MedWire News: Stroke patients with low socioeconomic status are commonly admitted to hospitals that see few stroke cases, reducing their chances of making a good recovery, a Canadian study shows.
"Canadians of different socioeconomic groups may have theoretical equal access to healthcare but practical access to unequal facilities," Gustavo Saposnik (St Michael's Hospital, Toronto) and colleagues write in the journal Stroke.
The researchers studied data on 25,228 ischemic stroke patients included in a national database. They divided patients into quintiles based on the median income of their neighborhood. The bottom two and the top three quintiles were taken to represent low and high income, respectively.
Many previous studies have shown high rates of case fatality among low-income stroke patients. That finding was replicated by Saposnik et al, who report case-fatality rates of 8.4%, 8.2%, 7.7%, 7.1%, and 6.6% among patients in the first, second, third, fourth, and fifth income quintiles, respectively.
But the team also found that low-income patients tended to be treated in hospitals with low stroke volumes. The proportion of patients treated in hospitals in the lowest quartile of stroke volumes (1-62 cases/year) fell from 30.4% of patients in the lowest income quintile to 10.3% of those in the highest quintile.
The reverse trend was apparent for hospitals in the highest stroke volume quartile (>198 cases/year), with the proportion of patients seen in these hospitals rising from 19.2% in the lowest income quintile to 35.9% in the highest.
Treatment in a low-volume hospital is an established risk factor for increased case fatality, as these hospitals tend to be short on specialist treatment facilities and physicians experiencing in dealing with stroke. In the current study, case-fatality rates fell across stroke-volume quartiles, from 9.4% to 5.9%.
Overall, the case-fatality rate was 7.8% among low-income patients treated in low-volume hospitals, compared with 6.2% among high-income patients treated in high-volume hospitals - a significant difference. The difference persisted after accounting for age, gender, comorbidities, hospital location and teaching status, and physician characteristics (specialist vs nonspecialist).
"Our study suggests that efforts should be directed toward identifying high-risk subsets of populations as well as institutions with higher-than-expected fatality rates," conclude the researchers.