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Abstract

Objective:

Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors.

Methods:

We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors.

Results:

Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17–2.68).

Conclusion:

Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.

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Supplementary Material

File (tables_e-1_and_e-2.doc)
File (wnl204668.pdf)

STUDY FUNDING

The research reported in this article was supported by the American Heart Association PRT-Spina Outcomes Research Center #0875135N, Los Angeles Stroke Prevention/Intervention Research Program in Health Disparities #U54NS081764, and by contracts N01-HC-85239, N01-HC-85079 through N01-HC-85086, N01-HC-35129, N01 HC-15103, N01 HC-55222, N01-HC-75150, N01-HC-45133, and grant HL080295 from the National Heart, Lung, and Blood Institute, with additional contribution from the National Institute of Neurological Disorders and Stroke. Additional support was provided through AG-023629, AG-15928, AG-20098, and AG-027058 from the National Institute on Aging. A full list of principal CHS investigators and institutions can be found at http://www.chs-nhlbi.org/pi.htm. Dr. Brown was also supported by the NIH/National Center for Advancing Clinical and Translational Science grant #UL1TR000124.

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Letters to the Editor
1 July 2013
Neighborhood socioeconomic disadvantage and mortality after stroke
Manoj K. Mittal, Neurocritical Care Fellow
Jennifer B. McCormick, Rochester, MN

Brown et al. reported higher post-stroke mortality among residents of the most socioeconomic disadvantaged census tracts relative to the residents of the least disadvantaged census tracts.[1] The authors did not find any association by race or income. Table e-2 shows that whites have 1.49 times higher risk of post-stroke mortality at 1 year (p value=0.06). Interestingly, a previous cardiovascular health study showed 2.9 times higher risk of post-stroke mortality in blacks (p value less than 0.05).[2] This association of race and mortality is surprising. The authors could address this paradox by comparing the race/ethnicity of participants who were excluded secondary to geocoding issues with their addresses to those who were included. Other potential confounders could be patient mobility status and use of IV thrombolysis, which are independent risk factors for post-stroke mortality.[2-4] Black race and low income are significant predictors for not receiving IV thrombolysis.[5] The effect of neighborhood on mortality should be adjusted for mobility status and use of IV thrombolysis. Better health policies are needed to improve access of care for minorities and the poor to provide life-saving, FDA approved treatments like IV thrombolysis and post-stroke care.

DISCLAIMER: The views expressed by authors do not represent the views of the Mayo Clinic.

1. Brown AF, Liang LJ, Vassar SD, et al. Neighborhood socioeconomic disadvantage and mortality after stroke. Neurology 2013; 80:520-527

2. Longstreth WT, Bernick C, Fitzpatrick A, et al. Frequency and predictors of stroke death in 5,888 participants in the Cardiovascular Health Study. Neurology 2001;56:368-375.

3. Webster F, Saposnik G, Kapral MK, Fang J, O'Callaghan C, Hachinski V. Organized Outpatient Care: Stroke Prevention Clinic Referrals Are Associated With Reduced Mortality After Transient Ischemic Attack and Ischemic Stroke. Stroke 2011;42:3176-3182.

4. Fischer U, Mono M-L, Zwahlen M, et al. Impact of Thrombolysis on Stroke Outcome at 12 Months in a Population: The Bern Stroke Project. Stroke 2012;43:1039-1045.

5. Kimball MM, Neal D, Waters MF, Hoh BL. Race and Income Disparity in Ischemic Stroke Care: Nationwide Inpatient Sample Database, 2002 to 2008. Journal of Stroke and Cerebrovascular Diseases 2013.

For disclosures, please contact the journal at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 80Number 6February 5, 2013
Pages: 520-527
PubMed: 23284071

Publication History

Received: June 14, 2012
Accepted: October 2, 2012
Published online: January 2, 2013
Published in print: February 5, 2013

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Disclosure

A.F. Brown is coinvestigator on several grants through the NIH and was the principal investigator for this project funded by the American Heart Association PRT-Spina Outcomes Research Center. L.-J. Liang is a coinvestigator on several grants funded by the NIH and the American Heart Association PRT-Spina Outcomes Research Center. S.D. Vassar and S.S. Merkin report no disclosures. W.T. Longstreth is a coinvestigator on several grants and contracts funded through the NIH and was a consultant funded through the American Heart Association PRT-Spina Outcomes Research Center for this research project. B. Ovbiagele and T. Yan report no disclosures. J.J. Escarce is coinvestigator on several grants through the NIH and was a coinvestigator for this project funded by the American Heart Association PRT-Spina Outcomes Research Center. Go to Neurology.org for full disclosures.

Authors

Affiliations & Disclosures

Arleen F. Brown, MD, PhD
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
1)NIH/National Center for Advancing Translational Science (NCATS), UCLA Clinical and Translational Science Institute (CTSI) UL1TR000124 (Steven Dubinett) 06/01/2011-02/29/20162).3)NIH/Centers for Disease Control The Diabetes Health Plan: A System Level Intervention to Prevent & Treat Diabetes, 1U58DP002722 (Carol Mangione) 09/30/10 - 09/29/154)NIH/NHLBI, N01-HC-95160 (Watson)., 08/15/08-08/15/11. Subclinical Cardiovascular Disease Study Multi-Ethnic Study of Atherosclerosis (MESA)5)CDC, City of Los Angeles/ DHHS Award CDC Public Health Preparedness Grant: Community Resiliency Pilot, PH001516 (UCLA PI: Kenneth Wells; Prime PI: Plough)01/14/11 - 08/09/11 6)NIH/NIMHD. 1P60MD00692301 (Mays), 08/01/2012-01/31/2017, "Financial Incentives and SMS to Improve African American Women's Glycemic Control," in the Bridging Research, Innovation, Training & Education Solutions for Minority Health Center
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
1)Robert Wood Johnson Foundation Using Member Financial Incentives and Culturally Tailored Diabetes Outreach to Reduce Disparities in Glycemic Control 20101548 01/01/11 - 12/31/13 2)American Heart Association, Are Neighborhood Characteristics Associated with Stroke Incidence and Outcomes? 0875133N (Brown; Center Director Vickrey), 10/1/2008 to 9/30/2012.
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Li-Jung Liang, PhD
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Stefanie D. Vassar, MS
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Sharon Stein Merkin, PhD
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
1)NIH/NIA, 1R01AG033067-01A1, Data Analyst, 2009-20132)NIH/subcontract, 5R01HI101161-03, Data Analyst, 2010-20133)NIH/NIA, 5R01AG032271-02, Data Analyst, 2009-2012
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
W.T. Longstreth, Jr, MD
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Bruce Ovbiagele, MD
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
1) Assistant Editor: Stroke2) Editorial Board: Journal of Stroke and Cerebrovascular Diseases
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NIH-NINDS, U01 NS079179, Principal Investigator
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Tingjian Yan, PhD
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Serves on the editorial board for Home Health CareServices Quarterly (2009 to present
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
SCAN Health Plan, Healthcare Researcher
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Funded as a postdoctoral fellow by the American HeartAssociation Pharmaceutical Roundtable -Spina OutcomesResearch Center#0875133N
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
José J. Escarce, MD, PhD
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Health Services Research, Editor-in-Chief, 2006-Present
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1)Robert Wood Johnson Foundation, 59968 (Brook),Associate Director of RWJF Clinical Scholars Program,2012-2013(2)Robert Wood Johnson Foundation, 69075 (Escarce),Primary Investigator, 2011-2012(3)DHHS/Health Resources & Services Administration,5R40MC21516 (Chung), co-investigator, 2011-2014(4)Robert Wood Johnson Foundation, 20101548 (Escarce),Primary Investigator, 2011-2013(5)Robert Wood Johnson Foundation, 20101548 (Ting),co-investigator, 2010-2013(6)NIH/National Institute of Health on Aging, 1RC4AG039077(Shapiro), co-investigator, 2010-2013(7)DHHS/Agency for Healthcare Research and Quality,R01HS19311-01 (Ong), co-investigator, 2010-2013(8)DHHS/AHRQ/RAND Corporation,99201000055 (Sood,Newhouse), co-investigator, 2009-2013(9)American Heart Association, 0875133N (Vickery),co-investigator, 2008-2012Robert Wood Johnson Foundation
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to Dr. Brown: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Dr. Brown: study supervision, study concept and design, analysis and interpretation, drafting/revising the manuscript. Dr. Liang: analysis and interpretation, drafting/revising the manuscript. S.D. Vassar: analysis and interpretation, drafting/revising the manuscript. Dr. Merkin: analysis and interpretation, drafting/revising the manuscript. Dr. Longstreth: analysis and interpretation, drafting/revising the manuscript. Dr. Ovbiagele: analysis and interpretation, drafting/revising the manuscript. Dr. Yan: analysis and interpretation, drafting/revising the manuscript. Dr. Escarce: study concept and design, analysis and interpretation, drafting/revising the manuscript.

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  10. Impact of areal socioeconomic status on prehospital delay of acute ischaemic stroke: retrospective cohort study from a prefecture-wide survey in Japan, BMJ Open, 13, 8, (e075612), (2023).https://doi.org/10.1136/bmjopen-2023-075612
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