People with lower incomes are less likely to present at a hospital within 3 hours of stroke symptoms and thus have lower rates of thrombolysis therapy or post-stroke care than their more affluent counterparts, according to a retrospective analysis.
Writing in Stroke, Moira Kapral (Toronto General Hospital, Ontario, Canada) and colleagues speculate that "individuals from lower-income areas could benefit from focused education about stroke warning signs and the importance of timely assessment."
They examined the medical records of 11,050 patients who had been admitted for stroke or transient ischemic attack between July 2003 and March 2008. While stroke severity and outcome were similar across income quintiles, those in higher-income groups had a shorter duration between stroke onset and hospital arrival (median of 3.7 hours for those with the highest income versus 5.7 hours for those with the lowest income), higher rates of admission to a stroke unit (66.7% versus 63.8%), and more use of thrombolysis for those with ischemic stroke (14.6% vs 12.8%).
Rates of discharge to an inpatient rehabilitation unit were similar among income groups, but those in lower-income quintiles were less likely to be referred to stroke secondary prevention clinics. Higher-income patients also had significantly more physician visits in the 3 months following their stroke. There were no significant differences across incomes in terms of rates of occupational and physical therapy and speech language pathology.
"Although the small differences in care that we observed across income groups are unlikely to contribute to major differences in survival after stroke, it is concerning that in each case care was slightly better for those in the higher compared with the lower income groups," write the investigators. "All patients in our study received care at regional stroke centers, so the findings cannot be attributed to variability in the availability of specialized stroke resources."
Kapral and colleagues observe that improved patient outcomes in stroke have been linked with stroke unit and vascular neurologist care, and that stroke secondary prevention clinics "provide counseling, education, and monitoring of treatment adherence that may be particularly valuable to lower-income patients with a high prevalence of vascular risk factors."
Therefore, they add, "health care systems and providers should work to reduce income-related disparities in stroke care both during and after the initial index hospitalization."
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