalusia and Spain for both sexes and most age groups.

Health Inequalities Associated with Post-Stroke Visual Impairment in the United Kingdom and Ireland: A Systematic Review

The aim of this study was to report on the health inequalities facing stroke survivors with visual impairments as described in the current literature. A systemic review of the literature was conducted to investigate the potential health inequalities facing stroke survivors with subsequent visual impairments. A quality-of-evidence and risk-of-bias assessment was conducted for each of the included articles using the appropriate tool dependent on the type of article. Only four articles discussed health inequalities affecting stroke survivors with visual impairment specifically. A further 23 articles identified health inequalities after stroke, and 38 reported on health inequalities within the visually impaired UK or Irish population. Stroke survivors with visual impairment face inconsistency in eye care provision nationally, along with variability in the assessment and management of visual disorders. The subgroups identified as most at risk were females; black ethnicity; lower socioeconomic status; older age; and those with lower education attainment. The issue of inconsistent service provision for this population must be addressed in future research. Further research must be conducted in order to firmly establish whether or not stroke survivors are at risk of the aforementioned sociodemographic and economic inequalities.

Social deprivation and stroke severity on admission: a French cohort study in Burgundy and the West Indies - Guyana region

BACKGROUND AND PURPOSE

Although there is growing and convincing evidence that socially deprived patients are at higher risk of stroke and worse outcomes, it remains controversial whether or not they suffer more severe stroke. This study aimed to evaluate the influence of social deprivation on initial clinical severity in patients with stroke.

METHODS

A total of 1536 consecutive patients with an acute first-ever stroke (both ischaemic stroke and intracerebral hemorrhage) were prospectively enrolled from six French study centers. Stroke severity on admission was measured by the National Institutes of Health Stroke Scale score. Social deprivation was assessed at the individual level by the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examen de Santé (EPICES) score, a validated multidimensional questionnaire, and several additional single socioeconomic indicators. Polytomous logistic regression analyses were performed to evaluate the association between social deprivation and stroke severity.

RESULTS

In univariate analysis, the EPICES score (P = 0.039) and level of education (P = 0.018) were the only two socioeconomic variables associated with stroke severity. Multivariate analysis of the association between EPICES and National Institutes of Health Stroke Scale scores showed that more deprived patients presented a significantly higher risk of both mild and moderate/severe stroke (odds ratio for mild versus minor stroke, 1.39; 95% confidence interval, 1.06-1.84; odds ratio for moderate/severe versus minor stroke, 1.44; 95% confidence interval, 1.09-1.92). A non-significant trend towards a higher risk of both mild and moderate/severe stroke in less educated patients was observed.

CONCLUSIONS

Social deprivation was associated with a more severe clinical presentation in patients with stroke. These findings may contribute to the worse outcome after stroke in deprived patients, and underline the need for strategies to reduce social inequalities for stroke.

Money is Brain: Financial Barriers and Consequences for Canadian Stroke Patients

BACKGROUND

Stroke patients of lower socioeconomic status have worse outcomes. It remains poorly understood whether this is due to illness severity or personal or health system barriers. We explored the experiences of stroke patients with financial barriers in a qualitative descriptive pilot study, seeking to capture perceived challenges that interfere with their poststroke health and recovery.

METHODS

We interviewed six adults with a history of stroke and financial barriers in Alberta, Canada, inquiring about their: (1) experiences after stroke; (2) experience of financial barriers; (3) perceived reasons for financial barriers; (4) health consequences of financial barriers; and (5) mechanisms for coping with financial barriers. Two reviewers analyzed data using inductive thematic analysis.

RESULTS

The participants developed new or worsened financial circumstances as a consequence of stroke-related disability. Poststroke impairments and financial barriers took a toll on their mental health. They struggled to access several aspects of long-term poststroke care, including allied health professional services, medications, and proper nutrition. They described opportunity costs and tradeoffs when accessing health services. In several cases, they were unaware of health resources available to them and were hesitant to disclose their struggles to their physicians and even their families.

CONCLUSION

Some patients with financial barriers perceive challenges to accessing various aspects of poststroke care. They may have inadequate knowledge of resources available to them and may not disclose their concerns to their health care team. This suggests that providers themselves might consider asking stroke patients about financial barriers to optimize their long-term poststroke care.

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.

Socioeconomic deprivation and mortality in people after ischemic stroke: The China National Stroke Registry

Background

Previous findings of the association between socioeconomic deprivation and mortality after ischemic stroke are inconsistent. There is a lack of data on the association with combined low education, occupational class, and income. We assessed the associations of three indicators with mortality.

Methods

We examined data from the China National Stroke Registry, recording all stroke patients occurred between September 2007 and August 2008. Baseline socioeconomic deprivation was measured using low levels of education at <6 years, occupation as manual laboring, and average family income per capita at ≤¥1000 per month. A total of 12,246 patients with ischemic stroke were analyzed.

Results

In a 12-month follow-up 1640 patients died. After adjustment for age, sex, cardiovascular risk factors, severity of stroke, and prehospital medications, odds ratio for mortality in patients with low education was 1.25 (95%CI 1.05–1.48), manual laboring 1.37 (1.09–1.72), and low income 1.19 (1.03–1.37). Further adjustment for acute care and medications in and after hospital made no substantial changes in these odds ratios, except a marginal significant odds ratio for low income (1.15, 0.99–1.33). The odds ratio for low income was 1.27 (1.01–1.60) within patients with high education. Compared with no socioeconomic deprivation, the odds ratio in patients with socioeconomic deprivation determined by any one indicator was 1.33 (1.11–1.59), by any two indicators 1.36 (1.10–1.69), and by all three indicators 1.56 (1.23–1.97).

Conclusions

There are significant inequalities in survival after ischemic stroke in China in terms of social and material forms of deprivation. General socioeconomic improvement, targeting groups at high risk of mortality is likely to reduce inequality in survival after stroke.

The effects of socioeconomic status on stroke risk and outcomes

The latest evidence on socioeconomic status and stroke shows that stroke not only disproportionately affects low-income and middle-income countries, but also socioeconomically deprived populations within high-income countries. These disparities are reflected not only in risk of stroke but also in short-term and long-term outcomes after stroke. Increased average levels of conventional risk factors (eg, hypertension, hyperlipidaemia, excessive alcohol intake, smoking, obesity, and sedentary lifestyle) in populations with low socioeconomic status account for about half of these effects. In many countries, evidence shows that people with lower socioeconomic status are less likely to receive good-quality acute hospital and rehabilitation care than people with higher socioeconomic status. For clinical practice, better implementation of well established treatments, effective management of risk factors, and equity of access to high-quality acute stroke care and rehabilitation will probably reduce inequality substantially. Overcoming barriers and adapting evidence-based interventions to different countries and health-care settings remains a research priority.

The impact of social deprivation on mortality following acute myocardial infarction, stroke or subarachnoid haemorrhage: a record linkage study

Background

The impact of social deprivation on mortality following acute myocardial infarction (AMI), stroke and subarachnoid haemorrhage (SAH) is unclear. Our objectives were, firstly, to determine, for each condition, whether there was higher mortality following admission according to social deprivation and secondly, to determine how any higher mortality for deprived groups may be correlated with factors including patient demographics, timing of admission and hospital size.

Methods

Routinely collected, linked hospital inpatient, mortality and primary care data were analysed for patients admitted as an emergency to hospitals in Wales between 2004 and 2011 with AMI (n = 30,663), stroke (37,888) and SAH (1753). Logistic regression with Bonferroni correction was used to examine, firstly, any significant increases in mortality with social deprivation quintile and, secondly, the influence of patient demographics, timing of admission and hospital characteristics on any higher mortality among the most socially deprived groups.

Results

Mortality was 14.3 % at 30 days for AMI, 21.4 % for stroke and 35.6 % for SAH. Social deprivation was significantly associated with higher mortality for AMI (25 %; 95 % CI = 12 %, 40 %) higher for quintile V compared with I), stroke (24 %; 14 %, 34 %), and non-significantly for SAH (32 %; −7 %, 87 %).

The higher mortality at 30 days with increased social deprivation varied significantly according to patient age for AMI patients and time period for SAH. It was also highest for both AMI and stroke patients, although not significantly for female patients, for admissions on weekdays and during autumn months.

Conclusions

We have demonstrated a positive association between social deprivation and higher mortality following emergency admissions for both AMI and stroke. The study findings also suggest that the influence of patient demographics, timing of admission and hospital size on social inequalities in mortality are quite similar for AMI and stroke.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-015-0045-x) contains supplementary material, which is available to authorized users.

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.

Socioeconomic deprivation and survival after stroke in China: a systematic literature review and a new population-based cohort study

OBJECTIVE

To assess the association of socioeconomic deprivation (SED) with survival after stroke in China.

DESIGN

A systematic literature review and a new population-based cohort study.

SETTING AND PARTICIPANTS

In urban and rural communities in Anhui, China, 2978 residents aged ≥60 years took part in baseline investigation and were followed up for 5 years; five published studies were identified for a systematic review.

PRIMARY AND SECONDARY OUTCOME MEASURES

167 of 2978 participants (5.6%) had doctor-diagnosed stroke at baseline or 1 year later. All-cause mortality in the follow-up.

RESULTS

In the Anhui cohort follow-up of 167 patients with stroke, 64 (38.3%) died. Multivariate adjusted hazard ratio (HR) of mortality in patients with educational level of less than or equal to primary school was 1.88 (95% CI 1.05 to 3.36) compared to those having more than primary school education. Increased HR of mortality in patients living in a rural area was at borderline significant (1.64, 0.97 to 2.78), but the HR in patients with lower levels of occupation and income was not significant. Published studies showed a significant increase in stroke mortality in relation to some SED indicators. Pooled relative risk (RR) of mortality in patients with low education was 3.07 (1.27 to 7.34), in patients with low income 1.58 (1.50 to 1.65) and in patients living in rural areas 1.47 (1.37 to 1.58).

CONCLUSIONS

The evidence suggests the presence of a mortality gradient after stroke for material as well as social forms of deprivation in China. Inequalities in survival after stroke persist and need to be taken into account when implementing intervention programmes.

Unemployment, government healthcare spending, and cerebrovascular mortality, worldwide 1981-2009: an ecological study

BACKGROUND

The global economic downturn has been associated with unemployment rises, reduced health spending, and worsened population health. This has raised the question of how economic variations affect health outcomes.

AIM

We sought to determine the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality globally.

METHODS

Data were obtained from the World Bank and World Health Organization. Multivariate regression analysis was used to assess the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality. Country-specific differences in infrastructure and demographics were controlled for. One- to five-year lag analyses and robustness checks were conducted.

RESULTS

Across 99 countries worldwide, between 1981 and 2009, every 1% increase in unemployment was associated with a significant increase in cerebrovascular mortality (coefficient 187, CI: 86.6-288, P = 0.0003). Every 1% rise in government healthcare expenditure, across both genders, was associated with significant decreases in cerebrovascular deaths (coefficient 869, CI: 383-1354, P = 0.0005). The association between unemployment and cerebrovascular mortality remained statistically significant for at least five years subsequent to the 1% unemployment rise, while the association between government healthcare expenditure and cerebrovascular mortality remained significant for two years. These relationships were both shown to be independent of changes in gross domestic product per capita, inflation, interest rates, urbanization, nutrition, education, and out-of-pocket spending.

CONCLUSIONS

Rises in unemployment and reductions in government healthcare expenditure are associated with significant increases in cerebrovascular mortality globally. Clinicians may also need to consider unemployment as a possible risk factor for cerebrovascular disease mortality.

Long-term survival of older Australian women with a history of stroke

BACKGROUND

Although many people survive an initial stroke, little is known about long-term impacts of stroke on survival.

METHODS

Data from the Australian Longitudinal Study on Women's Health were used to compare 12-year survival rates in older women with prevalent stroke, incident stroke, and no stroke. Cox regression models were fitted to assess the effect of lifestyle and demographic characteristics on the relationship between stroke and all-cause mortality. The "no stroke" group was used as the reference category in all statistical models.

RESULTS

At baseline, 4% of the women reported a previous stroke (prevalent stroke). At survey 2 in 1999, a further 3% reported having a stroke between 1996 and 1999 (incident stroke). Stroke was significantly associated with reduced long-term survival. Age-adjusted hazards ratios (HRs) were: 1.64 (1.43-1.89) for the "prevalent stroke" group and 2.29 (1.97-2.66) for the "incident stroke" group. Adjusting for comorbidities reduced the HRs, but the risk of death was still significantly higher in the 2 stroke groups. Adjusting for demographic and lifestyle factors did not make any further difference to the relationship between stroke and survival. However, obesity and past smoking were also risk factors for mortality.

CONCLUSIONS

This study highlights the long-term impacts of stroke on life expectancy and the importance of comorbidities and other lifestyle factors in affecting poststroke survival.