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Study of the Relationship Between Social Deprivation and Outcome After Stroke

Study of the Relationship Between Social Deprivation and Outcome After Stroke,Nicolas U. Weir,Alison Gunkel,Michael McDowall,Martin S. Dennis

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Study of the Relationship Between Social Deprivation and Outcome After Stroke   (Citations: 9)
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Background and Purpose—Although the incidence and mortality of stroke are known to be inversely related to socioeconomic status (SES), the relationship between SES and recovery after stroke has been little-studied. This study has investigated the relationship between SES and case fatality, "death or dependency," and "death or institutional care" at 6 months after stroke. Methods—Patients with acute stroke (n2709) were identified using routine hospital discharge data and SES was measured using Carstairs scores (an ecological index of social deprivation). Case mix and treatment data were collected by medical chart review, case fatality by record linkage, and functional status and place of residence by questionnaire. Logistic regression was used to adjust the association of social deprivation and outcome for case mix and selected treatment variables. Results—With increasing social deprivation, patients were younger, more likely to live alone, and, on admission, more likely to need help to walk. Social deprivation was not associated with case fatality or with "death or institutional care" in any analysis. However, patients residing in the most deprived areas (deprivation categories 6 and 7) were significantly more likely to be dead or dependent than patients from more affluent areas. This association was weakened but remained after adjusting for case mix and treatment variables. Conclusions—These findings contribute to growing evidence of an inverse social gradient in disability after stroke. Institutionalization, as a proxy for functional outcome, may not reflect this fact. A marked social gradient in case fatality after stroke seems unlikely. (Stroke. 2005;36:815-819.)
Published in 2010.
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    • ...Many studies have demonstrated the considerable value of routine inpatient data for population studies, including studies of disease incidence, outcomes and risk factors....

    Stephen E Roberts, et al. Feasibility of using routinely collected inpatient data to monitor qua...

    • ...Furthermore, 1 study found that in acute stroke patients D-dimer levels were not associated with long-term stroke outcome after adjustment for aetiological stroke subtype [,...

    Paul Welsh, et al. Associations of Inflammatory and Haemostatic Biomarkers with Poor Outc...

    • ......

    Ulrika Löfmark, et al. Education-Related Differences in Case Fatality among Elderly with Stro...

    • ...However, these associations were not confirmed by other studies....

    Koen Putman, et al. Effect of socioeconomic status on functional and motor recovery after ...

    • ... also showed that under 65, there was an increased risk of mortality from stroke with increasing deprivation category. However, the risk gradient almost disappeared in the over 65 age group. The incidence of first hospitalised stroke in those over 55 showed a clear rising gradient with deprivation, with people from deprivation category 7 being about 1.6 times more likely to be admitted with first hospitalised stroke in this age group.There are several possible explanations for the lack of effect of social deprivation on case fatality in our study of hospitalised stroke patients. One may argue that with improvements in a multidisciplinary approach to stroke management, the effect of living in a less affluent area is negated. An alternative explanation relates to the fact that there were significant differences in the age of patients in the different deprivation categories, the more affluent patients who had a stroke tending to be older. Age is one of the most important predictors of adverse outcome. However, interestingly, when age and a number of other predictor variables were taken into account in a multivariate analysis (Cox regression), deprivation category still did not predict outcome. It is difficult in these studies to separate age, risk factors (importantly, smoking), comorbidity and deprivation since they are all interlinked to some extent. Multivariate analysis is the best possible tool to disentangle some of these issues, although it is far from ideal.It appears that in our study, patients more socially deprived had strokes at a younger age and behaved as if they were older patients who were less socially deprived (i.e. length of hospital stay and case fatality was similar). Although the more deprived patients were younger, this benefit could have been offset by smoking with its related diseases. However, it did not appear that there were more smoking-related deaths in the deprived group in our study population, although our method of identifying smoking-related deaths was imperfect.We further tested the hypothesis that in the younger age group (<65 years), social deprivation could have an effect on case fatality. However, there was none. So, although social deprivation increases the incidence of strokes in younger individuals, once the stroke occurred, the outcome appeared similar across deprivation category groups.In the present study, the affluent was slightly more disabled before the stroke as evidenced by the premorbid Barthel and Philadelphia Geriatric IADL Scores. However, the stroke appeared to have equalised this disability difference between the deprivation groups, in contrary to Weir et al.’s [...

    K. Y. K. Wong, et al. Effect of Social Deprivation on Mortality and the Duration of Hospital...

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