Farr Institute of Health Informatics Research, University College London, London, UK.
Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK.
Lancet Public Health. 2018 Apr;3(4):e185-e193. doi: 10.1016/S2468-2667(18)30030-6. Epub 2018 Mar 15.
We aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England.
In this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards).
Of the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7-2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3-1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07-1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20-1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05-1·17).
Wide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke.
NHS England and the Welsh Government.
本研究旨在评估英格兰成年人群中首次发生卒中的住院率、医疗质量和卒中后生存率的社会经济差异。
在这项队列研究中，我们从 2013 年 7 月 1 日至 2016 年 3 月 31 日，从英格兰全国性登记系统中获取了因首次急性缺血性卒中和原发性脑内出血住院的年龄在 18 岁或以上的患者的数据。我们使用剥夺程度的邻里衡量指标——多因素剥夺指数，将社会经济地位划分为下超级输出区（Lower Super Output Areas）水平。使用多变量模型估计首次卒中住院的发生率（负二项式）、使用 12 项质量指标评估的医疗质量（多水平逻辑）以及全因 1 年病死率（Cox 比例风险）。
在英格兰的 4380 万成年人中，有 145324 人因首次卒中住院：126640 人（87%）为缺血性卒中，17233 人（12%）为脑内出血，1451 人（1%）为未确定的卒中类型。我们观察到缺血性卒中（调整发病率比 2.0，95%置信区间 1.7-2.3，最贫困与最富裕十分位数）和脑内出血（1.6，1.3-1.9）的住院率存在社会经济梯度。来自社会经济最低组的患者首次发生卒中的中位时间比来自社会经济最高组的患者早 7 年（p<0.0001），且卒中前残疾和糖尿病的患病率更高。来自社会经济较低组的患者不太可能接受 12 项护理流程中的 5 项，但更有可能接受早期支持性出院（调整比值比 1.14，95%置信区间 1.07-1.22）。低社会经济地位与 1 年死亡率的调整后风险增加 26%相关（调整后的危害比 1.26，95%置信区间 1.20-1.33，最高与最低贫困十分位数），但在调整了卒中前糖尿病、高血压和心房颤动的存在后，这种梯度基本减弱（1.11，1.05-1.17）。
在英格兰，缺血性卒中和脑内出血的负担存在广泛的社会经济差异，最显著的差异是卒中住院风险和病死率，在一定程度上还存在医疗质量差异。要缩小这些差异，需要采取干预措施来改善急性卒中的医疗质量，并解决卒中前心血管危险因素的差异。
英国国家医疗服务体系（NHS England）和威尔士政府。
