Association of Neighborhood Socioeconomic Status With Outcomes in Patients Surviving 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.

Socioeconomic Status and Stroke: A Review of the Latest Evidence on Inequalities and Their Drivers

The latest research on socioeconomic status (SES) and stroke continues to demonstrate that individuals with low SES are at a higher risk of stroke, receive lower-quality care, and experience poorer outcomes. Despite growing evidence on the impact of SES on stroke, gaps remain in understanding the underlying mechanisms and the influence of SES in different contexts, particularly in low- and middle-income countries. This narrative review builds upon our previous reviews from 2006 to 2015, focusing on studies published since 2015 to update on the influence of SES on stroke. Reports from nationwide or population-based observational studies in the past decade have confirmed that these inequalities persist globally and have provided new evidence on their mechanisms. In high-income countries, inadequate control of cardiovascular risk factors (hypertension, diabetes, obesity, and dyslipidemia) among lower socioeconomic groups has been found to explain much of the inequality in stroke risk. Exposure to particulate air pollution (both environmental and indoor from solid fuel cooking) synergizes with cardiovascular risk factors, especially hypertension, as major causes in low- and middle-income countries. Lower SES is persistently associated with disparities in care and increased poststroke disability and mortality. Lower SES also exacerbates other causes of health inequality among women, ethnic minorities, and migrants. Addressing stroke inequalities requires an interdisciplinary approach. Targeting cardiovascular risk factors, providing equitable quality of acute and rehabilitative stroke care, enacting legislative measures, and implementing societal changes remain leading global priorities.

The TBI Model Systems Neighborhood Socioeconomic Disadvantage Index (TBIMS-NSDI): Development and Comparison to Individual Socioeconomic Characteristics

OBJECTIVE

To create a census-based composite neighborhood socioeconomic deprivation index (NSDI) from geocoded residential addresses and to quantify how NSDI aligns with individual-level socioeconomic factors among people with traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

People enrolled in the TBI Model Systems National Database (TBIMS NDB).

DESIGN

Secondary analysis of a longitudinal cohort study.

MAIN MEASURES

The TBIMS-NSDI was calculated at the census tract level for the United States population based on a principal components analysis of eight census tract-level variables from the American Community Survey. Individual socioeconomic characteristics from the TBIMS NDB were personal household income, education (years), and unemployment status. Neighborhood:Individual NSDI residuals represent the difference between predicted neighborhood disadvantage based on individual socioeconomic characteristics versus observed neighborhood disadvantage based on the TBIMS-NSDI .

RESULTS

A single principal component was found to encompass the eight socioeconomic neighborhood-level variables. It was normally distributed across follow-up years 2, 5, and 10 post-injury in the TBIMS NDB. In all years, the TBIMS-NDSI was significantly associated with individual-level measures of household income and education but not unemployment status. Males, persons of Black and Hispanic background, Medicaid recipients, persons with TBI caused by violence, and those living in urban areas, as well as in the Northeast or Southern regions of the United States, were more likely to have greater neighborhood disadvantage than predicted based on their individual socioeconomic characteristics.

CONCLUSIONS

The TBIMS-NSDI provides a neighborhood-level indicator of socioeconomic disadvantage, an important social determinant of outcomes from TBI. The Neighborhood:Individual NSDI residual adds another dimension to the TBIMS-NSDI by summarizing how a person's socioeconomic status aligns with their neighborhood socioeconomics. Future studies should evaluate how both measures affect TBI recovery and life quality. Research studying neighborhood socioeconomic disadvantage may improve our understanding of how systemic adversity influences outcomes after TBI.

The association between neighborhood social vulnerability and community-based rehabilitation after stroke

BACKGROUND

Timely rehabilitative care is vital for functional recovery after stroke. Social determinants may influence access to and use of post-stroke care but have been inadequately explored. The study examined the relationship between the Social Vulnerability Index (SVI) and community-based rehabilitation utilization.

METHODS

We included 6,843 adults (51.6% female; 75.1% White; mean age 70.1) discharged home after a stroke enrolled in the COMprehensive Post-Acute Stroke Services study, a pragmatic trial conducted in 40 North Carolina hospitals from 2016-2019. Rehabilitation utilization was sourced from administrative claims. Geocoded addresses were linked to 2018 Census tract SVI. Associations between SVI and 90-day rehabilitation use, adjusted for patient's clinical and socio-economic characteristics, were obtained from generalized estimating equations. We also examined the associations of SVI with therapy setting, types of therapy, intensity of visits, and time to first visit.

RESULTS

Thirty-five percent of patients had at least one physical (PT) or occupational therapy (OT) visit within 90 days, ranging from 32.4%-38.7% across SVI quintiles. In adjusted analysis, there was no dose-reponse relationship between higher summary SVI, nor most of its sub-domains, and 90-day rehabilitation use. Greater vulnerability in household composition and disability was modestly associated with -0.4% (95% CI -4.1% to 3.4%) to -4.3% (95% CI -0.8% to -7.7%) lower rehabilitation use across SVI quartiles. Greater summary and subdomain SVI was associated with higher odds of receiving therapy in the home versus outpatient clinic (OR = 1.88, 1.58 to 2.17 for Q5 vs Q1 summary SVI) and receiving both PT and OT versus a single-type therapy (1.72, 1.48 to 1.97 for Q5 vs. Q1 summary SVI). No differences were observed for therapy intensity or time to therapy.

CONCLUSION

Use of rehabilitation care was low, and largely similar across levels of SVI and most of its subdomains. Individuals residing in areas of high SVI were more likely to receive therapy in the home and to receive dual therapy, possibly reflecting greater need among these individuals. Future studies should evaluate potential mechanisms for these findings and further identify both patient and community factors that may inform strategies to improve rehabilitation use.

CLINICAL TRIAL NUMBER

https://www.

CLINICALTRIALS

gov/ NCT02588664 [registration date: 2015-10-23].

The association between social networks and functional recovery after stroke

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Disparities in Emergency Medical Services Use, Prehospital Notification, and Symptom Onset to Arrival in Patients With Acute Stroke

BACKGROUND

Disparities in time to hospital presentation and prehospital stroke care may be important drivers in inequities in acute stroke treatment rates, functional outcomes, and mortality. It is unknown how patient-level factors, such as race and ethnicity and county-level socioeconomic status, affect these aspects of prehospital stroke care.

METHODS

Cross-sectional study of patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage in the Get With the Guidelines-Stroke registry, presenting from July 2015 to December 2019, with symptom onset ≤24 hours. Multivariable logistic regression and quantile regression were used to investigate the outcomes of interest: emergency medical services (EMS) transport (versus private vehicle), EMS prehospital notification (versus no prehospital notification), and stroke symptom onset to time of arrival at the emergency department. Prespecified covariates included patient-level, hospital-level, and county-level characteristics.

RESULTS

The inclusion criteria was met by the 606 369 patients. Of the patients, 51.2% were men and 69.9% White, with a median National Institutes of Health Stroke Severity of 4 (IQR, 2-10), and median social deprivation index (SDI) of 51 (IQR, 27-75). Median symptom onset to arrival time was 176 minutes (IQR, 64-565). Black race was significantly associated with prolonged symptom onset to emergency department arrival time (+28.21 minutes [95% CI, 25.59-30.84]), and decreased odds of EMS prehospital notification (OR, 0.80 [95% CI, 0.78-0.82]). SDI was not associated with differences in EMS use but was associated with lower odds of EMS prehospital notification (upper SDI tercile versus lowest, OR, 0.79 [95% CI, 0.78-0.81]). SDI was also significantly associated with stroke symptom onset to emergency department arrival time (upper SDI tercile versus lowest +2.56 minutes [95% CI, 0.58-4.53]).

CONCLUSIONS

In this national cross-sectional study, Black race was associated with prolonged symptom onset to time of arrival intervals and significantly decreased odds of EMS prehospital notification, despite similar use of EMS transport. Greater county-level deprivation was also associated with reduced odds of EMS prehospital notification and slightly prolonged stroke symptom onset to emergency department arrival time. Efforts to reduce place-based disparities in stroke care must address significant inequities in prehospital care of acute stroke and continue to address health inequities associated with race and ethnicity.

Predicting functional outcome in ischemic stroke patients using genetic, environmental, and clinical factors: a machine learning analysis of population-based prospective cohort study

Ischemic stroke (IS) is a leading cause of adult disability that can severely compromise the quality of life for patients. Accurately predicting the IS functional outcome is crucial for precise risk stratification and effective therapeutic interventions. We developed a predictive model integrating genetic, environmental, and clinical factors using data from 7819 IS patients in the Third China National Stroke Registry. Employing an 80:20 split, we randomly divided the dataset into development and internal validation cohorts. The discrimination and calibration performance of models were evaluated using the area under the receiver operating characteristic curves (AUC) for discrimination and Brier score with calibration curve in the internal validation cohort. We conducted genome-wide association studies (GWAS) in the development cohort, identifying rs11109607 (ANKS1B) as the most significant variant associated with IS functional outcome. We employed principal component analysis to reduce dimensionality on the top 100 significant variants identified by the GWAS, incorporating them as genetic factors in the predictive model. We employed a machine learning algorithm capable of identifying nonlinear relationships to establish predictive models for IS patient functional outcome. The optimal model was the XGBoost model, which outperformed the logistic regression model (AUC 0.818 versus 0.756, P < .05) and significantly improved reclassification efficiency. Our study innovatively incorporated genetic, environmental, and clinical factors for predicting the IS functional outcome in East Asian populations, thereby offering novel insights into IS functional outcome.

Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors

BACKGROUND

Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation.

OBJECTIVES

The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations.

METHODS

We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations.

RESULTS

Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors.

CONCLUSIONS

These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care.

Stroke but no hospital admission: Lost opportunity for whom?

To counter the spread of COVID-19, the French government imposed several stringent social and political measures across its entire population. We hereto assess the impact of these political decisions on healthcare access in 2020, focusing on patients who suffered from an ischemic stroke. We divide our analysis into four distinct periods: the pre-COVID-19 pandemic period, the lockdown period, the "in-between" or transitional period, and the shutdown period. Our methodology involves utilizing a retrospective dataset spanning 2019-2020, an exhaustive French national hospital discharge diagnosis database for stroke inpatients, integrated with income information from the reference year of 2019. The results reveal that the most affluent were more likely to forgo medical care, particularly in heavily affected areas. Moreover, the most disadvantaged exhibited even greater reluctance to seek care, especially in the most severely impacted regions. The data suggest a loss of opportunity for less severely affected patients to benefit from healthcares during this lockdown period, regardless of demographic, location, and socioeconomic determinants. Furthermore, our analysis reveals a notable discrepancy in healthcare-seeking behavior, with less affluent patients and seniors (over 75 years old) experiencing slower rates of return to healthcare access compared to pre-pandemic levels. This highlights a persistent gap in healthcare accessibility, particularly among socioeconomically disadvantaged groups, despite the easing of COVID-19 restrictions.

Neighborhood Resources and Health Outcomes Among Stroke Survivors in a Population-Based Cohort

BACKGROUND

Stroke survivors believe neighborhood resources such as community centers are beneficial; however, little is known about the influence of these resources on stroke outcomes. We evaluated whether residing in neighborhoods with greater resource density is associated with favorable post-stroke outcomes.

METHODS AND RESULTS

We included Mexican American and non-Hispanic White stroke survivors from the Brain Attack Surveillance in Corpus Christi project (2009-2019). The exposure was density of neighborhood resources (eg, community centers, restaurants, stores) within a residential census tract at stroke onset. Outcomes included time to death and recurrence, and at 3 months following stroke: disability (activities of daily living/instrumental activities of daily living), cognition (Modified Mini-Mental State Exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life scale). We fit multivariable Cox regression and mixed linear models. We considered interactions with stroke severity, ethnicity, and sex. Among 1786 stroke survivors, median age was 64 years (interquartile range, 56-73), 55% men, and 62% Mexican American. Resource density was not associated with death, recurrence, or depression. Greater resource density (75th versus 25th percentile) was associated with more favorable cognition (Modified Mini-Mental State Exam mean difference=0.838, 95% CI=0.092, 1.584) and among moderate-severe stroke survivors, with more favorable functioning (activities of daily living/instrumental activities of daily living=-0.156 [95% CI, -0.284 to 0.027]) and quality of life (abbreviated Stroke-Specific Quality of Life scale=0.194 [95% CI, 0.029-0.359]).

CONCLUSIONS

We observed associations between greater resource density and cognition overall and with functioning and quality of life among moderate-severe stroke survivors. Further research is needed to confirm these findings and determine if neighborhood resources may be a tool for recovery.

Person and Environment Factors Supporting Self-Care Performance and Social Participation After Mild Stroke

Mild stroke survivors seldom receive occupational therapy services as their deficits are assumed to be minor enough to not affect their daily occupations. Yet many mild stroke survivors report deficits in self-care performance and social participation. This study investigates person and environment factors influencing self-care performance and social participation among mild stroke survivors, using the Person-Environment-Occupation-Performance (PEOP) model. A retrospective cohort analysis of 736 mild stroke survivors was conducted using electronic health records. Person factors included demographic characteristics and clinical characteristics, and environment factors included the Social Vulnerability Index. The analysis included logistic regression. Approximately, 10% of patients reported deficits in self-care or social participation. Disability level was the only person factor associated with self-care performance. Person factors affecting social participation included mobility and unemployment. Socioeconomic status was associated with both occupation measures. Occupational therapy practitioners must address the person and environment factors affecting mild stroke survivors' self-care performance and social participation.

Social Disconnectedness, Perceived Loneliness, and Cognitive Functioning: The Role of Neighborhood Environment

Background and Objectives

Social disconnectedness and loneliness pose significant challenges for older Chinese immigrants. Yet, it remains unclear whether they are associated with an increased risk of cognitive decline in this population. This study aimed to investigate the association of social disconnectedness and loneliness with cognitive functioning and examine the moderation role of neighborhood contexts.

Research Design and Methods

This longitudinal analysis examined a sample of individuals aged 60 years and older from the Population Study of Chinese Elderly in Chicago (N = 2,044). Global cognition was assessed using the averaged z-scores of cognitive performance tests. Social disconnectedness was constructed using 5 indicators about structural aspects of social relationships. Loneliness was assessed with the R-UCLA loneliness scale. Neighborhood socioeconomic status (NSES) and neighborhood segregation index were constructed using 2010-2014 American Community Survey data at the census tract level. Individual perceptions about neighborhood environments were used to construct neighborhood cohesion index and neighborhood disorder index (NDI). Latent growth curve models with adjusted cluster robust standard errors were estimated.

Results

More loneliness was associated with a higher level of initial cognitive functioning (B = 0.030, p < .01), but also with a faster decline rate over time (B = -0.007, p < .01) after adjusting for covariates. High NSES and less neighborhood segregation buffered the negative effects of loneliness on cognitive decline, respectively. High NDI amplified the positive relationship between loneliness and initial functioning, but accelerated the rate of cognitive decline associated with loneliness.

Discussion and Implications

The study revealed that perceived loneliness, but not social disconnectedness, is a risk factor for cognitive decline among older Chinese immigrants. Living in a neighborhood with low socioeconomic status, more segregation, and high disorder elevated the detrimental effect of loneliness on long-term cognitive decline. Further research needs to investigate the complex interplay between social relationships, neighborhood environment, and cognition.

DeepBiomarker2: Prediction of Alcohol and Substance Use Disorder Risk in Post-Traumatic Stress Disorder Patients Using Electronic Medical Records and Multiple Social Determinants of Health

Prediction of high-risk events amongst patients with mental disorders is critical for personalized interventions. We developed DeepBiomarker2 by leveraging deep learning and natural language processing to analyze lab tests, medication use, diagnosis, social determinants of health (SDoH) parameters, and psychotherapy for outcome prediction. To increase the model's interpretability, we further refined our contribution analysis to identify key features by scaling with a factor from a reference feature. We applied DeepBiomarker2 to analyze the EMR data of 38,807 patients from the University of Pittsburgh Medical Center diagnosed with post-traumatic stress disorder (PTSD) to determine their risk of developing alcohol and substance use disorder (ASUD). DeepBiomarker2 predicted whether a PTSD patient would have a diagnosis of ASUD within the following 3 months with an average c-statistic (receiver operating characteristic AUC) of 0.93 and average F1 score, precision, and recall of 0.880, 0.895, and 0.866 in the test sets, respectively. Our study found that the medications clindamycin, enalapril, penicillin, valacyclovir, Xarelto/rivaroxaban, moxifloxacin, and atropine and the SDoH parameters access to psychotherapy, living in zip codes with a high normalized vegetative index, Gini index, and low-income segregation may have potential to reduce the risk of ASUDs in PTSD. In conclusion, the integration of SDoH information, coupled with the refined feature contribution analysis, empowers DeepBiomarker2 to accurately predict ASUD risk. Moreover, the model can further identify potential indicators of increased risk along with medications with beneficial effects.

Retrospective analysis of acute ischemic stroke shows timing of antidepressant use associated with short-term recovery and functional independence at 90-days

BACKGROUND

Little is known about how the timing of antidepressant use influences stroke outcomes. Previous research shows conflicting results on the impact of a new antidepressant prescription on stroke recovery.

OBJECTIVE

The objective of this exploratory, retrospective analysis is to examine stroke outcomes by timing of antidepressant use among patients who received stroke treatment.

METHODS

12,590 eligible patients were treated for a primary or secondary diagnosis of ischemic stroke. The outcome variables were a change in ambulation or modified Rankin scale (mRs) from pre-stroke to discharge; and a change in mRS from pre-stroke to 90-days post-discharge. The independent variable of interest was timing of antidepressant treatment. Logistic regression with generalized estimating equations was used, controlling for covariates.

RESULTS

Our model predicted that a new antidepressant prescription at discharge was associated with a ∼7% decrease in the likelihood of returning to baseline functional independence at 90-days compared to patients currently using an antidepressant (AOR:0.510, CI:0.277-0.938, p = 0.03).

CONCLUSION

These results suggest that use of antidepressants was associated with stroke recovery, but the effects are moderated by sex. Further study is needed to determine if this relationship is causal and the mechanisms between timing of antidepressant treatment and outcomes.

Post-Stroke Brain Health Monitoring and Optimization: A Narrative Review

Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health following stroke thus warrants increased attention from clinicians and researchers alike. In this narrative review based on an open timeframe search of the PubMed, Scopus, and Web of Science databases, we define post-stroke brain health and appraise the body of research focused on modifiable vascular, lifestyle, and psychosocial factors for optimizing post-stroke brain health. In addition, we make clinical recommendations for the monitoring and management of post-stroke brain health at major post-stroke transition points centered on four key intertwined domains: cognition, psychosocial health, physical functioning, and global vascular health. Finally, we discuss potential future work in the field of post-stroke brain health, including the use of remote monitoring and interventions, neuromodulation, multi-morbidity interventions, enriched environments, and the need to address inequities in post-stroke brain health. As post-stroke brain health is a relatively new, rapidly evolving, and broad clinical and research field, this narrative review aims to identify and summarize the evidence base to help clinicians and researchers tailor their own approach to integrating post-stroke brain health into their practices.

Association of Neighborhood Recreation Centers and Poststroke Outcomes in a Population-Based Cohort

BACKGROUND

Higher neighborhood socioeconomic status has been favorably associated with stroke outcomes. This may be due to these areas having more beneficial resources such as recreational centers. We aimed to determine if neighborhood density of recreation centers is favorably associated with stroke outcomes.

METHODS

We conducted analyses of data from the Brain Attack Surveillance in Corpus Christi project, a cohort of stroke survivors ≥45 years of age residing in Nueces County, TX (2009-2020). We included non-Hispanic White and Mexican American incident stroke survivors, who were not institutionalized prestroke and completed baseline and follow-up assessments (N=1392). We calculated the density of fitness and recreational sports centers within their residential census tract during the year of their stroke. Outcomes included function (self-ratings on activities of daily living and instrumental activities of daily living), cognition (modified mini-mental state exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life Scale). We fit confounder-adjusted gamma-distributed mixed generalized linear models with a log link for each outcome and considered interaction with stroke severity.

RESULTS

On average, participants were 65 years old, 53% male, and 63% Mexican American. Median recreational centers were 1.60 per square mile (interquartile range, 0.41-3.06). Among moderate-severe stroke survivors, greater density of recreation centers (75th versus 25th percentile) was associated with more favorable function and possibly quality of life (activities of daily living/instrumental activities of daily living, 4.8% change [95% CI, -0.11% to -9.27%]; Stroke-Specific Quality of Life Scale, 3.7% change [95% CI, -0.7% to 8.2%]). Minimal nonsignificant differences were observed among the overall stroke population and those with mild stroke.

CONCLUSIONS

The availability of recreation centers may be beneficial for poststroke function and quality of life among those with moderate-severe stroke. If further research confirms recreation centers to be beneficial, this could inform rehabilitation following stroke.

Enhanced Street Crossing Features are Associated with Higher Post-Stroke Physical Quality of Life

BACKGROUND

Features of the physical environment may affect post-stroke recovery, but empirical evidence is limited. This study examines associations between features of the physical environment and post-stroke physical quality of life (PH-QOL).

METHODS

The study sample included stroke survivors enrolled in the Caring for Adults Recovering from the Effects of Stroke project, a prospective cohort. Features of the physical environment surrounding participants' home addresses were audited using Google Earth. Audits captured information about crossings (e.g. curb-cuts; range 0-4), street segments (e.g. sidewalks; range 0-17.5), and a route (e.g. parks; range 0-27) near participants' home. Summary scores were categorized into tertials representing "few," "some," and "many" pedestrian-friendly features. Post-stroke PH-QOL was measured by the SF-12 (range 0-100) around 6 to 12-, 18-, 27-, and 36-months post-stroke. Linear mixed models were used to estimate PH-QOL over time. Chained multiple imputation was used to account for missing data.

RESULTS

Two hundred and seventy-five participants were eligible, among whom 210 had complete data. Most participants lived in areas with "few" features to promote outdoor mobility. Participants living in environments with "some" crossing features had a 4.90 (95% CI: 2.32, 7.48) higher PH-QOL score across the observation period in comparison to participants living in environments with "few" crossing features. Features of the physical environment along street segments and routes were not associated with post-stroke PH-QOL.

CONCLUSION

Crossing features are associated with post-stroke PH-QOL. Modifying features of the physical environment at nearby crossings, such as curb-cuts, may be a promising strategy for increasing PH-QOL.

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.

Area-level and individual-level socio-economic differences in health-related quality of life trajectories: Results from a 10-year longitudinal stroke study

BACKGROUND

We examined area-level (aSES) and individual-level (iSES) socio-economic status on trajectories of HRQoL to 10 years following stroke.

METHODS

Participants with strokes between 1/5/1996 and 30/4/1999 completed the Assessment of Quality of Life instrument (AQoL, range: -0.04 [worse than death] to 0 [death] to 1 [full health]) at ≥one of 3month, 6-month, 1-year, 2-year, 3-year, 4-year, 5-year, 7-year and 10-year interviews after stroke. Sociodemographic and health information were collected at baseline. We derived aSES from postcode using the Australian Socio-Economic Indexes For Area (2006) (categories: high, medium, low), and iSES from lifetime occupation (categories: non-manual, manual). Multivariable linear mixed effects modelling was used to estimate trajectories of HRQoL over 10 years, by aSES and iSES, adjusting for age, sex, cardiovascular disease, smoking, diabetes, stroke severity, stroke type, and the time influence on age and health conditions.

RESULTS

Of 1,686 participants enrolled, we excluded 239 with 'possible' stroke and 284 with missing iSES. Among the remaining 1,163 participants, 1,123 (96.6%) had AQoL assessed at ≥3 timepoints. In multivariable analysis, over time, people in the medium aSES group had mean 0.02 (95% CI -0.06, 0.02) greater reduction in AQoL score, and people in the low aSES group had mean 0.04 (95% CI, -0.07, -0.001) greater reduction, than those in the high aSES group. Manual workers had an average 0.04 (95% CI, -0.07, -0.01) greater reduction in AQoL score over time than non-manual workers.

CONCLUSIONS

Over time, HRQoL declines in all people with stroke, declining most rapidly in lower SES groups.

Without Affordable, Accessible, and Adequate Housing, Health Has No Foundation

Policy Points Today's housing disparities are rooted in the increasing commodification of housing that has taken precedence over the need for shelter, a basic human right. With rising housing costs across the country, more residents are finding their monthly income going to rent, mortgage payments, property taxes, and utilities, leaving little for food and medication. Housing is a determinant of health, and with increasing housing disparities, action must be taken to ensure no individual is displaced, communities remain intact, and cities continue to thrive.

Neighborhood segregation, socioeconomic status, and cognitive function among older Chinese immigrants

BACKGROUND

The fast-growing population of older Chinese immigrants and their segregated residences highlight the importance of understanding the role of neighborhood context in cognitive health. The segregation-cognition association is equivocal based on a limited number of studies among Hispanic and Asian Americans. To close the knowledge gap, this study examined the associations of neighborhood segregation and socioeconomic status (NSES) with cognitive functioning among older Chinese immigrants.

METHODS

Four waves of cognitive performance tests were conducted in the Population Study of Chinese Elderly in Chicago (2011-2019) and linked to the 2010 to 2014 American Community Survey estimates of neighborhood contexts. NSES was a summary z-score of six census variables of education, income/wealth, and occupation. Neighborhood segregation was measured by the Index of Concentrations at the Extremes (ICE), which simultaneously assesses Chinese and English language use within a given census tract. There were 170 census tracts in the present sample of 2044 participants. Latent growth curve models with adjusted cluster robust standard errors were estimated.

RESULTS

On average, cognitive functioning declined over time (B = -0.07, p < 0.001). After adjusting for individual-level predictors, living in high-NSES neighborhoods was associated with slower cognitive decline (B = 0.003, p = 0.04). ICE was not associated with cognitive functioning, but boosted the protective effect of high NSES on cognitive decline (B = 0.006, p = 0.05).

CONCLUSIONS

Neighborhood socioeconomic advantage was related to slower cognitive decline among older Chinese immigrants, especially among those living in neighborhoods with more English speakers or less segregation. This finding suggests complex associations between neighborhood context and cognitive health among Chinese immigrants.

Racial and ethnic differences in sleep-disordered breathing and sleep duration among stroke patients

OBJECTIVE

We sought to characterize racial and ethnic differences in pre- and post-stroke sleep-disordered breathing (SDB) and pre-stroke sleep duration.

METHODS

Within the Brain Attack Surveillance in Corpus Christi cohort of patients with ischemic stroke (8/26/2010-1/31/2020), pre-stroke SDB risk was assessed retrospectively using the Berlin Questionnaire. Post-stroke SDB was defined by prospective collection of the respiratory event index (REI) using the ApneaLink Plus performed shortly after stroke. Pre-stroke sleep duration was self-reported. We used separate regression models to evaluate the association between race/ethnicity and each outcome (pre-stroke SDB, post-stroke SDB, and pre-stroke sleep duration), without and with adjustment for potential confounders.

RESULTS

There was no difference in pre-stroke risk of SDB between Black and non-Hispanic white (NHW) participants (odds ratio (OR) 1.07, 95% CI 0.77-1.49), whereas MA (Mexican American), compared to NHW, participants had a higher risk of SDB before adjusting for demographic and clinical variables (OR 1.26, 95% CI 1.08-1.47). Post-stroke SDB risk was higher in MA (estimate 1.16, 95% CI 1.06-1.28) but lower in Black (estimate 0.79, 95% CI 0.65-0.96) compared to NHW participants; although, only the ethnic difference remained after adjustment. MA and Black participants had shorter sleep duration than NHW participants (OR 0.83, 95% CI 0.72-0.96 for MA; OR 0.67, 95% CI 0.49-0.91 for Black participants) before but not after adjustment.

CONCLUSIONS

Racial/ethnic differences appear likely to exist in pre- and post-stroke SDB and pre-stroke sleep duration. Such differences might contribute to racial/ethnic disparities in stroke incidence and outcomes.

"Well in in this neighborhood I have walked, not at all": Stroke survivors lived experience in the outdoor environment

Stroke survivors face unique challenges in the outdoor environment when returning to their home community following a stroke. Challenges include navigating uneven terrain, social stigma, and adapting to changes in functioning. Outdoor environments may serve as potential points of intervention to promote independence and participation post stroke. This study aimed to understand lived post-stroke experience in the outdoor environment as it pertains to independent mobility.

METHODS

Qualitative semi-structured interviews were conducted with 20 stroke survivors (8 males, 12 females; mean age 64.2 years: range 45 years-90 years). Participants were eligible if they were over the age of 45, could communicate in English, lived outside a nursing home, able to walk safely outdoors, were a minimum of six-months post stroke, and had no severe cognitive impairment. Interviews with participants were tape recorded, audio files were transcribed verbatim, codes were created and applied to transcripts, and themes were generated using interpretative phenomenological analysis.

RESULTS

Post-stroke experiences in the outdoor environment were multidimensional. Three themes emerged from the stroke survivors' description of personal experiences in the outdoor environment. These themes included feelings of vigilance, employing adaptation strategies, and management of dynamic relations between the self and context.

DISCUSSION

The findings highlight the post-stroke experience traversing the outdoor environment. Investing in the public outdoor environment to remove barriers and install facilitators could reduce feelings of apprehension and hypervigilance while walking in the outdoor environment. Future research is needed to evaluate the role of environmental interventions on hypervigilance in the outdoor environment post stroke.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity

Importance

Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes.

Objective

To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke.

Design, Setting, and Participants

This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022.

Exposures

Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other.

Main Outcomes and Measures

Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke.

Results

Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke.

Conclusions and Relevance

In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.

Difference in rural and urban Medicare prescription pattern for Parkinson’s disease in Hawai‘i

Background

Medical management of Parkinson’s Disease (PD) is becoming complex. Increasing evidence suggests that patients have better outcomes when they are managed by neurologists. However, access to neurologists can be limited in rural areas. Analysis of prescription pattern can provide insight into access gap rural patients face.

Methods

This retrospective observational study used National Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from 2013 to 2018. Query was made for levodopa, dopamine agonists and other antiparkinsonian medications. The data elements obtained included drug name, number of prescribers, prescriber specialty, number of claims, number of standardized 30-day Part D prescriptions, and number of Medicare beneficiaries in the state of Hawai‘i. Individual prescribing providers were categorized as urban or rural based on their cities of practice. Prescription patterns of urban and rural providers in Hawai‘i as well as difference in provider specialty were compared, using standardized 30-day prescriptions as the primary measure of utilization.

Results

Practice patterns differed between rural and urban areas. In rural Hawai‘i, Rytary, Rotigoitne and selegiline were rarely prescribed. Levodopa percentage was higher in urban Hawai‘i. In urban Hawai‘i, 74.4% of the prescriptions were provided by movement disorders and general neurologists. In rural Hawai'i, 25.1% of the prescriptions were written by neurologists and 74.9% by general practitioners.

Conclusions

In the state of Hawai‘i, there is an urban–rural access gap to neurologists as evidenced by Medicare prescription pattern. Further study is needed to understand the reasons for rural–urban differences in prescription patterns and their impact on outcomes.

Social Determinants of Health in Neurology

Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.

Functional Limitations and Perceived Neighborhood Walkability Among Urban Dwelling Older Adults

Older adults with functional limitations (FLs) often experience obstacles to walking. Although health promotion programs targeting physical activity are available in lower-income areas, few studies have compared the walking experiences of older adults who have FLs with those who do not in the community. The purpose of this cross-sectional survey was to compare perceptions of neighborhood walkability among older adults living in lower-income communities with and without FLs. Participants (N = 132) were recruited in 2018 at regional health clinics in Flint, Michigan. To be eligible, participants had to be 65 years of age or older, report no cognitive decline, and be Flint residents. Of the 132 participants, the mean age was 69.74 (SD = 4.97). The majority were female (66%); African American (77%); single, divorced, or widowed (72%); educated below the General Education Development level (57%), and had a FL (67%). Older adults with FLs were significantly (p < 0.05) less likely than those without to visit many places within walking distance, to have well-lit neighborhoods at night, and to reside in neighborhoods where sidewalks were separated from the road and traffic. Multiple regression analyses revealed that having a FL was associated with poorer neighborhood perceptions of mixed-land-use (b = −0.19, p < 0.05) and more walking hazards (b = −0.26, p < 0.05). Findings suggest that a FL is associated with perceptions of walkability. It is essential to develop disability-friendly support systems and accommodations to encourage walking in lower-income communities.