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Investigating Multiple Mediators to Mitigate Socioeconomic Differences in Patient-Reported Outcomes After Stroke:
Anita Lindmark1, David Darehed2
1Department of Statistics, Umeå School of Business, Economics and Statistics Umeå University Umeå Sweden.
Background:
Substantial socioeconomic differences in patient-reported outcome measures (PROMs) 3 months after stroke have recently been shown. We aimed to understand the underlying mechanisms and investigate potential interventional targets to equalize differences.
Methods:
All patients aged 18 to 64 years, independent in activities of daily living, registered with a first-time stroke in Riksstroke (the Swedish Stroke Register) from 2015 to 2017 were included. PROMs 3 months after stroke included activities of daily living status, mood, fatigue, pain, and general health. Socioeconomic status (SES) was measured on the basis of income and education. Using causal mediation analysis, we simulated the effect of interventions on the distributions of smoking, metabolic health (diabetes, antihypertensive treatment, statin treatment), atrial fibrillation, and stroke characteristics (stroke type, severity) on the absolute SES-related risk difference in PROMs.
Results:
Of 6910 patients, 8% had become dependent in activities of daily living, 13% reported low mood, 42% fatigue, 23% pain, and 17% poor general health 3 months after stroke. Adjusted for sex and age, low SES was associated with increased absolute risks of poor PROMs with between 6% and 18% compared with higher SES with the largest increase for general health (18.2% [95% CI, 13.5%-22.9%]). Intervening to shift the distribution of all mediators among patients with low SES to those of patients with higher SES potentially reduces SES disparities by a proportion of 14% to 45%. For most PROMs the most important intervention was reducing smoking and improving metabolic health.
Conclusions:
Working-age patients with low SES report more severe outcomes 3 months after stroke than patients with higher SES. Targeted interventions reducing the prevalence of smoking, diabetes, hypertension, and high cholesterol in patients with low SES could mitigate these disparities.
