The effect of socioeconomic status on three-year mortality after first-ever ischemic stroke in Nanjing, China

Role of cognitive reserve in ischemic stroke prognosis: A systematic review

Objective

This systematic review was performed to identify the role of cognitive reserve (CR) proxies in the functional outcome and mortality prognostication of patients after acute ischemic stroke.

Methods

PubMed, Embase, Web of Science, and Cochrane Library were comprehensively searched by two independent reviewers from their inception to 31 August 2022, with no restrictions on language. The reference lists of reviews or included articles were also searched. Cohort studies with a follow-up period of ≥3 months identifying the association between CR indicators and the post-stroke functional outcome and mortality were included. The outcome records for patients with hemorrhage and ischemic stroke not reported separately were excluded. The Quality In Prognosis Studies (QUIPS) tool was used to assess the quality of included studies.

Results

Our search yielded 28 studies (n = 1,14,212) between 2004 and 2022, of which 14 were prospective cohort studies and 14 were retrospective cohort studies. The follow-up period ranged from 3 months to 36 years, and the mean or median age varied from 39.6 to 77.2 years. Of the 28 studies, 15 studies used the functional outcome as their primary outcome interest, and 11 of the 28 studies included the end-point interest of mortality after ischemic stroke. In addition, two of the 28 studies focused on the interest of functional outcomes and mortality. Among the included studies, CR proxies were measured by education, income, occupation, premorbid intelligence quotient, bilingualism, and socioeconomic status, respectively. The quality of the review studies was affected by low to high risk of bias.

Conclusion

Based on the current literature, patients with ischemic stroke with higher CR proxies may have a lower risk of adverse outcomes. Further prospective studies involving a combination of CR proxies and residuals of fMRI measurements are warranted to determine the contribution of CR to the adverse outcome of ischemic stroke.

Systematic review registration

PROSPERO, identifier CRD42022332810, https://www.crd.york.ac.uk/PROSPERO/.

A cohort study on the relationship between education level and high-risk population of stroke

Objective

To explore the relationship between education level and high-risk population among stroke screening populations in Zunyi City, China.

Methods

The cluster sampling method was adopted to collect the medical history, laboratory examinations and physical examinations for the permanent residents of Zunyi City, Guizhou Province. Taking education level as a key socioeconomic status (SES) indicator, multivariate logistic regression analysis was used to evaluate the risk factors of high-risk groups with different education levels.

Results

Among the included 4149 subjects, 494 were in the high-risk group and 3655 were in the non-high-risk group. The proportion of the high-risk population with education level ≥ high secondary school (8.7%) was significantly higher than that of the low-risk population. After adjusting for age, gender, and BMI, the OR of those with education leve l ≥ high secondary school was 2.8 (95% CI 1.9-4.2), which was significantly higher than those with education level of illiterate/primary school. In the model adjusted for all confounding factors, compared with illiterate/primary school, people with education level ≥ high secondary school were more likely to be at high risk of stroke (OR 3.0, 95% CI 1.9-4.6).

Conclusion

Education level ≥ high secondary school is an independent influencing factor for the high-risk population of stroke in Zunyi, which may be related to smoking and lipid metabolism abnormalities of people with high education level. Key interventions for high-risk populations with high education levels may have positive significance in reducing the incidence of stroke.

Long-Term Effect of Income Level on Mortality after Stroke: A Nationwide Cohort Study in South Korea

We investigated whether income level has long-term effects on mortality rate in stroke patients and whether this varies with time after the first stroke event, using the National Health Insurance Service National Sample Cohort data from 2002 to 2015 in South Korea. The study population was new-onset stroke patients ≥18 years of age. Patients were categorized into Category (1) insured employees and Category (2) insured self-employed/Medical Aid beneficiaries. Each category was divided into three and four income level groups, retrospectively. The study population comprised of 11,668 patients. Among the Category 1 patients (n = 7720), the low-income group's post-stroke mortality was 1.15-fold higher than the high-income group. Among the Category 2 patients (n = 3948), the lower income groups had higher post-stroke mortality than the high-income group (middle-income, aOR (adjusted odds ratio) 1.29; low-income, aOR 1.70; Medical Aid beneficiaries, aOR 2.19). In this category, the lower income groups' post-stroke mortality risks compared to the high-income group were highest at 13-36 months after the first stroke event(middle-income, aOR 1.52; low-income, aOR 2.31; Medical Aid beneficiaries, aOR 2.53). Medical Aid beneficiaries had a significantly higher post-stroke mortality risk than the high-income group at all time points.

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

Background

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

Methods and Results

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

Conclusions

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

Registration

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

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

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Low socioeconomic status influence on the risk of stroke mortality.

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

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

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

Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the Global Burden of Disease Study 2017

BACKGROUND

Socioeconomic status (SES) is associated with stroke incidence and mortality. Distribution of stroke risk factors is changing worldwide; evidence on these trends is crucial to the allocation of resources for prevention strategies to tackle major modifiable risk factors with the highest impact on stroke burden.

METHODS

We extracted data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. We analysed trends in global and SES-specific age-standardised stroke incidence, prevalence, mortality, and disability-adjusted life years (DALYs) lost from 1990 to 2017. We also estimated the age-standardised attributable risk of stroke mortality associated with common risk factors in low-, low-middle-, upper-middle-, and high-income countries. Further, we explored the effect of age and sex on associations of risk factors with stroke mortality from 1990 to 2017.

RESULTS

Despite a growth in crude number of stroke events from 1990 to 2017, there has been an 11.3% decrease in age-standardised stroke incidence rate worldwide (150.5, 95% uncertainty interval [UI] 140.3-161.8 per 100,000 in 2017). This has been accompanied by an overall 3.1% increase in age-standardised stroke prevalence rate (1300.6, UI 1229.0-1374.7 per 100,000 in 2017) and a 33.4% decrease in age-standardised stroke mortality rate (80.5, UI 78.9-82.6 per 100,000 in 2017) over the same time period. The rising trends in age-standardised stroke prevalence have been observed only in middle-income countries, despite declining trends in age-standardised stroke incidence and mortality in all income categories since 2005. Further, there has been almost a 34% reduction in stroke death rate (67.8, UI 64.1-71.1 per 100,000 in 2017) attributable to modifiable risk factors, more prominently in wealthier countries.

CONCLUSIONS

Almost half of stroke-related deaths are attributable to poor management of modifiable risk factors, and thus potentially preventable. We should appreciate societal barriers in lower-SES groups to design tailored preventive strategies. Despite improvements in general health knowledge, access to healthcare, and preventative strategies, SES is still strongly associated with modifiable risk factors and stroke burden; thus, screening of people from low SES at higher stroke risk is crucial.

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

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

Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda

Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.

The Incidence and Risk Factors of In-Stent Restenosis for Vertebrobasilar Artery Stenting

BACKGROUND AND OBJECTIVES

In-stent restenosis (ISR) remains a challenge for vertebrobasilar artery stenting (VBAS). We aimed to investigate the incidence and risk factors of ISR.

METHODS

This was a retrospective study. From July 28, 2005, to July 30, 2015, patients who received VBAS with an angiographic follow-up time of 6 to 12 months after surgery were enrolled. The clinical and angiographic issues were recorded and analyzed.

RESULTS

In total, 283 patients with 335 stents were incorporated into the study. Vertebral ostial lesions accounted for 73.4% (246/335) of the lesions. During the follow-up period, 58 patients with 60 stents experienced ISR (>50%). Stepwise logistic regression analysis showed that the degree of residual stenosis, stent diameter, and alcohol consumption were independent predictors of ISR.

CONCLUSIONS

Our study demonstrated the incidence and risk factors of ISR after VBAS. This retrospective study with the largest cohort to date provided insight into the occurrence of ISR after VBAS.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Low socioeconomic status is an independent risk factor for ischemic stroke: a case-control study in North Indian population

BACKGROUND

Stroke is a multifactorial disease and is influenced by complex environmental interactions. The contribution of various risk factors to the burden of stroke worldwide is not well known, particularly in developing countries. The present case-control study is aimed at exploring the association between a low socioeconomic status and the risk of ischemic stroke among the North Indian population.

METHODS

The study design was a hospital-based, case-control study. Age- and sex-matched controls were included. The demographic characteristics and risk factor variables were documented by means of a personal interview through a standardized case record form. The household asset index for determining the socioeconomic status (HAISS) was used for the assessment of the socioeconomic status of the population. HAISS was validated with the widely used Kuppuswamy scale for measurement of socioeconomic status. The multivariable logistic regression model was used to estimate the odds ratio associated with stroke.

RESULTS

In all, 224 ischemic stroke patients and 224 controls were recruited between February 2009 and February 2012. The mean age of cases and controls was 53.47 ± 14 and 52.92 ± 13.4, respectively. The low economic status was independently associated with the risk of ischemic stroke after adjustment for demographic and risk factor variables (OR 2.8; 95% CI 1.2-6.3).

CONCLUSION

Our findings suggest that there is a significant association between a low socioeconomic status and the risk of ischemic stroke risk in North Indian population. Well-designed studies embedded with long-term prospective cohorts are required for confirming the results.

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

OBJECTIVE

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

DESIGN

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

SETTING AND PARTICIPANTS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Educational history is an independent predictor of cognitive deficits and long-term survival in postacute patients with mild to moderate ischemic stroke

BACKGROUND AND PURPOSE

Poststroke cognitive decline and white matter lesions (WML) are related to poor poststroke survival. Whether cognitive reserve as reflected by educational history associates with cognitive decline, recurrent strokes, and poststroke mortality independent of WML is not known.

METHODS

A total of 486 consecutive acute mild/moderate ischemic stroke patients subjected to comprehensive neuropsychological assessment (n=409) and magnetic resonance imaging (n=395) 3 months poststroke were included in the study and followed-up for up to 12 years. Odds ratios (OR) for logistic and hazard ratios for Cox regression analyses are reported (OR and hazard ratio≤1 indicates a beneficial effect).

RESULTS

Long educational history (per tertile) was associated with lower frequency of executive dysfunction in models adjusted for age, sex, marital status, and stroke severity (OR, 0.75; P<0.05) but not when adding WML as a covariate. In contrast, educational history was independently associated with less memory impairment (OR, 0.67; P<0.01), aphasia (OR, 0.69; P<0.05), visuospatial and constructive deficits (OR, 0.70; P<0.05), Mini-Mental State Examination score<25 (OR, 0.53; P<0.0001), and dementia (OR, 0.66; P<0.01). In Cox regression analysis, educational history was not associated with recurrent strokes, but it associated independently with favorable poststroke survival (hazard ratio, 0.86; P<0.05).

CONCLUSIONS

Long educational history associates with less poststroke cognitive deficits, dementia, and favorable long-term survival independent of age, gender, marital status, stroke severity, and WML in patients with mild/moderate ischemic stroke. This supports the hypothesis that educational history as a proxy indicator of cognitive reserve protects against deficits induced by acute stroke.

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

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

Socioeconomic status and stroke: an updated review

BACKGROUND AND PURPOSE

Rates of stroke incidence and mortality vary across populations with important differences between socioeconomic groups worldwide. Knowledge of existing disparities in stroke risk is important for effective stroke prevention and management strategies. This review updates the evidence for associations between socioeconomic status and stroke. Summary of Review- Studies were identified with electronic searches of MEDLINE and EMBASE databases (January 2006 to July 2011) and reference lists from identified studies were searched manually. Articles reporting the association between any measure of socioeconomic status and stroke were included.

CONCLUSIONS

The impact of stroke as measured by disability-adjusted life-years lost and mortality rates is >3-fold higher in low-income compared with high- and middle-income countries. The number of stroke deaths is projected to increase by >30% in the next 20 years with the majority occurring in low-income countries. Higher incidence of stroke, stroke risk factors, and rates of stroke mortality are generally observed in low compared with high socioeconomic groups within and between populations worldwide. There is less available evidence of an association between socioeconomic status and stroke recurrence or temporal trends in inequalities. Those with a lower socioeconomic status have more severe deficits and are less likely to receive evidence-based stroke services, although the results are inconsistent. Poorer people within a population and poorer countries globally are most affected in terms of incidence and poor outcomes of stroke. Innovative prevention strategies targeting people in low socioeconomic groups are required along with effective measures to promote access to effective stroke interventions worldwide.

Predictors of dependency on nursing care after stroke: results from the Dortmund and Münster stroke registry

BACKGROUND

The long-term effects of stroke have been inadequately studied. We identified social and clinical factors that were associated with application for insurance payments for long-term care within 3.6 years after stroke.

METHODS

In a quality-assurance project called "Stroke Northwest Germany," information was obtained from 2286 stroke patients on their socio-demographic background, type of stroke, comorbidities, and degree of physical impairment during their hospital stay, as measured on the Rankin Scale, the Barthel Index, and the Neurological Symptom Scale. We used logistic regression models to identify possible associations between these factors and application for insurance payments for long-term care within 3.6 years after stroke. We developed an appropriate prognostic model by means of backward selection.

RESULTS

734 (32.1%) of the patients participated in follow-up and reported whether they had applied for insurance payments for long-term care. 22.5% had submitted an application. The rate of application was positively correlated with age, female sex, the number of comorbidities and complications during hospitalization, and the degree of physical impairment.

CONCLUSION

Stroke has major long-term effects. The probability that a stroke patient will apply for insurance payments for long-term care is a function of the patient's age, sex, previous stroke history, and physical impairment as measured on the Rankin Scale and the Barthel Index.

Socioeconomic differences in quality of care and clinical outcome after stroke: a nationwide population-based study

BACKGROUND AND PURPOSE

The association among socioeconomic status, quality of care, and clinical outcome after stroke remains poorly understood. In a Danish nationwide follow-up study, we examined whether socioeconomic-related differences in acute stroke care occur and, if so, whether they explain socioeconomic differences in case-fatality and readmission risk.

METHODS

Using population-based public registries, we identified and followed all patients aged≤65 years admitted with stroke from 2003 to 2007 (n=14,545). We compared the proportion of patients receiving 7 specific processes of care according to income, educational attainment, and employment status. Furthermore, we computed 30-day and 1-year hazard ratios for death and readmission adjusted for patient characteristics and received processes of acute stroke care.

RESULTS

For low-income patients and disability pensioners, the relative risk of receiving all of the relevant processes of care was 0.82 (95% CI, 0.78 to 0.86) and 0.83 (95% CI, 0.79 to 0.87), respectively, compared with high-income patients and employed patients. Adjusted 30-day and 1-year hazard ratios for death for unemployed patients were 1.57 (95% CI, 1.25 to 1.97) and 1.58 (1.32 to 1.88), respectively, compared with employed patients. Unemployed patients also had a higher risk of readmission. The differences in mortality and readmission risk remained after controlling for received processes of acute stroke care.

CONCLUSIONS

Low socioeconomic status was associated with a lower chance of receiving optimal acute stroke care. However, the differences in acute care did not appear to explain socioeconomic differences in mortality and readmission risk.

Comparison of Recovery Patterns and Prognostic Indicators for Ischemic and Hemorrhagic Stroke in China

Background and Purpose— Limited data exist on the comparative recovery patterns and outcomes of patients with ischemic stroke and intracerebral hemorrhage in China.

Methods— Data on baseline characteristics and outcomes of 6354 patients at 3 and 12 months poststroke are from ChinaQUEST (QUality Evaluation of Stroke Care and Treatment), a multicenter, prospective, 62-hospital registry study in China. Logistic regression was used to determine factors associated with a poor outcome defined by death/dependency (modified Rankin Scale score of 3 to 5) on follow-up. Generalized estimating equations were used to assess variations in recovery pattern by stroke type.

Results— Baseline severity and rate of functional recovery in the early phase were significantly greater for intracerebral hemorrhage. However, patients with ischemic stroke were on average twice as likely to experience a good outcome (modified Rankin Scale score <3) by 12 months poststroke (OR: 1.98, CI: 1.76 to 2.24). In patients with ischemic stroke, diabetes and atrial fibrillation were strongly associated with a poor outcome at 12 months poststroke even after adjustment for confounding factors such as age, prior stroke/dependency, time to presentation, and stroke severity, whereas use of antiplatelets and lipid-lowering therapy after stroke were associated with improved outcome. For patients with intracerebral hemorrhage, low education and atrial fibrillation were associated with a poor outcome after adjustment for potential confounders and antihypertensive use was strongly associated with improved outcome.

Conclusions— Patients with intracerebral hemorrhage and ischemic stroke have different recovery patterns in China. However, they share similar prognostic factors and in the use of evidence-based secondary prevention therapies to maximize chances of a good outcome.

Trends in nutritional inequality by educational level: a case of South Korea

OBJECTIVE

There is much evidence of a cross-sectional relation between socioeconomic position and dietary intakes but the trend of this relation is little studied. This study aimed to examine the extent and trend of nutritional inequality by educational level based on the prevalence of inadequate nutrient intakes.

METHODS

Three cross-sectional nationwide surveys (1998, 2001, 2005) of the Korean National Health and Nutrition Examination Survey were used. A total of 20 777 participants > or = 20 y old were included. The socioeconomic position indicator was educational level. Dietary nutrient intakes were assessed by a 24-h recall and inadequacy of intake for nutrients was assessed on the basis of the percentage of attainment of the dietary reference intakes for Koreans. To assess nutritional inequality by educational level, the prevalence ratio, relative index of inequality, and slope index of inequality were used.

RESULTS

Poorer dietary intakes and higher estimated prevalence of nutrient inadequacy were more apparent in the lower education group than the higher education group for both genders and each survey year. Graded patterns of inequalities in nutrient intakes by educational level were generally clear at each survey year. The trend of the relative nutritional inequalities in Korean men and women remained unchanged from 1998 to 2005, with some exceptions.

CONCLUSION

The inequality in nutrient intakes by educational level was persistently apparent for both genders in the Korean adult population, although the relative inequalities did not increase over time.

Cardiovascular disease in Chinese women: an emerging high-risk population and implications for nursing practice

BACKGROUND

Globally, cardiovascular disease (CVD) is the leading cause of death among women. In China, the burden of CVD is increasing at an alarming rate; yet, it is underestimated and has important primary, secondary, and tertiary prevention issues.

AIM

This article seeks to document the issues surrounding the increased rate of CVD among Chinese women and describe the etiological factors and potential strategies to decrease the burden of disease.

METHODS

The Medline, Current Information in Nursing and Allied Health Literature, Ovid, Science Direct, and Government Reports were searched using the key words heart disease, cardiovascular, ischemic heart disease, coronary, women, and Chin (China, Chinese). Articles were selected if they described epidemiological factors and/or interventions to address heart disease in Chinese women.

FINDINGS

Rapid industrialization and urbanization in China have extended the life expectancy of the population, particularly among women. Social, political, and economic factors have caused lifestyle changes that have a direct bearing on health. Heart disease has become the most common cause of death among Chinese women and the second most common cause among men. Paradoxically, prevention and management strategies are sparse in relation to the high prevalence. A number of modifiable risk factors have been identified as major contributors of CVD and should be a focus of primary, secondary, and tertiary prevention.

CONCLUSION

Cardiovascular disease is already a leading cause of death and disability among Chinese women. The high prevalence of risk factors and low rate of awareness, treatment, and control signal an urgent need for focusing on this issue in Chinese women. Strategies on individual, community, and government levels are recommended. Involving Chinese nurses in these strategies is essential.

Socioeconomic status, hospital volume, and stroke fatality in Canada

BACKGROUND AND PURPOSE

Low socioeconomic status is associated with stroke fatality; however, the mechanism behind this association is uncertain. We sought to determine whether residence in a low-income neighborhood was associated with admission to low-volume facilities and whether this contributed to differences in fatality after stroke.

METHODS

All hospitalizations for ischemic stroke from April 2003 to March 2004 were identified from a national administrative database containing patient-level sociodemographic, diagnostic, procedural, and administrative information. Patients were assigned to income quintiles based on the median income of their primary neighborhood of residence and then categorized as low income (quintiles 1 and 2) or high income (quintiles 3 through 5). Hospitals were categorized as low or high volume on the basis of their annual number of stroke admissions. Multivariable analyses were performed to compare stroke fatality at 7 days and at discharge in patients in low- and high-income groups seen at low- and high-volume facilities.

RESULTS

Overall, 25,228 patients with ischemic stroke were included in the analysis. Those from high-income areas were more likely to be admitted to high-volume hospitals. Fatality at 7 days was 8.4%, 8.2%, 7.7%, 7.1, and 6.6% (chi(2)=0.002) for income quintiles 1 (lowest) to 5 (highest), respectively. Low-income patients admitted to low-volume hospitals had the highest risk-adjusted stroke fatality.

CONCLUSIONS

Patients from low-income areas presenting with acute stroke are more likely to be seen in low-volume facilities. This subgroup of patients had a higher risk-adjusted fatality than those from high-income areas seen at high-volume facilities. Understanding the pathways through which socioeconomic status affects health care may lead to strategies for quality improvement.

Prediction of functional outcome of ischemic stroke patients in northwest China

OBJECTIVES

To identify the clinical factors which predicted the outcome of ischemic stroke patients in northwest China.

PATIENTS AND METHODS

We retrospectively reviewed 489 consecutive patients with ischemic stroke admitted to the Neurology Department of Xijing Hospital. Demographic, clinical and laboratory data were recorded. Follow-up assessments were performed by telephone interviews or letters. The clinical outcome was assessed by using the modified Rankin Scale (mRS) and categorized as good (score 0-2) or poor (score 3-6) outcomes. Univariate and multivariate logistic regression analyses were performed to explore predictors of ischemic stroke.

RESULTS

The follow-up period was up to 47 months (mean, 28.3 months). Fifty-five patients (11.2%) were lost. Among these 434 patients, 244 (56.2%) patients had good outcome and 190 (43.8%) had poor outcome. The poor outcome was associated with old age (OR: 3.505; CI 95%: 2.100-5.849), lower educational level (OR: 0.686; CI 95%: 0.570-0.825), having stroke history (OR: 2.481; CI 95%: 1.442-4.268), and higher NIHSS total score (OR: 2.619; CI 95%: 1.584-4.330).

CONCLUSION

The results suggest that age, the educational level, stroke history, and NIHSS score are useful in the prediction of functional outcome of ischemic stroke in Chinese northwest area.

Acute treatment and long-term management of stroke in developing countries

Developing countries have some of the highest stroke mortality rates in the world that account for over two-thirds of stroke deaths worldwide. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries, resulting in differing needs for acute and long-term care. Data on stroke care provision in developing countries are sparse and most of the available studies are biased towards urban settings in reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is largely patchy in low-income and middle-income countries, with areas of excellence intermixed with areas of severe need, depending upon patients' location, socioeconomic status, education, and cultural beliefs. Here we review the available literature on acute and long-term stroke management in developing countries. On the basis of available studies, largely from developed countries, we discuss the need to develop basic organised stroke-unit care in developing countries.

Arterial stenosis detected by digital subtraction angiography and its relationship with the Oxfordshire Community Stroke Project classification

The aim of this study was to assess extra-and intracranial arterial stenosis in first-ever stroke patients and to analyse the relationship between arterial stenosis and the Oxfordshire Community Stroke Project (OCSP) classification. Chinese patients (n = 817) were classified according to OCSP criteria, and arterial abnormalities were evaluated in 342 of the patients by digital subtraction angiography. Prevalence of significant stenosis in the extracranial internal carotid artery was highest among total anterior circulation infarct patients and lowest among patients with lacunar infarct. There was no evidence that the frequency of patients with intracranial arterial significant stenosis was different among OCSP subtypes. The results suggest that extracranial internal carotid artery stenosis was significantly related to OCSP subtype and that patients with total anterior circulation infarct were more likely to have extracranial internal carotid artery stenosis than patients having partial anterior circulation infarct, posterior circulation infarct or lacunar infarct.