Socioeconomic Status and Care After Stroke

Results From the Registry of the Canadian Stroke Network

Kun Huang, PhD, MD; Nadia Khan, MD, MSc, FRCPC; Allison Kwan, MD; Jiming Fang, PhD;
Lingsong Yun, MSc; Moira K. Kapral, MD, MSc, FRCPC

Background and PurposeSocioeconomic status is inversely associated with mortality after stroke; however, the reasons
behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and
medication adherence vary with neighborhood income.
MethodsWe conducted a cohort study of 11050 patients with ischemic stroke or transient ischemic attack admitted to
any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic
status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to
administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We
used multivariable analyses to assess whether differences in stroke care and medication adherence existed across
income groups after adjustment for age, sex, stroke severity, and comorbid conditions.
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ResultsHigher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to
secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates
were small. There was no difference across income quintiles in the use of postdischarge homecare services or in
adherence to antihypertensive, antithrombotic, or lipid-lowering medications.
ConclusionsHigher income is associated with improvements in some aspects of stroke care delivery. However, the
magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed
association between socioeconomic status and survival after stroke. (Stroke. 2013;44:477-482.)
Key Words: Registry of the Canadian Stroke Network secondary prevention socioeconomic status stroke care

S
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ocioeconomic status is an important predictor of health status

and mortality in most industrialized nations, with an inverse
association between socioeconomic status and both
incidence and mortality from stroke and other cardiovascular
diseases.15 Various measures of socioeconomic status,
includ-ing income, wealth, and education, all have been
linked to stroke outcomes, as have both individual-level and
area-level socioeconomic factors.625
The mechanisms by which socioeconomic status affects
stroke incidence and fatality are not well-established. Lower
socioeconomic status is associated with vascular risk factors and
comorbidities that contribute to higher stroke incidence and are
likely to decrease survival after stroke.11,2123 Some studies also
have suggested an association between socioeco-nomic status
and the quality of stroke care delivery; however, results from
previous studies have been inconsistent.8,2325 Most research
has focused on care during the acute stroke hos-pitalization, and
little is known about whether socioeconomic differences exist in
risk factor modification or in the quality or intensity of
postdischarge care.
We used a clinical database, the Registry of the Canadian
Stroke Network (RCSN), linked to population-based admin-
istrative databases to determine whether socioeconomic sta-
tus, defined as neighborhood income group, is associated
with stroke care delivery, follow-up visits, and medication
adher-ence within 1 year of admission for acute stroke or
transient ischemic attack.
Methods
Setting
We conducted a retrospective analysis of Ontarians admitted with acute
stroke or transient ischemic attack to any of 11 regional stroke centers
between June 1, 2003 and March 31, 2008. These institutions each
examine 500 to 1000 stroke cases annually (20% of all stroke/ transient
ischemic attack cases in the province), and all are large-volume tertiary
care centers with stroke care expertise and the capacity to administer
thrombolysis and perform neurosurgery. Provincial residents have
universal access to hospital care, physicians services, and postdischarge
health services, including nursing, physiotherapy, and occupational
therapy; residents aged 65 years have universal access to prescription
drugs covered by the provincial formulary.

Received July 28, 2012; final revision received October 10, 2012; accepted October 29, 2012.
From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine,
University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of
Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of
General Internal Medicine and Toronto General Research Institute, University Health Network, Toronto Canada (M.K.K.).
Correspondence to Moira K. Kapral, MD, MSc, FRCPC, Toronto General Hospital, 200 Elizabeth St, 14EN-215, Toronto ON M5G 2C4, Canada. E-
mail moira.kapral@uhn.on.ca
2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.112.672121

477
 478 Stroke February 2013
Data Sources and Study Sample
The RCSN collects detailed information on acute stroke manage-
ment, including prehospital and emergency services and in-hospital
care, complications, and outcomes for all consecutive patients ex-
amined at regional stroke centers. Chart abstraction is performed by
trained neurology research nurses, and validation by duplicate chart
abstraction has shown excellent agreement for key variables, includ-
ing age, sex, stroke type, use of thrombolysis, and stroke unit care. 26
The data collection software forces chart abstraction personnel to
per-form complete data entry before the case record can be
submitted for inclusion in the database, ensuring that there are no
missing data. The RCSN is prescribed under provincial privacy
legislation so that chart abstraction may be performed without
individual patient consent. The RCSN is housed at the Institute for
Clinical Evaluative Sciences, where it is linked to population-based
administrative databases using unique anonymized patient
identifiers. We used the physician claims database to provide data
on follow-up visits, the Community Care Access Center database to
provide data on nursing, physiotherapy, and occupational therapy
services provided after discharge, and the Ontario Drug Benefits
Database to provide data on prescription claims, including the
quantity and dates of drugs dispensed, for pa-tients aged 65 years.
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For the present study, we included all patients with ischemic
stroke or transient ischemic attack who were admitted to hospital
and dis-charged alive. For patients with >1 stroke event during the
study pe-riod, only the first event was included in the present
analyses. Patients with strokes that occurred as in-hospital
complications, those with invalid postal codes, and those with
income quintiles that could not be determined were excluded.
Assessment of Socioeconomic Status
The RCSN database does not contain individual-level measures of
so-cioeconomic status; therefore, socioeconomic status was imputed
us-ing median neighborhood income based on the 2006 Canada
Census database. Patients from the RCSN were linked to the
dissemination area of their principal residence using the Statistics
Canada Postal Code Conversion File. On the basis of median
income in each dis-semination area, neighborhoods were divided
into income quintiles, with quintiles 1 and 5 having the lowest and
highest median incomes, respectively.8
Outcomes
Using the RCSN database, we evaluated the following outcomes across
income quintiles: (1) the use of thrombolysis, stroke unit care, and
neurologist consultation during the initial acute stroke hospi-talization;
(2) referrals to specialized stroke secondary prevention clinics; (3)
discharges to inpatient rehabilitation facilities; and (4) prescriptions of
antihypertensive, antithrombotic, and lipid-lowering medications at
discharge. Using the Community Care Access Center and physician
claims databases, we determined the proportion of pa-tients who
received outpatient nursing, physiotherapy, occupational therapy, speech
language pathology services, or physician visits during the first 3 months
after an acute stroke admission. Using the Ontario Drug Benefits
database, we evaluated adherence to antihy-pertensive medications
(including angiotensin-converting enzyme inhibitors, diuretics, beta
blockers, calcium channel blockers, and angiotensin receptor blockers),
3-hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins),
and warfarin (in the subgroup of pa-tients with atrial fibrillation) within
1 year of discharge.
Statistical Analysis
Patient baseline characteristics and outcomes were compared across
income groups using a CochranArmitage trend test for categori-cal
variables and simple linear regression and median regression for
continuous variables. Where differences in outcomes were observed,
multivariable logistic regression models were developed to
determine the relationship of neighborhood income to these
outcomes, with ad-justment for age, sex, rural residence, stroke
type, stroke severity, and time from stroke onset to hospital arrival.
Analyses of medication adherence were performed for the sub-group
of patients aged 66 years, who were admitted to hospital be-tween July
1, 2003 and March 31, 2006, who were alive at 3 months after discharge,
and who filled a medication prescription within 3 months of hospital
discharge. To simplify presentation of these re-sults, income quintiles
were collapsed into 3 groups: low income (the 2 lowest income
quintiles); medium income (containing the third and fourth quintiles);
and high income (containing the highest income quintile). We calculated
the 1-year proportion of days covered (PDC), defined as the number of
days a patient had a medication available during the year divided by 365,
for each patient and each drug class. For patients who died during this
period, we used survival time since the first prescription fill as the
denominator. PDC values were cat-egorized as 0.8 to reflect high
adherence and as <0.8 to reflect sub-optimal adherence, because PDCs
>0.8 have been associated with improved blood pressure control and
reduced mortality compared with lower levels of adherence. 2730
Differences in PDC across income groups were compared using 2 tests.
SAS version 9.1 was used for all analyses. The study was
approved by the Research Ethics Board of the Sunnybrook Health
Sciences Center, Toronto, Canada.
Results
After exclusions, the study sample consisted of 11050 patients
admitted to hospital with stroke or transient ischemic attack.
Overall, 47.1% were women, and the median age was 74 years
(Table 1). Those in the higher income quintiles were more likely
to be men and white than those in the lower income quintiles,
and they were less likely to live alone, to smoke cigarettes, and
to have coronary artery disease or diabetes mellitus (Table 1).
Stroke type and severity were similar across income quin-tiles
(Table 2). Higher socioeconomic status was associated with a
shorter duration between stroke onset and hospital arrival (Table
2). There was no significant difference in the use of
neuroimaging, carotid imaging, antithrombotic therapy, lipid-
lowering therapy, or warfarin for ischemic stroke with atrial
fibrillation across income quintiles (Table 2). However, higher
neighborhood income was associated with increased rates of
admission to a stroke unit (66.7% in the highest com-pared with
63.8% in the lowest income quintile; P=0.02), care by a
neurologist (75.0% vs 68.1%; P<0.001), and use of
thrombolysis for ischemic stroke (14.6% vs 12.8%; P=0.04;
Table 2), and these differences persisted even after adjustment
for age, sex, comorbid conditions, and stroke severity (data not
shown). The difference in thrombolysis rates by income quin-
tile was no longer significant once the analysis was restricted to
patients presenting within 3 hours of symptom onset.
Rates of discharge to inpatient rehabilitation facilities were
similar across income quintiles (Table 3). However, those in the
higher income quintiles were more likely to be referred to stroke
secondary prevention clinics compared with those in the lower
income quintiles (43.3% for the highest income quintile vs
33.8% for the lowest quintile; P<0.001; Table 3), even after
adjustment for age and other factors (data not shown). Within
the first 3 months of discharge, there was no significant
difference across income quintiles in the proportion of patients
receiving home care nursing, physiotherapy, occupational
therapy, or speech language pathology, or in the median number
of visits for each of these services; however, higher income was
associated with an increased number of physician visits (mean
number of visits 4.5 for the highest vs 4.2 for the lowest income
quintile; P<0.001; Table 3). In the subgroup of patients aged
66 years who filled a prescription
 Huang et al Socioeconomic Status and Care 479

Table 1. Baseline Characteristics of Patients by Income Quintile

Income Quintile*
Variable 1 (Lowest) 2 3 4 5 (Highest) P
N 2683 2329 2108 1860 2070
Median neighborhood income, Cdn$ 19 481 24 703 28 587.5 31 776.5 38 615.5 <0.001
Women, % 49.4 46.8 48.1 43.9 46.1 <0.01
Age, y (median) 74 74 74 74 76 <0.001
Rural residence, % 10.2 9.7 11.1 10.1 10.3 0.76
White, % 53.3 57 56.4 58.9 60.1 <0.001
Living alone, % 28.4 22.8 18.4 18.3 17.0 <0.001
Smoking, % 25.6 21.5 19.4 17.3 15.0 <0.001
Previous stroke, % 22.4 19.5 21.9 21.7 20.0 0.30
Diabetes mellitus, % 28 26.1 24.3 24.6 20.8 <0.001
Hypertension, % 68.7 68.4 65.3 67.3 66.5 0.06
Atrial fibrillation, % 14.1 15.8 14.9 15.9 17.3 <0.01
Previous myocardial infarction, % 16.1 14.9 14.3 14.9 13.7 0.03
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CharlsonDeyo score > 2, % 36.8 34.1 33.3 34.2 30.6 <0.001

Stroke type, % 0.77
Ischemic 83.3 83.8 82.4 83.8 83
TIA 16.7 16.2 17.6 16.2 17
CNS score >8, % 65.4 63.8 64.1 65 65.5 0.76
Arrival to ED within 2 h of stroke onset, % 31.2 35.2 37 37.3 37.8 <0.001
Median time from stroke onset to ED arrival, h 5.67 4.89 4.25 3.93 3.71 <0.001
Cdn$ indicates Canadian dollars; CNS, The Canadian Neurological Scale; ED, emergency department; and TIA, transient ischemic attack.
*Neighborhoods were divided into quintiles based on median income from 2006 Canada Census data, where quintile 1 represents the
lowest and quintile 5 represents the highest income quintile.
Ethnic origin could not be determined through chart review in 36% of patients.
P value based on test for trend.
Data source: Registry of the Canadian Stroke Network.

Table 2. In-hospital Stroke Management by Income Quintile

Income Quintile*
Variables 1 (Lowest) 2 3 4 5 (Highest) P
N 2683 2329 2108 1860 2070
Neuroimaging done, % 98.9 99 98.7 99.1 99.5 0.05
Admission to stroke unit, % 63.8 64.2 65 65.6 66.7 0.02
Neurologist as most responsible physician, % 68.1 72.3 70.9 73.8 75.0 <0.001
Carotid imaging done, % 83.5 86.1 86.3 86.1 86.3 <0.01
Lipid levels measured, % 72.8 73.7 73.6 73.5 73.9 0.47
Occupational therapy, % 79.2 79.4 79.2 76.8 79.6 0.50
Physiotherapy, % 82.9 83.5 81.9 80.4 82.5 0.14
Speech language pathology, % 59.4 60.1 58.9 57.7 61 0.78
Social work, % 48.5 49.3 45.8 45.2 48.9 0.32
Subgroup with ischemic stroke, N 2235 1952 1738 1558 1718
Thrombolysis administered to all ischemic stroke patients, % 12.8 15.4 16.7 16.6 14.6 0.04
Thrombolysis administered if arrival within 3 h of stroke onset, % 35.6 38.3 40.1 40.4 33.9 0.79
Neuroimaging includes computed tomography and magnetic resonance imaging. Carotid imaging includes carotid Doppler ultrasound,
computed tomographic angiography, magnetic resonance angiography, and catheter angiography.
*Neighborhoods were divided into quintiles based on median income from 2006 Canada Census data, where quintile 1 represents the
lowest and quintile 5 represents the highest income quintile.
P value based on test for trend.
Data source: Registry of the Canadian Stroke Network.
 480 Stroke February 2013

Table 3. Stroke Care Within 3 Months of Discharge by Income Quintile

Income Quintile*
Variables 1 (Lowest) 2 3 4 5 (Highest) P
N 2683 2329 2108 1860 2070
At discharge
Antithrombotic therapy, % 94.5 94.6 94.3 96 94.9 0.16
Warfarin for atrial fibrillation, % 70.9 70.3 69.1 76 74.1 0.09
Antihypertensive therapy, % 79.9 78.7 77.5 79.1 76 <0.01
Lipid-lowering therapy, % 68.1 69.4 67.5 68.4 68.8 0.88
Transfer to inpatient rehabilitation, % 29.9 30.1 29 29.5 30 0.86
Referral to stroke prevention clinic, % 33.8 35.3 35.7 39.5 43.3 <0.001
Three months postdischarge
Any outpatient physician visit, % 87.0 89.8 88.8 89.9 90.3 <0.001
No. of outpatient physician visits, mean 4.2 4.5 4.3 4.8 4.5 <0.001
Any home nursing visit, % 7.9 7.7 8 7 7.2 0.23
No. of nursing visits, median 8 7 7 8 7 0.27
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Home occupational therapy, % 14.8 15.7 14.8 15.2 14.8 0.85

No. of occupational therapy visits, median 2 2 2 2 2 1.00
Home physiotherapy, % 9.3 11.1 8.7 9.5 8.2 0.06
No. of physiotherapy visits, median 4 3 3 4 4 1.00
Home speech language therapy, % 4.3 4.9 5.3 4.7 4.5 0.76
No. of speech language therapy visits, median 3 3 3 2 3 1.00
Home social worker, % 1.5 1.4 1.1 1.2 0.6 <0.01
Social worker visits, median 3 2 2 2 2.5 1.00
Antithrombotic therapy includes aspirin, clopidogrel, dipyridamole, and warfarin.
*Neighborhoods were divided into quintiles based on median income from 2006 Canada Census data, where quintile 1
represents the lowest and quintile 5 represents the highest income quintile.
P value based on test for trend.
Data sources: Registry of the Canadian Stroke Network, Physician Claims Database, and Community Care Access Center Database.

within 3 months of discharge, the proportion of patients who was slightly better for those in the higher compared with the
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were highly adherent (with a PDC >0.8) ranged from a low
of 51.9% for warfarin to a high of 81.8% for statins, and
there were no differences in medication adherence across
income groups (Table 4).
Discussion
We found that individuals from lower income areas were less
likely than those from high income areas to present within 3
hours of stroke onset and thus were less likely to receive throm-
bolysis, were less likely to be cared for on a stroke unit or by a
neurologist, less likely to be referred to a stroke secondary
prevention clinic at discharge, and less likely to have physician
visits within 3 months of discharge. We found no differences in
the amount of home care provided by nursing, physiotherapy,
occupational therapy, or speech language pathology, and no
differences in 1-year adherence to antihypertensive, lipid-low-
ering, or anticoagulant medications by income group.
Previous studies have documented that socioeconomic status
is inversely associated with mortality after stroke, and that this is
only partially explained by differences in processes of care and
measurable baseline factors.14,23,30 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
lower income groups. 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, and
it is possible that gaps in care between low- and high-income
groups would have been more marked with the inclusion of
patients from other types of hospitals. Both stroke unit and
vascular neurologist care have been associated with improved
patient outcomes, and 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.31,32
Because patients who receive thrombolysis are more likely to
receive both stroke unit and neurologist care, it is possible that
delays in presentation and subsequent ineligibility for
thrombolysis contributed to lower rates of these services for
those from lower income areas.
This study adds to the literature by providing information
on care after the initial stroke hospitalization and by suggest-
ing that there are no significant differences in the intensity of
home care services provided by nursing, physiotherapy, and
occupational therapy, and no differences in rates of dis-
charge to inpatient rehabilitation facilities based on socioeco-
nomic status. However, the finding of fewer physician visits
after hospital discharge in those from low-income compared
with higher-income areas is unanticipated, given the higher
 Huang et al Socioeconomic Status and Care 481

Table 4. High Adherence to Medications (At Least adherence. However, prescription data have been shown to
80% of Days Covered) Within 365 Days of Discharge, correlate with estimates from home inventories and physician
by Income Group, in Patients Aged 66 Years office records, and adherence based on prescription data has
Income Group* been correlated with a broad range of patient outcomes. 37,38
Low Quintiles Medium Quintiles High Quintile
Finally, our findings are based on data from specialized
1 and 2 3 and 4 5 P stroke centers within Ontarios organized system of stroke
care and in the context of Canadas universal health care
N 996 896 475
system and may not be generalizable to other jurisdictions or
Diuretics, % 68.6 66.6 67.8 0.57 health care settings.
ACE inhibitors, % 76.2 73.1 76.7 0.32 This study suggests that individuals from lower-income
Diuretic/ACE 64.9 58.5 66.9 0.36 areas could benefit from focused education about stroke
combinations, % warn-ing signs and the importance of timely assessment, and
ARBs, % 73.0 71.6 75.9 0.97 that strategies are needed to improve medication adherence
Calcium channel 73.5 71.4 76.5 0.67 in all income groups. Health care systems and providers
blockers, % should work to reduce income-related disparities in stroke
Beta blockers, % 75.8 74.4 74.8 0.97 care both during and after the index hospitalization.
Statins, % 78.0 81.8 76.7 0.36
Warfarin, % 52.4 51.9 55.7 0.63 Sources of Funding
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The Registry of the Canadian Stroke Network/Ontario Stroke

ACE indicates angiotensin-converting enzyme; and ARB,
angiotensin receptor blocker.
Statins represent 3-hydroxymethyl glutaryl coenzyme A reductase inhibitors.
*Neighborhoods were divided into quintiles based on median income from 2006
Canada Census data, where quintile 1 represents the lowest and quintile
5 represents the highest income quintile.
P value based on test for trend.
Data source: Ontario Drug Benefits Database.
Registry is funded by the Canadian Stroke Network and the Ontario
Ministry of Health and Long-Term Care. The Institute for Clinical
Evaluative Sciences is supported by an operating grant from the
Ontario Ministry of Health and Long-Term Care. M.K. Kapral holds
a Career Investigator Award from the Heart and Stroke Foundation
of Canada. N. Khan holds a career award from the Michael Smith
Foundation for Heath Research.

Disclosures
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prevalence of comorbid illness and need for follow-up care in

low-income groups, and contrasts with the findings from stud-
ies of patients with coronary artery disease, in whom lower
income has been associated with increased resource use.4
Multiple clinical trials have shown that treatment of hyper-
tension, antithrombotic therapy, and lipid-lowering therapy
reduce cardiovascular morbidity and mortality after stroke,
and recommendations on the use of these medications have
been incorporated into evidence-based guidelines for second-
ary stroke prevention.33 High adherence to antihypertensive
medications has been associated with both improved blood
pressure control and with reduced mortality after stroke. 27
30,34
Our finding of similar rates of adherence across income
groups to medications for secondary stroke prevention sug-
gests that medication adherence is not a major contributor to
socioeconomic statusrelated differences in outcomes after
stroke. Of note, medication adherence was suboptimal in all
patients, with high adherence rates at 1 year ranging from a
low of 51.9% for warfarin to a high of 81.8% for statins.
Some study limitations merit comment. We used income as
our marker of socioeconomic status, rather than education,
wealth, or other measures. Although these measures are gener-
ally highly correlated, they may not be consistent in direction
and magnitude for all outcomes.12,15 In addition, we used area-
level rather than individual-level measures of socioeconomic
status. Although this may lead to underestimates of the impact
of socioeconomic status on outcomes, such area-level income
measures generally provide results that are complementary to
those found using individual-level data, and reflect the avail-
ability of community resources, such as parks and schools, that
may affect health.35,36 We used prescription data rather than pill
counts or other measures to evaluate medication
None.
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 Socioeconomic Status and Care After Stroke: Results From the Registry of the Canadian
Stroke Network
Kun Huang, Nadia Khan, Allison Kwan, Jiming Fang, Lingsong Yun and Moira K. Kapral

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