Vasileios Lioutas, MD

Huang K, Khan N, Kwan A, Fang J, Yun L, Kapral MK. Socioeconomic Status and Care After Stroke: Results From the Registry of the Canadian Stroke Network. Stroke. 2013; 44: 477-482.

Acute stroke is a leading cause of death and disability worldwide. Access to specialized stroke centers, intravenous thrombolysis in the acute phase, post-stroke rehabilitation and secondary prevention has proven of great significance in improving outcomes. In this interesting study Huang et al are investigating the impact of socioeconomic status in stroke care looking for associations between median neighbourhood income and parameters of stroke care, focusing on post-hospitalization management. This is a retrospective analysis of 11,000 patients older than 65 years admitted to regional stroke care centers with acute stroke or TIA in Ontario, Canada.

Higher income was found to be associated with increased likelihood of admission to stroke unit, care by a neurologist during hospitalization, referral to specialized secondary stroke prevention clinic and greater number of post-discharge physician visits. Conversely, thrombolysis rates, discharge to inpatient rehabilitation facilities and access to home care nursing, physical and occupational therapy were not affected by the socioeconomic status. Medication adherence was not different among income quintiles, but universally relatively poor, especially with regards to anticoagulation (adherence rate approximately 55%).

There are some points that merit highlighting:

Though there were differences that reached statistical significance, the absolute differences were small (for instance, patients in the higher income quintile had a mean number of 4.5 physician visits versus 4.2 for the lower quintile, which nevertheless yielded a p value of <0.001).

Although the parameters investigated are known to influence stroke outcome, the ultimate question remains whether functional outcome and mortality rate are affected. Therefore, strictly speaking, only indirect extrapolations pertaining to this particular issue can be made from the current study.

Most importantly, the study was conducted with in a very specific healthcare model context with widely available access to specialized stroke services. The results are therefore applicable to settings with similarly organized stroke care, but it is questionable whether they are representative of lower income countries or even high-income societies with deeper socioeconomic disparities and fragmented healthcare systems.

Stroke’s impact on individual patients and the society as a whole is tremendous with an intricate correlation to socioeconomic status; more specifically, evidence suggests that stroke outcome is inversely related to income stratum. One interpretation of the results of this interesting study is that existence of a universal healthcare system with organized, readily and widely available stroke care resources can attenuate the effect of economic inequality on stroke care accessibility and disease outcome.