Socioeconomic differences in one-year survival after ischemic stroke: the effect of acute and post-acute care-pathways in a cohort study

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Abstract

Background

The reasons for socioeconomic inequity in stroke mortality are not well understood. The aim of this study was to explore the role of ischemic stroke care-pathways on the association between education level and one-year survival after hospital admission.

Methods

Hospitalizations for ischemic stroke during 2011/12 were selected from Lazio health data. Patients’ clinical history was defined by retrieving previous hospitalizations and drugs prescriptions. The association between education level and mortality after stroke was studied for acute and post-acute phases using multilevel logistic models (Odds Ratio (OR)). Different scenarios of quality care-pathways were identified considering hospital performance, access to rehabilitation and drug treatment post-discharge. The probability to survive to acute and post-acute phases according to education level and care-pathway scenarios was estimated for a “mean-severity” patient. One-year survival probability was calculated as the product of two probabilities. For each scenario, the 1-year survival probability ratio, university versus elementary education, and its Bootstrap Confidence Intervals (95 % BCI) were calculated.

Results

We identified 9,958 patients with ischemic stroke, 53.3 % with elementary education level and 3.2 % with university. The mortality was 14.9 % in acute phase and 14.3 % in post-acute phase among survived to the acute phase. The adjusted mortality in acute and post-acute phases decreased with an increase in educational level (OR = 0.90 p-trend < 0.001; OR = 0.85 p-trend < 0.001). For the best care-pathway, the one-year survival probability ratio was 1.06 (95 % BCI = 1.03–1.10), while it was 1.17 (95 % BCI = 1.09–1.25) for the worst.

Conclusions

Education level was inversely associated with mortality both in acute and post-acute phases. The care-pathway reduces but does not eliminate 1-year survival inequity.

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Most cited references 26

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Hospital volume and stroke outcome: does it matter?

, A Baibergenova, Moira Kapral … (2007)

Although hospital-outcome relationships have been explored for a variety of procedures and interventions, little is known about the association between annual stroke admission volumes and stroke mortality. Our aim was to determine whether facility type and hospital volume was associated with stroke mortality. All hospital admissions for ischemic stroke were identified from the Hospital Morbidity database (HMDB) from April 2003 to March 2004. The HMDB is a national database that contains patient-level sociodemographic, diagnostic, procedural, and administrative information across Canada. Ischemic stroke was identified through patient's principal diagnosis recorded using the International Classification of Diseases (9 and 10). Multivariable analysis was performed with generalized estimating equations with adjustment for demographic characteristics, provider specialty, facility type, hospital volume, and clustering of observations at institutions. Overall, 26,676 patients with ischemic stroke were admitted to 606 hospitals. Seven-day stroke mortality was 7.6% and mortality at discharge was 15.6%. Adverse outcomes were more frequent in patients treated in low-volume facilities ( 200 strokes patients/year) (for 7-day mortality: 9.5 vs 7.3%, p < 0.001; 9.5 vs 6.0%, p < 0.001; for discharge mortality: 18.2 vs 15.2%, p < 0.001; 18.2 vs 12.8%, p < 0.001). The difference persisted after multivariable adjustment or when hospital volume was divided into quartiles. High annual hospital volume was consistently associated with lower stroke mortality. Our study encourages further research to determine whether this is due to differences in case mix, more organized care in high-volume facilities, or differences in the performance or in the processes of care among facilities.

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The socioeconomic gradient in the incidence of stroke: a prospective study in middle-aged women in Sweden.

Hannah Kuper, Hans-Olov Adami, Hans-Olov Adami … (2007)

A socioeconomic gradient in stroke has been demonstrated in a variety of settings, but mostly in men. Our purpose was to establish whether a socioeconomic gradient in stroke existed in a group of Swedish women and whether this gradient could be explained by established stroke risk factors or psychosocial factors. The Women's Lifestyle and Health Cohort Study includes 49 259 women from Sweden aged 30 to 50 years at baseline (1991 to 1992). The women completed an extensive questionnaire and were traced through linkages to national registries until the end of 2002. Among the 47 942 women included in these analyses, there were 200 cases of incident stroke during follow up (121 ischemic stroke, 47 hemorrhagic stroke, and 32 of unknown origin). Statistical analysis was through the Cox proportional hazards model. The risk of stroke was significantly inversely related to years of education completed, our proxy for socioeconomic status (hazard ratio comparing lowest with highest education group=2.1, 95% CI: 1.4 to 2.9, P for trend <0.001). This association was reduced after adjustment for established risk factors, although remaining significant (1.5, 1.0 to 2.2, P for trend=0.04). The gradient was more pronounced for ischemic stroke (2.9, 1.8 to 4.7, P for trend <0.001) than for hemorrhagic stroke (1.4, 0.7 to 2.9, P for trend=0.35). Job strain and social support were unrelated to risk of stroke. Self-rated health was strongly related to risk of stroke mediated by established risk factors. Psychosocial factors did not contribute toward the socioeconomic gradient in stroke. There was a strong gradient in risk of stroke by years of education, especially for ischemic stroke. Most of the social gradient was explained by established risk factors, particularly smoking and alcohol, but not by psychosocial factors.

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Socioeconomic inequalities in cause-specific mortality in 15 European cities

Marc Marí-Dell'Olmo, Mercè Gotsens, Laia Palència … (2015)

Socioeconomic inequalities are increasingly recognised as an important public health issue, although their role in the leading causes of mortality in urban areas in Europe has not been fully evaluated. In this study, we used data from the INEQ-CITIES study to analyse inequalities in cause-specific mortality in 15 European cities at the beginning of the 21st century.

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Author and article information

Contributors

Nera Agabiti: +39 06 99722124 , n.agabiti@deplazio.it

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2458

Publication date (Electronic): 16 May 2016

Publication date PMC-release: 16 May 2016

Publication date Collection: 2016

Volume: 16

Electronic Location Identifier: 408

Affiliations

Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147 Rome, Italy

Article

Publisher ID: 3019

DOI: 10.1186/s12889-016-3019-8

PMC ID: 4868039

PubMed ID: 27184959

SO-VID: 4544ef55-82bf-4768-91cc-f8e7391a289f

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 14 November 2015

Date accepted : 9 April 2016

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ScienceOpen disciplines: Public health

Keywords: socioeconomic-position,stroke,pathway-analysis,survival

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ScienceOpen disciplines: Public health

Keywords: socioeconomic-position, stroke, pathway-analysis, survival

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Socioeconomic differences in one-year survival after ischemic stroke: the effect of acute and post-acute care-pathways in a cohort study

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Abstract

Background

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Stroke MRI

Most cited references 26

Hospital volume and stroke outcome: does it matter?

The socioeconomic gradient in the incidence of stroke: a prospective study in middle-aged women in Sweden.

Socioeconomic inequalities in cause-specific mortality in 15 European cities

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Cited by 6

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