Pan et al Socioeconomic Status and Quality of Stroke Care 2837 by levels of education , occupational class , and average family income per capita on quality of care in stroke patients

Stroke is the leading cause of disability and the second cause of death in the world. There is evidence that increased quality of care during the early phase of stroke is significantly associated with reduced risk of disability and mortality. However, the quality of stroke care has varied globally; high-income countries have better quality of stroke care than lowand middle-income countries; and even in the same country, inequalities in stroke care exist across populations. Although stroke patients with low socioeconomic status (SES) have an increased mortality and poorer functional recovery, the association between SES and quality of stroke care remains unclear. Recent findings from the United Kingdom suggest that lower SES was associated with reduced odds of being admitted to hospital (stroke unit or otherwise). The association was also found in other studies undertaken in high-income countries. However, other studies did not detect such a social gradient association. These inconsistent findings may be because of different measurements of the quality of stroke care and SES. Few studies have used levels of education, occupation, and income or other SES indicators simultaneously to examine their associations with quality of stroke care. It is unknown whether there are interactions and combined effects of these SES indicators on the quality of stroke care. There is lack of data from lowand middleincome countries, where quality of stroke care is much poorer and stroke mortality is higher than that in high-income countries. The association of SES with the quality of stroke care has not been well studied. In this article, we examined a large cohort data from China to assess the impacts of SES indicated Background and Purpose—The association of socioeconomic status (SES) with quality of stroke care is not well understood, and few studies have examined the association with different indicators of SES simultaneously. We assessed the impacts of low levels of education, occupation, and income on the quality of stroke care. Methods—We examined data from the China National Stroke Registry recording consecutive stroke patients between September 2007 and August 2008. Baseline low SES was measured using educational level <6 years, occupation as manual workers or no job, and average family income per capita at ≤¥1000 per month. Compliance with 11 performances was summarized in a composite score defined as the proportion of all needed care given. Poor quality of care was defined as having a composite score of 0.71 or less. Results—Among 12 270 patients with ischemic stroke, 38.6% had <6 educational years, 37.6% had manual workers/no job, and 34.7% had income ≤¥1000 per month. There was an increased chance of receiving poor quality of care in patients with low education (adjusted odds ratio 1.15, 95% confidence interval 1.03–1.28), low occupation (adjusted odds ratio 1.16, 95% confidence interval 1.01–1.32), and low income (adjusted odds ratio 1.18, 95% confidence interval 1.06–1.30), respectively. People with low SES had poor performances on some aspects of care quality. Combined effects existed among these SES indicators; those with low SES from all 3 indicators had the poorest quality of care. Conclusions—There was a social gradient in the quality of stroke care. Continuous efforts of socioeconomic improvement will increase the quality of acute stroke care. (Stroke. 2016;47:2836-2842. DOI: 10.1161/STROKEAHA.116.013292.)