Impact of Multiple Social Determinants of Health on Incident Stroke

Impact of Race on Outcomes in the Endovascular and Microsurgical Treatment in Patients With Intracranial Aneurysms

BACKGROUND AND OBJECTIVES

The impact of race on outcomes in the treatment of intracranial aneurysm (IA) remains unclear. We aimed to investigate the relationship between race classified into White, Black, Hispanic, and other and treatment outcomes in patients with ruptured and unruptured IAs.

METHODS

The study population consisted of 2836 patients with IA with endovascular treatment or microsurgical treatment (MST) from 16 centers in the United States and Asia, all participating in the observational "STAR" registry. The primary outcome was a 90-day modified Rankin Scale of 0 to 2. Secondary outcomes included periprocedural cerebral infarction and intracranial hemorrhage, perioperative symptomatic cerebral vasospasm in ruptured IA and mortality, and all causes of mortality within 90 days.

RESULTS

One thousand fifty-three patients were White (37.1%), 350 were Black (12.3%), 264 were Hispanic (9.3%), and 1169 were other (41.2%). Compared with White patients, Hispanic patients had a significantly lower proportion of primary outcome (adjusted odds ratio [aOR] 0.36, 95% CI, 0.23-0.56) and higher proportion of the periprocedural cerebral infarction, perioperative mortality, and all causes of mortality (aOR 2.53, 95% CI, 1.40-4.58, aOR 1.84, 95% CI, 1.00-3.38, aOR 1.83, 95% CI, 1.06-3.17, respectively). Outcomes were not significantly different in Black and other patients. The subgroup analysis showed that Hispanic patients with age ≥65 years (aOR 0.19, 95% CI, 0.10-0.38, interaction P = .048), Hunt-Hess grades 0 to 3 (aOR 0.29, 95% CI, 0.19-0.46, interaction P = .03), and MST (aOR 0.24, 95% CI, 0.13-0.44, interaction P = .04) had a significantly low proportion of primary outcome.

CONCLUSION

This study demonstrates that Hispanic patients with IA are more likely to have a poor outcome at 90 days after endovascular treatment or MST than White patients. Physicians have to pay attention to the selection of treatment modalities, especially for Hispanic patients with specific factors to reduce racial discrepancies.

Social Vulnerability Index and All-Cause Mortality After Acute Ischemic Stroke, Medicare Cohort 2020-2023

Background

Inequities in stroke outcomes have existed for decades, and the COVID-19 pandemic amplified these inequities.

Objectives

This study examined the association between social vulnerability and all-cause mortality among Medicare beneficiaries hospitalized with acute ischemic stroke (AIS) during COVID-19 pandemic periods.

Methods

We analyzed data on Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with AIS between April 1, 2020, and December 31, 2021 (followed until December 31, 2023) merged with county-level data from the 2020 Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry's Social Vulnerability Index (SVI). We used a Cox proportional hazard model to examine the association between SVI quartile and all-cause mortality.

Results

Among 176,123 Medicare fee-for-service beneficiaries with AIS, 29.9% resided in the most vulnerable counties (SVI quartile 4), while 14.9% resided in counties with least social vulnerability (SVI quartile 1). AIS Medicare beneficiaries living in the most vulnerable counties had the highest proportions of adults aged 65 to 74 years, non-Hispanic Black or Hispanic, severe stroke at admission, a history of COVID-19, and more prevalent comorbidities. Compared to those living in least vulnerable counties, AIS Medicare beneficiaries living in most vulnerable counties had significantly higher all-cause mortality (adjusted HR: 1.11, 95% CI: 1.08-1.14). The pattern of association was largely consistent in subgroup analyses by age group, sex, and race and ethnicity.

Conclusions

Higher social vulnerability levels were associated with increased all-cause mortality among AIS Medicare beneficiaries. To improve outcomes and address disparities, it may be important to focus efforts toward addressing social vulnerability.

The association between social networks and functional recovery after stroke

BACKGROUND AND PURPOSE

Social determinants of health (SDOH), including social networks, impact disability and quality of life post-stroke, yet the direct influence of SDOH on functional change remains undetermined. We aimed to identify which SDOH predict change on the modified Rankin Scale (mRS) within 90 days after stroke hospitalization.

METHODS

Stroke patients from the Transitions of Care Stroke Disparities Study (TCSDS) were enrolled from 12 hospitals in the Florida Stroke Registry. TCSDS aims to identify disparities in hospital-to-home transitions after stroke. SDOH were collected by trained interviewers at hospital discharge. The mRS was assessed at discharge, 30- and 90-day post-stroke. Multinomial logistic regression models examined contributions of each SDOH to mRS improvement or worsening (compared to no change) from discharge to 30- and 90-day, respectively.

RESULTS

Of 1190 participants, median age was 64 years, 42% were women, 52% were non-Hispanic White, and 91% had an ischemic stroke. Those with a limited social support network had greater odds of functional decline at 30 days (aOR = 1.39, 1.17-1.66), adjusting for age and onset to arrival time and at 90 days (aOR = 1.50, 1.10-2.05) after adjusting for age. Results were consistent after further adjustment for additional SDOH and participant characteristics. Individuals living with a spouse/partner had reduced odds of functional decline at 90 days (aOR = 0.74, 0.57-0.98); however, results were inconsistent with more conservative modeling approaches.

CONCLUSION

The findings highlight the importance of SDOH, specifically having a greater number of individuals in your social network in functional recovery after stroke.

Cardiovascular disease and cancer: shared risk factors and mechanisms

Cardiovascular disease (CVD) and cancer are among the leading causes of morbidity and mortality globally, and these conditions are increasingly recognized to be fundamentally interconnected. In this Review, we present the current epidemiological data for each of the modifiable risk factors shared by the two diseases, including hypertension, hyperlipidaemia, diabetes mellitus, obesity, smoking, diet, physical activity and the social determinants of health. We then review the epidemiological data demonstrating the increased risk of CVD in patients with cancer, as well as the increased risk of cancer in patients with CVD. We also discuss the shared mechanisms implicated in the development of these conditions, highlighting their inherent bidirectional relationship. We conclude with a perspective on future research directions for the field of cardio-oncology to advance the care of patients with CVD and cancer.

The impact of residential environment on stroke onset and its spatial heterogeneity: A multiscale exploration in Shanghai

BACKGROUND

Stroke is a worldwide concern due to its high disability and mortality rates, especially in many countries entering ageing societies. This study aims to understand the spatial heterogeneity of stroke onset and residential environment influence scopes from multiscale.

METHODS

The 2013 to 2022 spatiotemporal distribution pattern of stroke onset was obtained via out-patient data from a hospital in Shanghai. Then nine residential environmental factors were selected to estimate the association of stroke onset by multiscale geographically weighted regression (MGWR), in three scenarios.

RESULTS

Accessibility to pubs/bars (PUB) and building density (BD) were the top two residential environmental factors both for the entire sample and by gender. Stress-related environmental factors have a greater impact on the onset of stroke in men but are limited in scope. The population of elderly people have relevance to environmental variables heterogeneity. The indicators relating to unhealthy food and alcohol suggest that habit-inducing environmental factors have a limited impact on stroke onset, but rather that pre-existing habits play a greater role.

CONCLUSIONS

MGWR analyses individual components across multiple bandwidths, revealing geographical disparities in the impact of elements that would otherwise be undetected on a global scale. Environmental factors have a limited impact on the onset of stroke. When society is faced with both heavy ageing and fiscal constraints, some of the blue-green space budgets can be scaled back to invest in more secure facilities.

Cognitive function in adolescence and the risk of early-onset stroke

BACKGROUND

Stroke is increasingly prevalent at younger ages but the risk factors are uncertain. We examined the association between adolescent cognitive function and early-onset stroke.

METHODS

This was a nationwide population-based cohort study of 1 741 345 Israeli adolescents (42% women) who underwent comprehensive cognitive function tests at age 16-20 years, before mandatory military service, during 1987-2012. Cognitive function (range: 1-9) was categorised as low (1-3, corresponding to IQ score below 89), medium (4-7, IQ score range: 89-118), or high (8-9, IQ score above 118). Participant data were linked to the Israeli National Stroke Registry. Cox proportional hazard models were used to estimate risks for the first occurrence of ischaemic stroke during 2014-2018.

RESULTS

During 8 689 329 person-years of follow-up, up to a maximum age of 50 years, 908 first stroke events occurred (767 ischaemic and 141 haemorrhagic). Compared with a reference group of people with high cognitive function, body mass index-adjusted and sociodemographic-adjusted HRs (95% CIs) for early-onset stroke were 1.78 (1.33-2.38) in medium and 2.68 (1.96-3.67) in low cognitive function groups. There was evidence of a dose-response relationship (P for trend <0.0001) such that one-unit of lower cognitive function z-score was associated with a 33% increased risk of stroke (1.33; 1.23-1.42). These associations were similar for ischaemic stroke but lower for haemorrhagic stroke; persisted in sensitivity analyses that accounted for diabetes status and hypertension; and were evident before age 40 years.

CONCLUSIONS

Alongside adolescent obesity and hypertension, lower cognitive function may be a risk factor for early-onset stroke.

Social Determinants of Health Phenotypes and Cardiometabolic Condition Prevalence Among Patients in a Large Academic Health System: Latent Class Analysis

Background

Adverse social determinants of health (SDoH) have been associated with cardiometabolic disease; however, disparities in cardiometabolic outcomes are rarely the result of a single risk factor.

Objective

This study aimed to identify and characterize SDoH phenotypes based on patient-reported and neighborhood-level data from the institutional electronic medical record and evaluate the prevalence of diabetes, obesity, and other cardiometabolic diseases by phenotype status.

Methods

Patient-reported SDoH were collected (January to December 2020) and neighborhood-level social vulnerability, neighborhood socioeconomic status, and rurality were linked via census tract to geocoded patient addresses. Diabetes status was coded in the electronic medical record using International Classification of Diseases codes; obesity was defined using measured BMI ≥30 kg/m2. Latent class analysis was used to identify clusters of SDoH (eg, phenotypes); we then examined differences in the prevalence of cardiometabolic conditions based on phenotype status using prevalence ratios (PRs).

Results

Complete data were available for analysis for 2380 patients (mean age 53, SD 16 years; n=1405, 59% female; n=1198, 50% non-White). Roughly 8% (n=179) reported housing insecurity, 30% (n=710) reported resource needs (food, health care, or utilities), and 49% (n=1158) lived in a high-vulnerability census tract. We identified 3 patient SDoH phenotypes: (1) high social risk, defined largely by self-reported SDoH (n=217, 9%); (2) adverse neighborhood SDoH (n=1353, 56%), defined largely by adverse neighborhood-level measures; and (3) low social risk (n=810, 34%), defined as low individual- and neighborhood-level risks. Patients with an adverse neighborhood SDoH phenotype had higher prevalence of diagnosed type 2 diabetes (PR 1.19, 95% CI 1.06-1.33), hypertension (PR 1.14, 95% CI 1.02-1.27), peripheral vascular disease (PR 1.46, 95% CI 1.09-1.97), and heart failure (PR 1.46, 95% CI 1.20-1.79).

Conclusions

Patients with the adverse neighborhood SDoH phenotype had higher prevalence of poor cardiometabolic conditions compared to phenotypes determined by individual-level characteristics, suggesting that neighborhood environment plays a role, even if individual measures of socioeconomic status are not suboptimal.

Correlations of Socioeconomic and Clinical Determinants with United States County-Level Stroke Prevalence

Socioeconomic status (SES) is a multi-faceted theoretical construct associated with stroke risk and outcomes. Knowing which SES measures best correlate with population stroke metrics would improve its accounting in observational research and inform interventions. Using the Centers for Disease Control and Prevention's (CDC) Population Level Analysis and Community Estimates (PLACES) and other publicly available databases, we conducted an ecological study comparing correlations of different United States county-level SES, health care access and clinical risk factor measures with age-adjusted stroke prevalence. The prevalence of adults living below 150% of the federal poverty level most strongly correlated with stroke prevalence compared to other SES and non-SES measures (correlation coefficient = 0.908, R2 = 0.825; adjusted partial correlation coefficient: 0.589, R2 = 0.347). ANN NEUROL 2024.

Social determinants of health and clinical outcomes among patients with atrial fibrillation: evidence from a global federated health research network

BACKGROUND

Few studies have investigated the role of social determinants of health (SDoH) in patients with atrial fibrillation (AF).

AIM

To investigate the relationship between SDoH and adverse events in a large multinational AF cohort.

DESIGN

Retrospective study utilizing a global federated health research network (TriNetX).

METHODS

Patients with AF were categorized as socially deprived defined according to ICD codes based on three SDoHs: (i) extreme poverty; (ii) unemployment; and/or (iii) problems related with living alone. The outcomes were the 5-year risk of a composite outcomes of all-cause death, hospitalization, ischemic heart disease (IHD), stroke, heart failure (HF) or severe ventricular arrhythmias. Cox regression was used to compute hazard rate ratios (HRs) and 95% confidence intervals (CIs) following 1:1 propensity score matching (PSM).

RESULTS

The study included 24 631 socially deprived (68.8 ± 16.0 years; females 51.8%) and 2 462 092 non-deprived AF patients (75.5 ± 13.1 years; females 43.8%). Before PSM, socially deprived patients had a higher risk of the composite outcome (HR 1.9, 95% CI 1.87-1.93), all-cause death (HR 1.34, 95% CI 1.28-1.39), hospitalization (HR 2.01, 95% CI 1.98-2.04), IHD (HR 1.67, 95% CI 1.64-1.70), stroke (HR 2.60, 95% CI 2.51-2.64), HF (HR 1.91, 95% CI 1.86-1.96) and severe ventricular arrhythmias (HR 1.83, 95% CI 1.76-1.90) compared to non-deprived AF patients. The PSM-based hazard ratios for the primary composite outcome were 1.54 (95% CI 1.49-1.60) for the unemployed AF patients; 1.39 (95% CI 1.31-1.47) for patients with extreme poverty or with low income; and 1.42 (95% CI 1.37-1.47) for those with problems related with living alone.

CONCLUSIONS

In patients with AF, social deprivation is associated with an increased risk of death and adverse cardiac events. The presence of possible unmeasured bias associated with the retrospective design requires confirmation in future prospective studies.

Socioeconomic Disparities in Women's Cardiovascular Health in the United States and Canada

Cardiovascular disease has been the leading cause of death in the United States and Canada for decades. Although it affects millions of people across a multitude of backgrounds, notable disparities in cardiovascular health are observed among women and become more apparent when accounting for race and socioeconomic status. Although intrinsic sex-specific physiologic differences predispose women to poorer outcomes, social determinants of health (SDOH) and biases at both the individual provider and the larger health care system levels play an equal, if not greater, role. This review examines socioeconomic disparities in women compared with men regarding cardiovascular risk factors, treatments, and outcomes. Although various at-risk subpopulations exist, we highlight the impact of SDOH in specific populations, including patients with disabilities, transgender persons, and South Asian and Indigenous populations. These groups are underrepresented in studies and experience poorer health outcomes owing to structural barriers to care. These findings emphasise the significance of understanding the interplay of different socioeconomic factors and how their stacking can negatively affect women's cardiovascular health. To address these disparities, we propose a multipronged approach to augment culturally sensitive and patient-centred care. This includes increased cardiovascular workforce diversity, inclusion of underrepresented populations into analyses of cardiovascular metrics, and greater utilisation of technology and telemedicine to improve access to health care. Achieving this goal will necessitate active participation from patients, health care administrators, physicians, and policy makers, and is imperative in closing the cardiovascular health gap for women over the coming decades.

The interaction between social determinants of health, health behaviors, and child's intellectual developmental diagnosis

INTRODUCTION

Social determinants of health (SDOH) may impact caregivers' ability to implement evidence-based health practices at home during early childhood, especially in families with children with intellectual and developmental disabilities (IDD). Therefore, we examined the influence of SDOH and children's diagnosis (typically developing [TD], Down syndrome [DS], autism) on caregiver's self-report of meeting evidence-based health practices.

METHODS

Caregivers (n=172) of children ages 2-6 years (TD: n=93, DS: n=40, autism: n=39) completed an online survey on SDOH and health practices related to child nutrition (CN), physical activity (PA), outdoor play (OP), and screen time (ST). A total SDOH score was computed by assigning 1 point for each favorable SDOH metric (range 0-13). Linear regressions were used to examine associations between SDOH and CN, PA, OP, ST health practices and the moderating effect of IDD diagnosis.

RESULTS

Most caregivers were non-Hispanic White (84.3%), female (76.7%), 18-35 years old (55.2%), and married (89.5%). The DS group had the lowest SDOH score (mean = 8.4±1.0) compared to autism (mean = 10.1±1.0) and TD (mean = 11.0±0.9). No family scored 100% in evidence-based practices for any health practice. SDOH score was significantly associated with evidence-based practices met score for CN (b = 1.94, 95% CI = 0.84, 3.04; p = 0.001) and PA (b = 4.86, 95% CI = 2.92, 6.79; p <0.0001). Moderation analysis showed no association in the DS and autism groups between SDOH score and CN percent total score, or between SDOH score and CN, PA, and OP for percent evidence-based practices met. SDOH score was also not associated with OP percent total score for the DS group.

CONCLUSIONS

This study highlights the differential influence of SDOH on caregivers' implementing health practices in families with children of different IDD diagnoses. Future research is needed to understand impacts of SDOH on non-typically developing children.

Prevalence of Stroke - Behavioral Risk Factor Surveillance System, United States, 2011-2022

Stroke was the fifth leading cause of death in the United States in 2021, and cost U.S. residents approximately $56.2 billion during 2019-2020. During 2006-2010, self-reported stroke prevalence among noninstitutionalized adults had a relative decrease of 3.7%. Data from the Behavioral Risk Factor Surveillance System were used to analyze age-standardized stroke prevalence during 2011-2022 among adults aged ≥18 years. From 2011-2013 to 2020-2022, overall self-reported stroke prevalence increased by 7.8% nationwide. Increases occurred among adults aged 18-64 years; females and males; non-Hispanic Black or African American (Black), non-Hispanic White (White), and Hispanic or Latino (Hispanic) persons; and adults with less than a college degree. Stroke prevalence was higher among adults aged ≥65 years than among younger adults; among non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or Pacific Islander, and Black adults than among White adults; and among adults with less than a high school education than among those with higher levels of education. Stroke prevalence decreased in the District of Columbia and increased in 10 states. Initiatives to promote knowledge of the signs and symptoms of stroke, and the identification of disparities in stroke prevalence, might help to focus clinical and programmatic interventions, such as the Million Hearts 2027 initiative or the Paul Coverdell National Acute Stroke Program, to improve prevention and treatment of stroke.

Social Determinants of Health and Incident Apparent Treatment-Resistant Hypertension Among White and Black US Adults: The REGARDS Study

BACKGROUND

We examined the association of multilevel social determinants of health with incident apparent treatment-resistant hypertension (aTRH).

METHODS AND RESULTS

We analyzed data from 2774 White and 2257 Black US adults from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study taking antihypertensive medication without aTRH at baseline to estimate the association of social determinants of health with incident aTRH. Selection of social determinants of health was guided by the Healthy People 2030 domains of education, economic stability, social context, neighborhood environment, and health care access. Blood pressure (BP) was measured during study visits, and antihypertensive medication classes were identified through a pill bottle review. Incident aTRH was defined as (1) systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, or systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg for those with diabetes or chronic kidney disease while taking ≥3 classes of antihypertensive medication or (2) taking ≥4 classes of antihypertensive medication regardless of BP level, at the follow-up visit. Over a median 9.5 years of follow-up, 15.9% of White and 24.0% of Black adults developed aTRH. A percent of the excess aTRH risk among Black versus White adults was mediated by low education (14.2%), low income (16.0%), not seeing a friend or relative in the past month (8.1%), not having someone to care for them if ill or disabled (7.6%), lack of health insurance (10.6%), living in a disadvantaged neighborhood (18.0%), and living in states with poor public health infrastructure (6.0%).

CONCLUSIONS

Part of the association between race and incident aTRH risk was mediated by social determinants of health.

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.

Trends in Demographic and Geographic Disparities in Stroke Mortality Among Older Adults in the United States

BACKGROUND

Stroke is a leading cause of morbidity and mortality in the United States among older adults. However, the impact of demographic and geographic risk factors remains ambiguous. A clear understanding of these associations and updated trends in stroke mortality can influence health policies and interventions.

METHODS

This study characterizes stroke mortality among older adults (age ≥55) in the US from January 1999 to December 2020, sourcing data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Segmented regression was used to analyze trends in crude mortality rate and age-adjusted mortality rate (AAMR) per 100,000 individuals stratified by stroke subcategory, sex, ethnicity, urbanization, and state.

RESULTS

A total of 3,691,305 stroke deaths occurred in older adults in the US between 1999 and 2020 (AAMR = 233.3), with an overall decrease in AAMR during these years. The highest mortality rates were seen in nonspecified stroke (AAMR = 173.5), those 85 or older (crude mortality rate1276.7), men (AAMR = 239.2), non-Hispanic African American adults (AAMR = 319.0), and noncore populations (AAMR = 276.1). Stroke mortality decreased in all states from 1999 to 2019 with the greatest and least decreases seen in California (-61.9%) and Mississippi (-35.0%), respectively. The coronavirus pandemic pandemic saw increased stroke deaths in most groups.

CONCLUSIONS

While there's a decline in stroke-related deaths among US older adults, outcome disparities remain across demographic and geographic sectors. The surge in stroke deaths during coronavirus pandemic reaffirms the need for policies that address these disparities.

Health Inequity and Time From Pediatric Stroke Onset to Arrival

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of Recurrent Stroke and Mortality Among Black and White Patients With Poststroke Depression

BACKGROUND

Poststroke depression (PSD) is a treatable and common complication of stroke that is underdiagnosed and undertreated in minority populations. We compared outcomes of Black and White patients with PSD in the United States to assess whether race is independently associated with the risk of recurrent stroke and mortality.

METHODS

We used deidentified Medicare data from inpatient, outpatient, and subacute nursing facilities for Black and White US patients from January 1, 2016, to December 31, 2019, to perform this retrospective cohort analysis. International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with depression within 6 months of index stroke with no depression diagnosis 1-year preceding index stroke. We performed an unadjusted Kaplan-Meier analysis of the cumulative risk of recurrent stroke up to 3 years after index acute ischemic stroke admission and all-cause mortality following acute ischemic stroke stratified by Black and White race. We performed adjusted and reduced Cox regression to calculate hazard ratios for the main predictor of race (Black versus White), for recurrent stroke and all-cause mortality, adjusting for sociodemographic characteristics, comorbidities, characteristics of the hospitalization, and acute stroke interventions.

RESULTS

Of 474 770 Medicare patients admitted with acute index stroke, 443 486 were categorized as either Black or White race and 35 604 fulfilled our criteria for PSD. Within the PSD cohort, 25 451 (71.5%) had no death or recurrent stroke within 6 months and 5592 (15.7%) had no death or readmission of any cause within 6 months. Black patients with PSD had a persistently elevated cumulative risk of recurrent stroke compared with White patients with PSD up to 3 years following acute ischemic stroke (log-rank P=0.0011). In our reduced multivariable model, Black patients had a 19.8% (hazard ratio, 1.198 [95% CI, 1.022-1.405]; P=0.0259) greater risk of recurrent stroke than White patients. The unadjusted cumulative risk of all-cause mortality was higher in this cohort of older White patients with PSD compared with Black patients; however, this difference disappeared with adjustment for age and other cofactors.

CONCLUSIONS

Black patients with PSD face a persistently elevated risk of recurrent stroke compared with White patients but a similar risk of all-cause mortality. Our findings support that black race is an independent predictor of recurrent stroke in patients with PSD and highlight the need to address social determinants of health and systemic racism that impact poststroke outcomes among racial minorities.

Social Determinants of Cardiovascular Risk Factors Among Asian American Subgroups

BACKGROUND

Social determinants of health (SDOH) play a significant role in the development of cardiovascular risk factors. We investigated SDOH associations with cardiovascular risk factors among Asian American subgroups.

METHODS AND RESULTS

We utilized the National Health Interview Survey, a nationally representative survey of US adults, years 2013 to 2018. SDOH variables were categorized into economic stability, neighborhood and social cohesion, food security, education, and health care utilization. SDOH score was created by categorizing 27 SDOH variables as 0 (favorable) or 1 (unfavorable). Self-reported cardiovascular risk factors included diabetes, high cholesterol, high blood pressure, obesity, insufficient physical activity, suboptimal sleep, and nicotine exposure. Among 6395 Asian adults aged ≥18 years, 22.1% self-identified as Filipino, 21.6% as Asian Indian, 21.0% as Chinese, and 35.3% as other Asian. From multivariable-adjusted logistic regression models, each SD increment of SDOH score was associated with higher odds of diabetes among Chinese (odds ratio [OR], 1.45; 95% CI, 1.04-2.03) and Filipino (OR, 1.24; 95% CI, 1.02-1.51) adults; high blood pressure among Filipino adults (OR, 1.28; 95% CI, 1.03-1.60); insufficient physical activity among Asian Indian (OR, 1.42; 95% CI, 1.22-1.65), Chinese (OR, 1.58; 95% CI, 1.33-1.88), and Filipino (OR, 1.24; 95% CI, 1.06-1.46) adults; suboptimal sleep among Asian Indian adults (OR, 1.20; 95% CI, 1.01-1.42); and nicotine exposure among Chinese (OR, 1.56; 95% CI, 1.15-2.11) and Filipino (OR, 1.50; 95% CI, 1.14-1.97) adults.

CONCLUSIONS

Unfavorable SDOH are associated with higher odds of cardiovascular risk factors in Asian American subgroups. Culturally specific interventions addressing SDOH may help improve cardiovascular health among Asian Americans.

Do social determinants influence post-stroke aphasia outcomes? A scoping review

PURPOSE

To conduct a scoping review on five individual social determinants of health (SDOHs): gender, education, ethnicity, socioeconomic status, and social support, in relation to post-stroke aphasia outcomes.

MATERIALS AND METHODS

A comprehensive search across five databases was conducted in 2020 and updated in 2022. Twenty-five studies (3363 participants) met the inclusion criteria. Data on SDOHs and aphasia outcomes were extracted and analysed descriptively.

RESULTS

Twenty studies provide information on SDOH and aphasia recovery outcomes. Five studies provide insights on SDOH and response to aphasia intervention. Research on SDOH and aphasia recovery has predominantly focussed solely on language outcomes (14 studies), with less research on the role of SDOH on activity, participation, and quality of life outcomes (6 studies). There is no evidence to support a role for gender or education on language outcomes in the first 3 months post stroke. SDOHs may influence aphasia outcomes at or beyond 12 months post onset.

CONCLUSIONS

Research on SDOHs and aphasia outcomes is in its infancy. Given SDOHs are modifiable and operate over a lifetime, and aphasia is a chronic condition, there is a pressing need to understand the role of SDOHs on aphasia outcomes in the long term.

Exploring the association between social determinants and aphasia impairment: A retrospective data integration approach

INTRODUCTION

Traditionally, the study of aphasia focused on brain trauma, clinical biomarkers, and cognitive processes, rarely considering the social determinants of health. This study evaluates the relationship between aphasia impairment and demographic, socioeconomic, and contextual determinants among people with aphasia (PWA).

METHODS

PWA indexed within AphasiaBank-a database populated by multiple clinical aphasiology centers with standardized protocols characterizing language, neuropsychological functioning, and demographic information-were matched with respondents in the Medical Expenditure Panel Survey based on response year, age, sex, race, ethnicity, time post stroke, and mental health status. Generalized log-linear regression models with bootstrapped standard errors evaluated the association between scores on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R AQ) and demographic, economic, and contextual characteristics accounting for clustering of respondents and the stratification of data collection. Region, age, and income specific models tested the sensitivity of results.

RESULTS

PWA over age 60 had 2.4% (SE = 0.020) lower WAB-R AQ scores compared with younger PWA. Compared to White PWA, Black and Hispanic PWA had 4.7% (SE = 0.03) and 0.81% (SE = 0.06) lower WAB-R AQ scores, respectively, as did those and living in the Southern US (-2.2%, SE = 0.03) even after controlling for age, family size, and aphasia type. Those living in larger families (β = 0.005, SE = 0.008), with income over $30,000 (β = 0.017, SE = 0.022), and a college degree (β = 0.030, SE = 0.035) had higher WAB-R AQ relative to their counterparts. Region-specific models showed that racial differences were only significant in the South and Midwest, while ethnic differences are only significant in the West. Sex differences only appeared in age-specific models. Racial and ethnic differences were not significant in the high-income group regression.

CONCLUSION

These findings support evidence that circumstances in which individuals live, work, and age are significantly associated with their health outcomes including aphasia impairment.

Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019

Importance

Stroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies.

Objective

To present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location.

Design, Setting, and Participants

An in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020.

Exposures

In this study, no particular exposure was specifically targeted.

Main Outcomes and Measures

The primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals.

Results

In 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota).

Conclusions and Relevance

In this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.

Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities

Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.

Analyzing Multiple Social Determinants of Health Using Different Clustering Methods

Social determinants of health (SDoH) have become an increasingly important area to acknowledge and address in healthcare; however, dealing with these measures in outcomes research can be challenging due to the inherent collinearity of these factors. Here we discuss our experience utilizing three statistical methods-exploratory factor analysis (FA), hierarchical clustering, and latent class analysis (LCA)-to analyze data collected using an electronic medical record social risk screener called Protocol for Responding to and Assessing Patient Assets, Risks, and Experience (PRAPARE). The PRAPARE tool is a standardized instrument designed to collect patient-reported data on SDoH factors, such as income, education, housing, and access to care. A total of 2380 patients had complete PRAPARE and neighborhood-level data for analysis. We identified a total of three composite SDoH clusters using FA, along with four clusters identified through hierarchical clustering, and four latent classes of patients using LCA. Our results highlight how different approaches can be used to handle SDoH, as well as how to select a method based on the intended outcome of the researcher. Additionally, our study shows the usefulness of employing multiple statistical methods to analyze complex SDoH gathered using social risk screeners such as the PRAPARE tool.

A retrospective analysis of the social determinants of health affecting stroke outcomes in a small hospital situated in a health professional shortage area (HPSA)

Where someone lives is a major determinant of population health. In the United States, people who live in Health Professional Shortage Areas are considered medically underserved and have a higher propensity for conditions such as stroke, hypertension, and diabetes. Our goal was to better understand the diverse needs of patients presenting to the Crouse Hospital emergency department with stroke symptoms. Crouse Hospital is a small community hospital located in a shortage area serving both urban and rural populations in and around Syracuse, New York. Despite its small size, Crouse Hospital quickly became a major comprehensive stroke center in Central New York. With this study we assessed the social factors affecting the stroke patient population in the community and compared these characteristics between those living in served and underserved areas. Informed by the social determinants of health framework, we analyzed 1731 incidents of stroke that occurred between January 2019 and January 2021, and observed that the circumstances associated with stroke varied by service category and race, with White patients and those from served areas having better stroke outcomes compared to those residing in underserved areas and those that were not White. Our analyses help us to understand the underlying factors influencing the observed disparities and allow us to move forward by implementing informed community-based interventions to decrease stroke incidence and improve post-stroke care. Using our example other small hospitals can enact similar strategies to address the social determinants affecting their patients to improve stroke outcomes in their region.

Association Between Social Determinants of Health and Communication Difficulties in Poststroke U.S. Hispanic and Non-Hispanic White Populations

PURPOSE

The relationship among ethnicity, social determinants of health (SDOH), and disparities in poststroke outcomes is complex, and the impact on communication difficulties is unclear. This study investigated the presence and nature of communication difficulties in poststroke non-Hispanic White (PsnHw) and Hispanic U.S. populations using population-level data.

METHOD

We performed a cross-sectional analysis of 2,861 non-Hispanic White and 353 Hispanic poststroke respondents included in the 2014-2018 National Health Interview Survey. Respondents self-reported difficulties communicating in their usual language, in addition to providing information relating to demographics and lifestyle, health care access and utilization, health status, and SDOH. We used univariate statistics, generalized linear models, and an exploratory mediation analysis, to characterize the pattern of differences between these cohorts, examine associations between variables and communication difficulties, and determine the potential intermediate role of cumulative SDOH on the likelihood of reporting communication difficulties.

RESULTS

Findings indicated a more challenging life context for the poststroke Hispanic population due to SDOH disparities. Poverty and Internet use were associated with greater and lower odds of communication difficulties for PsnHw, respectively. The mediation analysis showed that ethnicity significantly affected communication difficulties, but only when mediated by SDOH. SDOH accounted for approximately two thirds of the total effect on reporting communication difficulties.

CONCLUSIONS

This study underscores the need for uniform measures of SDOH in prospective research and for interventions aimed at mitigating health disparities through addressing disparities in SDOH. Future research should focus on evaluating the effectiveness of such strategies in diverse ethnic and socioeconomic poststroke populations.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24521419.

Looking Upstream to Understand Race/Ethnicity as a Moderator for Poststroke Neuroinflammation and a Social Determinant for Poststroke Aphasia Outcomes

INTRODUCTION

Over the past decade, the stroke literature has begun to acknowledge and explore explanations for longstanding racial/ethnic differences in stroke outcomes. Poststroke cognitive impairment (PSCI) and poststroke aphasia are two such negative poststroke outcomes where racial/ethnic differences exist. Physiological differences, such as stroke type and lesion size, have been used to partially explain the variation in PSCI and aphasia. However, there is some evidence, although limited, that suggests neuroinflammatory processes as part of allostatic load may be a key contributor to the observed disparities.

METHOD

In this tutorial, we explore the influence of race differences in inflammation on poststroke cognitive outcomes. We suggest lifetime stress and other external determinants of health such as neighborhood environment and discriminatory practices through "weathering" explain differences in inflammation. While using an allostatic load framework, we explore the literature focusing specifically on the role of neuroinflammation on poststroke outcomes.

CONCLUSIONS

Examination of the immune response poststroke provides a foundation for understanding the mechanisms of PSCI and poststroke aphasia and the potential contributions of neuroinflammatory processes on poststroke cognitive outcomes. Furthermore, understanding of racial differences in those processes may contribute to a better understanding of racial disparities in general stroke outcomes as well as poststroke aphasia.

Risk Prediction for Atherosclerotic Cardiovascular Disease With and Without Race Stratification

Importance

Use of race-specific risk prediction in clinical medicine is being questioned. Yet, the most commonly used prediction tool for atherosclerotic cardiovascular disease (ASCVD)-pooled cohort risk equations (PCEs)-uses race stratification.

Objective

To quantify the incremental value of race-specific PCEs and determine whether adding social determinants of health (SDOH) instead of race improves model performance.

Design, Setting, and Participants

Included in this analysis were participants from the biracial Reasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort study. Participants were aged 45 to 79 years, without ASCVD, and with low-density lipoprotein cholesterol level of 70 to 189 mg/dL or non-high-density lipoprotein cholesterol level of 100 to 219 mg/dL at baseline during the period of 2003 to 2007. Participants were followed up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke. Study data were analyzed from July 2022 to February 2023.

Main outcome/measures

Discrimination (C statistic, Net Reclassification Index [NRI]), and calibration (plots, Nam D'Agostino test statistic comparing observed to predicted events) were assessed for the original PCE, then for a set of best-fit, race-stratified equations including the same variables as in the PCE (model C), best-fit equations without race stratification (model D), and best-fit equations without race stratification but including SDOH as covariates (model E).

Results

This study included 11 638 participants (mean [SD] age, 61.8 [8.3] years; 6764 female [58.1%]) from the REGARDS cohort. Across all strata (Black female, Black male, White female, and White male participants), C statistics did not change substantively compared with model C (Black female, 0.71; 95% CI, 0.68-0.75; Black male, 0.68; 95% CI, 0.64-0.73; White female, 0.77; 95% CI, 0.74-0.81; White male, 0.68; 95% CI, 0.64-0.71), in model D (Black female, 0.71; 95% CI, 0.67-0.75; Black male, 0.68; 95% CI, 0.63-0.72; White female, 0.76; 95% CI, 0.73-0.80; White male, 0.68; 95% CI, 0.65-0.71), or in model E (Black female, 0.72; 95% CI, 0.68-0.76; Black male, 0.68; 95% CI, 0.64-0.72; White female, 0.77; 95% CI, 0.74-0.80; White male, 0.68; 95% CI, 0.65-0.71). Comparing model D with E using the NRI showed a net percentage decline in the correct assignment to higher risk for male but not female individuals. The Nam D'Agostino test was not significant for all race-sex strata in each model series, indicating good calibration in all groups.

Conclusions

Results of this cohort study suggest that PCE performed well overall but had poorer performance in both BM and WM participants compared with female participants regardless of race in the REGARDS cohort. Removal of race or the addition of SDOH did not improve model performance in any subgroup.

DECODING STROKE DISPARITIES: ZIP CODES, COLOR CODES, AND EPIGENETIC CODES

Despite decreases in overall stroke incidence and mortality in the United States, racial and ethnic disparities continue unabated. Of note, the long-standing disproportionate burden of stroke on African Americans compared to other racial and ethnic groups persists, and national projections indicate this toll will likely worsen over the next decade. Why have we not been able to bend the stroke disparities curve for African Americans? Well, this is mainly because traditional stroke risk factors, such as hypertension, diabetes, etc., account for just half of the Black vs. non-Hispanic White stroke disparity. As such, there is increasing interest in evaluating understudied factors like upstream social determinants of health, including geography, psychosocial stress, and environmental pollution; identifying potential mediators; and testing multilevel interventions to address them. This paper highlights emerging avenues that may help decode the excess stroke risk in African Americans, focusing on zip codes, color codes, and epigenetic codes.

Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps

Stroke is a leading cause of death and disability in the United States and worldwide, necessitating comprehensive efforts to optimize stroke risk factor management. Health disparities in stroke incidence, prevalence, and risk factor management persist among various race/ethnic, geographic, and socioeconomic populations and negatively impact stroke outcomes. This review highlights existing literature and guidelines for stroke risk factor management, emphasizing health disparities among certain populations. Moreover, stroke risk factors for special groups, including the young, the very elderly, and pregnant/peripartum women are outlined. Strategies for stroke risk factor improvement at every level of the health care system are discussed, from the individual patient to providers, health care systems, and policymakers. Improving stroke risk factor management in the context of the social determinants of health, and with the goal of eliminating inequities and disparities in stroke prevention strategies, are critical steps to reducing the burden of stroke and equitably improving public health.

Social Determinants of Health, Cardiovascular Health, and Outcomes in Community-Dwelling Adults Without Cardiovascular Disease

Background

Limited data exist regarding the prognostic implications of social determinants of health (SDOH) and cardiovascular health (CVH) in Chinese community populations.

Objectives

The aim of this study was to evaluate the associations of SDOH and CVH with major adverse cardiovascular events (MACE) and all-cause death.

Methods

Individuals without cardiovascular disease were obtained from the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project. SDOH (educational attainment, economic stability, health care access, social support, and neighborhood) and CVH components were extracted. Participants were divided into groups with low and high burden of unfavorable SDOH and groups with poor, intermediate, and ideal CVH. MACE (a composite of coronary heart disease or myocardial infarction, stroke, heart failure, and cardiovascular death) and all-cause death were identified by linking hospital records with resident identity card number.

Results

Among the cohort (n = 38,571, median age 54 years, 60.5% women), the proportion of individuals with a high burden of unfavorable SDOH was 68.9%, and that with poor CVH was 30.7%. In reference to the group with a low burden of unfavorable SDOH, the adjusted HRs for MACE and all-cause death in the high burden group were 1.18 (95% CI: 1.08-1.30) and 1.35 (95% CI: 1.09-1.68), respectively. In reference to the group with ideal CVH, poor CVH was associated with higher risks for MACE and all-cause death. A high burden of unfavorable SDOH and poor CVH exerted joint effects on all-cause death (HR: 2.20; 95% CI: 1.08-4.48).

Conclusions

A high burden of unfavorable SDOH and poor CVH were associated with increased risks for MACE and mortality. Dedicated efforts are needed to address these health disparities.

APOL1 Risk Variants Associate With the Prevalence of Stroke in African American Current and Past Smokers

BACKGROUND

African American smokers have 2.5 times higher risk for stroke compared with nonsmokers (higher than other races). About 50% of the African American population carry 1 or 2 genetic variants (G1 and G2; rare in other races) of the apolipoprotein L1 gene (APOL1). Studies showed these variants may be associated with stroke. However, the role of the APOL1 risk variants in tobacco-related stroke is unknown.

METHODS AND RESULTS

In a cross-sectional study, we examined whether APOL1 risk variants modified the relationship between tobacco smoking and stroke prevalence in 513 African American adults recruited at University of California, San Francisco. Using DNA, plasma, and questionnaires we determined APOL1 variants, smoking status, and stroke prevalence. Using logistic regression models, we examined the association between smoking (ever versus never smokers) and stroke overall, and among carriers of APOL1 risk variants (1 or 2 risk alleles), and noncarriers, separately. Among participants, 41% were ever (current and past) smokers, 54% were carriers of the APOL1 risk variants, and 41 had a history of stroke. The association between smoking and stroke differed by APOL1 genotype (Pinteraction term=0.014). Among carriers, ever versus never smokers had odds ratio (OR) 2.46 (95% CI, 1.08-5.59) for stroke (P=0.034); OR 2.00 (95% CI, 0.81-4.96) among carriers of 1 risk allele, and OR 4.72 (95% CI, 0.62-36.02) for 2 risk alleles. Among noncarriers, smoking was not associated with a stroke.

CONCLUSIONS

Current and past smokers who carry APOL1 G1 and/or G2 risk variants may be more susceptible to stroke among the African American population.

Racial Impact on Inpatient Stroke Quality of Care in Two Community Hospitals

INTRODUCTION

This analysis was conducted as a part of a quality improvement project aiming at identifying racial disparity in inpatient stroke quality of care.

METHODS

The Get With The Guidelines (GWTG) database was used to identify all patients discharged with any stroke diagnosis between January and December 2021. An additional chart review was conducted to ensure the accuracy of racial/ethnic categorization. The sample was dichotomized into white vs. non-white groups and compared with univariate analysis.

RESULTS

The study sample comprised 1408 encounters (1347 patients) with Mean age of 71 ± 15 years, 51% women, 82% white patients, 15% non-white patients, 72% acute ischemic stroke (AIS); 15% transient ischemic attack (TIA), 9% intracerebral hemorrhage (ICH), 3% subarachnoid hemorrhage (SAH), and 1% stroke not otherwise specified. Non-white patients were younger and had fewer concomitant diagnoses, a lower proportion of TIA, and a higher proportion of ICH (p = 0.004). In the AIS cohort, compared to white patients, non-white patients had less frequent ambulance (p = 0.009), arrived at the hospital later than white patients (7.7 h longer; p < 0.001), had more severe strokes, and had less frequent IV thrombolysis utilization (7% vs. 13%; p = 0.042). Similarly, in the TIA cohort, non-white patients' utilization of EMS was lower than that of white patients, and their hospital arrival was delayed. In the ICH cohort, non-white patients were younger and had a lower frequency of atrial fibrillation and a non-significant trend toward higher disease severity. The SAH cohort had only eight non-white patients, six of whom were transferred to a higher level of hospital care within a few hours of arrival. Importantly, the hospital-based quality metrics, such as door-to-CT time, door-to-needle time, and the Joint Commission stroke quality metrics, were similar between the two groups.

CONCLUSIONS

There is a racial disparity in the pre-hospital phase of the stroke chain of survival of non-white patients, impacting IV thrombolysis utilization. The younger age and worse lipid profile and hemoglobin A1c of non-white patients suggest the need for better preventative care starting at a young age.

Association of educational attainment with cancer mortality in a national cohort study of black and white adults: A mediation analysis

Background

Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown.

Methods

Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains.

Results

Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209).

Conclusions

In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.

Most Promising Approaches to Improve Stroke Outcomes: The Stroke Treatment Academic Industry Roundtable XII Workshop

The Stroke Treatment Academic Industry Roundtable XII included a workshop to discuss the most promising approaches to improve outcome from acute stroke. The workshop brought together representatives from academia, industry, and government representatives. The discussion examined approaches in 4 epochs: pre-reperfusion, reperfusion, post-reperfusion, and access to acute stroke interventions. The participants identified areas of priority for developing new and existing treatments and approaches to improve stroke outcomes. Although many advances in acute stroke therapy have been achieved, more work is necessary for reperfusion therapies to benefit the most possible patients. Prioritization of promising approaches should help guide the use of resources and investigator efforts.

Impact of Social Vulnerability on Diabetes-Related Cardiovascular Mortality in the United States

Background Social vulnerability impacts the natural history of diabetes as well as cardiovascular disease (CVD). However, there are little data regarding the social vulnerability association with diabetes-related CVD mortality. Methods and Results County-level mortality data (where CVD was the underlying cause of death with diabetes among the multiple causes) extracted from the Centers for Disease Control multiple cause of death (2015-2019) and the 2018 Social Vulnerability Index databases were aggregated into quartiles based on their Social Vulnerability Index ranking from the least (first quartile) to the most vulnerable (fourth quartile). Stratified by demographic groups, the data were analyzed for overall CVD, as well as for ischemic heart disease, hypertensive disease, heart failure, and cerebrovascular disease. In the 5-year study period, 387 139 crude diabetes-related cardiovascular mortality records were identified. The age-adjusted mortality rate for CVD was higher in the fourth quartile compared with the first quartile (relative risk [RR], 1.66 [95% CI, 1.64-1.67]) with an estimated 39 328 excess deaths. Among the youngest age group (<55 years), those with the highest social vulnerability had 2 to 4 times the rate of cardiovascular mortality compared with the first quartile: ischemic heart disease (RR, 2.07 [95% CI, 1.97-2.17]; heart failure (RR, 3.03 [95% CI, 2.62-3.52]); hypertensive disease (RR, 3.79 [95% CI, 3.45-4.17]; and cerebrovascular disease (RR, 4.39 [95% CI, 3.75-5.13]). Conclusions Counties with greater social vulnerability had higher diabetes-related CVD mortality, especially among younger adults. Targeted health policies that are designed to reduce these disparities are warranted.

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Importance

Involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF.

Objective

To determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF.

Design, Setting, and Participants

This retrospective cohort study used data from the Reasons for Geographic and Racial Difference in Stroke (REGARDS) cohort. Participants included adults who experienced an adjudicated hospitalization for HF between 2009 and 2017 in all 48 contiguous states in the US. Data analysis was performed from November 2022 to January 2023.

Exposures

A total of 9 candidate SDOH, aligned with the Healthy People 2030 conceptual model, were examined: Black race, social isolation, social network and/or caregiver availability, educational attainment less than high school, annual household income less than $35 000, living in rural area, living in a zip code with high poverty, living in a Health Professional Shortage Area, and living in a state with poor public health infrastructure.

Main Outcomes and Measures

The primary outcome was cardiologist involvement, defined as involvement of a cardiologist as the primary responsible clinician or as a consultant. Bivariate associations between each SDOH and cardiologist involvement were examined using Poisson regression with robust SEs.

Results

The study included 1000 participants (median [IQR] age, 77.8 [71.5-84.0] years; 479 women [47.9%]; 414 Black individuals [41.4%]; and 492 of 876 with low income [56.2%]) hospitalized at 549 unique US hospitals. Low annual household income (<$35 000) was the only SDOH with a statistically significant association with cardiologist involvement (relative risk, 0.88; 95% CI, 0.82-0.95). In a multivariable analysis adjusting for age, race, sex, HF characteristics, comorbidities, and hospital characteristics, low income remained inversely associated with cardiologist involvement (relative risk, 0.89; 95% CI, 0.82-0.97).

Conclusions and Relevance

This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.

Perceived Interpersonal Racism and Incident Stroke Among US Black Women

Importance

Black individuals in the US experience stroke and stroke-related mortality at younger ages and more frequently than other racial groups. Studies examining the prospective association of interpersonal racism with stroke are lacking.

Objective

To examine the association of perceived interpersonal racism with incident stroke among US Black women.

Design, Setting, and Participants

The Black Women's Health Study, a prospective cohort study of 59 000 Black women from across the US, assessed the longitudinal association between perceived interpersonal racism and stroke incidence. Stroke-free participants were followed up from 1997 until onset of stroke, death, loss to follow-up, or the end of the study period (December 31, 2019). Cox models were used to estimate hazard ratios (HRs) and 95% CIs, adjusting for major confounders, including education, neighborhood socioeconomic environment, and cardiometabolic factors. Data analysis was performed from March 2021 until December 2022.

Exposure

On a questionnaire completed in 1997, participants reported experiences of racism in everyday life and when dealing with situations that involved employment, housing, and interactions with police.

Main Outcomes and Measures

Strokes were identified through self-report on biennial questionnaires, medical records adjudication, and linkage with the National Death Index.

Results

In 1997, 48 375 Black women (mean [SD] age, 41 [10] years) provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer. During the 22 years of follow-up, 1664 incident stroke cases were identified; among them, 550 were definite cases confirmed by neurologist review and/or National Death Index linkage. Multivariable HRs for reported experiences of racism in all 3 domains of employment, housing, and interactions with police vs no such experiences were 1.38 (95% CI, 1.14-1.67), a 38% increase, for all incident cases and 1.37 (95% CI, 1.00-1.88) for definite cases. For comparisons of women in the highest quartile of everyday interpersonal racism score vs women in the lowest quartile, multivariable HRs were 1.14 (95% CI, 0.97-1.35) for analyses that included all incident stroke and 1.09 (95% CI, 0.83-1.45) for analyses that included definite cases only.

Conclusions and Relevance

In this study, Black women who reported experiences of interpersonal racism in situations involving employment, housing, and interactions with police appeared to have an increased risk of stroke, even after accounting for demographic and vascular risk factors, suggesting that the high burden of racism experienced by Black US women may contribute to racial disparities in stroke incidence.

Disparities in Guideline Concordant Statin Treatment in Individuals With Chronic Obstructive Pulmonary Disease

Rationale

Cardiovascular disease (CVD) affects the prognosis of patients with chronic obstructive pulmonary disease (COPD). Black women with COPD have a disproportionate risk of CVD-related mortality, yet disparities in CVD prevention in COPD are unknown.

Objectives

We aimed to identify race-sex differences in the receipt of statin treatment for CVD prevention, and whether these differences were explained by factors influencing health care utilization in the REasons for Geographic And Racial Differences in Stroke (REGARDS) COPD study sub-cohort.

Methods

We conducted a cross-sectional analysis among REGARDS Medicare beneficiaries with COPD. Our primary outcome was the presence of statin on in-home pill bottle review among individuals with an indication. Prevalence ratios (PR) for statin treatment among race-sex groups compared to White men were estimated using Poisson regression with robust variance. We then adjusted for covariates previously shown to impact health care utilization.

Results

Of the 2032 members within the COPD sub-cohort with sufficient data, 1435 participants (19% Black women, 14% Black men, 28% White women, and 39% White men) had a statin indication. All race-sex groups were less likely to receive statins than White men in unadjusted models. After adjusting for covariates that influence health care utilization, Black women (PR 0.76, 95% confidence interval [CI] 0.67 to 0.86) and White women (PR 0.84 95% CI 0.76 to 0.91) remained less likely to be treated compared to White men.

Conclusions

All race-sex groups were less likely to receive statin treatment in the REGARDS COPD sub-cohort compared to White men. This difference persisted in women after controlling for individual health care utilization factors, suggesting structural interventions are needed.

Socioeconomic status and quality of life among older adults with hypertension in rural Shandong, China: a mediating effect of social capital

Background

Improving the quality of life (QoL) of older adults is becoming an important global issue. However, very few studies have been focused on the relationship between socioeconomic status (SES) and QoL in older adults with hypertension. The purpose of this study is to investigate (a) the status of QoL and (b) the mediating effect of social capital in the relationship between SES and QoL, among rural older adults with hypertension in China.

Methods

Using multistage stratified random sampling, a face-to-face questionnaire survey was conducted among rural older adults with hypertension in Shandong province of China from June to July 2021. Three typical measures representing SES were used, namely, annual household income, educational level, and employment status. Individual social capital and QoL were assessed by the Resource Generator-China Scale (RG-China) and a 34-item simplified Patient Report Outcome (PRO)-specific scale for older adults with hypertension, respectively. A total of 950 rural older adults with hypertension were included in the analysis. The mediation model based on bootstrap analyses was employed to explore the relationship between SES and QoL and the mediating role of social capital in the SES-QoL nexus.

Results

The sampled rural older adults with hypertension had an upper-middle level of QoL, and the average score was 132.57 ± 19.40. SES was positively correlated with both QoL and individual social capital; individual social capital was significantly positively correlated with QoL. Controlling for sociodemographic variables, SES was still significantly associated with individual social capital (β = 0.140, P < 0.001), and the higher the individual social capital, the better QoL (β = 0.153, P < 0.001). Individual social capital played a partially mediating role in the association between SES and QoL (indirect effect = 0.021, 95% CI: 0.010-0.038), which accounted for 9.38% of the total effect.

Conclusion

This study provides evidence that the effect of SES on QoL was partially mediated by individual social capital among rural older adults with hypertension in China. The government should pay more attention to the rural older hypertensive population with lower SES and strive to reduce the negative impact of poor SES on their QoL, based on effective strategies including improving their individual social capital.

POINT: Pipeline for Offline Conversion and Integration of Geocodes and Neighborhood Data

OBJECTIVES

Geocoding, the process of converting addresses into precise geographic coordinates, allows researchers and health systems to obtain neighborhood-level estimates of social determinants of health. This information supports opportunities to personalize care and interventions for individual patients based on the environments where they live. We developed an integrated offline geocoding pipeline to streamline the process of obtaining address-based variables, which can be integrated into existing data processing pipelines.

METHODS

POINT is a web-based, containerized, application for geocoding addresses that can be deployed offline and made available to multiple users across an organization. Our application supports use through both a graphical user interface and application programming interface to query geographic variables, by census tract, without exposing sensitive patient data. We evaluated our application's performance using two datasets: one consisting of 1 million nationally representative addresses sampled from Open Addresses, and the other consisting of 3,096 previously geocoded patient addresses.

RESULTS

A total of 99.4 and 99.8% of addresses in the Open Addresses and patient addresses datasets, respectively, were geocoded successfully. Census tract assignment was concordant with reference in greater than 90% of addresses for both datasets. Among successful geocodes, median (interquartile range) distances from reference coordinates were 52.5 (26.5-119.4) and 14.5 (10.9-24.6) m for the two datasets.

CONCLUSION

POINT successfully geocodes more addresses and yields similar accuracy to existing solutions, including the U.S. Census Bureau's official geocoder. Addresses are considered protected health information and cannot be shared with common online geocoding services. POINT is an offline solution that enables scalability to multiple users and integrates downstream mapping to neighborhood-level variables with a pipeline that allows users to incorporate additional datasets as they become available. As health systems and researchers continue to explore and improve health equity, it is essential to quickly and accurately obtain neighborhood variables in a Health Insurance Portability and Accountability Act (HIPAA)-compliant way.

Intersectional sociodemographic and neurological relationships in the naming ability of persons with post-stroke aphasia

INTRODUCTION

Significant attention has been given to the role of brain function and disruption in determining performance on naming tasks among individuals with aphasia. However, scholarly pursuit of a neurological explanation has overlooked the fundamental cornerstone of individual health-the underlying social, economic, and environmental factors that shape how they live, work, and age, also known as the social determinants of health (SDOH). This study examines the correlation between naming performance and these underlying factors.

METHODS

Individual level data from the 2010 Moss Aphasia Psycholinguistic Project Database (MAPPD) was matched with the 2009-2011 Medical Expenditure Panel Survey (MEPS) using a propensity score algorithm based on functional, health, and demographic characteristics. Multilevel, generalized, nonlinear regression models were applied to the resulting data set to assess the correlation between the Boston Naming Test (BNT) percentile score and age, income, sex, race, household size, marital status, aphasia type, and region of residence. Poisson regression models with bootstrapped standard errors were used to estimate these relationships RESULTS: Discrete dependent variable estimation with non-normal prior specification included individual level (age, marital status, years of education), socioeconomic (family income), health (aphasia type), household (family size), and environmental (region of residence) characteristics. Regression results indicated that, relative to individuals with Wernicke's, individuals with Anomic (0.74, SE = 0.0008) and Conduction (0.42, SE = 0.0009) aphasia performed better on the BNT. While age at the time of testing was not significantly correlated, higher income level (0.15, SE = 0.0003) and larger family size (0.002, SE = 0.002) was associated with higher BNT score percentiles. Finally, Black persons with aphasia (PWA) (-0.0124, SE = 0.0007) had lower average score percentiles when other factors were held constant.

CONCLUSIONS

The findings reported here suggest higher income and larger family size are associated with better outcomes. As expected, aphasia type was significantly associated with naming outcomes. However, poorer performance by Black PWA and individuals with low income suggests that SDOH can play a critical role (positive and negative) in naming impairment in some populations with aphasia.

Association of Unfavorable Social Determinants of Health With Stroke/Transient Ischemic Attack and Vascular Risk Factors in Hispanic/Latino Adults: Results From Hispanic Community Health Study/Study of Latinos

BACKGROUND AND PURPOSE

Social determinants of health (SDOH) are non-medical factors that may contribute to the development of diseases, with a higher representation in underserved populations. Our objective is to determine the association of unfavorable SDOH with self-reported stroke/transient ischemic attack (TIA) and vascular risk factors (VRFs) among Hispanic/Latino adults living in the US.

METHODS

We used cross-sectional data from the Hispanic Community Health Study/Study of Latinos. SDOH and VRFs were assessed using questionnaires and validated scales and measurements. We investigated the association between the SDOH (individually and as count: ≤1, 2, 3, 4, or ≥5 SDOH), VRFs and stroke/TIA using regression analyses.

RESULTS

For individuals with stroke/TIA (n=388), the mean age (58.9 years) differed from those without stroke/TIA (n=11,210; 46.8 years; P<0.0001). In bivariate analysis, income <$20,000, education less than high school, no health insurance, perceived discrimination, not currently employed, upper tertile for chronic stress, and lower tertiles for social support and language- and social-based acculturation were associated with stroke/TIA and retained further. A higher number of SDOH was directly associated with all individual VRFs investigated, except for at-risk alcohol, and with number of VRFs (β=0.11, 95% confidence interval [CI]=0.09-0.14). In the fully adjusted model, income, discrimination, social support, chronic stress, and employment status were individually associated with stroke/TIA; the odds of stroke/TIA were 2.3 times higher in individuals with 3 SDOH (95% CI 1.6-3.2) and 2.7 times (95% CI 1.9-3.7) for those with ≥5 versus ≤1 SDOH.

CONCLUSION

Among Hispanic/Latino adults, a higher number of SDOH is associated with increased odds for stroke/TIA and VRFs. The association remained significant after adjustment for VRFs, suggesting involvement of non-vascular mechanisms.

Racial and Ethnic Differences in the Risk of Ischemic Stroke After Nontraumatic Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with an increased risk of ischemic stroke. Whether there are racial and ethnic disparities in the risk of ischemic stroke after ICH is poorly understood. We therefore aimed to test the hypothesis that non-Hispanic Black and Hispanic ICH patients have a higher risk of ischemic stroke compared with non-Hispanic White ICH patients.

METHODS

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project (HCUP) on all hospitalizations at all nonfederal hospitals in Florida from 2005 to 2018 and New York from 2006 to 2016. Race and ethnicity were coded as a single variable in HCUP. We included patients with an ICH, and without a prior or concomitant diagnosis of ischemic stroke, ascertained using validated International Classification of Diseases-Clinical Modification-9 and 10 diagnosis codes. Using Cox proportional hazard models, we studied the relationship between race and risk of ischemic stroke starting from the time of discharge from ICH hospitalization, after adjustment of demographics and vascular comorbidities.

RESULTS

We included 91 342 patients with ICH-62% non-Hispanic White, 18% non-Hispanic Black, and 12% Hispanic patients. Non-Hispanic Black and Hispanic patients were younger and had a higher prevalence of cardiovascular comorbidities; however, atrial fibrillation was more prevalent among non-Hispanic White patients. During a median follow-up period of 4.4 years (interquartile range, 1.5-8.1), an incident ischemic stroke occurred in 3377 (6%) non-Hispanic White, 1323 (8%) non-Hispanic Black, and 844 (8%) Hispanic patients. In adjusted Cox models, the risk of an ischemic stroke was significantly higher among non-Hispanic Black patients (hazard ratio, 1.6 [95% CI, 1.5-1.8]) and Hispanic patients (hazard ratio, 1.4 [95% CI, 1.3-1.5]), compared with non-Hispanic White patients. Similar results were obtained in sensitivity analyses when using death as a competing risk and after excluding patients with atrial fibrillation and valvular heart disease.

CONCLUSIONS

In a large heterogeneous cohort of patients with ICH, we found that non-Hispanic Black and Hispanic patients had a significantly higher risk of ischemic stroke compared with non-Hispanic White patients.

Stroke Outcomes Among English- and Spanish-Speaking Mexican American Patients

OBJECTIVES

We examined whether language preference was associated with 90-day poststroke outcomes among Mexican American (MA) patients.

METHODS

Patients with ischemic stroke and intracerebral hemorrhage from the population-based Brain Attack Surveillance in Corpus Christi project (2009-2018) were compared by language preference in 90-day neurologic, functional, and cognitive outcomes using weighted Tobit regression. Models were adjusted for demographics, initial NIH Stroke Scale (NIHSS), medical history, stroke characteristics, and insurance status.

RESULTS

Of 1,096 stroke patients, 926 were English-speaking and 170 were Spanish-only-speaking. Spanish speakers were older (p < 0.01), received less education (p < 0.01), had higher initial NIHSS values (p = 0.02), had higher prevalence of atrial fibrillation (p < 0.01), and had lower prevalence of smoking (p = 0.01) than English speakers. In fully adjusted models, Spanish-only speakers had worse neurologic outcome (NIHSS, range 0-44 [higher worse], mean difference: 1.93, p < 0.01) but no difference in functional outcome measured by activities of daily living/instrumental activities of daily living or cognitive outcome compared with English speakers.

DISCUSSION

This population-based study found worse neurologic but similar functional and cognitive stroke outcomes among Spanish-only-speaking MA patients compared with English-speaking MA patients.

Recommendations on Social Determinants of Health in Neurologic Disease

Social determinants of health (SDOH) are increasingly recognized as important drivers of inequities in neurologic disease and outcomes. However, our understanding of the biopsychosocial mechanisms by which SDOH affect neurologic disease remains in its infancy. The most robust epidemiologic research has been on the associations between education, schooling, and place-based social determinants on cognition, dementia, and cerebrovascular disease later in life. Further research is needed to more deeply understand the complex interplay of SDOH on neurologic disease. Few SDOH screening tools have been validated in populations with neurologic disease. In addition, comparison across studies and populations is hampered by lack of standardized common data elements. Experiences of populations historically underrepresented in research should be centered in future research studies, and changes should be made in recruitment expectations and measurement choices. For research on inequities, it is critical to support and incentivize institutional infrastructure to foster meaningful engagement with populations affected by research. Finally, it remains to be seen whether individual-level health or behavioral interventions or place-level, systemic or policy interventions to reduce population burden will be most effective in reducing inequities in neurologic disease and outcomes. Although numerous clinical trials have focused on addressing downstream SDOH such as health literacy and health behaviors (e.g., medication adherence, physical activity, diet), few have addressed upstream, structural determinants which may have a more profound impact on addressing inequities in neurologic disease. Ultimately, further research is needed to determine which specific SDOH should be targeted and how, when, and by whom they should be addressed to improve neurologic outcomes.

Determinants of Inequities in Neurologic Disease, Health, and Well-being: The NINDS Social Determinants of Health Framework

A National Institute of Neurological Disorders and Stroke working group developed the Determinants of Inequities in Neurological Disease, Health, and Well-being framework. Our goal was to guide and inspire a new generation of neurologic research that pushes the field to design and test new approaches in pursuit of health equity, population health, and social justice. We seek to expand the lens of those looking to reduce or eliminate racial, socioeconomic status, and other inequities in neurologic disease, health, and well-being to improve our collective ability to create research, programs, and policies that lead to larger, more impactful, and more sustainable change in neurologic disease patterns. In this context, we outline a framework that includes and highlights "upstream" factors in the hopes of enhancing the focus of research, programmatic, and policy efforts to reduce and eliminate inequities in neurologic health and well-being. We explicitly discuss racism and other structural factors to clarify that social determinants are not natural and unchangeable. Populations with a disproportionate burden of neurologic disease are not inherently deficient, despite what some approaches to framing health inequities imply. The framework is presented linearly, but the pathways linking the determinants of neurologic disease, health, and well-being are far more complex than those demonstrated by the arrows included in the figure. The framework highlights the different levels and scale of causation, including the structural and intermediary social determinants and their impact on neurologic health. We offer this framework to refine efforts to contextualize the interpretation of neurologic research findings and suggest new avenues for their application. We illustrate how behavioral and biological factors occur in a social and economic context, factors that have been understudied as points of intervention to reduce inequities in neurologic disease. Considering social and structural determinants of health provides promising new opportunities to achieve neurologic health equity, reach social justice, and improve our science. Extending our work in this fashion is not simply about health equity or social justice but to fundamentally improve the quality of neurologic research by enhancing underlying theory and improving study design and implementation.

Implications of Social Disadvantage Score in Cardiovascular Outcomes and Risk Assessment: Findings From the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Social determinants of health contribute to disparate cardiovascular outcomes, yet they have not been operationalized into the current paradigm of cardiovascular risk assessment.

METHODS

Data from the Multi-Ethnic Study of Atherosclerosis, which includes participants from 6 US field centers, were used to create an index of baseline Social Disadvantage Score (SDS) to explore its association with incident atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality and impact on ASCVD risk prediction. SDS, which ranges from 0 to 4, was calculated by tallying the following social factors: (1) household income less than the federal poverty level; (2) educational attainment less than a high school diploma; (3) single-living status; and (4) experience of lifetime discrimination. Cox models were used to examine the association between SDS and each outcome with adjustment for traditional cardiovascular risk factors. Changes in the discrimination and reclassification of ASCVD risk by incorporating SDS into the pooled cohort equations were examined.

RESULTS

A total of 6434 participants (mean age, 61.9±10.2 years; female 52.8%; non-white 60.9%) had available SDS 1733 (26.9%) with SDS 0; 2614 (40.6%) with SDS 1; 1515 (23.5%) with SDS 2; and 572 (8.9%) with SDS ≥3. In total, 775 incident ASCVD events and 1573 deaths were observed over a median follow-up of 17.0 years. Increasing SDS was significantly associated with incident ASCVD and all-cause mortality after adjusting for traditional risk factors (ASCVD: per unit increase in SDS hazard ratio, 1.15 [95% CI, 1.07-1.24]; mortality: per unit increase in SDS hazard ratio, 1.13 [95% CI, 1.08-1.19]). Adding SDS to pooled cohort equations components in a Cox model for 10-year ASCVD risk prediction did not significantly improve discrimination (P=0.208) or reclassification (P=0.112).

CONCLUSIONS

Although SDS is independently associated with incident ASCVD and all-cause mortality, it does not improve 10-year ASCVD risk prediction beyond pooled cohort equations.

Social Determinants of Health and Uncontrolled Blood Pressure in a National Cohort of Black and White US Adults: the REGARDS Study

BACKGROUND

Determining the contribution of social determinants of health (SDOH) to the higher proportion of Black adults with uncontrolled blood pressure (BP) could inform interventions to improve BP control and reduce cardiovascular disease.

METHODS

We analyzed data from 7306 White and 7497 Black US adults taking antihypertensive medication from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003-2007). SDOH were defined using the Healthy People 2030 domains of education, economic stability, social context, neighborhood environment, and health care access. Uncontrolled BP was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg.

RESULTS

Among participants taking antihypertensive medication, 25.4% of White and 33.7% of Black participants had uncontrolled BP. The SDOH included in the current analysis mediated the Black-White difference in uncontrolled BP by 33.0% (95% CI, 22.1%-46.8%). SDOH that contributed to excess uncontrolled BP among Black compared with White adults included low annual household income (percent-mediated 15.8% [95% CI, 10.8%-22.8%]), low education (10.5% [5.6%-15.4%]), living in a health professional shortage area (10.4% [6.5%-14.7%]), disadvantaged neighborhood (11.0% [4.4%-18.0%]), and high-poverty zip code (9.7% [3.8%-15.5%]). Together, the neighborhood-domain accounted for 14.1% (95% CI, 5.9%-22.9%), the health care domain accounted for 12.7% (95% CI, 8.4%-17.3%), and the social-context-domain accounted for 3.8% (95% CI, 1.2%-6.6%) of the excess likelihood of uncontrolled BP among Black compared with White adults, respectively.

CONCLUSIONS

SDOH including low education, low income, living in a health professional shortage area, disadvantaged neighborhood, and high-poverty zip code contributed to the excess likelihood of uncontrolled BP among Black compared with White adults.

Disentangling Social Determinants of Health and Rurality in Head and Neck Cancer 2-Year Mortality

Social determinants of health (SDoH) and rurality are known factors that may influence outcomes in head and neck squamous cell carcinoma (HNSCC). Patients residing in remote locations or those with multiple SDoH may encounter barriers to initial diagnosis, adherence to multidisciplinary treatments, and posttreatment surveillance, which may impact their overall survival. However, previous studies have shown mixed results associated with rural residence. The aim of this study is to identify the impact of rurality and SDoH on 2-year survival in HNSCC. The study was conducted using a Head and Neck Cancer Registry at a single institution from June 2018 through July 2022. Rurality, defined by US census scores, and individual measures of SDoH were used. Our results indicate that each additional adverse SDoH factor results in 1.5 times the odds of mortality at 2 years. Individualized measures of SDoH, rather than rurality alone, better reflect patient prognosis in HNSCC.