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

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BMC Public Health

, 16:408

Chronic Disease epidemiology


BackgroundThe 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.

MethodsHospitalizations 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.

ResultsWe 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.

ConclusionsEducation 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.

KeywordsSocioeconomic-position Stroke Pathway-analysis Survival AbbreviationsBCIbootstrap confidence intervals

HRhazard ratio

ICD-9-CMinternational classification of diseases -9th revision-clinical modification

IPWinverse probability weighting

ORodds ratio

PRprobability ratio

SESsocio-economic status

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