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Socioeconomic Deprivation and Provision of Acute and Long-Term Stroke Care:

A cohort study within the South London Stroke Register (SLSR)

Ruoling Chen, Christopher J. McKevitt, Siobhan L. Crichton, Anthony G. Rudd and Charles D.A. Wolfe

Division of Health and Social Care Research

B k d B k d Background Background

Socioeconomic deprivation (SED) increases stroke incidence and mortality.

(Cox AM, McKevitt C, Rudd AG, Wolfe CD.

y

( f Socioeconomic status and stroke. Lancet Neurol 2006;5:181-188)

Many but not all studies have shown a relationship Many but not all studies have shown a relationship between socioeconomic deprivation and poor stroke care

(L d t l (2011) A i h t l (2008))

stroke care. (Langagergaard et al (2011) vs Arrich et al (2008))

 Long-term stroke care  Secular trends in the relationship  Ethnic differences

Presented by

M th d (1) M th d (1) Methods (1) Methods (1)

 South London Stroke Register (SLSR) of 1995 – 2010

 covering 272,000 residents in Lambeth and Southwark, South London  an ongoing prospective population-based stroke register set up in January

1995

 Records all first-ever strokes in patients of all ages

 identifying cases using multiple sources of notification by specially trained

study nurses and fieldworkers - Hospital surveillance of admissions for stroke, Community surveillance for stroke

 diagnosing stroke using the WHO clinical definition

Presented by

M th d (2) M th d (2) Methods (2) Methods (2)

S i i D i ti t

 Socioeconomic Deprivation measurement

 by calculating the Carstairs score (deprivation index) for

h ti t di t th i t d f id each patient according to their postcode of residence

 an area based measure of socio-economic deprivation derived from

decennial 2001 census data

 using levels of male unemployment, overcrowding, car ownership and

proportion in social classes IV and V (partly skilled, and unskilled) in a small area

Presented by

M th d (3) M th d (3) Methods (3) Methods (3)

 Processes of acute stroke care  Processes of acute stroke care

 A range of indicators of the processes of care after an acute stroke

suggested to be useful proxy measures for the overall quality of stroke care stroke care

 Hospital admission, Stroke unit admission, >50% of stay on stroke unit,

Brain imaging, Swallow test

 Physiotherapy (PT) assessment within 72 hours Occupational therapy  Physiotherapy (PT) assessment within 72 hours, Occupational therapy

(OT) within seven days, Speech and language therapy (SALT) within seven days

 Other interventions: thrombolysis, receipt of aspirin, enteral feeding,

Other interventions: thrombolysis, receipt of aspirin, enteral feeding, provision of intravenous fluids

 Processes of long-term stroke care

 After hospital discharge, follow-up data were collected by validated

postal or face-to-face instruments with patients and/or their carers.

 patients were assessed at 3 months and annually after their stroke

Presented by

 a

specialist

• r

general practitioner (GP) follow-up, PT/OT, SALT, secondary prevention drugs

R lt R lt

Table 1. Characteristics of 4,202 stroke patients across

Results Results

socioeconomic deprivation groups in SLSR of 1995-2010

Socioeconomic Deprivation (Carstairs score – quintile)

Variable

Least deprived (1

st Q)

N=841 2

nd Q

N=841 3

rd Q

N=850 4

th Q

N=841 Most deprived (5

th Q)

N=829 P value % % % % % n % n % n % n % n %

Age (years),

72.3 (61.9-81.3) 72.8 (61.3-81.5) 73.4 (63.3-81.3) 72.8 (61.3-81.2) 70.9 (59.2-80.6) 0.026

median, IQR Male sex, n(%)

410 48.9 435 51.9 433 51.1 440 52.5 399 48.3 0.342

Ethnicity, n(%) White

581 69.1 611 72.7 628 73.9 630 74.9 548 66.1 0.001

Black

202 24.0 160 19.0 155 18.2 150 17.8 190 22.9

Other

41 4 9 46 5 5 43 5 1 42 5 0 70 8 4

Presented by

Other

41 4.9 46 5.5 43 5.1 42 5.0 70 8.4

Unknown

17 2.0 24 2.9 24 2.8 19 2.3 21 2.5

Characteristics of Stroke Patients

Patients in the most deprived groups were less likely to live in a nursing home, compared with all others. Th i ifi t diff i f t k There were no significant differences in year of stroke, Barthel Index (BI) prior to stroke, stroke subtype, Glasgow coma score incontinence speech deficit Glasgow coma score, incontinence, speech deficit, swallow impairment and motor deficit among the 5 SED groups.

Presented by

Table 2. Interventions in acute stroke in SLSR of 1995-2010§

Values are numbers of patients with process/total number of patients with data on process measure (%) unless stated otherwise with data on process measure (%) unless stated otherwise

Socioeconomic Deprivation (Carstairs score)

V i bl

L t d i d (1

stQ)

2

nd Q

3

rd Q

4

th Q

M t d i d (5

thQ)

P l

Variable

Least deprived (1

st Q)

N=799 2

nd Q

N=794 3

rd Q

N=815 4

th Q

N=801 Most deprived (5

th Q)

N=781 P value n % n % n % n % n %

Hospital admission, n(%)

721/799 90.2 668/794 84.1 722/815 88.6 701/801 87.5 692/781 88.6 0.004

Stroke unit

402/708 56 8 345/649 53 2 392/701 55 9 384/686 56 0 397/674 58 9 0 334

Stroke unit admission,* n(%)

402/708 56.8 345/649 53.2 392/701 55.9 384/686 56.0 397/674 58.9 0.334

>50% of stay on stroke unit*

295/635 46.5 250/587 42.6 305/641 47.6 286/624 45.8 294/602 48.8 0.258

stroke unit* Brain imaging, n(%)

719/771 93.0 702/753 93.2 712/776 91.8 713/764 93.3 700/751 93.2 0.711

Swallow test *

665/713 93 3 604/667 90 6 668/720 92 8 640/695 92 1 612/686 89 2 0 038

Swallow test,* n(%)

665/713 93.3 604/667 90.6 668/720 92.8 640/695 92.1 612/686 89.2 0.038

§ i thi l i 212 ti t ith b h id h h (SAH) l d d b th h diff i d

Presented by

§ in this analysis 212 patients with a subarachnoid haemorrhage (SAH) were excluded because they have differing needs for acute care and are typically managed in neurosurgical wards following different protocols. * limited to patients admitted to hospital

Table 3. Odds ratio (OR)† for receiving provision of acute stroke care in SLSR of 1995-2010§

† d d f h l d b f k d f k BI k

Socioeconomi Hospitaladmission Stroke nitadmission* >50%ofsta onstroke Brainima in S allo test*

† adjusted for age, sex, ethnicity, living conditions before stroke, period of stroke, BI prior to stroke, stroke subtype, Glasgow coma scale sore (≥13), incontinence, speech deficit and motor deficit

Socioeconomi c Hospital admission Stroke unit admission* >50% of stay on stroke unit * Brain imaging Swallow test* deprivation

OR† 95% CI p OR† 95% CI p OR† 95% CI p OR† 95% CI p OR† 95% CI p

All patients All patients Deprivation# No

1.00 1.00 1.00 1.00 1.00

Yes

0.71 (0.54‐0.94) 0.017 0.87 (0.71‐1.07) 0.182 0.86 (0.68‐1.08) 0.194 0.93 (0.55‐1.58) 0.791 0.65 (0.45‐0.95) 0.023

# patients with socioeconomic deprivation were those who had Carstairs score of 2nd to 5th quintiles, and

Presented by

# patients with socioeconomic deprivation were those who had Carstairs score of 2 to 5 quintiles, and patients without deprivation were those who had Carstairs score of 1st quintiles.

Secular trends and pooled ORs Secular trends and pooled ORs Secular trends and pooled ORs Secular trends and pooled ORs

3 00

Stroke occurring before 2001 Stroke occurring since 2001

1 50 2.00 2.50 3.00 0 00 0.50 1.00 1.50 0.00 dmission dmission troke ... imaging llow test Pooled OR dmission dmission troke ... imaging llow test Pooled OR Hostpial adm Stroke unit adm 50 of stay on str Brain i Swall Po Hostpial adm Stroke unit adm 50 of stay on str Brain i Swall Po

Presented by 10

St >50 St >50

Ethnic differences and pooled ORs Ethnic differences and pooled ORs Ethnic differences and pooled ORs Ethnic differences and pooled ORs

4.00

Black patients (n=857) White patients (n=2998)

2.00 2.50 3.00 3.50 0 00 0.50 1.00 1.50 2.00 0.00 d m i s s i

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t p i a l a d m S t r

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s t r B r a i n i S w a l l P

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• Presented by

11

S t > 5

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t > 5

There were no significant differences among the 5 SED groups in receiving 6 interventions (PT/OT, SALT, thrombolysis, anytime aspirin, fed by enteral route, intravenous fluids) in SLSR of 2005-2010.

After pooling the impact of SED on the 6 interventions combined we found a significant interventions combined, we found a significant association in black patients (pooled-OR 0.48, 0.32- 0.72), but not in whites (0.89, 0.70-1.13). 0.72), but not in whites (0.89, 0.70 1.13).

Presented by

Long-term stroke care from hospital Long-term stroke care from hospital discharge to 5 years follow-up

There was no significant reduction in ORs for receiving follow-up with specialist/GP, PT/OT or SALT, at 3 follow up with specialist/GP, PT/OT or SALT, at 3 months, 1 year and up to 5 years follow up.

Presented by

Table 4. Associations between socio-economic deprivation and access to Atrial Fibrillation (AF) medical follow up in SLSR of 1995-2010

OR† - adjusted for age, sex, ethnicity, living conditions before stroke, period of stroke, BI (each analysis changed at its data collection), stroke subtype, Glasgow coma scale sore (≥13), incontinence, speech deficit and motor deficit.

Atrial Fibrillation Medication* Socioeconomic

Yes No Multivariate adjusted

deprivation

n % n % p OR† 95% CI p By 3 Months

Deprivation# No

45 35.2 47 18.5

Yes

83 64.8 207 81.5 .000 0.46 0.27-0.79 .005

By 1 Year

Deprivation# No

37 30.8 53 22.5

Yes

83 30.7 183 77.5 .086 0.75 0.42-1.31 .311

By 2 Year

D i i # Deprivation# No

22 25.3 37 20.6

Yes

65 74.7 143 79.4 .382 0.93 0.45-1.94 .856

Presented by

* based on eligible patients

Table 5. Associations between socio-economic deprivation and access to Atrial Fibrillation (AF) medical follow up in SLSR of 1995-2010

OR† - adjusted for age, sex, ethnicity, living conditions before stroke, period of stroke, BI (each analysis changed at its data collection), stroke subtype, Glasgow coma scale sore (≥13), incontinence, speech deficit and motor deficit.

A i l Fib ill i M di i * Atrial Fibrillation Medication* Socioeconomic

Yes No Multivariate adjusted

deprivation

n % n % p OR† 95% CI p By 3 Year

Deprivation# No

27 29.0 33 22.3

Yes

66 71.0 115 77.7 .239 0.69 0.33-1.43 .316

By 4 Year

Deprivation# N

19 25 0 33 23 7

No

19 25.0 33 23.7

Yes

57 75.0 106 76.3 .837 0.79 0.36-1.72 .554

By 5 Year

D i ti # Deprivation# No

21 32.8 19 16.7

Yes

43 67.2 95 83.3 .013 0.39 0.17-0.88 .024

Presented by

* based on eligible patients

Table 6. Associations between socio-economic deprivation and access to medications follow up in SLSR of 1995-2010

High Cholesterol Treatment* Diabetes* Socioeconomic

Yes No Multivariate adjusted Yes No Multivariate adjusted

deprivation

n % n % p OR† 95% CI p n % n % p OR† 95% CI p By 3 Months By 3 Months

Deprivation# No

121 22.2 51 16.6 73 23.1 23 19.7

Yes

425 77 8 256 83 4 053 0 51 0 32 0 83 006 243 76 9 94 80 3 0 74 0 41 1 35 328

Yes

425 77.8 256 83.4 .053 0.51 0.32-0.83 .006 243 76.9 94 80.3 0.74 0.41-1.35 .328

By 1 Year

Deprivation# N

113 19 2 62 21 1 66 22 7 22 16 7

No

113 19.2 62 21.1 66 22.7 22 16.7

Yes

477 80.8 232 78.9 .496 1.11 0.72-1.69 .627 225 77.3 110 83.3 .158 0.60 0.33-1.08 .088

By 2 Year

D i ti # Deprivation# No

89 17.9 36 16.4 48 23.1 10 10.8

Yes

409 82.1 183 83.6 .641 0.81 0.50-1.30 .381 160 76.9 83 89.2 .012 0.34 0.15-0.80 .013

Presented by

No significant association of SED in 3, 4 and 5 years follow up

There was no significant reduction in ORs for receiving Antihypertensive medication and Antiplatelets (f

i h i

Antihypertensive medication and Antiplatelets (for ischemic

stroke patients only).

Presented by

Pooled OR for 5 secondary prevention drugs Pooled OR for 5 secondary prevention drugs in different time of follow up in different time of follow up

3.50

Black patients White patients

2.00 2.50 3.00

Black patients White patients

1.00 1.50 2.00 0.00 0.50 h s r s s s s h s r s s s s B y 3 M

• n

t h s B y 1 Y e a r B y 2 Y e a r s B y 3 Y e a r s B y 4 Y e a r s B y 5 Y e a r s B y 3 M

• n

t h s B y 1 Y e a r B y 2 Y e a r s B y 3 Y e a r s B y 4 Y e a r s B y 5 Y e a r s

Presented by 18

No significant associations in the analysis of the period

• f stroke.

C l i C l i Conclusions Conclusions

1. Socioeconomic deprivation reduces the chance of receiving optimal acute and long-term stroke care. g p g 2 Th i t f SED t i bl k ti t 2. The impact of SED was stronger in black patients than whites. 3. These relationships have improved over time, but 3. ese e at o s ps ave p oved ove t e, but stroke health care inequalities still exist for some important indicators.

Presented by

p

Acknowledgements Acknowledgements Acknowledgements Acknowledgements

We wish to thank all the patients and their families and the health care professionals involved. Particular thanks to all the fieldworkers and the team who have collected data since 1995 for the SLSR team who have collected data since 1995 for the SLSR. The study was funded by the Northern and Yorkshire National Health Service (NHS) Research and Development Programme in Cardiovascular Disease and Stroke Guy’s and St Thomas’ Hospital Cardiovascular Disease and Stroke, Guy s and St Thomas Hospital Charity, The Stroke Association, and Department of Health (Health Quality Improvement Programmer grant) UK. W k l d fi i l f h D f We acknowledge financial support from the Department of Health via the National Institute for Health Research (NIHR) Biomedical Research Centre and the Programme Grant award to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London (RP-PG-0407-10184).

Presented by