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Socioeconomic disparities in stroke case fatality: observations from Riks-Stroke, the Swedish stroke register
Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden.
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2014 (English)In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 9, no 4, 429-436 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Low socioeconomic status (low education and income level) has been found to be associated with increased stroke mortality. However, findings from previous studies on the association between socioeconomic status and case fatality (survival) after stroke have been inconsistent.

AIMS: The study aims to explore the association between socio-economic status and survival after stroke using Riks-Stroke, the Swedish Stroke Register, with emphasis on changes in survival (in)equality with time after stroke.

METHODS: All 76 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. Riks-Stroke data on 18- to 74-year-old patients with onset of first stroke during the years 2001-2009 were combined with data from other official Swedish registers. Case fatality was analyzed by socioeconomic status (education, income, country of birth, and cohabitation) and other patient characteristics.

RESULTS: Of the 62 497 patients in the study, a total of 6094 (9·8%) died within the first year after stroke. Low income, primary school education, and living alone were independently associated with higher case fatality after the acute phase. Differences related to income and cohabitation were present already early, at 8-28 days after stroke, with the gaps expanding thereafter. The association between education and case fatality was not present until 29 days to one-year after stroke. Dissimilarities in secondary preventative medications prescribed on discharge from hospital had only a minor impact on these differences.

CONCLUSIONS: Socioeconomic status had only a limited effect on acute phase case fatality, indicating minor disparities in acute stroke treatment. The survival inequality, present already in the subacute phase, increased markedly over time since the stroke event. The socioeconomic differences could not be explained by differences in secondary prevention at discharge from hospital. Large socioeconomic differences in long-term survival after stroke may exist also in a country with limited income inequity.

Place, publisher, year, edition, pages
John Wiley & Sons, 2014. Vol. 9, no 4, 429-436 p.
Keyword [en]
stroke, outcome, socioeconomic status, case fatality, registers
National Category
Social Sciences Anesthesiology and Intensive Care
URN: urn:nbn:se:umu:diva-79991DOI: 10.1111/ijs.12133ISI: 000335664900013PubMedID: 23981768ScopusID: 2-s2.0-84899987546OAI: diva2:645851
Available from: 2013-09-05 Created: 2013-09-05 Last updated: 2016-09-28Bibliographically approved
In thesis
1. Statistical methods for register based studies with applications to stroke
Open this publication in new window or tab >>Statistical methods for register based studies with applications to stroke
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Statistiska metoder för registerbaserade studier med tillämpningar på stroke
Abstract [en]

This thesis adds to the area of register based research, with a particular focus on health care quality and (in)equality. Contributions are made to the areas of hospital performance benchmarking, mediation analysis, and regression when the outcome variable is limited, with applications related to Riksstroke (the Swedish stroke register).

An important part of quality assurance is to identify, follow up, and understand the mechanisms of inequalities in outcome and/or care between different population groups. The first paper of the thesis uses Riksstroke data to investigate socioeconomic differences in survival during different time periods after stroke. The second paper focuses on differences in performance between hospitals, illustrating the diagnostic properties of a method for benchmarking hospital performance and highlighting the importance of balancing clinical relevance and the statistical evidence level used.

Understanding the mechanisms behind observed differences is a complicated but important issue. In mediation analysis the goal is to investigate the causal mechanisms behind an effect by decomposing it into direct and indirect components. Estimation of direct and indirect effects relies on untestable assumptions and a mediation analysis should be accompanied by an analysis of how sensitive the results are to violations of these assumptions. The third paper proposes a sensitivity analysis method for mediation analysis based on binary probit regression. This is then applied to a mediation study based on Riksstroke data.

Data registration is not always complete and sometimes data on a variable are unavailable above or below some value. This is referred to as censoring or truncation, depending on the extent to which data are missing. The final two papers of the thesis are concerned with the estimation of linear regression models for limited outcome variables. The fourth paper presents a software implementation of three semi-parametric estimators of truncated linear regression models. The fifth paper extends the sensitivity analysis method proposed in the third paper to continuous outcomes and mediators, and situations where the outcome is truncated or censored.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2016. 30 p.
Statistical studies, ISSN 1100-8989 ; 49
Registers, quality of care, socioeconomic status, hospital performance, stroke, mediation, sensitivity analysis, truncation, censoring
National Category
Probability Theory and Statistics
Research subject
urn:nbn:se:umu:diva-125953 (URN)978-91-7601-553-7 (ISBN)
Public defence
2016-10-21, Hörsal E, Humanisthuset, Umeå, 09:30 (English)
Available from: 2016-09-30 Created: 2016-09-23 Last updated: 2016-09-29Bibliographically approved

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