Sociodemographic Disparities in Long-Term Mortality Among Stroke Survivors in the United States

Temporal Trends and Racial Disparities in Long-Term Survival After Stroke

BACKGROUND AND OBJECTIVES

Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality.

METHODS

All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression.

RESULTS

We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32).

DISCUSSION

Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.

Unveiling the evolving landscape of stroke care costs: A time-driven analysis

INTRODUCTION

Stroke is a common cause of mortality in the United States. However, the economic burden of stroke on the healthcare system is not well known. In this study, we aim to calculate the annual cumulative and per-patient cost of stroke.

METHODS

We conducted a retrospective analysis of Nationwide Emergency Department Sample (NEDS). We calculate annual trends in cost for stroke patients from 2006 to 2019. A multivariate linear regression with patient characteristics (e.g. age, sex, Charlson Comorbidity Index) as covariates was used to identify factors for higher costs.

RESULTS

In this study time-period, 2,998,237 stroke patients presented to the ED and 2,481,171 (83 %) were admitted. From 2006 to 2019, the cumulative ED cost increased by a factor of 7.0 from 0.49 ± 0.03 to 3.91 ± 0.16 billion dollars (p < 0.001). The cumulative inpatient (IP) cost increased by a factor of 2.7 from 14.42 ± 0.78 to 37.06 ± 2.26 billion dollars (p < 0.001. Per-patient ED charges increased by a factor of 3.0 from 1950 ± 64 to 7818 ± 260 dollars (p < 0.001). Per-patient IP charges increased by 89 % from 40.22 +/- 1.12 to 76.06 ± 3.18 thousand dollars (p < 0.001).

CONCLUSION

Strokes place an increasing financial burden on the US healthcare system. Certain patient demographics including age, male gender, more comorbidities, and insurance type were significantly associated with increased cost of care.

Educational attainment, severity and short-term prognosis of intracerebral haemorrhage

Background

Educational attainment is a critical social determinant of health that impacts the risk and severity of incident ischaemic stroke, but less is known of its impact on intracerebral haemorrhage (ICH). The objective of this study is to determine whether educational attainment is associated with ICH severity and short-term prognosis.

Methods

Subjects were enrolled in a prospectively ascertained cohort with primary ICH from 1994 to 2020 at Massachusetts General Hospital. Educational attainment, medical history of ICH risk factors, ICH volume and ICH score were obtained on admission. The primary outcomes were ICH volume and the ICH score.

Results

Of 2539 eligible patients eligible, the median age of the sample was 74 (IQR 64-82) and 2159 (85%) had high school-only education. 1655 (65%) presented with an ICH volume less than or equal to 30 mL and 1744 (69%) presented with an ICH score less than 3. In multivariable logistic regression analyses controlling for age, income, employment history and prestroke diagnoses of hypertension and coronary artery disease, patients with high school-only education were more likely to have an ICH volume greater than 30 mL compared with college diplomates (OR 1.58, 95% CI 1.24 to 2.08) and more likely to have an ICH score of 3 or greater compared with college diplomates (OR 2.37, 95% CI 1.77 to 3.19).

Discussion

Prestroke educational attainment is independently associated with ICH severity and short-term prognosis, with lower educational attainment associated with larger ICH volumes and higher ICH scores. Future studies should examine how educational attainment impacts exposure to traditional clinical risk factors.

Factors influencing survival outcomes in patients with stroke in Zimbabwe: A 12-month longitudinal study

Background

In this longitudinal study, we aimed to determine factors influencing survival outcomes among patients with stroke over a 12-month period. The investigation sought to uncover influential determinants to enhance the precision of prognostic assessments and inform targeted interventions for individuals affected by strokes.

Methods

Employing a longitudinal study design, participants were observed for 12 months from baseline, censoring survivors at the endpoint. The dataset originated from a comprehensive study involving stroke patients treated at three referral hospitals in Zimbabwe: Parirenyatwa, Sally Mugabe, and Chitungwiza Central Hospital. The primary outcome variable, the duration of survival until death, was measured in days from the initiation of stroke treatment. Gompertz parametric regression analysis was utilized for data modeling following Accelerated Failure Time (AFT) model diagnostics.

Results

In our study, 188 stroke patients were enrolled at baseline. However, 51 patients were excluded from the analysis due to either missing information or loss to follow-up. Among the remaining 137 patients who were tracked over a 12-month period, 42% were censored, and 58% were deceased. Individuals utilizing 'Free Service (older than 65/pensioners/retirees)' hospital bill payment methods showed a decreased risk of death (HR: 0.4, 95% CI: 0.20, 0.80), suggesting a protective effect compared to cash paying patients. Those with a secondary school level education displayed a significantly lower risk of death (HR: 0.2, 95% CI: 0.04, 0.69) compared to those without formal education. Age was a significant factor, with individuals aged 45-65 and those over 65 years showing higher adjusted hazard ratios (HR: 4.9, 95% CI: 1.80, 13.25; HR: 5.5, 95% CI: 1.92, 15.95, respectively) relative to those below 45 years of age. Housing status revealed a protective effect for those residing with parents/relatives (adjusted HR: 0.4, 95% CI: 0.20, 0.66), while individuals with a 'Very severe' functional outcome showed an increased hazard (adjusted HR: 4.9, 95% CI: 1.12, 21.33).

Conclusion

The study findings demonstrate that hospital bill payment methods, housing status, educational attainment, functional outcome, and age significantly affect survival outcomes among stroke patients. This highlights the need to consider socio-demographic and clinical variables in the development of prognostic assessments and targeted interventions for individuals recovering from stroke.

Disability-Related Mortality Inequity in South Korea: Comparison in Terms of Seoul Metropolitan/Non-Metropolitan Areas and Income Levels

Despite the improved living standards in South Korea, people with disabilities still experience health disparities. Therefore, we analyzed differences in mortality rates among people with disabilities according to income level and residential area using representative data from the National Health Insurance Service in South Korea. Descriptive statistics and Cox proportional risk models were used to identify the risk factors for mortality affecting people with disabilities stratified by income level and residential area. Those living in non-metropolitan areas and low-income households had high mortality risks, suggesting that income level and residential area were related to mortality risk. The mortality risk of those with a high-income level was 1.534 times higher in non-metropolitan areas than in Seoul metropolitan areas (95% confidence interval [CI] = 1.44-1.63). Among people with low income living in non-metropolitan areas, the crude hazard ratios of mortality risk were 1.26 (95% CI = 1.14-1.39), 1.44 (95% CI = 1.34-1.54), and 1.39 (95% CI = 1.20-1.61) for those with brain lesions, sensory impairment (visual/hearing/speech impairment), and kidney failure, respectively. No significant differences were observed between people with autism in non-metropolitan and Seoul metropolitan areas and those with low- and high-income levels. Health issues and countermeasures are crucial to reduce mortality risk among people with disabilities.

The relationship of income on stroke incidence in Finland and China

BACKGROUND

Stroke incidence has continued to increase recently in most countries. The roles of individual-level income on the incidence of overall stroke and its subtypes are still unknown, especially in low- and middle-income countries and the cross-national evidence is also limited. We explored the association between individual-level income and stroke incidence in Finland and China.

METHODS

Changde Social Health Insurance Database (N=571 843) and Finnish population register (N=4 046 205) data were used to calculate standard stroke incidence rates, which were employed to assess the absolute incidence difference between income quintiles. Cox regression was used to compare income differences in first-ever stroke incidence.

RESULTS

The highest income quintile had lower overall and subtype stroke incidence when compared to lower-income quintiles. The relative difference was more evident in hemorrhagic stroke incidence. After adjusting for age and employment status, the disparity of stroke incidence between the lowest and highest income quintiles was high among both men and women and in Finland and China. The disparity was particularly notable among men: in Finland, the hazard ratio (HR) for hemorrhagic stroke was 0.633 [95% confidence interval (95% CI) 0.576-0.696] and HR 0.572 (95% CI 0.540-0.606) for ischemic stroke. The respective figures were HR 0.452 (95% CI 0.276-0.739) and HR 0.633 (95% CI 0.406-0.708) for China.

CONCLUSIONS

Individual-level income is related to overall and subtype stroke incidence. Future studies should explore the causal relationship between individual-level income and stroke incidence.

Telehealth Trials to Address Health Equity in Stroke Survivors

Telehealth has seen rapid expansion into chronic care management in the past 3 years because of the COVID-19 pandemic. Telehealth for acute care management has expanded access to equitable stroke care to many patients over the past two decades, but there is limited evidence for its benefit for addressing disparities in the chronic care of patients living with stroke. In this review, we discuss advantages and disadvantages of telehealth use for the outpatient management of stroke survivors. Further, we explore opportunities and potential barriers for telehealth in addressing disparities in stroke outcomes related to various social determinants of health. We discuss two ongoing large randomized trials that are utilizing telehealth and telemonitoring for management of blood pressure in diverse patient populations. Finally, we discuss strategies to address barriers to telehealth use in patients with stroke and in populations with adverse social determinants of health.

Secondary Stroke Risk Reduction in Black Adults: a Systematic Review

OBJECTIVE

To address the fact that Black adults (BAs) experience significantly greater stroke burden than the general population, we conducted a systematic literature review which described evidence-based interventions targeting secondary stroke risk reduction in BAs.

DATA SOURCE

Publications were selected from PubMed, Ovid, Cochrane, and Web of Science databases. We included peer-reviewed, longitudinal, English-language studies performed in the USA which reported results for BAs separately and had adult participants who had experienced stroke-related events.

RESULTS

Six of the 7 studies employed behavioral interventions which promoted education on stroke risk factors, problem-solving skills, and healthy-coping strategies. These studies demonstrated improvements in one or more biologic outcomes including cholesterol control and systolic blood pressure.

CONCLUSIONS

Existing interventions on secondary stroke risk reduction approaches are effective in reducing secondary stroke risk among BAs, especially in individuals with poorly controlled blood pressure at baseline. However, additional research is needed because the current approaches may limit generalizability.

Incidence and mortality of cerebrovascular disease in Spain: 1,600,000 hospital admissions between 2001 and 2015

Background: To analyze the incidence and mortality of cerebrovascular diseases (CeVD) in Spain from 2001 to 2015.Methods: Retrospective study of hospital incidence, hospital case-fatality and population mortality, with records from the Spanish Government Statistics. Days of hospital stay and risk of death during admission (RD) were estimated adjusting for age, sex, first stroke (FS), atrial fibrillation (AF), diabetes, hypertension, and smoking.Results: There were 1,662,487 stroke cases older than 15 years of age admitted to hospital (1,096,748 FS), with a national incidence = 291/105 in this period (Murcia maximum [367/105], Canary Islands minimum [238/105]). Population mortality (-50%) decreased while case-fatality remained stable (-3%), despite the increase in the age of patients (+2.29 years) and the incidence (+25%). Canary Islands had the youngest patients (-3.5 years for men and -6 years for women) and the longest hospital stay (+5.1 days). Andalusia (OR= 1.21 [1.19; 1.22]) and the Canaries (OR= 1.18 [1.15; 1.21]) had the highest RD. The factors associated to the highest increases in RD were FS (OR = 1.34 [95%CI= 1.33-1.35]) and AF (OR = 1.30 [95%CI= 1.29-1.31]).Conclusions: Population mortality due to CeVD was reduced by half in Spain between 2001 and 2015, but hospital incidence increased. Andalusia and the Canary Islands had the highest RD in the country. These Islands presented the lowest incidence, but their patients were younger, and their hospital stay longer. FS and AF were the factors associated with a higher risk of death.

Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

The Survival Status and Predictors of Mortality Among Stroke Patients at North West Ethiopia

INTRODUCTION

Stroke is one of the commonest non-communicable disease types that has a great public health impact both in developed and developing countries. However, in Ethiopia, the long-term survival status of stroke patients is not very understood. This study aimed at assessing survival status and predictors of mortality among stroke patients at Felege Hiwot comprehensive specialized hospital from September 1, 2014, to August 31, 2019, Bahirdar, North West Ethiopia.

METHODS

An institutional-based retrospective cohort study was conducted using 368 registered stroke patients between September 1, 2014, and August 31, 2019. We used Kaplan-Meier together with a Log-rank test to compare the survival rate of the study participants using categorical variables and to compare covariate and both bi-variable and multivariable Cox proportional hazards regression analysis model was conducted to identify predictors of mortality among stroke patients. The association between outcome and independent variables was expressed using an adjusted hazard ratio (AHR) with a 95% confidence interval and statistical significances were declared at P-value of <0.05.

RESULTS

Fifty-six (15.2%) of the 368 stroke patients included in the study died, and 312 (84.8%) were correctly censored. The overall survival rate was 72.2% at 51 months of follow-up with a median survival time of 0.26 months. Age greater than 65 (AHR 6.31, 95% CI 1.75-22.74), body temperature >7.1 degree centigrade (AHR = 7.14, 95% CI: 2.76-18.5), potassium level below <2 mmol/l (AHR = 2, 95% CI: 1.9-23.53) and creatinine level >1.2 mg/dl (AHR = 7.85, 95% CI: 2.7-22.6) were predictive predictors of mortality.

CONCLUSIONS

In the follow-up of 51 months, significant mortality occurred. Important predictive predictors of survival status were identified. Interventions should be focused on health education and awareness creation of the community for the early management of stroke.

Characterizing the performance of emergency medical transport time metrics in a residentially segregated community

OBJECTIVE

To derive and characterize the performance of various metrics of emergency transport time in assessing for sociodemographic disparities in the setting of residential segregation. Secondarily to characterize racial disparities in emergency transport time of suspected stroke patients in Austin, Texas.

DATA SOURCES

We used a novel dataset of 2518 unique entries with detailed spatial and temporal information on all suspected stroke transports conducted by a public emergency medical service in Central Texas between 2010 and 2018.

STUDY DESIGN

We conducted one-way ANOVA tests with post-hoc pairwise t-tests to assess how mean hospital transport times varied by patient race. We also developed a spatially-independent metric of emergency transport urgency, the ratio of expected duration of self-transport to a hospital and the measured transport time by an ambulance.

DATA COLLECTION/EXTRACTION

We calculated ambulance arrival and destination times using sequential temporospatial coordinates. We excluded any entries in which patient race was not recorded. We also excluded entries in which ambulances' routes did not pass within 100 m of either the patient's location or the documented hospital destination.

PRINCIPAL FINDINGS

We found that mean transport time to a hospital was 2.5 min shorter for black patients compared to white patients. However, white patients' transport times to a hospital were found to be, on average, 4.1 min shorter than expected compared to 3.4 min shorter than expected for black patients. One-way ANOVA testing for the spatially-independent index of emergency transport urgency was not statistically significant, indicating that average transport time did not vary significantly across racial groups when accounting for variations in transport distance.

CONCLUSIONS

Using a novel transport urgency index, we demonstrate that these findings represent race-based variation in spatial distributions rather than racial bias in emergency medical transport. These results highlight the importance of closely examining spatial distributions when utilizing temporospatial data to investigate geographically-dependent research questions.

Are there disparities in acute stroke treatment between the Jewish and Arab populations in Israel? Results from the National Acute Stroke Israeli registry

BACKGROUND

According to the latest reported data from the National Acute Stroke Israeli Survey (NASIS), around 18,000 strokes occur annually in Israel. Data regarding disparities in stroke care between the Jewish and the Arab populations in Israel are lacking.

AIMS

We wished to compare demographics, comorbidities, stroke characteristics and outcomes between Jewish and Arab stroke patients in Israel that were acutely treated with intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), in order to test if there are disparities or any ethnic-specific parameters.

METHODS

The National Acute Stroke Israeli registry of patients undergoing revascularization (NASIS-REVASC) prospectively enrolled patients in six comprehensive stroke centers between 1/2014 and 3/2016. In this observational research, we compared demographics, comorbidities, time metrics, stroke characteristics and outcomes between Jewish and Arab patients enrolled.

RESULTS

NASIS-REVASC included 1432 patients out of which 143 (10%) were of Arab ethnicity and 1289 (90%) of Jewish ethnicity. Arab patients were significantly younger (66 ± 14 vs. 73 ± 29, p = 0·004), exhibited higher rates of smoking and diabetes (31% vs. 18% and 57% vs. 34%, p < 0·001 for both), and were less often treated with systemic thrombolysis (48% vs. 59%, p = 0·012). However, the rates of any interventional treatment with either intravenous thrombolysis or endovascular thrombectomy as well as the rates of favorable outcomes and mortality were comparable between groups.

CONCLUSIONS

Despite several baseline differences between Arab and Jewish Israeli stroke patients, treatment allocations, survival and functional outcomes were similar indicating lack of disparity in stroke care among patients treated acutely with IVT and/or EVT in Israel.

DATA ACCESS STATEMENT

Full data is available following a formal request to the NASIS-REVASC registry at the Israeli Health Ministry.

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.

Education Level and Long-term Mortality, Recurrent Stroke, and Cardiovascular Events in Patients With Ischemic Stroke

Background

Epidemiological studies have reported discrepant findings on the relationship between education level and outcomes after stroke. We aimed to prospectively investigate the relationship between education level and mortality, recurrent stroke, and cardiovascular events in Chinese patients with ischemic stroke.

Methods and Results

We included 3861 participants from the China Antihypertensive Trial in Acute Ischemic Stroke. Education level was categorized as illiteracy, primary school, middle school, and college. Study outcomes were all‐cause mortality, stroke‐specific mortality, recurrent stroke, and cardiovascular events within 2 years after ischemic stroke. A meta‐analysis was conducted to incorporate the results of the current study and previous other studies on the association of education level with outcomes after stroke. Within 2 years after ischemic stroke, there were 327 (8.5%) all‐cause deaths, 264 (6.8%) stroke‐specific deaths, 303 (7.9%) recurrent strokes, and 364 (9.4%) cardiovascular events, respectively. The Kaplan–Meier curves showed that patients with the lowest education level had the highest cumulative incidence rates of all‐cause mortality, stroke‐specific mortality, and cardiovascular events (log‐rank P≤0.01). After adjusted for covariates, hazard ratios and 95% CIs of illiteracy versus college education were 2.79 (1.32–5.87) for all‐cause mortality, 3.68 (1.51–8.98) for stroke‐specific mortality, 2.82 (1.20–6.60) for recurrent stroke, and 3.46 (1.50–7.95) for cardiovascular events. The meta‐analysis confirmed the significant association between education status and mortality after stroke (pooled relative risk for lowest versus highest education level, 1.24 [95% CI, 1.05–1.46]).

Conclusions

Low education level was significantly associated with increased risk of mortality, recurrent stroke, and cardiovascular events after ischemic stroke, independently of established risk factors.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT01840072.

Socioeconomic status and survival after stroke - using mediation and sensitivity analyses to assess the effect of stroke severity and unmeasured confounding

Background

Although it has been established that low socioeconomic status is linked to increased risk of death after stroke, the mechanisms behind this link are still unclear. In this study we aim to shed light on the relationship between income level and survival after stroke by investigating the extent to which differences in stroke severity account for differences in survival.

Methods

The study was based on patients registered in Riksstroke (the Swedish stroke register) with first time ischemic stroke (n = 51,159) or intracerebral hemorrhage (n = 6777) in 2009–2012. We used causal mediation analysis to decompose the effect of low income on 3-month case fatality into a direct effect and an indirect effect due to stroke severity. Since causal mediation analysis relies on strong assumptions regarding residual confounding of the relationships involved, recently developed methods for sensitivity analysis were used to assess the robustness of the results to unobserved confounding.

Results

After adjustment for observed confounders, patients in the lowest income tertile had a 3.2% (95% CI: 0.9–5.4%) increased absolute risk of 3-month case fatality after intracerebral hemorrhage compared to patients in the two highest tertiles. The corresponding increase for case fatality after ischemic stroke was 1% (0.4–1.5%). The indirect effect of low income, mediated by stroke severity, was 1.8% (0.7–2.9%) for intracerebral hemorrhage and 0.4% (0.2–0.6%) for ischemic stroke. Unobserved confounders affecting the risk of low income, more severe stroke and case fatality in the same directions could explain the indirect effect, but additional adjustment to observed confounders did not alter the conclusions.

Conclusions

This study provides evidence that as much as half of income-related inequalities in stroke case fatality is mediated through differences in stroke severity. Targeting stroke severity could therefore lead to a substantial reduction in inequalities and should be prioritized. Sensitivity analysis suggests that additional adjustment for a confounder of greater impact than age would be required to considerably alter our conclusions.

Income inequalities in stroke incidence and mortality: Trends in stroke-free and stroke-affected life years based on German health insurance data

Background

Due to substantial improvements in prevention and therapy, stroke incidence and mortality rates have decreased during the last decades, but evidence is still lacking on whether all socioeconomic groups benefited equally and how the length of life affected by stroke developed over time. Our study investigates time trends in stroke-free life years and life years affected by stroke. Special emphasis is given to the question whether trends differ between income groups, leading to decreasing or increasing social inequalities.

Methods

The analyses are based on claims data of a German statutory health insurance company of the two time periods 2006–2008 and 2014–2016. Income inequalities and time trends in incidence and mortality risks were estimated using multistate survival models. Trends in stroke-free life years and life years affected by stroke are analysed separately for income groups by applying multistate life table analyses.

Results

Stroke incidence and mortality risks decreased in men and women in all income groups. While stroke-free lifetime could be gained in men having higher incomes, improvements in mortality counterbalanced decreasing incidences, leading to increases in life years affected by stroke among men of the lower and higher income group. Among women, no significant changes in life years could be observed.

Conclusions

Changes in stroke-affected life years occur among men in all income groups, but are more pronounced in the higher income group. However, irrespective of the income group the proportion of stroke-affected life years remains quite stable over time, pointing towards constant inequalities. Further research is needed on whether impairments due to stroke reduced over time and whether all socioeconomic groups are affected equally.

Neighborhood Socioeconomic Status and Trajectories of Physical Health-Related Quality of Life Among Stroke Survivors

Background and Purpose- Stroke is the leading cause of serious, long-term disability in the United States, and the number of stroke survivors is projected to rise. Physical functioning status may be compromised in survivors living in low socioeconomic status environments in comparison to higher socioeconomic status environments. Higher socioeconomic status environments may include benefits in the built environment such as sidewalks, accessible transit, or low traffic volume. Investigation is needed to understand the effects of the socioenvironmental context on trajectories of stroke survivors' physical health-related quality of life (PH-QOL) over time. Methods- Participants from the REGARDS (REasons for Geographic and Racial Differences in Stroke) study enrolled in the ancillary Caring for Adults Recovering from the Effects of Stroke project completed the SF-12 around 6 to 12, 18, 27, and 36 months poststroke. Measures of area-level income, wealth, education, and employment at the census tract level were combined to represent participants' neighborhood socioeconomic status. Linear mixed models were used to predict trajectories of PH-QOL over time, controlling for individual characteristics. Results- The average trajectory of PH-QOL was flat over time. However, women and younger stroke survivors had better trajectories over time than men and older stroke survivors. Higher neighborhood socioeconomic status was significantly associated with better PH-QOL across all time points (β=1.73; 95% CI, 0.17-3.30), after controlling for demographic variables and severity of stroke. Conclusions- Our findings demonstrate that neighborhood socioeconomic status, sex, and age are associated with the poststroke recovery process. The results of this study suggest the importance of evaluating the environment surrounding stroke survivors when they return to their home communities. Future research should identify specific features of the environment within different socioeconomic status neighborhoods to better understand how they contribute to PH-QOL among stroke survivors.

Association between Socioeconomic Status, Physical Health and Need for Long-term Care among the Chinese Elderly

The aim of this study was to explore the relationship between socioeconomic status (SES), physical health and the need for long-term care (NLTC) of the Chinese elderly, and further, to provide evidence-based advice for establishing an LTC system in China. A cross-sectional survey was conducted in Shandong Province, China in 2017 by using multi-stage random sampling method. Data were collected from elderly individuals aged 60 years and older by self-designed questionnaires through face-to face interviews. A total of 7070 participants were finally included in the database (40.3% male, 59.7% female). Chi-square test analysis and structural equation modeling (SEM) were conducted to clarify the association between SES, physical health and NLTC among the Chinese elderly men and women in Shandong Province. The results of the SEM analysis showed that physical health exerted a strong and negative effect on the NLTC for both genders, with a slightly stronger effect found among the elderly men. SES was found to be significantly and negatively related to the NLTC among the elderly women, while no statistical significance was found for the association between SES and NLTC for elderly men. A significant and positive association between SES and physical health was observed among the elderly men and women, with a slightly stronger effect among the elderly women. Implications for lowering the NLTC and developing an LTC system were addressed based on the findings above.