Neighborhood Socioeconomic Status and Stroke Incidence: A Systematic Review

Impact of Poverty on Stroke Recurrence: A Population-Based Study

BACKGROUND AND OBJECTIVES

Poverty is associated with greater stroke incidence. The relationship between poverty and stroke recurrence is less clear.

METHODS

In this population-based study, incident strokes within the Greater Cincinnati/Northern Kentucky region were ascertained during the 2015 study period and followed up for recurrence until December 31, 2018. The primary exposure was neighborhood socioeconomic status (nSES), defined by the percentage of households below the federal poverty line in each census tract in 4 categories (≤5%, >5%-10%, >10%-25%, >25%). Poisson regression models provided recurrence rate estimates per 100,000 residents using population data from the 2015 5-year American Community Survey, adjusting for age, sex, and race. In a secondary analysis, Cox models allowed for the inclusion of vascular risk factors in the assessment of recurrence risk by nSES among those with incident stroke.

RESULTS

Of 2,125 patients with incident stroke, 245 had a recurrent stroke during the study period. Poorer nSES was associated with increased stroke recurrence, with rates of 12.5, 17.5, 25.4, and 29.9 per 100,000 in census tracts with ≤5%, >5%-10%, >10%-25%, and >25% below the poverty line, respectively (p < 0.01). The relative risk (95% CI) for recurrent stroke among Black vs White individuals was 2.54 (1.91-3.37) before adjusting for nSES, and 2.00 (1.47-2.74) after adjusting for nSES, a 35.1% decrease. In the secondary analysis, poorer nSES (HR 1.74, 95% CI 1.10-2.76 for lowest vs highest category) and Black race (HR 1.31, 95% CI 1.01-1.70) were both independently associated with recurrence risk, though neither retained significance after full adjustment. Age, diabetes, and left ventricular hypertrophy were associated with increased recurrence risk in fully adjusted models.

DISCUSSION

Residents of poorer neighborhoods had a dose-dependent increase in stroke recurrence risk, and neighborhood poverty accounted for approximately one-third of the excess risk among Black individuals. These results highlight the importance of poverty, race, and the intersection of the 2 as potent drivers of stroke recurrence.

Association of Neighborhood Socioeconomic Status With Withdrawal of Life-Sustaining Therapies After Intracerebral Hemorrhage

BACKGROUND AND OBJECTIVES

Mortality after intracerebral hemorrhage (ICH) is common. Neighborhood socioeconomic status (nSES) is an important social determinant of health (SDoH) that can affect clinical outcome. We hypothesize that SDoH, including nSES, contribute to differences in withdrawal of life-sustaining therapies (WLSTs) and mortality in patients with ICH.

METHODS

We performed a retrospective study of patients with ICH at 3 tertiary care hospitals between January 2017 and December 2022 identified through the Get with the Guidelines Database. We collected data on age, clinical severity, race/ethnicity, median household income, insurance, marital status, religion, mortality before discharge, and WLST from the electronic medical record. We assessed for associations between SDoH and WLST, mortality, and poor discharge mRS using Mann-Whitney U tests and χ2 tests. We performed multivariable analysis using backward stepwise logistic regression.

RESULTS

We identified 868 patients (median age 67 [interquartile range (IQR) 55-78] years; 43% female) with ICH. Of them, 16% were Black non-Hispanic, 17% were Asian, and 15% were of Hispanic ethnicity; 50% were on Medicare and 22% on Medicaid, and the median (IQR) household income was $81,857 ($58,669-$122,078). Mortality occurred in 17% of patients, and of them, 84% of patients had WLST. Patients from zip codes with higher median household incomes had higher incidence of WLST and mortality (p < 0.01). Black non-Hispanic race was associated with lower WLST and discharge mortality (p ≤ 0.01 for both). In multivariable analysis adjusting for age and clinical severity scores, patients who lived in zip codes with high-income levels were more likely to have WLST (adjusted odds ratio [aOR] 1.88; 95% CI 1.29-2.74) and mortality before discharge (aOR 1.5; 95% CI 1.06-2.13).

DISCUSSION

SDoH, including nSES, are associated with WLST after ICH. This has important implications for the care and management of patients with ICH.

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

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

Cardiovascular Disease in China: Socioeconomic Status Variation in Prevalence

Introduction

Cardiovascular disease is the single largest contributor to global mortality and the leading cause of both death and premature death in China. Data on the association between cardiovascular disease and socioeconomic status are sparse, especially for Asian countries. Our study collected data to describe the socioeconomic status variation across cardiovascular disease using a large nationwide cross-sectional study.

Methods

We chose participants using the cluster sampling method, prepared a face-to-face questionnaire interview for the selected community residents, and collected information on health conditions, socioeconomic status, demographics, and comorbidities. All collected data were reported as frequencies and corresponding percentages. Linear regression and simple and multivariable logistic regression were performed to identify the prevalence variation. All statistical analyses were performed using SPSS version 26 software.

Results

Socioeconomic information was available for 394,688 participants (covering most provincial districts). The prevalence of cardiovascular disease was 7.9%. The prevalence was higher in rural areas than that in urban areas (rural, 8.4%; urban, 7.5%). There was a negative relationship between urbanization and cardiovascular disease prevalence. Furthermore, cardiovascular disease prevalence had a negative relationship with average earnings.

Conclusion

This cross-sectional analysis of socioeconomic status variation in the prevalence of cardiovascular disease in China showed a significant negative relationship between regional and individual socioeconomic status and cardiovascular disease. The results imply that governments would benefit communities by focusing on effective and targeted interventions for prevention, screening, and treatment in individuals who may be in the socioeconomic status with a high risk for cardiovascular disease.

Neighborhood greenspace and neighborhood income associated with white matter grade worsening: Cardiovascular Health Study

INTRODUCTION

We examined whether a combined measure of neighborhood greenspace and neighborhood median income was associated with white matter hyperintensity (WMH) and ventricle size changes.

METHODS

The sample included 1260 cognitively normal ≥ 65-year-olds with two magnetic resonance images (MRI; ≈ 5 years apart). WMH and ventricular size were graded from 0 (least) to 9 (most) abnormal (worsening = increase of ≥1 grade from initial to follow-up MRI scans). The four-category neighborhood greenspace-income measure was based on median neighborhood greenspace and income values at initial MRI. Multivariable logistic regression tested associations between neighborhood greenspace-income and MRI measures (worsening vs. not).

RESULTS

White matter grade worsening was more likely for those in lower greenspace-lower income neighborhoods than higher greenspace-higher income neighborhoods (odds ratio = 1.73; 95% confidence interval = 1.19-2.51).

DISCUSSION

The combination of lower neighborhood income and lower greenspace may be a risk factor for worsening white matter grade on MRI. However, findings need to be replicated in more diverse cohorts.

HIGHLIGHTS

Population-based cohort of older adults (≥ 65 years) with greenspace and MRI dataCombined measure of neighborhood greenspace and neighborhood income at initial MRIMRI outcomes included white matter hyperintensities (WMH) and ventricular sizeLongitudinal change in MRI outcomes measured approximately 5 years apartWorsening WMH over time more likely for lower greenspace-lower income neighborhoods.

Access to mechanical thrombectomy and ischemic stroke mortality in Japan: a spatial ecological study

Background

Advances in stroke treatment have greatly improved outcomes; however, disparities in access to treatment might increase. Achieving equitable access to stroke treatment is a health policy challenge, as rapid treatment is essential for positive outcomes. This ecological cross-sectional study aimed to determine the relationship between the disparities in spatial accessibility to mechanical thrombectomy (SAMT) and stroke mortality rates in Japan, hypothesizing that disparities in SAMT may increase the differences in stroke mortality between regions.

Methods

We used the average number of ischemic stroke (IS) deaths between 2020 and 2021 as the response variable; and SAMT, medical resources, and socioeconomic characteristics of each municipality as explanatory variables. A conditional autoregressive model was used to examine the association between the risk of stroke mortality and SAMT. The standardized mortality ratio (SMR) was mapped to understand the nationwide disparities in stroke mortality risk.

Results

The median number of IS deaths was 17.5 persons per year in the municipalities (2020 to 2021). The study also found that municipalities with low SAMT were located in the northern part of Japan. The non-spatial regression model results indicated that poor accessibility, a small proportion of bachelor's degrees or higher, and a high proportion of workers in secondary industries were related to high IS mortality. Three models were evaluated using spatial analysis; Model 1 with accessibility indicators alone, Model 2 with medical resources added to Model 1, and Model 3 with socioeconomic characteristics added to Model 2. In Models 1 and 2, the population-weighted spatial accessibility index (PWSAI) showed a significant negative relationship with stroke mortality. However, this was not evident in Model 3. Mapping using Model 3 showed that the high-risk areas were predominantly located in northern Japan, excluding Hokkaido.

Conclusion

Access to mechanical thrombectomy was estimated, and regional differences were observed. The relationship between accessibility and IS mortality is unknown; however, regardless of accessibility, municipalities with a high proportion of workers in secondary industries and a small proportion with bachelor's degrees or above are at risk of death from stroke.

Association between neighborhood socioeconomic status and mechanical thrombectomy for acute ischemic stroke: A nationwide multilevel observational study

OBJECTIVE

Acute ischemic stroke is a major health burden worldwide and mechanical thrombectomy is the treatment of choice for large-vessel occlusion stroke. This study aimed to evaluate the association between neighborhood socioeconomic status (SES) and the likelihood of receiving mechanical thrombectomy in patients with acute ischemic stroke.

METHODS

A nationwide cross-sectional study was conducted using the National Emergency Department Information System database. Patients who were diagnosed with ischemic stroke in the emergency department (ED) within 24 h of symptom onset between 2018 and 2021 were included. The neighborhood SES index was measured at the county level using property tax per capita, education level, and the proportions of single families and single-parent households. The study population was divided into quartiles based on the neighborhood SES index. The study outcome was mechanical thrombectomy. Multilevel multivariable logistic regression was performed. An interaction analysis between mental status at the ED triage and neighborhood SES was also performed.

RESULTS

Among the 196,007 patients, 8968 (4.6%) underwent mechanical thrombectomy. Compared with the affluent group, the deprived-middle and deprived groups were less likely to receive mechanical thrombectomy; the adjusted ORs (95% CIs) were 1.00 (0.92-1.09), 0.82 (0.74-0.91), and 0.82 (0.72-0.93) for the affluent-middle, deprived-middle, and deprived groups, respectively. Altered mental status at the ED triage strengthened the association between neighborhood SES and the likelihood of receiving mechanical thrombectomy (adjusted ORs [95% CIs] 0.85 [0.81-0.89] for the affluent-middle to deprived-middle group and 0.66 [0.65-0.66] for deprived groups, p-value for interaction < 0.05).

CONCLUSIONS

For patients diagnosed with acute ischemic stroke at the ED, low neighborhood SES is associated with low odds of receiving mechanical thrombectomy. Public health strategies should be developed to resolve these disparities and to decrease the health care burden of acute ischemic stroke.

Stroke in women between 2006 and 2018: Demographic, socioeconomic, and age disparities

BACKGROUND

Black Americans have a higher prevalence of stroke and stroke-related deaths than any other racial group. Racial disparities in stroke outcomes are even wider among women than men. Conventional studies have cited differences in lifestyle (i.e. smoking, alcohol consumption, etc.) and vascular risk factors between races as the source of these disparities. However, these studies fail to account for the higher prevalence of minoritized populations at the lower end of the socioeconomic distribution.

OBJECTIVES

This study explores differences in stroke risk factors across age and socioeconomic cohorts to determine whether comorbidities can sufficiently explain disparities at all ages and income levels.

DESIGN

Using the 2006-2018 National Health Interview Survey data, statistical analysis evaluated differences in risk factors among a full sample cohort (aged 18-85 years; n = 131,091) and a "young" subsample cohort (aged 18-59 years; n = 6183) of women.

METHODS

Logistics and unconditional quantile regression models assessed the relationship between stroke and comorbid, demographic, and behavioral characteristics across socioeconomic classes.

RESULTS

Results suggest that Black women had a 1.415-fold (confidence interval = 1.259, 1.591) higher likelihood of stroke compared with White women after controlling for age, behavior, and comorbidities. Racial disparities were not statistically significant at the higher income ranges for either the full (odds ratio = 1.404, p = 0.3114) or young samples (odds ratio = 1.576, p = 0.7718). However, Blacks had significantly higher odds of stroke in the lower quartiles (lower odds ratio: 1.329, p = 0.0242; lower middle odds ratio: 1.233, p = 0.0486; and upper middle odds ratio: 1.994, p = 0.0005). Disparities were larger among young women (odds ratio = 1.449, confidence interval = 1.211, 1.734).

CONCLUSION

While comorbidities were highly associated with stroke prevalence in all socioeconomic cohorts, Blacks only had higher relative odds in the lower income classes. Lack of biological or behavioral explanations for these findings suggests that unobserved or uncontrolled factors such as systemic racism, prejudicial institutions, or differential treatment may contribute to this.

Spatial-temporal analysis of cerebral infarction mortality in Hokkaido, Japan: an ecological study using a conditional autoregressive model

BACKGROUND

Accessibility to stroke treatments is a challenge that depends on the place of residence. However, recent advances in medical technology have improved health outcomes. Nevertheless, the geographic heterogeneity of medical resources may increase regional disparities. Therefore, evaluating spatial and temporal influences of the medical system on regional outcomes and advanced treatment of cerebral infarction are important from a health policy perspective. This spatial and temporal study aims to identify factors associated with mortality and to clarify regional disparities in cerebral infarction mortality at municipality level.

METHODS

This ecological study used public data between 2010 and 2020 from municipalities in Hokkaido, Japan. We applied spatial and temporal condition autoregression analysis in a Bayesian setting, with inference based on the Markov chain Monte Carlo simulation. The response variable was the number of deaths due to cerebral infarction (ICD-10 code: I63). The explanatory variables were healthcare accessibility and socioeconomic status.

RESULTS

The large number of emergency hospitals per 10,000 people (relative risk (RR) = 0.906, credible interval (Cr) = 0.861 to 0.954) was associated with low mortality. On the other hand, the large number of general hospitals per 10,000 people (RR = 1.123, Cr = 1.068 to 1.178) and longer distance to primary stroke centers (RR = 1.064, Cr = 1.014 to 1.110) were associated with high mortality. The standardized mortality ratio decreased from 2010 to 2020 in Hokkaido by approximately 44%. Regional disparity in mortality remained at the same level from 2010 to 2015, after which it narrowed by approximately 5% to 2020. After mapping, we identified municipalities with high mortality rates that emerged in Hokkaido's central and northeastern parts.

CONCLUSION

Cerebral infarction mortality rates and the disparity in Hokkaido improved during the study period (2010-2020). This study emphasized that healthcare accessibility through places such as emergency hospitals and primary stroke centers was important in determining cerebral infarction mortality at the municipality level. In addition, this study identified municipalities with high mortality rates that require healthcare policy changes. The impact of socioeconomic factors on stroke is a global challenge, and improving access to healthcare may reduce disparities in outcomes.

Risk Factors and Distribution Characteristics of Intracranial and Intracranial Artery Stenosis in Young Sufferers with Ischemic Stroke

In order to explore the risk factors of intracranial and intracranial arterial stenosis, the distribution of young ischemic stroke sufferers with intracranial and intracranial arterial stenosis and the related are analyzed. In this study, a total of 213 young sufferers with ischemic stroke (IS) admitted to our hospital from February 2019 to September 2021 are selected. According to the CT diagnosis of intracranial artery stenosis (AS), 213 patients are divided into two groups, with 86 in the AS Group and 127 in the non-AS Group. To analyze the distribution of intracranial and intracranial AS in young patients with ischemic stroke, 86 patients with AS are examined by carotid B-mode ultrasound. Furthermore, a univariate analysis is performed on the relevant indicators of the sufferers in the cancer (CA) set and the two sets without CA, and then, the indicators with statistically extensive disparity were selected for multivariate logistic regression analysis of the risk factors for CA symptoms. The results show 50% of the sufferers with moderate or severe ischemic CA in young adults and 63.95% of the sufferers with intracranial artery stenosis. It is clearly evident that the main risk factors affecting the occurrence of intracranial and intracranial arteries in young IS are hypertension and long-term smoking, long-term drinking, and hyperlipidemia.

Frequency of missed or delayed diagnosis in dementia is associated with neighborhood socioeconomic status

Introduction

Underdetection of dementia in areas with low socioeconomic status (SES) may interfere with findings concerning associations between SES and dementia.

Methods

Using administrative registers we assessed the associations between age‐ and sex‐adjusted dementia incidence and neighborhood socioeconomic status (nSES) in 94 Danish municipalities. Wealth was divided into income quartiles and other nSES variables were dichotomized into high versus low according to the median.

Results

High population density (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.18–1.24), higher proportion of inhabitants in higher income quartiles (P for trend < .0001), and high educational level (OR 1.19, 95% CI 1.15–1.22) were associated with higher incidence of dementia. High proportion of residents above 65 years was associated with lower age‐adjusted dementia incidence (OR 0.86, 95% CI 0.84–0.89).

Discussion

Low nSES municipalities have a lower age‐adjusted incidence of dementia diagnosis. These findings corroborate prior concerns that a large number of dementia diagnoses may be missed in municipalities characterized by low SES.

Matching participant address with public records database in a US national longitudinal cohort study

Background

Epidemiological studies utilize residential histories to assess environmental exposure risk. The validity from using commercially-sourced residential histories within national longitudinal studies remains unclear. Our study assessed predictors of non-agreement between baseline addresses from the commercially-sourced LexisNexis database and participants in the national longitudinal study, REasons for Geographic and Racial Differences in Stroke (REGARDS). Additionally, we assessed differences in stroke risk by neighborhood socioeconomic score (nSES) based on participant reported address compared to nSES from LexisNexis/REGARDS matched baseline address.

Methods

From January 2003–October 2007, REGARDS enrolled 30,239 black and white adults aged 45 and older within the continental United States and collected their baseline address. ArcGIS Desktop 10.5.1 with ESRI 2016 Business Analyst Data was used to geocode baseline addresses from LexisNexis and REGARDS. Logistic regression was used to estimate the likelihood that LexisNexis address matched REGARDS baseline address for each participant. Survival analysis was used to estimate association between nSES and incident stroke.

Results

Approximately 91% of REGARDS participants had a LexisNexis address. Of these geocoded addresses, 93% of REGARDS baseline addresses matched LexisNexis addresses. Odds of agreement between LexisNexis and REGARDS was higher for older-aged participants (OR = 1.02 per year, 95% CI: 1.01, 1.02), blacks compared to whites (OR = 1.16, 95% CI: 1.05, 1.29), females compared to males (OR = 1.15, 95% CI: 1.04, 1.26), participants with an income of $34k-74k compared to an income less than $20k (OR = 1.62, 95% CI: 1.39, 1.89). Odds of agreement were lower for residents in Midwest compared to residents in the south (OR = 0.82, 95% CI: 0.73, 0.94). No significant differences in nSES-stroke associations were observed between REGARDS only and LexisNexis/REGARDS matched addresses; however, differences in interactions were observed.

Conclusion

Agreement between LexisNexis and REGARDS addresses varied by sociodemographic groups, potentially introducing bias in studies reliant on LexisNexis alone for residential address data.

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Approximately 9% of REGARDS participants did not have a LexisNexis address history available.

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Of participants with both REGARDS and LexisNexis addresses available, 93% of these addresses matched.

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Agreement between REGARDS and LexisNexis address varied by socio-demographics—potentially biasing environmental exposures.

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Compared to LexisNexis, REGARDS addresses may be valuable in detecting interactions contributing to stroke disparities.