Socioeconomic Inequalities in Reperfusion Therapy for Acute Ischemic Stroke

Financial Concerns Are Common Among Family Surrogate Decision-Makers of Patients With Stroke: A Mixed Methods Study

Background and Objectives

Stroke has a large aggregate financial effect, but the prevalence and predictors of cost concerns among family surrogate decision-makers of patients with stroke are unknown. The aim of this study was to explore the prevalence, predictors, and nature of cost concerns among family surrogate decision-makers of patients with stroke.

Methods

Family surrogate decision-makers of patients with stroke were recruited from a largely biethnic population-based study in Nueces County, TX. The primary outcome was the presence of cost concerns, defined as being "very worried" or "moderately worried" about being able to pay stroke-related medical costs, assessed through surveys conducted at baseline (shortly after stroke) and 3-, 6-, and 12-month poststroke. Potential predictors included clinical and sociodemographic factors for patients and family members, obtained from surveys and medical charts. Exploratory multivariable logistic regression models identified factors associated with cost concerns, adjusting for covariates. We also explored the nature of cost concerns in semistructured interviews with a subset of participants.

Results

Of 465 eligible stroke cases, 318 family members of 256 patients with stroke participated. Patients were 52% female, 58% Mexican American (MA), 38% non-Hispanic White (NHW), and 8% other race/ethnicity, mean age 75 (SD 14), and median NIH Stroke Scale score of 12.5 (IQR 5-22). Family members were 76% female, 63% MA, 32% NHW, and 5% other race/ethnicity, mean age 56 (SD 13). Of 256 patients, 118 (46%) had a family member with cost concerns. After adjustment for all covariates, MA ethnicity and lack of insurance were associated with greater cost concerns. Cost concerns decreased over time and were less common among family members who were neither a spouse nor a child of the patient. In semistructured interviews, cost concerns related to postacute care were most frequently mentioned, but concerns regarding hospital costs and nonmedical costs were also common.

Discussion

Nearly half of family surrogate decision-makers of patients with stroke had at least moderate concerns about being able to afford stroke-related medical costs. Lack of adequate insurance and membership in a historically marginalized ethnic group were the strongest predictors of cost concerns.

Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS): A Comprehensive Meta-Analysis of Ethnicity, Socioeconomic Status, and Geographical Factors

BACKGROUND

Reperfusion therapies, such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), are crucial for improving outcomes in patients with acute ischemic stroke (AIS). However, access to these treatments can vary significantly due to ethnicity, socioeconomic status (SES), and geographical location, impacting patient outcomes.

OBJECTIVES

The Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS) study aims to systematically assess disparities in access to IVT and EVT on the basis of ethnicity, SES, and geographical location.

METHODS

A comprehensive meta-analysis was conducted, incorporating data from 38 studies involving 5,256,531 patients with AIS. The analysis evaluated IVT and EVT utilization rates across ethnic groups, SES levels, and geographical locations.

RESULTS

The findings reveal substantial disparities in access to reperfusion therapies. IVT and EVT utilization rates varied significantly by ethnicity (9% ethnic, 11% non-ethnic for IVT; 7% ethnic, 6% non-ethnic for EVT), SES (13% low SES, 16% high SES for IVT; 7% low SES, 10% high SES for EVT), and geography (9% rural, 12% urban for IVT; 1% rural, 4% urban for EVT). Black patients had significantly lower odds of receiving IVT (OR 0.69, p = 0.001) and EVT (OR 0.87, p = 0.005) compared with white patients. Similarly, patients with low SES and those from rural areas faced reduced odds of receiving IVT (OR 0.74, p < 0.001; OR 0.72, p = 0.002) and EVT (OR 0.74, p < 0.001; OR 0.39, p < 0.001). Rural patients also had significantly lower odds of timely hospital arrival (p < 0.001), posing a barrier to accessing reperfusion therapies.

CONCLUSIONS

The DARTS study (and this meta-analysis) reveals significant access disparities in AIS treatment related to ethnicity, geography, and SES, particularly affecting Black communities, low SES individuals, and rural populations. Despite advances in reperfusion therapies, suboptimal implementation rates persist. To address these issues, we recommend the EQUITY framework: Educate, Ensure Quality, provide Universal Access, Implement Inclusive Policy Reforms, Enhance Timely Data Collection, and Yield Culturally Sensitive Care Practices. Adopting these recommendations will improve access, reduce disparities, and enhance stroke management and outcomes globally. Equitable access is essential for all eligible patients to fully benefit from reperfusion treatments.

Association Between Sociodemographic Disparities and Door to Computerized Tomography Time in Patients with Acute Ischemic Stroke Across COVID-19 Periods in the Emergency Department: A Multi-Center Cohort Study

INTRODUCTION

Stroke is the fifth leading cause of death and long-term disability in the United States. The current guideline for stroke management includes a 25 min timeframe from door-to-computed tomography time (DTCT). However, sociodemographic backgrounds may impact the DTCT in acute stroke patients.

METHODS

This was a retrospective, multicenter, cohort study between January 2018 and August 2022 throughout North Texas. The primary endpoint was DTCT ≤ 25 min upon arrival to hospital for all patients suspected of acute ischemic stroke.

RESULTS

During the study period, a total of 23,364 patients were included. Only 4468 patients (19.1%) had DTCT times less than or equal to 25 min, and 16,464 patients (70.5%) had DTCT times more than 25 min. In our cohort, Black (OR 1.35; 95% CI 1.23-1.49) and Asian patients (OR 1.33; 95% CI 1.01-1.74) were more likely to have DTCT > 25 min compared to White patients. Hispanic patients (OR 1.20; 95% CI 1.07-1.34) were more likely to have DTCT > 25 min compared to non-Hispanics. Patients presenting during the COVID (OR 1.45; 95% CI 1.34-1.57) and post-COVID period (OR 1.46; 95% CI 1.30-1.65) were more likely to have DTCT > 25 min compared to the pre-COVID period.

CONCLUSIONS

We demonstrated a discrepancy in DTCT time for acute ischemic stroke patients based on their race and ethnic population and an increase in DTCT time after the start of COVID-19, which has persisted after the pandemic. These diverse factors highlight the complex interplay of logistical, organizational, and healthcare challenges that have influenced DTCT time.

Research progress on influencing factors and intervention measures of pre-hospital delays in acute ischemic stroke

BackgroundStroke, a leading cause of health impairment globally, sees intravenous thrombolysis as the primary treatment during the acute phase, yet delays persist due to pre-hospital and in-hospital factors. While research has reduced in-hospital delays significantly, pre-hospital delays remain a concern both domestically and internationally.ObjectiveThis article aims to provide a comprehensive review of the research progress on the influencing factors and intervention measures of pre-hospital delays in acute ischemic stroke.MethodsBy analyzing the literature, summarize the risk factors leading to treatment delay in acute ischemic stroke (AIS), and provide a review of potential improvement methods.ResultsPre-hospital delay in acute ischemic stroke (AIS) is influenced by both objective factors like age, gender, and regional economic status, as well as subjective factors such as stroke awareness. The introduction of "Stroke 120," a stroke education slogan tailored to Chinese language habits, aims to improve stroke awareness and address delayed treatment and low AIS venous thrombolysis utilization among the Chinese publicConclusionIn conclusion, collaborative efforts from the government, society, and hospitals are essential to enhance stroke education comprehensively. This will ensure widespread awareness of stroke knowledge, facilitating timely and effective treatment for AIS patients.

Geographical location of ischemic stroke patients affects thrombolysis availability in Denmark

INTRODUCTION

Early recognition and treatment of stroke is paramount for good outcome. Transport distance may result in delayed arrival for revascularization therapy. We investigated how transport time and distance to the revascularization unit affected the probability of receiving intravenous thrombolysis in Denmark between 2015 and 2020, for patients calling the Emergency Medical Services within three hours of symptom onset.

METHODS

We obtained records from the Danish Stroke Registry (DanStroke) and the patient administrative computer-assisted dispatch system (CAD). All patients diagnosed with stroke from the Capital Region and Region Zealand, who contacted the EMS within three hours of symptom onset were included. The study population was analyzed using multivariate logistical regression models.

RESULTS

For the Capital Region, longer transport time was associated with lower IVT rates, with an Odds-Ratio 0.91, 95 % CI [0.83;0.99], P-value 0.0386. There was no significant correlation between transport time and IVT rates for the Region of Zealand. However, fewer patients with >60 min estimated transport time received IVT than patients with 0-20 min estimated transport time in the Region of Zealand (Odds-ratio 0.63, 95 % CI [0.44;0.91], p-value 0.016).

CONCLUSIONS

Longer transport time to a revascularization unit is associated with significantly poorer IVT rates in the Capital Region of Denmark, despite calling in a timely manner for arrival within the 4.5-h treatment window. The same association was not established for the rural Region of Zealand; however, our findings do suggest that living >60 min from a revascularization unit is associated with a lower probability of receiving IVT in this region.

Trajectories of physical activity after ischaemic stroke: Exploring prediction of change

BACKGROUND AND PURPOSE

Physical activity (PA) is associated with lower risk of stroke and better functional outcome. However, low levels of PA after stroke are prevalent. The aim was to identify predictors of PA change after first-time ischaemic stroke and to develop prediction models to predict change in PA.

METHODS

Pre-stroke and 6 months post-stroke PA were quantified with the Physical Activity Scale for the Elderly (PASE). Considered predictors were clinical data and demographics including data on socioeconomic status (SES). PASE change was analysed using mixed models of repeated measures. Elastic net regression models were used to predict decrease from higher PASE quartile to the lowest and increase from lowest to higher.

RESULTS

A total of 523 first-time ischaemic stroke patients were included. Median (interquartile range, IQR) age was 69 years (IQR 59, 77), 181 (35%) were female and median National Institutes of Health Stroke Scale score was 3 (IQR 2, 5). Overall PASE score did not change, but 20% of patients decreased to the lowest PASE quartile whereas 48% from the lowest quartile increased to a higher. Prediction performance measured by area under the receiver operating curve was 0.679 for PA decrease and 0.619 for increase. SES factors were the most consistent predictors.

CONCLUSIONS

Half of the least active patients increased PA level after stroke whereas a fifth decreased with SES being the most consistent predictor. Despite comprehensive data, the prediction models only performed modestly. Efforts to optimize PA should include all stroke survivors to increase PA for least active patients and to prevent PA decrease.

Socioeconomic Disparities in Rate of Poststroke Dementia: A Nationwide Cohort Study

BACKGROUND

Socioeconomic disparities exist in acute stroke care as well as in long-term stroke outcomes. We aimed to investigate whether socioeconomic status was associated with the rate of poststroke dementia (PSD).

METHODS

This was a nationwide register-based cohort study including all patients with incident ischemic or hemorrhagic stroke in Denmark from 2010 to 2020. Socioeconomic status was defined by prestroke income, education, and employment. PSD was defined as a dementia diagnosis in the National Patient Registry or a dispensed prescription of dementia medication after a stroke. PSD incidence rates were compared between socioeconomic status groups using Poisson regression.

RESULTS

A total of 98 489 patients with incident stroke without a diagnosis of prestroke dementia were identified and followed for a median (IQR) of 4.2 (IQR, 2.1-7.3) years. Median age was 72 (62-80) years, 56% were male, 5.1% were immigrants, and 86% had ischemic stroke. Dementia was diagnosed in 5680 patients at a median of 2.4 (IQR, 0.9-4.8) years after stroke (incidence rate=12.1/1000 person-years). After adjusting for age, sex, and immigrant status, PSD rates were 1.24 (1.15-1.34) times higher for low income compared with high income, 1.11 (1.03-1.20) times higher for low education compared with high education, and 1.57 (1.38-1.77) times higher for patients without employment compared with patients with employment. Further adjustments for stroke severity, cohabitation, and comorbidities showed similar results. Stratified analyses showed that the socioeconomic disparities in PSD rates were more pronounced among women, immigrants, and patients <70 years of age.

CONCLUSIONS

Low socioeconomic status measured by prestroke income, education, and employment status was associated with higher rates of PSD. These socioeconomic disparities extended beyond what could be explained by common PSD risk factors.

Effects of Social Determinants of Health on Acute Stroke Care Among Patients With Acute Ischemic Stroke: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Social determinants of health (SDOH) are important contributors to poor stroke-related outcomes. While some have suggested that this association is driven by the increased incidence of stroke observed with poor SDOH, others have raised concerns regarding disparities in acute stroke care. This study aimed to determine the association between SDOH and the administration of thrombolytic therapy and mechanical thrombectomy among patients with acute ischemic stroke.

METHODS

A retrospective cohort analysis was conducted using Texas Emergency Department Public Use Data (2016-2019), including adult patients diagnosed with acute ischemic stroke. The risk ratios (RRs) of administering thrombolysis and thrombectomy based on variables representing SDOH and a collective measure (Social Vulnerability Index [SVI]) were computed using mixed-effects Poisson regression models accounting for the nested nature of patients in hospitals and neighborhoods. The Charlson comorbidity score was considered as a covariate.

RESULTS

Of the 139,852 patients with ischemic stroke (female, 51.7%; White, 67.2%; Black, 16.6%; Hispanic, 25.1%), 16,831 (12.3%) received thrombolytic therapy and 5,951 (4.3%) received mechanical thrombectomy. Age older than 65 years (RR 0.578 [0.537-0.621]) vs 18-45 years, Black (RR 0.801 [0.761-0.844]) vs White, Hispanic (RR 0.936 [0.895-0.98]) vs non-Hispanic, Medicare/Medicaid/Veterans Affairs (VA) (RR 0.917 [0.882-0.954]) or uninsured (RR 0.883 [0.833-0.935]) vs private insurance, and rural (RR 0.782 [0.723-0.845]) vs urban dwelling were less likely to be associated with thrombolysis. Patients in the highest quintile based on the SVI were less likely to receive thrombolysis than those in the lowest quintile (RR 0.926 [0.867-0.989]). Patients were less likely to receive thrombectomy if they were 65 years and older (RR 0.787 [0.691-0.895]), belonged to the Black race (RR 0.745 [0.679-0.818]) or Hispanic ethnicity (RR 0.919 [0.851-0.992]), had Medicare/Medicaid/VA insurance (RR 0.909 [0.851-0.971]), or were from a rural area (RR 0.909 [0.851-0.971]). Similarly, SVI decreased the likelihood of undergoing mechanical thrombectomy (RR 0.842 [0.747-0.95]).

DISCUSSION

Despite many improvements in stroke management, SDOH continue to be a significant driver of treatment access for acute ischemic stroke. While our findings are limited to Texas, our results should raise awareness and promote more studies regarding the effects of these SDOH at the national and international levels.

Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era

PURPOSE

To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018).

MATERIALS AND METHODS

We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization.

RESULTS

Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05).

CONCLUSIONS

We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Association of Neighborhood Deprivation With Thrombolysis and Thrombectomy for Acute Stroke in a Health System With Universal Access

BACKGROUND AND OBJECTIVES

The association between socioeconomic status and acute ischemic stroke treatments remain uncertain, particularly in countries with universal health care systems. This study aimed to investigate the association between neighborhood-level material deprivation and the odds of receiving IV thrombolysis or thrombectomy for acute ischemic stroke within a single-payer, government-funded health care system.

METHODS

We conducted a population-based cohort study using linked administrative data from Ontario, Canada. This study involved all community-dwelling adult Ontario residents hospitalized with acute ischemic stroke between 2017 and 2022. Neighborhood-level material deprivation, measured in quintiles from least to most deprived, was our main exposure. We considered the receipt of thrombolysis or thrombectomy as the primary outcome. We used multivariable logistic regression models adjusted for baseline differences to estimate the association between material deprivation and outcomes. We performed a sensitivity analysis by additionally adjusting for hospital type at initial assessment. Furthermore, we tested whether hospital type modified the associations between deprivation and outcomes.

RESULTS

Among 57,704 patients, those in the most materially deprived group (quintile 5) were less likely to be treated with thrombolysis or thrombectomy compared with those in the least deprived group (quintile 1) (16.6% vs 19.6%, adjusted odds ratio [aOR] 0.76, 95% CI 0.63-0.93). The association was consistent when evaluating thrombolysis (13.0% vs 15.3%, aOR 0.78, 95% CI 0.64-0.96) and thrombectomy (6.4 vs 7.8%, aOR 0.73, 95% CI 0.59-0.90) separately. There were no statistically significant differences between the middle 3 quintiles and the least deprived group. These associations persisted after additional adjustment for hospital type, and there was no interaction between material deprivation and hospital type (p interaction >0.1).

DISCUSSION

We observed disparities in the use of thrombolysis or thrombectomy for acute ischemic stroke by socioeconomic status despite access to universal health care. Targeted health care policies, public health messaging, and resource allocation are needed to ensure equitable access to acute stroke treatments for all patients.

Socioeconomic Inequalities in Functional Outcome After Reperfusion-Treated Ischemic Stroke

BACKGROUND

We aimed to investigate whether socioeconomic status (SES) was associated with functional outcome in patients with ischemic stroke treated with reperfusion therapy (intravenous thrombolysis and/or thrombectomy).

METHODS

This nationwide cohort study included reperfusion-treated patients with ischemic stroke ≥18 years registered in the Danish Stroke Registry between 2015 and 2018. Functional outcome was determined by the modified Rankin Scale score 90 days after stroke. SES was defined by educational attainment, family income, and employment status before stroke. SES data were available from Statistics Denmark and linked on the individual level with data from the Danish Stroke Registry. Uni- and multivariable ordinal logistic regression was performed for each socioeconomic parameter individually (education, income, and employment) to estimate the common odds ratios (cORs) for lower 90-day modified Rankin Scale scores.

RESULTS

A total of 5666 patients were included. Mean age was 68.7 years (95% CI, 68.3-69.0), and 38.4% were female. Low SES was associated with lower odds for achieving lower 90-day modified Rankin Scale score: Low versus high education, cOR, 0.69 (95% CI, 0.61-0.79), low versus high income, cOR, 0.59 (95% CI, 0.53-0.67), and unemployed versus employed, cOR, 0.70 (95% CI, 0.58-0.83). Inequalities were reduced after adjusting for age, sex, and immigrant status, except for unemployed versus employed patients, adjusted cOR, 0.66 (95% CI, 0.54-0.80). No statistically significant differences remained after adjusting for potentially mediating variables (eg, stroke severity, prestroke modified Rankin Scale, and smoking).

CONCLUSIONS

Socioeconomic inequalities were observed in functional outcome after reperfusion treated ischemic stroke. In particular, prestroke unemployment was negatively associated with good functional outcome. A more adverse prognostic profile among patients with low SES appeared to explain the majority of these inequalities.

Risk Factors, Presentation, and Outcome in Acute Stroke according to Social Position Indicators in Patients Hospitalised in a Referral Centre in Bogotá 2011-2019

INTRODUCTION

Treatment of stroke is time-dependent and it challenges patients' social and demographic context for timely consultation and effective access to reperfusion therapies.

OBJECTIVE

The objective of this study was to relate indicators of social position to cardiovascular risk factors, time of arrival, access to reperfusion therapy, and mortality in the setting of acute stroke.

METHODS

A retrospective analysis of patients with a diagnosis of ischaemic stroke in a referral hospital in Bogotá was performed. A simple random sample with a 5% margin of error and 95% confidence interval was selected. Patients were characterised according to educational level, place of origin, marital status, occupation, duration of symptoms before consultation, cardiovascular risk factors, access to reperfusion therapy, and mortality during hospitalisation.

RESULTS

558 patients were included with a slight predominance of women. Diagnosis of diabetes was more common in women and smoking in men (n = 68, 28.4% vs. n = 51, 15.9%; p = 0.0004). Rural origin was associated with higher prevalence of hypertension, diabetes, and dyslipidaemia (hypertension n = 45, 73.8% vs. n = 282, 57.4%; p = 0.007; diabetes n = 20, 33.3% vs. 109, 19.5%; p = 0.02; dyslipidaemia n = 19, 32.7% vs. n = 93, 18.9%; p = 0.02). Mortality was higher in rural patients (n = 8, 14.2% vs. n = 30, 6.1%; p = 0.03). Lower schooling was associated with higher frequency of hypertension and dyslipidaemia (hypertension n = 152, 76.0% vs. n = 94, 46.3%; p ≤ 0.0001; dyslipidaemia n = 56, 28% vs. n = 35, 17.0%; p = 0.009) as well as with late consultation (n = 30, 15% vs. n = 59, 28.7%; p = 0.0011) and lower probability of accessing reperfusion therapy (n = 12, 6% vs. n = 45, 22%; p ≤ 0.0001). Formal employment was associated with a visit to the emergency department in less than 3 h (n = 50, 25.2% vs. n = 58, 18%, p = 0.04 and a higher probability of accessing reperfusion therapy (n = 35, 17.6% vs. n = 33, 10.2%; p = 0.01). Finally, living in a household with a stratum higher than 3 was associated with a consultation before 3 h (n = 77, 25.5% vs. n = 39, 15.6%; p = 0.004) and a higher probability of reperfusion therapy (n = 57, 18.9% vs. n = 13, 5.2%; p ≤ 0.0001).

CONCLUSION

Indicators of socio-economic status are related to mortality, consultation time, and access to reperfusion therapy. Mortality and reperfusion therapy are inequitably distributed and, therefore, more attention needs to be directed to the cause of these disparities in order to reduce the access gap in the context of acute stroke in Bogotá.

Is the socioeconomic inequality in stroke prognosis changing over time and does quality of care play a role?

Introduction:

In a publicly financed healthcare system we aimed to study the development in socioeconomic disparity in ischemic stroke outcomes over time. In addition, we study whether the healthcare system affects these outcomes through the quality of early stroke care when adjustments are made for various patient characteristics incl. comorbidity and stroke severity.

Patients and methods:

Using nationwide, detailed individual-level register-data we analysed how income-related and education-related inequality in 30-day mortality and 30-day readmission risk developed between 2003 and 2018. In addition, focusing on income-related inequality, we applied mediation analyses to estimate the mediating role of quality of acute stroke care on 30-day mortality and 30-day readmission.

Results:

A total of 97,779 individual ischemic stroke patients were registered in Denmark with a first ever stroke in the study period. Three-point-seven percent died within 30 days of their index-admission and 11.5% were readmitted within 30 days of discharge. The income-related inequality in mortality remained virtually unchanged over time from an RR of 0.53 (95% CI: 0.38; 0.74) in 2003–06 to RR 0.69 (95% CI: 0.53; 0.89)) in 2015–18 when high income was compared to low income (Family income-time interaction: RR 1.00 (95% CI: 0.98–1.03)). A similar but less uniform trend was found for the education-related inequality in mortality (Education-time interaction: RR 1.00 (95% CI: 0.97–1.04)). The income-related disparity in 30-day readmission was smaller than in 30-day mortality and it diminished over time from 0.70 (95% CI: 0.58; 0.83) to 0.97 (95% CI: 0.87; 1.10). The mediation analysis showed no systematic mediating effect of quality of care on neither mortality nor readmission. However, it cannot be ruled out that residual confounding may have washed out some mediating effects.

Discussion and Conclusion:

The socioeconomic inequality in stroke mortality and re-admission risk has yet to be eliminated. Additional studies from different settings are warranted in order to clarify the impact of socioeconomic inequality of quality of acute stroke care.