Material deprivation increases costs, poor outcomes after stroke

Neighborhood material deprivation is linked to increased medical costs and poor clinical outcomes after stroke in a publicly funded universal health care system, according to a population-based, retrospective study published in Neurology.

“While universal health care access may address some barriers to affordability of care, higher disability is consistently reported in patients with stroke who are disadvantaged compared to those who are less disadvantaged,” Amy Y.X. Yu, MD, MSc, of University of Toronto’s department of medicine and Institute of Health Policy, Management and Evaluation in Toronto, and colleagues wrote. “A better understanding of the relationship between socioeconomic status and costs may provide additional motivation to invest in programs to promote health equity through action on social determinants of health.”

Yu and colleagues examined 90,289 adult Ontario residents who had an ischemic stroke or intracerebral hemorrhage between April 1, 2008, and March 31, 2017. With multiple strokes, only the first stroke was counted for analysis.

Investigators divided participants into quintiles based on neighborhood material deprivation, with Q1 being least deprived and Q5 being most deprived. Researchers evaluated direct payer and governmental costs directly related to patient care.

During the first year following stroke, the average direct total health care cost was $53,001. Q1 had the lowest direct costs at $50,602 on average; Q5 had the highest at $56,292 on average. While unadjusted average costs in the first three quintiles were similar, Q4 (very deprived group) costs were 5% higher than Q1’s (relative cost ratio [RCR] = 1.05; 95% CI, 1.03-1.08), and Q5 costs were 11% higher than Q1’s (RCR = 1.11; 95% CI, 1.08-1.13).

Mortality risk was higher in Q5 than in Q1 (HR = 1.07; 95% CI, 1.03-1.12) with fully adjusted models.

Need for long-term care within 1 year of stroke increased with higher levels of deprivation. In Q3 (slightly deprived group), long-term care admission was 18% higher than in Q1 (HR = 1.18; 95% CI, 1.09-1.27). It was 22% higher in Q4 (HR = 1.22; 95% CI, 1.13-1.31) and 30% higher in Q5 (HR = 1.3; 95% CI, 1.21-1.4).

“Our findings suggest that universal access to health care is insufficient in mitigating the disparity in health outcomes by socioeconomic status and that dedicated interventions or health programs are needed to improve outcomes after stroke in people experiencing material deprivation,” Yu told Healio Psychiatry.

Yu and colleagues suspected these results may be due to noncomprehensive universal health care; the intrinsic relationship of socioeconomics, education and health behaviors; and access to outpatient treatment clinics.

Limitations included measurement of neighborhood-level rather than individual-level material deprivation; non-evaluation of patient costs, such as lost income; no analysis of transient ischemic attack, minor strokes or treatment by IV thrombolysis or endovascular thrombectomy; observational design; and inability to assess quality of care.

“We are now investigating whether neighborhood-level material deprivation is associated with differences in primary and secondary stroke prevention care to gain knowledge on why material deprivation is associated with worse outcomes,” Yu said.