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Ewbank F, Hall S, Gaastra B, Fisher B, Coe L, Booker J, Kaldas A, Anderson I, Critchley G, Teo M, Toma A, Trivedi R, Uff C, Vindlacheruvu R, Dulhanty L, Javadpour M, Walsh D, Galea J, Patel H, Bulters D. Aneurysm management in patients over 80 years old with good grade subarachnoid haemorrhage. Br J Neurosurg 2023:1-7. [PMID: 37147868 DOI: 10.1080/02688697.2023.2205939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND An increasing proportion of aneurysmal subarachnoid haemorrhage (aSAH) occurs in older patients, in whom there is widespread variability in treatment rates due to a different balance of risks. Our aim was to compare outcomes of patients over 80 years old with good grade aSAH who underwent treatment of their aneurysm with those who did not. METHODS Adult patients with good grade aSAH admitted to tertiary regional neurosciences centres contributing to the UK and Ireland Subarachnoid Haemorrhage Database (UKISAH) and a cohort of consecutive patients admitted from three regional cohorts were included for analysis. Outcomes were functional outcome at discharge, three months and survival at discharge. RESULTS In the UKISAH, patients whose aneurysm was treated were more likely to have a favourable outcome at discharge (OR 2.34, CI 1.12-4.91, p = .02), at three months (OR 2.29, CI 1.11-4.76, p = .04), and lower mortality (10% vs. 29%, OR 0.83, CI 0.72-0.94, p < .01). In the regional cohort, a similar pattern was seen, but after correction for frailty and comorbidity there was no difference in survival (HR 0.45, CI 0.12-1.68, p = .24) or favourable outcome at discharge (OR 0.83, CI 0.23-2.94, p = .77) and at three months (OR 1.03, CI 0.25-4.29, p = .99). CONCLUSIONS Better early functional outcomes in those undergoing aneurysm treatment appear to be explained by differences in frailty and comorbidity. Therefore, treatment decisions in this patient group are finely balanced with no clear evidence overall of either benefit or harm in this cohort.
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Affiliation(s)
- Frederick Ewbank
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Samuel Hall
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Benjamin Gaastra
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Benjamin Fisher
- Department of Neurosurgery, King's College Hospital, London, UK
| | - Laura Coe
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - James Booker
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Antony Kaldas
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Ian Anderson
- Department of Neurosurgery, Leeds Teaching Hospitals, Leeds, UK
| | - Giles Critchley
- Department of Neurosurgery, University Hospitals Sussex, Brighton, UK
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol NHS Trust, Bristol, UK
| | - Ahmed Toma
- Department of Neurosurgery, University College London Hospitals, London, UK
| | - Rikin Trivedi
- Department of Neurosurgery, Cambridge University Hospitals, Cambridge, UK
| | - Chris Uff
- Department of Neurosurgery, Barts Health NHS Trust, London, UK
| | - Raghu Vindlacheruvu
- Department of Neurosurgery, Barking, Havering and Redbridge University Hospitals, Romford, UK
| | - Louise Dulhanty
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, UK
| | | | - Daniel Walsh
- Department of Neurosurgery, King's College Hospital, London, UK
| | - James Galea
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Hiren Patel
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, UK
| | - Diederik Bulters
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
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Striving for Socioeconomic Equity in Ischemic Stroke Care: Imaging and Acute Treatment Utilization From a Comprehensive Stroke Center. J Am Coll Radiol 2022; 19:348-358. [PMID: 35152960 PMCID: PMC8867840 DOI: 10.1016/j.jacr.2021.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Prior studies have shown socioeconomic disparities in advanced neuroimaging and acute treatment utilization in patients with ischemic stroke. The authors analyzed whether socioeconomic factors were associated with stroke neuroimaging and acute treatment utilization at a comprehensive stroke center. METHODS A retrospective study of consecutive acute ischemic stroke discharges from 2012 to 2020 at a comprehensive stroke center was performed. Differences in neuroimaging (CT angiography [CTA], CT perfusion, MRI, and MR angiography [MRA]) and acute treatment (intravenous thrombolysis [IVT] and endovascular thrombectomy [EVT]) utilization were evaluated on the basis of socioeconomic factors of age, sex, race, insurance type, and neighborhood-level median household income. Chi-square tests were used for bivariate analyses. Multivariable logistic regression analyses were performed to determine associations between socioeconomic factors and neuroimaging or treatment utilization while controlling for stroke-specific factors and comorbidities. RESULTS Among 6,140 ischemic stroke discharges, race and insurance type were not significantly associated with lower utilization of neuroimaging (CTA, CT perfusion, MRI, and MRA) or acute stroke treatment (IVT and EVT) after controlling for stroke-specific factors and comorbidities. However, median household income < $80,000/year was associated with lower IVT use (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.63-0.87). In addition, age ≥ 80 years had lower CTA (OR, 0.62; 95% CI, 0.51-0.75) and EVT (OR, 0.53; 95% CI, 0.39-0.73) utilization, and female sex had lower CTA (OR, 0.78; 95% CI, 0.65-0.93) utilization. Significantly higher utilization was observed for MRI in Asian (OR, 1.33; 95% CI, 1.04-1.69) and uninsured (OR, 1.64; 95% CI, 1.07-2.50) patients and for MRA (OR, 1.24; 95% CI, 1.04-1.49) and EVT (OR, 1.62; 95% CI, 1.20-2.20) in privately insured patients. CONCLUSIONS Once access to a comprehensive stroke center is achieved, socioeconomic disparities in the utilization of health care resources, particularly advanced neuroimaging and acute treatment, may be improved in patients with ischemic stroke.
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Morisod K, Luta X, Marti J, Spycher J, Malebranche M, Bodenmann P. Measuring Health Equity in Emergency Care Using Routinely Collected Data: A Systematic Review. Health Equity 2022; 5:801-817. [PMID: 35018313 PMCID: PMC8742300 DOI: 10.1089/heq.2021.0035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Achieving equity in health care remains a challenge for health care systems worldwide and marked inequities in access and quality of care persist. Identifying health care equity indicators is an important first step in integrating the concept of equity into assessments of health care system performance, particularly in emergency care. Methods: We conducted a systematic review of administrative data-derived health care equity indicators and their association with socioeconomic determinants of health (SEDH) in emergency care settings. Following PRISMA-Equity reporting guidelines, Ovid MEDLINE, EMBASE, PubMed, and Web of Science were searched for relevant studies. The outcomes of interest were indicators of health care equity and the associated SEDH they examine. Results: Among 29 studies identified, 14 equity indicators were identified and grouped into four categories that reflect the patient emergency care pathway. Total emergency department (ED) visits and ambulatory care-sensitive condition-related ED visits were the two most frequently used equity indicators. The studies analyzed equity based on seven SEDH: social deprivation, income, education level, social class, insurance coverage, health literacy, and financial and nonfinancial barriers. Despite some conflicting results, all identified SEDH are associated with inequalities in access to and use of emergency care. Conclusion: The use of administrative data-derived indicators in combination with identified SEDH could improve the measurement of health care equity in emergency care settings across health care systems worldwide. Using a combination of indicators is likely to lead to a more comprehensive, well-rounded measurement of health care equity than using any one indicator in isolation. Although studies analyzed focused on emergency care settings, it seems possible to extrapolate these indicators to measure equity in other areas of the health care system. Further studies elucidating root causes of health inequities in and outside the health care system are needed.
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Affiliation(s)
- Kevin Morisod
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Xhyljeta Luta
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Joachim Marti
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Jacques Spycher
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Mary Malebranche
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Medicine, University of Calgary, Calgary, Canada
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Socio-Economic Disparities in Access to Diagnostic Neuroimaging Services in the United Kingdom: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010633. [PMID: 34682379 PMCID: PMC8535632 DOI: 10.3390/ijerph182010633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/18/2022]
Abstract
Socio-economic factors affecting health care can lead to delays in diagnosis of neurological conditions, consequentially affecting treatment and morbidity rates. This inequality in health care can leave patients from lower socio-economic backgrounds more vulnerable to a poorer quality of care from health care providers in the United Kingdom (U.K.). Aims: In this systematic review, we assess the impact of socio-economic status on the use of diagnostic neuroimaging in the U.K., measured by the timeliness, accessibility and appropriate use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography, electroencephalography (EEG) and single-photon emission computed tomography (SPECT). We specifically evaluate the non-surgical use of neuroimaging techniques as this relies on the judgment of primary care-givers (e.g., doctors and radiologists), where health disparities are most common. This study includes the analysis of diagnostic imaging used for dementia, minor head injury, stroke, cancer, epilepsy, chronic inflammatory demyelinating polyneuropathy and Parkinson’s disease. With this study, we aim to assess the health inequalities at disease diagnosis. Methods: Using Medline (via Ovid), PubMed and Web of Science databases as sources of information, we critically appraise existing studies on neuroimaging use in the U.K. health care system, published between January 2010 and February 2021. Findings: A total of 18 studies were included in this research, revealing that there was an increase in patients of Black and Asian communities diagnosed with dementia and at an earlier age. There was little evidence to suggest that a lack of access to diagnostic imaging is associated with socio-economic status. However, there are data to suggest that people of a lower socio-economic background require more specialist services with diagnostic neuroimaging tools. In addition, there is evidence to suggest that diagnostic neuroimaging techniques could be utilised more effectively by health care workers to prevent unnecessary delays in diagnosis for patients in lower socio-economic areas.
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Redundant Imaging in Transient Ischemic Attack: Evidence From the Nationwide Emergency Department Sample. J Am Coll Radiol 2021; 18:1525-1531. [PMID: 34329612 DOI: 10.1016/j.jacr.2021.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/22/2021] [Accepted: 07/01/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Increasing emergency department (ED) compliance with transient ischemic attack (TIA) imaging guidelines has previously been demonstrated, along with a substantial rise in imaging utilization over the past decade. The purpose of this study was to characterize the most commonly used combinations of imaging studies during ED workup of TIA and to quantify prevalence of redundant imaging (RI). METHODS TIA discharges from EDs in the United States from 2006 to 2017 were identified in the Nationwide Emergency Department Sample. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. RI was defined as an ED encounter with any duplicate cross-sectional brain, brain-vascular, or neck-vascular imaging. Patient demographics and hospital characteristics were incorporated into a multivariable logistic regression analysis to identify significant associations with RI. RESULTS There were 184,870 discharges with TIA from EDs in 2017. RI (brain) was observed in 55,513 (30%) of encounters. RI (brain-vascular) and RI (neck-vascular) imaging was identified in 5,149 (2.8%) and 1,325 (0.7%) of encounters, respectively. Decreased odds of obtaining RI was observed in Medicaid patients(odds ratio [OR: 0.72, 95% confidence interval [CI]: 0.64-0.81), non-trauma centers(OR: 0.49, 95% CI: 0.26-0.93), rural hospital locations(OR: 0.18, 95% CI: 0.11-0.29), and weekend encounters(OR: 0.9, 95% CI: 0.85-0.96). Trend analysis from 2006 to 2017 demonstrated a rise in RI (brain) from 2.3% of encounters in 2006 to 30% of encounters in 2017. RI for patients discharged from EDs with TIA in 2017 resulted in additional charges of approximately US $8,670,832. CONCLUSION Increased imaging utilization for TIA workup across EDs in the United States is associated with rising use of redundant imaging. We identify imaging practices that could be targeted to mitigate health care expenditures, while adhering to TIA imaging guidelines.
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Valcárcel-Nazco C, Alonso-Modino D, Montón-Álvarez F, Sabatel-Hernández R, Pastor-Santoveña M, Mesa-Blanco P, López-Fernández J, Serrano-Aguilar P. Variability in the use of neuroimaging techniques for diagnosis and follow-up of stroke patients. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2019.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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7
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Grandes variaciones en la utilización de pruebas por imagen en el diagnóstico y seguimiento de los pacientes con ictus. Neurologia 2019; 34:360-366. [DOI: 10.1016/j.nrl.2017.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 11/21/2022] Open
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8
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Georgiou A, Konstantinou N, Phinikettos I, Kambanaros M. Neuronavigated theta burst stimulation for chronic aphasia: two exploratory case studies. CLINICAL LINGUISTICS & PHONETICS 2019; 33:532-546. [PMID: 30676091 DOI: 10.1080/02699206.2018.1562496] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/05/2018] [Accepted: 12/19/2018] [Indexed: 06/09/2023]
Abstract
The present study reports the findings of a 10-day neuronavigated continuous theta burst stimulation (cTBS) over the right pars triangularis for two individuals with chronic aphasia after a single left hemispheric stroke. Baseline language and quality of life measures were collected prior to the treatment study, post-treatment and at 3-month follow up. Therapy was tolerated well by both participants and no side effects were noticed during and after treatment. Results from one individual showed potential for positive change in performance in comprehension and expressive language both post-treatment and at the follow-up stage. Also, a trend towards improvement post-treatment was noticed in discourse and sentence productivity, and grammatical accuracy. In the follow up stage, grammatical accuracy showed a trend towards improvement; discourse productivity decreased and; sentence productivity skills showed mixed results. Results from the other participant showed potential for positive change in comprehension post-treatment, that was maintained at the follow-up stage. However, a decline in expressive language post-treatment and at follow-up, stronger post-treatment, was noticed. Regarding quality of life measurements, participant one appeared to have improved as his performance increased in the overall, physical and communication domains, but decreased slightly in the psychosocial domain. The second participant improved in the physical and communication domains and declined overall and in the psychosocial domains. Findings from this study indicate that cTBS over the right pars triangularis may have the potential to improve various language skills in patients suffering from chronic aphasia post-stroke. However, the potential benefits of this fast, non-invasive brain stimulation protocol on improvement of language abilities post-stroke need further exploration.
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Affiliation(s)
- Anastasios Georgiou
- a Department of Rehabilitation Sciences , Cyprus University of Technology , Limassol , Cyprus
| | - Nikos Konstantinou
- a Department of Rehabilitation Sciences , Cyprus University of Technology , Limassol , Cyprus
| | - Ioannis Phinikettos
- a Department of Rehabilitation Sciences , Cyprus University of Technology , Limassol , Cyprus
| | - Maria Kambanaros
- a Department of Rehabilitation Sciences , Cyprus University of Technology , Limassol , Cyprus
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9
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Asthana S, Moon G, Gibson A, Bailey T, Hewson P, Dibben C. Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:259-272. [PMID: 27747961 DOI: 10.1111/hsc.12384] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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10
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Bray BD, Paley L, Hoffman A, James M, Gompertz P, Wolfe CDA, Hemingway H, Rudd AG. Socioeconomic disparities in first stroke incidence, quality of care, and survival: a nationwide registry-based cohort study of 44 million adults in England. LANCET PUBLIC HEALTH 2018; 3:e185-e193. [PMID: 29550372 PMCID: PMC5887080 DOI: 10.1016/s2468-2667(18)30030-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND We aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England. METHODS In this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards). FINDINGS Of the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7-2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3-1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07-1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20-1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05-1·17). INTERPRETATION Wide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke. FUNDING NHS England and the Welsh Government.
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Affiliation(s)
- Benjamin D Bray
- Farr Institute of Health Informatics Research, University College London, London, UK.
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Alex Hoffman
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Martin James
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Patrick Gompertz
- National Cardiovascular Intelligence Network, Public Health England, London, UK
| | - Charles D A Wolfe
- School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Anthony G Rudd
- School of Population Health & Environmental Sciences, King's College London, London, UK
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11
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Peultier AC, Redekop K, Coche E, Severens JL. What are the images used to diagnose and assess suspected strokes?: A systematic literature review of care in four European countries. Expert Rev Pharmacoecon Outcomes Res 2018; 18:177-189. [PMID: 29400089 DOI: 10.1080/14737167.2018.1429270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The cost-effectiveness of clinical interventions is often assessed using current care as comparator. However, evidence suggests practice variation in stroke imaging across countries. For the purpose of feeding into cost-effectiveness analysis, this research aims to describe the patterns of stroke imaging, examine practice variations across countries and, as such, obtain results reflecting current care. AREAS COVERED A systematic literature review was conducted to identify original studies reporting the imaging workup used in acute stroke care in clinical practice in Hungary, Germany, Sweden and the UK. Information regarding the type and frequency of stroke imaging was analysed. Computed Tomography (CT) was reported as the main diagnostic imaging modality used in stroke care (78-98% across patient profiles and time periods). This review revealed patterns that were not observed in individual studies. Comparisons of UK studies revealed considerable variations in the proportion of scanned patients and timing of imaging. EXPERT COMMENTARY While the evidence about thrombectomy is difficult to translate in clinical practice, the evidence regarding the optimal imaging approach to diagnose stroke patients is lacking. The heterogeneity in stroke imaging reinforces the need to compare the quality of stroke care within and between countries.
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Affiliation(s)
- Anne-Claire Peultier
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands
| | - Ken Redekop
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands.,b Institute for Medical Technology Assessment , Erasmus University Rotterdam , Rotterdam , The Netherlands
| | - Emmanuel Coche
- c Department of Radiology , Cliniques Universitaires St-Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Johan L Severens
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands.,b Institute for Medical Technology Assessment , Erasmus University Rotterdam , Rotterdam , The Netherlands
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12
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Vagal A, Sanelli P, Sucharew H, Alwell KA, Khoury JC, Khatri P, Woo D, Flaherty M, Kissela BM, Adeoye O, Ferioli S, De Los Rios La Rosa F, Martini S, Mackey J, Kleindorfer D. Age, Sex, and Racial Differences in Neuroimaging Use in Acute Stroke: A Population-Based Study. AJNR Am J Neuroradiol 2017; 38:1905-1910. [PMID: 28838913 DOI: 10.3174/ajnr.a5340] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 06/05/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Limited information is available regarding differences in neuroimaging use for acute stroke work-up. Our objective was to assess whether race, sex, or age differences exist in neuroimaging use and whether these differences depend on the care center type in a population-based study. MATERIALS AND METHODS Patients with stroke (ischemic and hemorrhagic) and transient ischemic attack were identified in a metropolitan, biracial population using the Greater Cincinnati/Northern Kentucky Stroke Study in 2005 and 2010. Multivariable regression was used to determine the odds of advanced imaging use (CT angiography/MR imaging/MR angiography) for race, sex, and age. RESULTS In 2005 and 2010, there were 3471 and 3431 stroke/TIA events, respectively. If one adjusted for covariates, the odds of advanced imaging were higher for younger (55 years or younger) compared with older patients, blacks compared with whites, and patients presenting to an academic center and those seen by a stroke team or neurologist. The observed association between race and advanced imaging depended on age; in the older age group, blacks had higher odds of advanced imaging compared with whites (odds ratio, 1.34; 95% CI, 1.12-1.61; P < .01), and in the younger group, the association between race and advanced imaging was not statistically significant. Age by race interaction persisted in the academic center subgroup (P < .01), but not in the nonacademic center subgroup (P = .58). No significant association was found between sex and advanced imaging. CONCLUSIONS Within a large, biracial stroke/TIA population, there is variation in the use of advanced neuroimaging by age and race, depending on the care center type.
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Affiliation(s)
- A Vagal
- From the Departments of Radiology (A.V.)
| | - P Sanelli
- Department of Radiology (P.S.), Hofstra Northwell School of Medicine, Hempstead, New York
| | - H Sucharew
- Department of Biostatistics and Epidemiology (H.S., J.C.K.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - K A Alwell
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - J C Khoury
- Department of Biostatistics and Epidemiology (H.S., J.C.K.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - P Khatri
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - D Woo
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - M Flaherty
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - B M Kissela
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | | | - S Ferioli
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - F De Los Rios La Rosa
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio.,Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, Florida.,University of New Mexico Health Sciences Center and Department of Neurology (F.D.L.R.L.R.), Albuquerque, New Mexico
| | - S Martini
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - J Mackey
- Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis, Indiana
| | - D Kleindorfer
- Neurology (K.A.A., P.K., D.W., M.F., B.M.K., S.F., F.D.L.R.L.R., S.M., D.K.), University of Cincinnati Medical Center, Cincinnati, Ohio
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13
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Hanna KL, Rowe FJ. Health Inequalities Associated with Post-Stroke Visual Impairment in the United Kingdom and Ireland: A Systematic Review. Neuroophthalmology 2017; 41:117-136. [PMID: 28512502 DOI: 10.1080/01658107.2017.1279640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 10/19/2022] Open
Abstract
The aim of this study was to report on the health inequalities facing stroke survivors with visual impairments as described in the current literature. A systemic review of the literature was conducted to investigate the potential health inequalities facing stroke survivors with subsequent visual impairments. A quality-of-evidence and risk-of-bias assessment was conducted for each of the included articles using the appropriate tool dependent on the type of article. Only four articles discussed health inequalities affecting stroke survivors with visual impairment specifically. A further 23 articles identified health inequalities after stroke, and 38 reported on health inequalities within the visually impaired UK or Irish population. Stroke survivors with visual impairment face inconsistency in eye care provision nationally, along with variability in the assessment and management of visual disorders. The subgroups identified as most at risk were females; black ethnicity; lower socioeconomic status; older age; and those with lower education attainment. The issue of inconsistent service provision for this population must be addressed in future research. Further research must be conducted in order to firmly establish whether or not stroke survivors are at risk of the aforementioned sociodemographic and economic inequalities.
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Affiliation(s)
- K L Hanna
- Department of Health Services Research, University of Liverpool, Liverpool, United Kingdom
| | - F J Rowe
- Department of Health Services Research, University of Liverpool, Liverpool, United Kingdom
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Delbari A, Keyghobadi F, Momtaz YA, Keyghobadi F, Akbari R, Kamranian H, Yazdi MS, Tabatabaei SS, Fereshtehnejad SM. Sex differences in stroke: a socioeconomic perspective. Clin Interv Aging 2016; 11:1207-1212. [PMID: 27660426 PMCID: PMC5019160 DOI: 10.2147/cia.s113302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND A number of studies have explored the issue of sex differences in stroke from biomedical perspective; however, there are still large gaps in the existing knowledge. The purpose of this study was to assess whether the differences in socioeconomic status and living conditions between men and women may explain the part of the sex differences in incidence and outcomes of stroke. METHODS All stroke participants aged ≥60 years admitted in Vaseie Hospital in Sabzevar, Iran, from March 21, 2013, until March 20, 2014, were included in this study. Computerized tomography and magnetic resonance imaging were used to confirm stroke. A series of χ2 tests were performed and Statistical Program for Social Sciences, Version 21.0, was used to investigate the potential differences between older men and women in stroke incidence and outcomes. RESULTS A total of 159 incident stroke cases were documented during 1 year. The annual rate of stroke was statistically significantly higher in elderly women than in elderly men (401 vs 357 per 100,000; P<0.001). Female elderly participants had significantly lower socioeconomic status, poorer living conditions, and higher lifetime history of depression, hypertension, and diabetes mellitus than their male counterparts. CONCLUSION The findings from this study showed that elderly women are more adversely affected by stroke in terms of incidence and outcomes of stroke than elderly men. The most noticeable result is that sex differences in socioeconomic status and living conditions may result in increased incidence of stroke and poorer outcomes in elderly women. Therefore, it is imperative to identify vulnerable elderly women and provide them appropriate treatment and services.
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Affiliation(s)
- Ahmad Delbari
- Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Farzane Keyghobadi
- Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Khorasan, Iran
| | - Yadollah Abolfathi Momtaz
- Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
- Malaysian Research Institute on Ageing (MyAgeing™), Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Fariba Keyghobadi
- Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Khorasan, Iran
| | - Reza Akbari
- Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Khorasan, Iran
| | - Houman Kamranian
- Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Khorasan, Iran
| | - Mohammad Shouride Yazdi
- Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Khorasan, Iran
| | | | - Seyed-Mohammad Fereshtehnejad
- Department of Neurobiology, Division of Clinical Geriatrics, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden
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15
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Asthana S, Gibson A, Bailey T, Moon G, Hewson P, Dibben C. Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- College of Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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16
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Marshall IJ, Wang Y, Crichton S, McKevitt C, Rudd AG, Wolfe CDA. The effects of socioeconomic status on stroke risk and outcomes. Lancet Neurol 2016; 14:1206-18. [PMID: 26581971 DOI: 10.1016/s1474-4422(15)00200-8] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/23/2015] [Accepted: 07/29/2015] [Indexed: 11/19/2022]
Abstract
The latest evidence on socioeconomic status and stroke shows that stroke not only disproportionately affects low-income and middle-income countries, but also socioeconomically deprived populations within high-income countries. These disparities are reflected not only in risk of stroke but also in short-term and long-term outcomes after stroke. Increased average levels of conventional risk factors (eg, hypertension, hyperlipidaemia, excessive alcohol intake, smoking, obesity, and sedentary lifestyle) in populations with low socioeconomic status account for about half of these effects. In many countries, evidence shows that people with lower socioeconomic status are less likely to receive good-quality acute hospital and rehabilitation care than people with higher socioeconomic status. For clinical practice, better implementation of well established treatments, effective management of risk factors, and equity of access to high-quality acute stroke care and rehabilitation will probably reduce inequality substantially. Overcoming barriers and adapting evidence-based interventions to different countries and health-care settings remains a research priority.
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Affiliation(s)
- Iain J Marshall
- Division of Health and Social Care Research, King's College London, London, UK.
| | - Yanzhong Wang
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Siobhan Crichton
- Division of Health and Social Care Research, King's College London, London, UK
| | - Christopher McKevitt
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Anthony G Rudd
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Charles D A Wolfe
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre, Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
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17
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Thorne K, Williams JG, Akbari A, Roberts SE. The impact of social deprivation on mortality following acute myocardial infarction, stroke or subarachnoid haemorrhage: a record linkage study. BMC Cardiovasc Disord 2015; 15:71. [PMID: 26187051 PMCID: PMC4506594 DOI: 10.1186/s12872-015-0045-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 06/01/2015] [Indexed: 12/20/2022] Open
Abstract
Background The impact of social deprivation on mortality following acute myocardial infarction (AMI), stroke and subarachnoid haemorrhage (SAH) is unclear. Our objectives were, firstly, to determine, for each condition, whether there was higher mortality following admission according to social deprivation and secondly, to determine how any higher mortality for deprived groups may be correlated with factors including patient demographics, timing of admission and hospital size. Methods Routinely collected, linked hospital inpatient, mortality and primary care data were analysed for patients admitted as an emergency to hospitals in Wales between 2004 and 2011 with AMI (n = 30,663), stroke (37,888) and SAH (1753). Logistic regression with Bonferroni correction was used to examine, firstly, any significant increases in mortality with social deprivation quintile and, secondly, the influence of patient demographics, timing of admission and hospital characteristics on any higher mortality among the most socially deprived groups. Results Mortality was 14.3 % at 30 days for AMI, 21.4 % for stroke and 35.6 % for SAH. Social deprivation was significantly associated with higher mortality for AMI (25 %; 95 % CI = 12 %, 40 %) higher for quintile V compared with I), stroke (24 %; 14 %, 34 %), and non-significantly for SAH (32 %; −7 %, 87 %). The higher mortality at 30 days with increased social deprivation varied significantly according to patient age for AMI patients and time period for SAH. It was also highest for both AMI and stroke patients, although not significantly for female patients, for admissions on weekdays and during autumn months. Conclusions We have demonstrated a positive association between social deprivation and higher mortality following emergency admissions for both AMI and stroke. The study findings also suggest that the influence of patient demographics, timing of admission and hospital size on social inequalities in mortality are quite similar for AMI and stroke. Electronic supplementary material The online version of this article (doi:10.1186/s12872-015-0045-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kymberley Thorne
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - John G Williams
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - Ashley Akbari
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - Stephen E Roberts
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
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18
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Chen R, McKevitt C, Crichton SL, Rudd AG, Wolfe CDA. Socioeconomic deprivation and provision of acute and long-term care after stroke: the South London Stroke Register cohort study. J Neurol Neurosurg Psychiatry 2014; 85:1294-300. [PMID: 24729627 DOI: 10.1136/jnnp-2013-306413] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND AIMS Socioeconomic deprivation (SED) is associated with increased mortality after stroke, however, its associations with stroke care remains uncertain. We assessed the SED impacts on acute and long-term stroke care, and examined their ethnic differences and secular trends. METHODS We used data from 4202 patients with first-ever stroke (mean age 70.1 years, 50.4% male, 20.4% black), collected by a population-based stroke register in South London, England from 1995 to 2010. Carstairs deprivation score was measured for each patient, taking the 1st as the least deprived and the 2nd to 5th quintiles as SED, and was related to 20 indicators of care in multivariate logistic regression models. RESULTS Patients with SED had 29% and 35% statistically significant reductions in odds of being admitted to hospital and having swallow tests, respectively. The multivariate adjusted odds ratio (OR) for receiving five indicators of acute stroke care was 0.81 (95% CI 0.72 to 0.92). It was 0.76 (0.58 to 0.99) in black patients and 0.82 (0.71 to 0.96) in white patients; and 0.70 (0.58 to 0.84) in patients with stroke occurring before 2001 and 0.89 (0.75 to 1.05) since 2001. SED was further associated with receipt of some stroke care during 5 years of follow-up, including atrial fibrillation medication (0.63, 0.48 to 0.83), and in black patients physiotherapy and occupational therapy (0.32, 0.11 to 0.92). CONCLUSIONS Stroke healthcare inequalities in England exist for some important indicators, although overall it has improved over time. The impact of SED may be stronger in black patients than in white patients. Further efforts are required to achieve stroke care equality.
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Affiliation(s)
- Ruoling Chen
- Division of Health and Social Care Research, King's College London, London, UK
| | | | - Siobhan L Crichton
- Division of Health and Social Care Research, King's College London, London, UK
| | - Anthony G Rudd
- Division of Health and Social Care Research, King's College London, London, UK National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Charles D A Wolfe
- Division of Health and Social Care Research, King's College London, London, UK National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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19
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Disparities in Imaging Utilization for Acute Ischemic Stroke Based on Patient Insurance Status. AJR Am J Roentgenol 2014; 203:372-6. [DOI: 10.2214/ajr.13.12008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Brinjikji W, Rabinstein AA, McDonald JS, Cloft HJ. Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke in US hospitals. AJNR Am J Neuroradiol 2014; 35:553-6. [PMID: 23945232 PMCID: PMC7964730 DOI: 10.3174/ajnr.a3708] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 06/09/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have demonstrated that socioeconomic disparities in the treatment of cerebrovascular diseases exist. We studied a large administrative data base to study disparities in the utilization of mechanical thrombectomy for acute ischemic stroke. MATERIALS AND METHODS With the utilization of the Perspective data base, we studied disparities in mechanical thrombectomy utilization between patient race and insurance status in 1) all patients presenting with acute ischemic stroke and 2) patients presenting with acute ischemic stroke at centers that performed mechanical thrombectomy. We examined utilization rates of mechanical thrombectomy by race/ethnicity (white, black, and Hispanic) and insurance status (Medicare, Medicaid, self-pay, and private). Multivariate logistic regression analysis adjusting for potential confounding variables was performed to study the association between race/insurance status and mechanical thrombectomy utilization. RESULTS The overall mechanical thrombectomy utilization rate was 0.15% (371/249,336); utilization rate at centers that performed mechanical thrombectomy was 1.0% (371/35,376). In the sample of all patients with acute ischemic stroke, multivariate logistic regression analysis demonstrated that uninsured patients had significantly lower odds of mechanical thrombectomy utilization compared with privately insured patients (OR = 0.52, 95% CI = 0.25-0.95, P = .03), as did Medicare patients (OR = 0.53, 95% CI = 0.41-0.70, P < .0001). Blacks had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.35, 95% CI = 0.23-0.51, P < .0001). When considering only patients treated at centers performing mechanical thrombectomy, multivariate logistic regression analysis demonstrated that insurance was not associated with significant disparities in mechanical thrombectomy utilization; however, black patients had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.41, 95% CI = 0.27-0.60, P < .0001). CONCLUSIONS Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., J.S.M., H.J.C.)
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21
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Ji R, Wang D, Liu G, Shen H, Wang Y, Li H, Schwamm LH, Wang Y. Impact of macroeconomic status on prehospital management, in-hospital care and functional outcome of acute stroke in China. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/cpr.13.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Brinjikji W, Rabinstein AA, Cloft HJ. Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis 2013; 23:979-84. [PMID: 24119620 DOI: 10.1016/j.jstrokecerebrovasdis.2013.08.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/27/2013] [Accepted: 08/13/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated that socioeconomic disparities in access to treatment of cerebrovascular diseases exist. We studied the Nationwide Inpatient Sample (NIS) to determine if disparities exist in utilization of mechanical thrombectomy for acute ischemic stroke. METHODS Using the NIS for the years 2006-2010, we selected all discharges with a primary diagnosis of acute ischemic stroke. Patients who received mechanical thrombectomy for stroke were identified by using the International Classification of Diseases, Ninth Revision, procedure code 39.74. We examined the utilization rates of mechanical thrombectomy by race/ethnicity (white, black, Hispanic, and Asian/Pacific Islander), income quartile (first, second to third, and fourth), and insurance status (Medicare, Medicaid, self-pay, and private). We also studied thrombectomy utilization rates at hospitals that performed thrombectomy. RESULTS From 2006 to 2010, 2,087,017 patients were hospitalized with a primary diagnosis of acute ischemic stroke; 8946 patients (.4%) received mechanical thrombectomy. Compared with white patients, black patients had significantly lower rates of overall mechanical thrombectomy utilization (odds ratio [OR] = .59, 95% confidence interval [CI] = .55-.64, P < .0001) and at centers that offered mechanical thrombectomy (OR = .44, 95% CI = .41-.47, P < .0001). Compared with patients in the highest income quartile, patients in the lowest income quartile had significantly lower rates of mechanical thrombectomy utilization both overall (OR = .66, 95% CI = .62-.70, P < .0001) and at centers that offered mechanical thrombectomy (OR = .80, 95% CI = .75-.84, P < .0001). Compared with patients with private insurance, self-pay patients had significantly lower mechanical thrombectomy utilization both overall (OR = .71, 95% CI = .64-.78, P < .0001) and at centers that offered mechanical thrombectomy (OR = .81, 95% CI = .74-.90, P < .0001). CONCLUSIONS Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.
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Affiliation(s)
| | | | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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23
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Comparison of provision of stroke care in younger and older patients: findings from the South london stroke register. Stroke Res Treat 2012; 2012:319581. [PMID: 22593833 PMCID: PMC3347760 DOI: 10.1155/2012/319581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/30/2012] [Accepted: 02/11/2012] [Indexed: 12/26/2022] Open
Abstract
Background. Evidence-based stroke care should be available to all patients. However, evidence exists of inequalities according to age. This study compared access to care for younger adults to that for over 65s. Methods. Using population-based data from 4229 patients with first-ever stroke between 1995 and 2010, associations between age and 21 care indicators were investigated using multivariable logistic regression. Results. Age was not associated with stroke unit admission for ischaemic stroke (P = 0.666). Younger PICH patients were least likely to be admitted to stroke units (P = 0.001), instead treated on neurosurgical or ICU wards. Younger age was also associated with admission to neurosurgery or ICU after SAH (P = 0.006), increased occupational or physiotherapy at 1 year (P = 0.043), and contact with a GP 3 months after stroke (P < 0.001). Conclusion. Younger patients have equal or greater access to evidence-based care. However, there is a need to ensure that services meet the needs of this group.
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McKibbon KA, Lokker C, Wilczynski NL, Haynes RB, Ciliska D, Dobbins M, Davis DA, Straus SE. Search filters can find some but not all knowledge translation articles in MEDLINE: an analytic survey. J Clin Epidemiol 2012; 65:651-9. [PMID: 22424986 DOI: 10.1016/j.jclinepi.2011.10.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 10/06/2011] [Accepted: 10/26/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Advances from health research are not well applied giving rise to over- and underuse of resources and inferior care. Knowledge translation (KT), actions and processes of getting research findings used in practice, can improve research application. The KT literature is difficult to find because of nonstandardized terminology, rapid evolution of the field, and it is spread across several domains. We created multiple search filters to retrieve KT articles from MEDLINE. STUDY DESIGN AND SETTING Analytic survey using articles from 12 journals tagged as having KT content and also as describing a KT application or containing a KT theory. RESULTS Of 2,594 articles, 579 were KT articles of which 201 were about KT applications and 152 about KT theory. Search filter sensitivity (retrieval efficiency) maximized at 83%-94% with specificity (no retrieval of irrelevant material) approximately 50%. Filter performances were enhanced with multiple terms, but these filters often had reduced specificity. Performance was higher for KT applications and KT theory articles. These filters can select KT material although many irrelevant articles also will be retrieved. CONCLUSION KT search filters were developed and tested, with good sensitivity but suboptimal specificity. Further research must improve their performance.
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Affiliation(s)
- K Ann McKibbon
- Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, 137 CRL Building, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4K1.
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Addo J, Ayerbe L, Mohan KM, Crichton S, Sheldenkar A, Chen R, Wolfe CDA, McKevitt C. Socioeconomic status and stroke: an updated review. Stroke 2012; 43:1186-91. [PMID: 22363052 DOI: 10.1161/strokeaha.111.639732] [Citation(s) in RCA: 250] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Juliet Addo
- King's College London, Division of Health and Social Care Research, 7th Floor Capital House, 42 Weston Street, London SE1 3QD, UK.
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