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- Title
Association of Socioeconomic Status and Infarct Volume With Functional Outcome in Patients With Ischemic Stroke.
- Authors
Ghoneem, Ahmed; Osborne, Michael T.; Abohashem, Shady; Naddaf, Nicki; Patrich, Tomas; Dar, Tawseef; Abdelbaky, Amr; Al-Quthami, Adeeb; Wasfy, Jason H.; Armstrong, Katrina A.; Ay, Hakan; Tawakol, Ahmed
- Abstract
Key Points: Question: Is socioeconomic status (SES) independently associated with infarct size, clinical severity, and long-term functional outcomes in patients with ischemic stroke? Findings: In this single-center cohort study of 1098 consecutive patients with ischemic stroke, initial stroke severity was assessed using magnetic resonance imaging of the brain and clinical indexes. Socioeconomic status (measured as median neighborhood income and area deprivation index) was independently associated with imaging and clinical measures of initial stroke severity, which in turn accounted for 64% of the association between SES and long-term functional outcome. Meaning: These findings suggest that individuals with lower SES have worse long-term functional outcomes, primarily because lower SES is associated with larger infarcts and more clinically severe strokes on presentation, even after adjusting for differences in risk factors and therapies. This single-center cohort study assesses the association between socioeconomic status (SES) and infarct volume in patients presenting with with acute ischemic stroke and investigates the potential mediating role of infarct volume in the association between SES and long-term disbility. Importance: Long-term disability after stroke is associated with socioeconomic status (SES). However, the reasons for such disparities in outcomes remain unclear. Objective: To assess whether lower SES is associated with larger admission infarct volume and whether initial infarct volume accounts for the association between SES and long-term disability. Design, Setting, and Participants: This cohort study was conducted in a prospective, consecutive population (n = 1256) presenting with acute ischemic stroke who underwent magnetic resonance imaging (MRI) within 24 hours of admission. Patients were recruited in Massachusetts General Hospital, Boston, from May 31, 2009, to December 31, 2011. Data were analyzed from May 1, 2019, until June 30, 2020. Main Outcomes and Measures: Initial stroke severity (within 24 hours of presentation) was determined using clinical (National Institutes of Health Stroke Scale [NIHSS]) and imaging (infarct volume by diffusion-weighted MRI) measures. Stroke etiologic subtypes were determined using the Causative Classification of Ischemic Stroke algorithm. Long-term stroke disability was measured using the modified Rankin Scale. Socioeconomic status was estimated using zip code–derived median household income and census block group–derived area deprivation index (ADI). Regression and mediation analyses were performed. Results: A total of 1098 patients had imaging and SES data available (mean [SD] age, 68.1 [15.7] years; 607 men [55.3%]). Income was inversely associated with initial infarct volume (standardized β, −0.074 [95% CI, −0.127 to −0.020]; P =.007), initial NIHSS (standardized β, −0.113 [95% CI, −0.171 to −0.054]; P <.001), and long-term disability (standardized β, −0.092 [95% CI, −0.149 to −0.035]; P =.001), which remained significant after multivariable adjustments. Initial stroke severity accounted for 64% of the association between SES and long-term disability (standardized β, −0.063 [95% CI, −0.095 to −0.029]; P <.05). Findings were similar when SES was alternatively assessed using ADI. Conclusions and Relevance: The findings of this cohort study suggest that lower SES is associated with larger infarct volumes on presentation. These SES-associated differences in initial stroke severity accounted for most of the subsequent disparities in long-term disability in this study. These findings shift the culpability for SES-associated disparities in poststroke disability from poststroke factors to those that precede presentation.
- Subjects
MASSACHUSETTS; CONFIDENCE intervals; FUNCTIONAL status; ISCHEMIC stroke; REGRESSION analysis; SOCIOECONOMIC factors; INCOME; SEVERITY of illness index; STROKE patients; FACTOR analysis; DESCRIPTIVE statistics; DATA analysis software; LONGITUDINAL method
- Publication
JAMA Network Open, 2022, Vol 5, Issue 4, pe229178
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2022.9178