Department of Clinical Research, University of Southern Denmark, Denmark.
Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark.
Eur Stroke J. 2023 Mar;8(1):351-360. doi: 10.1177/23969873221146591. Epub 2022 Dec 28.
In a publicly financed healthcare system we aimed to study the development in socioeconomic disparity in ischemic stroke outcomes over time. In addition, we study whether the healthcare system affects these outcomes through the quality of early stroke care when adjustments are made for various patient characteristics incl. comorbidity and stroke severity.
Using nationwide, detailed individual-level register-data we analysed how income-related and education-related inequality in 30-day mortality and 30-day readmission risk developed between 2003 and 2018. In addition, focusing on income-related inequality, we applied mediation analyses to estimate the mediating role of quality of acute stroke care on 30-day mortality and 30-day readmission.
A total of 97,779 individual ischemic stroke patients were registered in Denmark with a first ever stroke in the study period. Three-point-seven percent died within 30 days of their index-admission and 11.5% were readmitted within 30 days of discharge. The income-related inequality in mortality remained virtually unchanged over time from an RR of 0.53 (95% CI: 0.38; 0.74) in 2003-06 to RR 0.69 (95% CI: 0.53; 0.89)) in 2015-18 when high income was compared to low income (Family income-time interaction: RR 1.00 (95% CI: 0.98-1.03)). A similar but less uniform trend was found for the education-related inequality in mortality (Education-time interaction: RR 1.00 (95% CI: 0.97-1.04)). The income-related disparity in 30-day readmission was smaller than in 30-day mortality and it diminished over time from 0.70 (95% CI: 0.58; 0.83) to 0.97 (95% CI: 0.87; 1.10). The mediation analysis showed no systematic mediating effect of quality of care on neither mortality nor readmission. However, it cannot be ruled out that residual confounding may have washed out some mediating effects.
The socioeconomic inequality in stroke mortality and re-admission risk has yet to be eliminated. Additional studies from different settings are warranted in order to clarify the impact of socioeconomic inequality of quality of acute stroke care.
在公共资助的医疗体系中，我们旨在研究随着时间的推移，缺血性脑卒中结局的社会经济差异的发展。此外，我们研究了在调整各种患者特征（包括合并症和卒中严重程度）后，医疗保健系统是否通过早期卒中护理的质量来影响这些结局。
使用全国性的详细个体水平登记数据，我们分析了 2003 年至 2018 年间，30 天死亡率和 30 天再入院风险的收入相关和教育相关不平等情况如何发展。此外，我们聚焦于收入相关的不平等，应用中介分析来估计急性卒中护理质量对 30 天死亡率和 30 天再入院的中介作用。
丹麦共登记了 97779 名患有首次缺血性卒中的个体患者。3.7%的患者在指数入院后 30 天内死亡，11.5%的患者在出院后 30 天内再次入院。死亡率的收入相关不平等在整个研究期间基本保持不变，从 2003-06 年的 RR0.53（95%CI：0.38；0.74）到 2015-18 年的 RR0.69（95%CI：0.53；0.89），当将高收入与低收入进行比较时（家庭收入-时间交互作用：RR1.00（95%CI：0.98-1.03））。在死亡率的教育相关不平等方面也发现了类似但不太一致的趋势（教育-时间交互作用：RR1.00（95%CI：0.97-1.04））。30 天再入院的收入相关差异小于 30 天死亡率，且随着时间的推移从 0.70（95%CI：0.58；0.83）缩小到 0.97（95%CI：0.87；1.10）。中介分析显示，护理质量对死亡率和再入院率均无系统的中介作用。然而，不能排除残留混杂可能消除了一些中介效应。
卒中死亡率和再入院风险的社会经济不平等尚未消除。需要来自不同环境的额外研究，以阐明社会经济不平等对急性卒中护理质量的影响。
