Osypuk Theresa L, Ehntholt Amy, Moon J Robin, Gilsanz Paola, Glymour M Maria
From the Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis (T.L.O.); Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA (A.E., P.G., M.M.G.); SBH Health System, Bronx Partners for Healthy Communities, NY (J.R.M.); and Department of Epidemiology & Biostatistics, University of California, San Francisco (P.G., M.M.G.).
Circ Cardiovasc Qual Outcomes. 2017 Feb;10(2). doi: 10.1161/CIRCOUTCOMES.116.002547. Epub 2017 Feb 22.
Post-stroke mortality is higher among residents of disadvantaged neighborhoods, but it is not known whether neighborhood inequalities are specific to stroke survival or similar to mortality patterns in the general population. We hypothesized that neighborhood disadvantage would predict higher poststroke mortality, and neighborhood effects would be relatively larger for stroke patients than for individuals with no history of stroke.
Health and Retirement Study participants aged ≥50 years without stroke at baseline (n=15 560) were followed ≤12 years for incident stroke (1715 events over 159 286 person-years) and mortality (5325 deaths). Baseline neighborhood characteristics included objective measures based on census tracts (family income, poverty, deprivation, residential stability, and percent white, black, or foreign-born) and self-reported neighborhood social ties. Using Cox proportional hazard models, we compared neighborhood mortality effects for people with versus people without a history of stroke. Most neighborhood variables predicted mortality for both stroke patients and the general population in demographic-adjusted models. Neighborhood percent white predicted lower mortality for stroke survivors (hazard ratio, 0.75 for neighborhoods in highest 25th percentile versus below, 95% confidence interval, 0.62-0.91) more strongly than for stroke-free adults (hazard ratio, 0.92; 95% confidence interval, 0.83-1.02; =0.04 for stroke-by-neighborhood interaction). No other neighborhood characteristic had different effects for people with versus without stroke. Neighborhood-mortality associations emerged within 3 months after stroke, when associations were often stronger than among stroke-free individuals.
Neighborhood characteristics predict mortality, but most effects are similar for individuals without stroke. Eliminating disparities in stroke survival may require addressing pathways that are not specific to traditional poststroke care.
中风后死亡率在弱势社区居民中较高，但尚不清楚社区不平等是否特定于中风存活情况，还是与一般人群的死亡率模式相似。我们假设社区劣势会预示更高的中风后死亡率，并且社区对中风患者的影响比对无中风病史个体的影响相对更大。
对基线时年龄≥50岁且无中风的健康与退休研究参与者（n = 15560）进行了长达12年的随访，以观察中风发病情况（159286人年期间发生1715例事件）和死亡率（5325例死亡）。基线社区特征包括基于普查区的客观指标（家庭收入、贫困、匮乏、居住稳定性以及白人、黑人或外国出生人口的百分比）和自我报告的社区社会关系。使用Cox比例风险模型，我们比较了有中风病史者和无中风病史者的社区死亡率影响。在人口统计学调整模型中，大多数社区变量预测了中风患者和一般人群的死亡率。社区白人百分比对中风幸存者较低死亡率的预测作用（最高第25百分位数及以上社区与以下社区相比，风险比为0.75，95%置信区间为0.62 - 0.91）比对无中风成年人的预测作用更强（风险比为0.92；95%置信区间为0.83 - 1.02；中风与社区交互作用的P值 = 0.04）。没有其他社区特征对有中风和无中风的人有不同影响。中风后3个月内出现了社区 - 死亡率关联，此时的关联通常比无中风个体之间的关联更强。
社区特征可预测死亡率，但对无中风个体的大多数影响是相似的。消除中风存活方面的差异可能需要解决并非特定于传统中风后护理的途径。
