Socioeconomic Deprivation and Provision of Acute and Long-Term - PowerPoint PPT Presentation

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 B Background Background k k d d Socioeconomic deprivation (SED) increases stroke incidence and mortality. y (Cox AM, McKevitt C, Rudd AG, Wolfe CD. ( 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 stroke care . (Langagergaard et al (2011) vs Arrich et al (2008)) (L d t l (2011) A i h t l (2008))  Long-term stroke care  Secular trends in the relationship  Ethnic differences Presented by

M th d M th d Methods (1) Methods (1) (1) (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 M th d Methods (2) Methods (2) (2) (2)  Socioeconomic Deprivation measurement S i i D i ti t  by calculating the Carstairs score (deprivation index) for each patient according to their postcode of residence h ti t di t th i t d f id  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 M th d Methods (3) Methods (3) (3) (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  a specialist or general practitioner (GP) follow-up, PT/OT, SALT, secondary prevention drugs Presented by

R R Results Results lt lt Table 1. Characteristics of 4,202 stroke patients across socioeconomic deprivation groups in SLSR of 1995-2010 Socioeconomic Deprivation (Carstairs score – quintile) st Q) nd Q rd Q th Q th Q) Least deprived (1 2 3 4 Most deprived (5 P value Variable N=841 N=841 N=850 N=841 N=829 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(%) 69.1 72.7 73.9 74.9 66.1 White 581 611 628 630 548 0.001 24.0 19.0 18.2 17.8 22.9 Black 202 160 155 150 190 Other Other 41 41 4.9 4 9 46 46 5 5 5.5 43 43 5.1 5 1 42 42 5 0 5.0 70 70 8 4 8.4 Unknown 17 2.0 24 2.9 24 2.8 19 2.3 21 2.5 Presented by

Characteristics of Stroke Patients Patients in the most deprived groups were less likely to live in a nursing home, compared with all others. There were no significant differences in year of stroke, Th i ifi t diff i f t k 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) nd Q nd Q rd Q rd Q th Q th Q st Q) st Q) th Q) th Q) Variable V i bl Least deprived (1 L t d i d (1 2 2 3 3 4 4 Most deprived (5 M t d i d (5 P P value l N=799 N=794 N=815 N=801 N=781 n % n % n % n % n % 721/799 90.2 668/794 84.1 722/815 88.6 701/801 87.5 692/781 88.6 0.004 Hospital admission, n(%) 402/708 402/708 56 8 56.8 345/649 345/649 53 2 53.2 392/701 392/701 55 9 55.9 384/686 384/686 56.0 56 0 397/674 397/674 58 9 58.9 0.334 0 334 Stroke unit Stroke unit admission,* n(%) >50% of stay on 295/635 46.5 250/587 42.6 305/641 47.6 286/624 45.8 294/602 48.8 0.258 stroke unit* stroke unit* 719/771 93.0 702/753 93.2 712/776 91.8 713/764 93.3 700/751 93.2 0.711 Brain imaging, n(%) Swallow test * Swallow test,* 665/713 665/713 93.3 93 3 604/667 604/667 90 6 90.6 668/720 668/720 92 8 92.8 640/695 640/695 92.1 92 1 612/686 612/686 89 2 89.2 0 038 0.038 n(%) § in this analysis 212 patients with a subarachnoid haemorrhage (SAH) were excluded because they have differing needs § i thi l i 212 ti t ith b h id h h (SAH) l d d b th h diff i d for acute care and are typically managed in neurosurgical wards following different protocols. * limited to patients admitted to hospital Presented by

Table 3. Odds ratio (OR) † for receiving provision of acute stroke care in SLSR of 1995-2010 § † d † adjusted for age, sex, ethnicity, living conditions before stroke, period of stroke, BI prior to stroke, d f h l d b f k d f k BI k stroke subtype, Glasgow coma scale sore ( ≥ 13), incontinence, speech deficit and motor deficit Socioeconomi Socioeconomi Hospital admission Hospitaladmission Stroke nitadmission* Stroke unit admission* >50%ofsta onstroke >50% of stay on stroke Brain imaging Brainima in S allo test* Swallow test* c unit * 95% CI p OR † 95% CI p OR † 95% CI p OR † 95% CI p OR † 95% CI p deprivation OR † All patients All patients Deprivation# 1.00 1.00 1.00 1.00 1.00 No 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 Yes # patients with socioeconomic deprivation were those who had Carstairs score of 2 nd to 5 th quintiles, and # 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 1 st quintiles. Presented by

Secular trends and pooled ORs Secular trends and pooled ORs Secular trends and pooled ORs Secular trends and pooled ORs Stroke occurring before 2001 Stroke occurring since 2001 3 00 3.00 2.50 2.00 1.50 1 50 1.00 0.50 0 00 0.00 llow test Pooled OR llow test Pooled OR dmission imaging dmission imaging dmission dmission troke ... troke ... Stroke unit adm Stroke unit adm Hostpial adm Hostpial adm 50 of stay on str Swall 50 of stay on str Swall Brain i Brain i Po Po St St >50 >50 10 Presented by

Ethnic differences and pooled ORs Ethnic differences and pooled ORs Ethnic differences and pooled ORs Ethnic differences and pooled ORs Black patients (n=857) White patients (n=2998) 4.00 3.50 3.00 2.50 2.00 2.00 1.50 1.00 0.50 0 00 0.00 t R t R g g n n s s n O n O . n . n e e o o . . o o . . i t i t i i d d g g i s i s e e s s a w a w s s e e s s k k i m i m l l i o i o m m o m m o m m o m m o l l l l r r i i o o r r i i o o l l l l d d t t d d t t d d a a d d a a n n P P P P s s a a w w a a i i a a n n t t l S l S r r i i a o a o n n B B i i u u p y p y a a t t e e s s t t k k o s o s o o H H f f o o o o r r t t t t S S S S 0 0 0 0 5 5 > > 11 Presented by

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