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KAZADI KABANDA I, KIANGEBENI NGONZO C, EMEKA BOWAMOU CK, DIVENGI NZAMBI JP, KIATOKO PONTE N, TUYINAMA MADODA O, NKODILA NATUHOYILA A, M’BUYAMBA-KABANGU JR, LONGO-MBENZA B, BANZULU BOMBA D, KIANU PHANZU B. Stroke signs knowledge and factors associated with a delayed hospital arrival of patients with acute stroke in Kinshasa. Heliyon 2024; 10:e28311. [PMID: 38571603 PMCID: PMC10988012 DOI: 10.1016/j.heliyon.2024.e28311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024] Open
Abstract
Background Rapid recognition and early medical intervention are essential to reduce stroke-related mortality and long-term disability. This study aimed to evaluate awareness of stroke symptoms/signs and determine factors delaying the hospital arrival of patients with acute stroke in Kinshasa. Methods Patients with stroke and/or accompanying family members were interviewed using a standard questionnaire, and their medical records were reviewed. Factors independently associated with a late arrival (≥4.5 h) to the hospital were identified using the logistic regression test in forward multivariate analysis. Results Overall, 202 patients with an average age of 57.9 ± 13.1 years were included. Only 27 (13.4%) patients immediately associated the initial symptoms with a stroke episode. Delayed hospital arrival was observed in 180 (89.1%) patients. Unmarried status (adjusted odds ratio [aOR], 2.29; 95% confidence interval [CI], 1.17-4.88; p = 0.007), low education level (aOR, 2.29; 95% CI, (1.12-5.10; p = 0,014), absence of impaired consciousness (aOR, 3.12; 95% CI, 1.52-4.43; p = 0.005), absence of a history of hypertention (aOR, 1.85; 95% CI, 1.18-3.78; p = 0.041), absence of a history of diabetes (aOR, 1.93; 95% CI, 1.15-4.58; p = 0.013), heavy alcohol consumption (aOR, 1.83; 95% CI, 1.12-2.83; p = 0.045), absence of a severe to very severe stroke (aOR, 4.93; 95% CI, 0.82-1.01; p = 0.002), and presence of ischemic stroke (aOR, 2.93; 95% CI, 1.54-4.59; p = 0.001) were identified as independent determinants of delayed hospital arrival. Conclusions This study depicted a low stroke awareness rate and a much longer prehospital delay than evidence-based guidelines recommend and identified eight factors that public health actions could target to promote the earliest management of stroke.
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Affiliation(s)
- Igor KAZADI KABANDA
- Faculty of Medicine, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | | | | | - Jean-Paul DIVENGI NZAMBI
- Department of Internal Medicine, Reference General Hospital, Kinshasa, the Democratic Republic of the Congo
| | - Nono KIATOKO PONTE
- Unit of Neurology, Centre Hospitalier Initiative Plus de Kinkole, Kinshasa, the Democratic Republic of the Congo
| | - Olivier TUYINAMA MADODA
- Emergency Unit, University Hospital of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Aliocha NKODILA NATUHOYILA
- Department of Biostatistics, Public Health School of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | | | - Benjamin LONGO-MBENZA
- Cardiology Unit, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Degani BANZULU BOMBA
- Department of Neuropsychiatry, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Bernard KIANU PHANZU
- Cardiology Unit, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
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Hu M, Yang T, Yang Y. Causal Associations of Education Level With Cardiovascular Diseases, Cardiovascular Biomarkers, and Socioeconomic Factors. Am J Cardiol 2024; 213:76-85. [PMID: 38199144 DOI: 10.1016/j.amjcard.2023.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/12/2023] [Accepted: 06/11/2023] [Indexed: 01/12/2024]
Abstract
An inverse association of education level with cardiovascular diseases has been documented in observational studies, yet the causality and potential mechanisms remain to be determined. To systematically investigate the causal associations of education level with cardiovascular diseases, cardiovascular biomarkers, and socioeconomic factors, a 2-sample Mendelian randomization was performed. The results revealed that higher genetically determined education level was associated with lower risks of type 2 diabetes mellitus (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.47 to 0.61, p = 3.04 × 10-23), peripheral artery disease (OR 0.62, 95% CI 0.51 to 0.76, p = 2.14 × 10-06), hypertension (OR 0.62, 95% CI 0.56 to 0.70, p = 4.22 × 10-16), coronary heart disease (OR 0.62, 95% CI 0.56 to 0.69, p = 3.50 × 10-19), myocardial infarction (OR 0.62, 95% CI 0.55 to 0.69, p = 2.58 × 10-16), ischemic stroke (OR 0.67, 95% CI 0.62 to 0.74, p = 6.00 × 10-19), deep vein thrombosis (OR 0.69, 95% CI 0.55 to 0.87, p = 0.0017), atrial fibrillation (OR 0.70, 95% CI 0.57 to 0.86, p = 0.0007), cardiac death (OR 0.71, 95% CI 0.60 to 0.86, p = 0.0003), heart failure (OR 0.72, 95% CI 0.65 to 0.79, p = 6.37 × 10-12), transient ischemic attack (OR 0.76, 95% CI 0.64 to 0.90, p = 0.0010), and venous thromboembolism (OR 0.79, 95% CI 0.67 to 0.92, p = 0.0028). Systolic blood pressure, diastolic blood pressure, C-reactive protein, body mass index, waist circumference, and triglycerides were decreased, whereas telomere length was increased. Subjects with higher education were less likely to smoke, intake salt, or be exposed to air pollution and depression state. They were more likely to take physical activity and possess more household income. In conclusion, higher education may causally decrease cardiovascular diseases through socioeconomic factors and cardiovascular biomarkers. Reducing education inequality is important in the management of cardiovascular diseases.
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Affiliation(s)
- Mengjin Hu
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Liu H, Jin A, Pan Y, Jing J, Meng X, Li H, Li Z, Wang Y. Trends of Sex Differences and Associated Factors in Stroke Outcomes Among Patients With Acute Ischemic Stroke: 2007 to 2018. Neurology 2024; 102:e207818. [PMID: 38165366 PMCID: PMC10834133 DOI: 10.1212/wnl.0000000000207818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Female patients have been shown to experience worse clinical outcomes after acute ischemic stroke (AIS) compared with male patients. We aimed to estimate the temporal trends in the sex differences in stroke outcomes and identify risk factors contributing to the sex differences spanning 10 years in China. METHODS This cohort study was conducted based on data from the China National Stroke Registries (CNSRs, comprising 3 phases, I-III, from 2007 to 2018). Patients with ischemic stroke within 7 days of symptom onset were included. The primary outcome was a 12-month poor functional outcome. Other outcomes included mortality and disability-adjusted life-year (DALY) lost. The sex differences in outcomes and associated factors were estimated using multivariable logistic regression. The sex differences between CNSRs were tested by the interaction of sex and time. RESULTS Among 42,564 patients included, 35.4% were female. The age-adjusted event rate of 12-month poor functional outcome and mortality decreased both in male and female patients after stroke onset (CNSRs I, II, and III, all p varies over time <0.001). There was a decrease in DALY lost for both sexes over the decade (male patients: from 10.1 to 9.3 DALYs; female patients: from 10.9 to 9.6 DALYs). Female patients showed worse 12-month poor functional outcome in CNSRs I and II (odds ratio [OR] with 95% CI: 1.24 [1.10-1.39] and 1.12 [1.01-1.25], respectively) compared with male patients, but the sex difference attenuated in CNSR III (OR with 95% CI: 1.02 [0.89-1.16]), with the temporal trend (p varies over time = 0.004). The sex difference and the temporal trend of the sex difference in mortality from 2007 to 2018 were not found (p varies over time = 0.45). The most important factors attenuating the sex difference in poor functional outcome in CNSRs I and III were education level, socioeconomic deprivation, baseline stroke severity, and current smoking. DISCUSSION This study demonstrated that the sex disparity in poor functional outcome at 12 months was substantially narrowed covering 10 years and completely attenuated in 2015-2018. The findings suggested that female patients have experienced larger improvements in stroke outcomes than male patients over the past decade.
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Affiliation(s)
- Huihui Liu
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Aoming Jin
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Jing Jing
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Hao Li
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Zixiao Li
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, China
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Lindmark A, Eriksson M, Darehed D. Mediation Analyses of the Mechanisms by Which Socioeconomic Status, Comorbidity, Stroke Severity, and Acute Care Influence Stroke Outcome. Neurology 2023; 101:e2345-e2354. [PMID: 37940549 PMCID: PMC10752643 DOI: 10.1212/wnl.0000000000207939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/28/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Low socioeconomic status (SES) is associated with increased risk of death and disability after stroke, but interventional targets to minimize disparities remain unclear. We aim to assess the extent to which SES-based disparities in the association between low SES and death and dependency at 3 months after stroke could be eliminated by offsetting differences in comorbidity, stroke severity, and acute care. METHODS This nationwide register-based cohort study included all 72 hospitals caring for patients with acute stroke in Sweden. All patients registered with an acute ischemic stroke in the Swedish Stroke Register in 2015-2016 who were independent in activities of daily living (ADL) during stroke were included. Data on survival and SES the year before stroke were retrieved by cross-linkage with other national registers. SES was defined by education and income and categorized into low, mid, and high. Causal mediation analysis was used to study the absolute risk of death and ADL dependency at 3 months depending on SES and to what extent hypothetical interventions on comorbidities, stroke severity, and acute care would equalize outcomes. RESULTS Of the 25,846 patients in the study, 6,798 (26.3%) were dead or ADL dependent 3 months after stroke. Adjusted for sex and age, low SES was associated with an increased absolute risk of 5.4% (95% CI 3.9%-6.9%; p < 0.001) compared with mid SES and 10.1% (95% CI 8.1%-12.2%; p < 0.001) compared with high SES. Intervening to shift the distribution of all mediators among patients with low SES to those of the more privileged groups would result in absolute reductions of these effects by 2.2% (95% CI 1.2%-3.2%; p < 0.001) and 4.0% (95% CI 2.6%-5.5%; p < 0.001), respectively, with the largest reduction accomplished by equalizing stroke severity. DISCUSSION Low SES patients have substantially increased risks of death and ADL dependency 3 months after stroke compared with more privileged patient groups. This study suggests that if we could intervene to equalize SES-related differences in the distributions of comorbidity, acute care, and stroke severity, up to 40 of every 1,000 patients with low SES could be prevented from dying or becoming ADL dependent.
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Affiliation(s)
- Anita Lindmark
- From the Department of Statistics (A.L., M.E.), Umeå School of Business, Economics and Statistics, and Sunderby Research Unit (D.D.), Department of Public Health and Clinical Medicine, Umeå University, Sweden.
| | - Marie Eriksson
- From the Department of Statistics (A.L., M.E.), Umeå School of Business, Economics and Statistics, and Sunderby Research Unit (D.D.), Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - David Darehed
- From the Department of Statistics (A.L., M.E.), Umeå School of Business, Economics and Statistics, and Sunderby Research Unit (D.D.), Department of Public Health and Clinical Medicine, Umeå University, Sweden
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Buus SMØ, Schmitz ML, Cordsen P, Paaske Johnsen S, Andersen G, Simonsen CZ. Socioeconomic Inequalities in Functional Outcome After Reperfusion-Treated Ischemic Stroke. Stroke 2023; 54:2040-2049. [PMID: 37377030 DOI: 10.1161/strokeaha.123.043547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- Sine Mette Øgendahl Buus
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
| | - Marie Louise Schmitz
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
| | - Pia Cordsen
- Danish Center for Health Services Research, Aalborg University, Gistrup, Denmark (P.C., S.P.J.)
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Aalborg University, Gistrup, Denmark (P.C., S.P.J.)
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (G.A., C.Z.S.)
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (G.A., C.Z.S.)
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Pantoja-Ruiz C, Porto F, Parra-Artunduaga M, Omaña-Alvarez L, Coral J, Rosselli D. Risk Factors, Presentation, and Outcome in Acute Stroke according to Social Position Indicators in Patients Hospitalised in a Referral Centre in Bogotá 2011-2019. Neuroepidemiology 2023; 57:170-175. [PMID: 37454654 DOI: 10.1159/000529794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Treatment of stroke is time-dependent and it challenges patients' social and demographic context for timely consultation and effective access to reperfusion therapies. OBJECTIVE The objective of this study was to relate indicators of social position to cardiovascular risk factors, time of arrival, access to reperfusion therapy, and mortality in the setting of acute stroke. METHODS A retrospective analysis of patients with a diagnosis of ischaemic stroke in a referral hospital in Bogotá was performed. A simple random sample with a 5% margin of error and 95% confidence interval was selected. Patients were characterised according to educational level, place of origin, marital status, occupation, duration of symptoms before consultation, cardiovascular risk factors, access to reperfusion therapy, and mortality during hospitalisation. RESULTS 558 patients were included with a slight predominance of women. Diagnosis of diabetes was more common in women and smoking in men (n = 68, 28.4% vs. n = 51, 15.9%; p = 0.0004). Rural origin was associated with higher prevalence of hypertension, diabetes, and dyslipidaemia (hypertension n = 45, 73.8% vs. n = 282, 57.4%; p = 0.007; diabetes n = 20, 33.3% vs. 109, 19.5%; p = 0.02; dyslipidaemia n = 19, 32.7% vs. n = 93, 18.9%; p = 0.02). Mortality was higher in rural patients (n = 8, 14.2% vs. n = 30, 6.1%; p = 0.03). Lower schooling was associated with higher frequency of hypertension and dyslipidaemia (hypertension n = 152, 76.0% vs. n = 94, 46.3%; p ≤ 0.0001; dyslipidaemia n = 56, 28% vs. n = 35, 17.0%; p = 0.009) as well as with late consultation (n = 30, 15% vs. n = 59, 28.7%; p = 0.0011) and lower probability of accessing reperfusion therapy (n = 12, 6% vs. n = 45, 22%; p ≤ 0.0001). Formal employment was associated with a visit to the emergency department in less than 3 h (n = 50, 25.2% vs. n = 58, 18%, p = 0.04 and a higher probability of accessing reperfusion therapy (n = 35, 17.6% vs. n = 33, 10.2%; p = 0.01). Finally, living in a household with a stratum higher than 3 was associated with a consultation before 3 h (n = 77, 25.5% vs. n = 39, 15.6%; p = 0.004) and a higher probability of reperfusion therapy (n = 57, 18.9% vs. n = 13, 5.2%; p ≤ 0.0001). CONCLUSION Indicators of socio-economic status are related to mortality, consultation time, and access to reperfusion therapy. Mortality and reperfusion therapy are inequitably distributed and, therefore, more attention needs to be directed to the cause of these disparities in order to reduce the access gap in the context of acute stroke in Bogotá.
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Affiliation(s)
- Camila Pantoja-Ruiz
- Department of Neurology, Faculty of Medicine, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Felipe Porto
- Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | | | - Juliana Coral
- Department of Neurology, Faculty of Medicine, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
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Naouri D, Allain S, Fery-Lemonier E, Wolff V, Derex L, Raynaud P, Costemalle V. Social inequalities and gender differences in health care management of acute ischemic strokes in France. Eur J Neurol 2022; 29:3255-3263. [PMID: 35789144 DOI: 10.1111/ene.15490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There are regional disparities in access to stroke units in France. Several studies have shown that living in disadvantaged areas is associated with higher frequency of stroke, worse severity at presentation, increased level of dependency, and higher mortality rates. However, few studies have explored the association between an individual's socioeconomic characteristics and stroke care. Our study aimed to determine if living standards are associated with stroke unit access for patients admitted to hospital for acute ischemic stroke. METHODS Using the EDP-Santé French administrative database, we selected all patients admitted to hospital for acute ischemic stroke between 2014 and 2017. Acute ischemic stroke corresponded to hospital stay with ICD-10 codes I63 or I64 as the main diagnosis. Multivariate logistic regression was used to identify if standard of living was associated with likelihood of admission to a stroke unit. RESULTS We identified 14 123 acute-care episodes, corresponding to 335 273 episodes in the general population when appropriately weighted. Of these, 52.9 % were admitted to a stroke unit. Being in the first (i.e., poorest) living standard quartile was associated with lower likelihood of admission to a stroke unit compared with the fourth (i.e., wealthiest) quartile, and was associated with a higher likelihood of paralysis and language disorder, and death at 1 year. CONCLUSION A low living standard was associated with lower likelihood of admission to a stroke unit as well as a greater chance of paralysis and aphasia at the end of hospitalization and a higher possibility of death at 1 year after stroke. Greater access to stroke units in disadvantaged people should be promoted.
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Affiliation(s)
- D Naouri
- Department for Research, Studies, Evaluation and Statistics (DREES), French Health and Social Affairs Ministry, Paris, France
| | - S Allain
- Department for Research, Studies, Evaluation and Statistics (DREES), French Health and Social Affairs Ministry, Paris, France
| | - E Fery-Lemonier
- Department for Research, Studies, Evaluation and Statistics (DREES), French Health and Social Affairs Ministry, Paris, France
| | - V Wolff
- Société Française de Neuro-Vasculaire (SFNV).,Service de neuro-vasculaire, Hôpital de Hautepierre, Strasbourg.,UR3072, Université de Strasbourg, Strasbourg
| | - L Derex
- Société Française de Neuro-Vasculaire (SFNV).,Stroke center, neurology department, neurological hospital, Hospices Civils de Lyon, France.,Research on Healthcare Performance (RESHAPE) U 1290 - INSERM, Université de Lyon, France
| | - P Raynaud
- Department for Research, Studies, Evaluation and Statistics (DREES), French Health and Social Affairs Ministry, Paris, France
| | - V Costemalle
- Department for Research, Studies, Evaluation and Statistics (DREES), French Health and Social Affairs Ministry, Paris, France
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Lindmark A, Eriksson M, Darehed D. Socioeconomic status and stroke severity: Understanding indirect effects via risk factors and stroke prevention using innovative statistical methods for mediation analysis. PLoS One 2022; 17:e0270533. [PMID: 35749530 PMCID: PMC9232158 DOI: 10.1371/journal.pone.0270533] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/11/2022] [Indexed: 11/19/2022] Open
Abstract
Background Those with low socioeconomic status have an increased risk of stroke, more severe strokes, reduced access to treatment, and more adverse outcomes after stroke. The question is why these differences are present. In this study we investigate to which extent the association between low socioeconomic status and stroke severity can be explained by differences in risk factors and stroke prevention drugs. Methods The study included 86 316 patients registered with an ischemic stroke in the Swedish Stroke Register (Riksstroke) 2012–2016. Data on socioeconomic status was retrieved from the Longitudinal integrated database for health insurance and labour market studies (LISA) by individual linkage. We used education level as proxy for socioeconomic status, with primary school education classified as low education. Stroke severity was measured using the Reaction Level Scale, with values above 1 classified as severe strokes. To investigate the pathways via risk factors and stroke prevention drugs we performed a mediation analysis estimating indirect and direct effects. Results Low education was associated with an excess risk of a severe stroke compared to mid/high education (absolute risk difference 1.4%, 95% CI: 1.0%-1.8%), adjusting for confounders. Of this association 28.5% was an indirect effect via risk factors (absolute risk difference 0.4%, 95% CI: 0.3%-0.5%), while the indirect effect via stroke prevention drugs was negligible. Conclusion Almost one third of the association between low education and severe stroke was explained by risk factors, and clinical effort should be taken to reduce these risk factors to decrease stroke severity among those with low socioeconomic status.
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Affiliation(s)
- Anita Lindmark
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
- * E-mail:
| | - Marie Eriksson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - David Darehed
- Department of Public Health and Clinical Medicine, Sunderby Research Unit, Umeå University, Sweden
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Buus SMØ, Schmitz ML, Cordsen P, Johnsen SP, Andersen G, Simonsen CZ. Socioeconomic Inequalities in Reperfusion Therapy for Acute Ischemic Stroke. Stroke 2022; 53:2307-2316. [PMID: 35579017 DOI: 10.1161/strokeaha.121.037687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reperfusion therapies (thrombolysis and thrombectomy) are of paramount importance for the recovery after ischemic stroke. We aimed to investigate if socioeconomic status (SES) was associated with the chance of receiving reperfusion therapy for ischemic stroke in a country with tax-funded health care. METHODS This nationwide register-based cohort study included patients with ischemic stroke registered in the Danish Stroke Registry between 2015 and 2018. SES was determined by prestroke educational attainment, income level, and employment status. Data on SES was obtained from Statistics Denmark and linked on an individual level with data from the Danish Stroke Registry. Risk ratios (RR) for receiving reperfusion therapies were calculated using univariate and multivariable Poisson regression with robust variance. RESULTS A total of 37 187 ischemic stroke patients were included. Low SES, as defined by education, income and employment status, was associated with lower treatment rates. The socioeconomic gradient was most pronounced according to employment status, with intravenous thrombolysis rates of 23.7% versus 15.8%, and thrombectomy rates of 5.1% versus 2.8% for employed versus unemployed patients. When the analyses were restricted to patients with timely hospital arrival, and adjusted for age, sex and immigrant status, low SES according to income and employment remained unfavorable for the likelihood of receiving intravenous thrombolysis: adjusted RR, 0.90 (95% CI, 0.86-0.95) for low versus high income, and adjusted RR, 0.77 (95% CI, 0.71-0.84) for unemployed versus employed patients. Similarly, low SES according to income and employment status remained unfavorable for the likelihood of receiving thrombectomy: adjusted RR, 0.83 (95% CI, 0.72-0.95) for low versus high income and adjusted RR, 0.68 (95% CI, 0.53-0.88) for unemployed versus employed patients. CONCLUSIONS Socioeconomic inequalities in reperfusion treatment rates among ischemic stroke patients prevail, even in a country with tax-funded universal health care.
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Affiliation(s)
| | - Marie Louise Schmitz
- Department of Neurology, Aarhus University Hospital, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Aalborg University, Denmark (P.C., S.P.J.)
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Aalborg University, Denmark (P.C., S.P.J.).,Department of Clinical Medicine, Aalborg University (S.P.J.)
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.).,Department of Clinical Medicine, Aarhus University (G.A., C.Z.S.)
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.).,Department of Clinical Medicine, Aarhus University (G.A., C.Z.S.)
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Sex and Economic Disparity Related to Reperfusion Therapies for Patients with Acute Ischemic Stroke in South Korea across a 10-Year Period: A Nationwide Population-Based Study Using the National Health Insurance Database. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053050. [PMID: 35270741 PMCID: PMC8910261 DOI: 10.3390/ijerph19053050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/25/2022] [Accepted: 03/03/2022] [Indexed: 12/10/2022]
Abstract
A complete enumeration study was conducted to evaluate trends related to reperfusion therapies (intravenous thrombolysis (IVT) and endovascular treatment (EVT)) in acute ischemic stroke (AIS) in South Korea, according to sex, economic status, and age, over a 10-year period retrospectively, using the National Health Information Database (NHIS-2020-1-481). This study included AIS patients aged ≥20 years who were hospitalized in a general hospital or tertiary hospital for ≥4 days and underwent brain imaging during the same period. Study participants were classified by sex, economic status (Medical Aid beneficiaries and National Health Insurance beneficiaries) and age (20-44, 45-64, 65-79, and ≥80 years). Women showed a significantly lower OR (Odds ratio) than men in IVT (OR: 0.75; 95% CI: 0.73-0.77), EVT (OR: 0.96; 95% CI: 0.93-0.99), and any therapy (OR: 0.82; 95% CI: 0.80-0.84). The Medical Aid beneficiaries showed significantly lower OR in IVT (OR 0.91, 95% CI 0.88-0.95), EVT (OR 0.93, 95% CI 0.89-0.98), and either therapy (OR 0.92, 95% CI 0.90-0.95) than the National Health Insurance beneficiaries. This study showed sex and economic disparity related to reperfusion therapies in patients with AIS in Korea.
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11
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Morisod K, Luta X, Marti J, Spycher J, Malebranche M, Bodenmann P. Measuring Health Equity in Emergency Care Using Routinely Collected Data: A Systematic Review. Health Equity 2022; 5:801-817. [PMID: 35018313 PMCID: PMC8742300 DOI: 10.1089/heq.2021.0035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Achieving equity in health care remains a challenge for health care systems worldwide and marked inequities in access and quality of care persist. Identifying health care equity indicators is an important first step in integrating the concept of equity into assessments of health care system performance, particularly in emergency care. Methods: We conducted a systematic review of administrative data-derived health care equity indicators and their association with socioeconomic determinants of health (SEDH) in emergency care settings. Following PRISMA-Equity reporting guidelines, Ovid MEDLINE, EMBASE, PubMed, and Web of Science were searched for relevant studies. The outcomes of interest were indicators of health care equity and the associated SEDH they examine. Results: Among 29 studies identified, 14 equity indicators were identified and grouped into four categories that reflect the patient emergency care pathway. Total emergency department (ED) visits and ambulatory care-sensitive condition-related ED visits were the two most frequently used equity indicators. The studies analyzed equity based on seven SEDH: social deprivation, income, education level, social class, insurance coverage, health literacy, and financial and nonfinancial barriers. Despite some conflicting results, all identified SEDH are associated with inequalities in access to and use of emergency care. Conclusion: The use of administrative data-derived indicators in combination with identified SEDH could improve the measurement of health care equity in emergency care settings across health care systems worldwide. Using a combination of indicators is likely to lead to a more comprehensive, well-rounded measurement of health care equity than using any one indicator in isolation. Although studies analyzed focused on emergency care settings, it seems possible to extrapolate these indicators to measure equity in other areas of the health care system. Further studies elucidating root causes of health inequities in and outside the health care system are needed.
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Affiliation(s)
- Kevin Morisod
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Xhyljeta Luta
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Joachim Marti
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Jacques Spycher
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Mary Malebranche
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Medicine, University of Calgary, Calgary, Canada
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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12
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Grau AJ, Dienlin S, Bartig D, Maier W, Buggle F, Becher H. Regional Deprivation, Stroke Incidence, and Stroke Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:397-402. [PMID: 34304754 DOI: 10.3238/arztebl.m2021.0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/07/2020] [Accepted: 02/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes. METHODS We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses. RESULTS The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile. CONCLUSION These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.
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Affiliation(s)
- Armin J Grau
- Department of Neurology, Ludwigshafen Hospital, Ludwigshafen; Quality Assurance Agency of Rhineland-Palatinate, Mainz; DRG Market, Osnabrück; Helmholtz Center Munich - German Research Center for Health and the Environment (Ltd), Institute for Health Economics and Management in Healthcare, Neuherberg; Oberwallis Hospital Center, Visp, Switzerland; Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg
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13
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Perrin A, Freyssenge J, Haesebaert J, Tazarourte K, Termoz A, Grimaud O, Derex L, Viprey M, Schott AM. Are there socio-economic inequities in access to reperfusion therapy: The stroke 69 cohort. Rev Neurol (Paris) 2021; 177:1168-1175. [PMID: 34274130 DOI: 10.1016/j.neurol.2021.02.394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/20/2021] [Accepted: 02/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Low socio-economic status of individuals has been reported to be associated with a higher incidence of stroke and influence the diagnosis after revascularization. However, whether it is associated with poorer acute stroke management is less clear. To determine whether social deprivation was associated with a poorer access to reperfusion therapy, either intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) in a population-based cohort. METHODS Over a 14-month period, all consecutive adult patients admitted to any emergency department or a comprehensive or primary stroke center (CSC/PSC) of the Rhône county with a confirmed ischemic stroke were included. The socioeconomic status of each patient was measured using the European Deprivation Index (EDI). The association between EDI and access to reperfusion therapy was assessed in univariate and multivariate logistic regression analyses. RESULTS Among the 1226 consecutive IS patients, 316 (25%) were admitted directly in a PSC or CSC, 241 (19.7%) received a reperfusion therapy; 155 IVT alone, 20 EVT alone, and 66 both therapies. Median age was 79 years, 1030 patients had an EDI level of 1 to 4, and 196 an EDI of 5 (the most deprived group). The most deprived patients (EDI level 5) did not have a poorer access to reperfusion therapy compared to all other patients in univariate (OR 1.22, 95%CI [0.85; 1.77]) nor in multivariate analyses (adjOR 0.97, 95%CI [0.57; 1.66]). CONCLUSIONS We did not find any significant association between socioeconomic deprivation and access to reperfusion therapy. This suggests that the implementation of EVT was not associated with increased access inequities.
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Affiliation(s)
- A Perrin
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.
| | - J Freyssenge
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; RESUVal - Réseau des Urgences de la Vallée du Rhône, 38200 Vienne, France
| | - J Haesebaert
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Pôle de santé publique, hospices civils de Lyon, 69003 Lyon, France
| | - K Tazarourte
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Service des urgences, hospices civils de Lyon, 69003 Lyon, France
| | - A Termoz
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Pôle de santé publique, hospices civils de Lyon, 69003 Lyon, France
| | - O Grimaud
- EHESP, REPERES (Recherche en pharmaco-épidémiologie et recours aux soins) - EA 7449, université de Rennes, 35000 Rennes, France
| | - L Derex
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Service de neurologie vasculaire, hospices civils de Lyon, 69500 Bron, France
| | - M Viprey
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Pôle de santé publique, hospices civils de Lyon, 69003 Lyon, France
| | - A M Schott
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Pôle de santé publique, hospices civils de Lyon, 69003 Lyon, France
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14
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Jeong S, Cho SI, Kong SY. Long-Term Effect of Income Level on Mortality after Stroke: A Nationwide Cohort Study in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228348. [PMID: 33187353 PMCID: PMC7697688 DOI: 10.3390/ijerph17228348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Seungmin Jeong
- Department of Preventive Medicine, Kangwon National University Hospital, Chuncheon-si, Gangwon-do 24289, Korea;
- Department of Public Health Science, Graduate School of Public Health, and Institute of Health and Environment, Seoul National University, Seoul 08826, Korea
| | - Sung-il Cho
- Department of Public Health Science, Graduate School of Public Health, and Institute of Health and Environment, Seoul National University, Seoul 08826, Korea
- Correspondence:
| | - So Yeon Kong
- Strategic Research, Laerdal Medical, 4002 Stavanger, Norway;
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15
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Ren X, Jing YX, Zhou ZW, Yang QM. MiR-17-5p inhibits cerebral hypoxia/reoxygenationinjury by targeting PTEN through regulation of PI3K/AKT/mTOR signaling pathway. Int J Neurosci 2020; 132:192-200. [PMID: 32762281 DOI: 10.1080/00207454.2020.1806836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the role and mechanism of miR-17-5p in cerebral hypoxia/reoxygenation (H/R)-induced apoptosis. METHODS The present study used human brain microvascular endothelial cells (HBMVECs) to establish cerebral H/R model. MTT was used to measure the cell viability. Flow cytometry was used to detect the cell apoptosis. The interaction between miR-17-5p and PTEN was determined using dual luciferase reporter assay. RT-qPCR and Western blotting were used for determination of the expression of miR-17-5p, PTEN, apoptosis- and PI3K/AKT/mTOR signalling-related proteins. RESULTS The cell viability and the expression of miR-17-5p were obviously down-regulated while the expression of PTEN was obviously up-regulated in H/R cells. The cell viability was remarkably enhanced, and the cell apoptosis induced by H/R injury was dramatically reduced when miR-17-5p was overexpressed in HBMVECs under H/R condition, which was reversed by overexpression of PTEN. Dual luciferase reporter assay showed PTEN was a direct target of miR-17-5p. Treatment of PI3K inhibitor LY294002 significantly increased the apoptosis rate of HBMVECs, and this effect was significantly reversed by transfection of miR-17-5p mimics, while further dramatically enhanced by overexpression of PTEN. CONCLUSION MiR-17-5p could ameliorate cerebral I/R injury-induced cell apoptosis by directly targeting PTEN and regulation of PI3K/AKT/mTOR signalling.
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Affiliation(s)
- Xiang Ren
- Department of Neurology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, PR China
| | - Ying-Xia Jing
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, PR China
| | - Zhi-Wen Zhou
- Department of Neurology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, PR China
| | - Qi-Ming Yang
- Department of Neurology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, PR China
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16
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Rosenich E, Hordacre B, Paquet C, Koblar SA, Hillier SL. Cognitive Reserve as an Emerging Concept in Stroke Recovery. Neurorehabil Neural Repair 2020; 34:187-199. [PMID: 32089097 DOI: 10.1177/1545968320907071] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Stroke is a leading cause of death and disability. It is a complex and largely heterogeneous condition. Prognosis for variations in impairment and recovery following stroke continues to be challenging and inaccurate, highlighting the need to examine the influence of other currently unknown variables to better predict and understand interindividual differences in stroke impairment and recovery. The concept of "cognitive reserve," a feature of brain function said to moderate the relationship between brain pathology and clinical outcomes, might provide a partial explanation. This review discusses the potential significance of cognitive reserve in the context of stroke, with reference to reduced burden of disability poststroke, health promotion, intervention and secondary prevention of cognitive impairment, ease and challenges of translation into clinical practice, prognosis and prediction of recovery, and clinical decisions and trial stratification. Discussions from the review aim to encourage stroke clinicians and researchers to better consider the role of premorbid, lifestyle-related variables, such as cognitive reserve, in facilitating successful neurological outcomes and recovery following stroke.
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Affiliation(s)
- Emily Rosenich
- University of South Australia, Adelaide, South Australia, Australia
| | - Brenton Hordacre
- University of South Australia, Adelaide, South Australia, Australia
| | - Catherine Paquet
- University of South Australia, Adelaide, South Australia, Australia
| | - Simon A Koblar
- University of Adelaide, Adelaide, South Australia, Australia
| | - Susan L Hillier
- University of South Australia, Adelaide, South Australia, Australia
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17
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Niklasson A, Herlitz J, Jood K. Socioeconomic disparities in prehospital stroke care. Scand J Trauma Resusc Emerg Med 2019; 27:53. [PMID: 31046804 PMCID: PMC6498576 DOI: 10.1186/s13049-019-0630-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 04/17/2019] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Amanda Niklasson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, plan 3, SE-413 45, Gothenburg, Sweden.
| | - Johan Herlitz
- PreHospen - Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Katarina Jood
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, plan 3, SE-413 45, Gothenburg, Sweden
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18
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Bray BD, Paley L, Hoffman A, James M, Gompertz P, Wolfe CDA, Hemingway H, Rudd AG. Socioeconomic disparities in first stroke incidence, quality of care, and survival: a nationwide registry-based cohort study of 44 million adults in England. LANCET PUBLIC HEALTH 2018; 3:e185-e193. [PMID: 29550372 PMCID: PMC5887080 DOI: 10.1016/s2468-2667(18)30030-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Benjamin D Bray
- Farr Institute of Health Informatics Research, University College London, London, UK.
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Alex Hoffman
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Martin James
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Patrick Gompertz
- National Cardiovascular Intelligence Network, Public Health England, London, UK
| | - Charles D A Wolfe
- School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Anthony G Rudd
- School of Population Health & Environmental Sciences, King's College London, London, UK
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Pennlert J, Asplund K, Glader EL, Norrving B, Eriksson M. Socioeconomic Status and the Risk of Stroke Recurrence. Stroke 2017; 48:1518-1523. [DOI: 10.1161/strokeaha.116.015643] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 03/01/2017] [Accepted: 03/13/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
This nationwide observational study aimed to investigate how socioeconomic status is associated with risk of stroke recurrence and how possible associations change over time.
Methods—
This study included 168 295 patients, previously independent in activities of daily living, with a first-ever stroke in the Swedish Stroke Register (Riksstroke) 2001 to 2012. Riksstroke was linked with Statistics Sweden as to add individual information on education and income. Subdistribution hazard regression was used to analyze time from 28 days after first stroke to stroke recurrence, accounting for the competing risk of other causes of death.
Results—
Median time of follow-up was 3.0 years. During follow-up, 23 560 patients had a first recurrent stroke, and 53 867 died from other causes. The estimated cumulative incidence of stroke recurrence was 5.3% at 1 year, and 14.3% at 5 years. Corresponding incidence for other deaths were 10.3% and 30.2%. Higher education and income were associated with a reduced risk of stroke recurrence. After adjusting for confounding variables, university versus primary school education returned a hazard ratio of 0.902; 95% confidence interval, 0.864 to 0.942, and the highest versus the lowest income tertile a hazard ratio of 0.955; 95% confidence interval, 0.922 to 0.989. The risk of stroke recurrence decreased during the study period, but the inverse effect of socioeconomic status on risk of recurrence did not change significantly.
Conclusions—
Despite a declining risk of stroke recurrence over time, the differences in recurrence risk between different socioeconomic groups remained at a similar level in Sweden during 2001 to 2012.
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Affiliation(s)
- Johanna Pennlert
- From the Department of Public Health and Clinical Medicine, Medicine, (J.P., K.A., E.-L.G.), and Department of Statistics, Umeå School of Business and Economics (M.E.), Umeå University, Sweden; and Department of Medical Sciences, Section of Neurology, Lund University, Sweden (B.N.)
| | - Kjell Asplund
- From the Department of Public Health and Clinical Medicine, Medicine, (J.P., K.A., E.-L.G.), and Department of Statistics, Umeå School of Business and Economics (M.E.), Umeå University, Sweden; and Department of Medical Sciences, Section of Neurology, Lund University, Sweden (B.N.)
| | - Eva-Lotta Glader
- From the Department of Public Health and Clinical Medicine, Medicine, (J.P., K.A., E.-L.G.), and Department of Statistics, Umeå School of Business and Economics (M.E.), Umeå University, Sweden; and Department of Medical Sciences, Section of Neurology, Lund University, Sweden (B.N.)
| | - Bo Norrving
- From the Department of Public Health and Clinical Medicine, Medicine, (J.P., K.A., E.-L.G.), and Department of Statistics, Umeå School of Business and Economics (M.E.), Umeå University, Sweden; and Department of Medical Sciences, Section of Neurology, Lund University, Sweden (B.N.)
| | - Marie Eriksson
- From the Department of Public Health and Clinical Medicine, Medicine, (J.P., K.A., E.-L.G.), and Department of Statistics, Umeå School of Business and Economics (M.E.), Umeå University, Sweden; and Department of Medical Sciences, Section of Neurology, Lund University, Sweden (B.N.)
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20
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Eriksson M, Glader EL, Norrving B, Stegmayr B, Asplund K. Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden. Brain Behav 2017; 7:e00654. [PMID: 28413705 PMCID: PMC5390837 DOI: 10.1002/brb3.654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 12/16/2016] [Accepted: 01/10/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Ambulance services and stroke alerts reduce the time from stroke onset to acute stroke diagnosis. We describe the use of stroke alerts and ambulance services in different hospitals and patient groups and their relationship with reperfusion therapy. METHODS This nationwide study included 49,907 patients admitted with acute stroke who were registered in The Swedish Stroke Register (Riksstroke) in 2011-2012. RESULTS The proportions of patients admitted as stroke alerts out of all acute stroke admissions varied from 12.2% to 45.7% in university hospitals (n = 9), 0.5% to 38.7% in specialized nonuniversity hospitals (n = 22), and 4.2% to 40.3% in community hospitals (n = 41). Younger age, atrial fibrillation (AF), living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were factors associated with a higher probability of stroke alerts. Living alone, primary school education, non-European origin, previous stroke, diabetes, smoking, and dependency in activities of daily living (ADL) were associated with a lower probability of stroke alert. The proportion of patients arriving at the hospital by ambulance varied from 60.3% to 94.5%. Older age, living alone, primary school education, being born in a European country, previous stroke, AF, dependency in ADL, living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were associated with ambulance services. Hospital stroke alert frequencies correlated strongly with reperfusion rates (r = .75). CONCLUSION Acute stroke alerts have a significant potential to improve stroke reperfusion rates. Prehospital stroke management varies conspicuously between hospitals and patient groups, and the elderly and patients living alone have a markedly reduced likelihood of stroke alerts.
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Affiliation(s)
- Marie Eriksson
- Department of Statistics USBE, Umeå University Umeå Sweden.,Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Bo Norrving
- Section of Neurology Department of Clinical Sciences Lund University Lund Sweden
| | - Birgitta Stegmayr
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Kjell Asplund
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
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Ullberg T, Glader EL, Zia E, Petersson J, Eriksson M, Norrving B. Associations between Ischemic Stroke Follow-Up, Socioeconomic Status, and Adherence to Secondary Preventive Drugs in Southern Sweden: Observations from the Swedish Stroke Register (Riksstroke). Neuroepidemiology 2017; 48:32-38. [DOI: 10.1159/000456618] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 01/14/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Currently, the knowledge that one has on adequate stroke follow-up practices is limited. We report associations between 90-day stroke follow-up, socio-economy and adherence to secondary prevention in southern Sweden. Methods: Data on 5,602 patients with ischemic stroke January 1, 2008-December 31, 2010, were obtained from Riksstroke and linked to official registers for information on education, birth country, doctor's follow-ups, and secondary prevention. Primary adherence at 4 months and persistence at 14 months post-stroke were calculated for warfarin, statins, antihypertensive, and antiplatelet drugs. Results: The 90-day follow-up rate was 75%. Patients not receiving a 90-day follow-up had lower age-adjusted OR of persistent drug use at 14 months for antihypertensive agents (OR = 0.74, 95% CI 0.60-0.91) and for antiplatelet drugs (OR = 0.72, 95% CI 0.60-0.87). Drug adherence rates 14 months post-stroke were 85% for antiplatelet drugs, 69% for warfarin, 88% for antihypertensive agents, and 76% for statins. One in three patients discontinued using one or more drug class within 14 months, and nonadherence was associated with activities of daily living dependency at 3 months (age-adjusted OR 0.63, 95% CI 0.57-0.69), but not with age, gender, or educational status. Conclusions: The use of secondary preventive drugs decreases over the first year after stroke and remains suboptimal. Specific reasons for nonadherence warrant further study.
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Eldh AC, Wallin L, Fredriksson M, Vengberg S, Winblad U, Halford C, Dahlström T. Factors facilitating a national quality registry to aid clinical quality improvement: findings of a national survey. BMJ Open 2016; 6:e011562. [PMID: 28128099 PMCID: PMC5128910 DOI: 10.1136/bmjopen-2016-011562] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement. METHODS Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression. RESULTS A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R2=0.76) with 'Colleagues' call for local results' (p=<0.001), 'Management Request of Registry data' (p=<0.001), and it was said to be 'Simple to explain the results to colleagues' (p=0.02). Using stepwise regression, 'Colleagues' call for local results' was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results. CONCLUSIONS While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.
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Affiliation(s)
- Ann Catrine Eldh
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- School of Health and Social Science, Dalarna University, Falun, Sweden
| | - Lars Wallin
- School of Health and Social Science, Dalarna University, Falun, Sweden
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Mio Fredriksson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Sofie Vengberg
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrika Winblad
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Christina Halford
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Tobias Dahlström
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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23
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Marshall IJ, Wang Y, Crichton S, McKevitt C, Rudd AG, Wolfe CDA. The effects of socioeconomic status on stroke risk and outcomes. Lancet Neurol 2016; 14:1206-18. [PMID: 26581971 DOI: 10.1016/s1474-4422(15)00200-8] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/23/2015] [Accepted: 07/29/2015] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Iain J Marshall
- Division of Health and Social Care Research, King's College London, London, UK.
| | - Yanzhong Wang
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Siobhan Crichton
- Division of Health and Social Care Research, King's College London, London, UK
| | - Christopher McKevitt
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Anthony G Rudd
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Charles D A Wolfe
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
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Lee SY, Ro YS, Shin SD, Song KJ, Ahn KO, Kim MJ, Hong SO, Kim YT. Interaction effects between highly-educated neighborhoods and dispatcher-provided instructions on provision of bystander cardiopulmonary resuscitation. Resuscitation 2016; 99:84-91. [DOI: 10.1016/j.resuscitation.2015.11.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/06/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
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