Incidence and Case Fatality at the County Level as Contributors to Geographic Disparities in Stroke Mortality

Howard, George; Safford, Monika M.; Howard, Virginia J.; Judd, Suzanne E.; Cushman, Mary; Kissela, Brett M; Investigators, Racial Differences in Stroke

doi:10.1159/000449102

Cited by 17 publications

(18 citation statements)

References 19 publications

(17 reference statements)

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“…27 The second suggested both a higher incidence and a higher case fatality contribute to the higher stroke mortality in the southeastern stroke belt. 28 Herein, we demonstrate that, like the stroke mortality in blacks, the rural disparity in stroke death is primarily attributable to higher incidence and not case fatality.…”

Section: Discussionmentioning

confidence: 66%

Contributors to the Excess Stroke Mortality in Rural Areas in the United States

Howard

Kleindorfer

Cushman

et al. 2017

Stroke

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Background and Purpose Stroke mortality is 30% higher in the rural US. This could be due to either higher incidence or higher case-fatality from stroke in rural areas. Methods The urban-rural status of 23,280 stroke-free participants recruited between 2003 and 2007 in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study was classified using the Rural/Urban Commuting Area scheme as residing in urban, large rural town/city, or small rural town or isolated areas. The risk of incident stroke was assessed using proportional hazards analysis, and case-fatality (death within 30 days of stroke) was assessed using logistic regression. Models were adjusted for demographics, traditional stroke risk factors, and measures of socio-economic status (SES). Results After adjustment for demographic factors and relative to urban areas, stroke incidence was 1.23-times higher (95% CI: 1.01 – 1.51) in large rural town/cities, and 1.30-times higher (95% CI: 1.03 – 1.62) in small rural towns or isolated areas. Adjustment for risk factors and SES only modestly attenuated this association, and the association became marginally non-significant (p = 0.071). There was no association of rural-urban status with case-fatality (p > 0.47). Conclusions The higher stroke mortality in rural regions appeared to be attributable to higher stroke incidence rather than case fatality. A higher prevalence of risk factors and lower SES only modestly contributed to the increased risk of incident stroke risk in rural areas. There was no evidence of higher case-fatality in rural areas.

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Section: Discussionmentioning

confidence: 66%

Contributors to the Excess Stroke Mortality in Rural Areas in the United States

Howard

Kleindorfer

Cushman

et al. 2017

Stroke

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“…Participants with low education were likely subjected to particularly severe economic circumstances with families hovering on the brink of starvation as well as dealing with barriers to employment, health and social services as a result of institutionalized racism (Dollard, 1957). There is now considerable evidence that certain geographically defined communities, particularly in the south are at greater risk for chronic illnesses including cancer, vascular diseases, stroke, increased all-cause mortality rates, reduced life expectancy, and most recently, for greater recording of dementia/AD in death certificates (Dwyer-Lindgren et al, 2016;Karp et al, 2016;Labarthe et al, 2016;Rosenberg et al, 2016;Taylor, Greenlund, McGuire, Lu, & Croft, 2017). The explanations given for these geographically defined areas of increased risk include socioeconomic disparities, access to health care, lifestyle factors such as physical inactivity and smoking, obesity-increased rates of vascular risk factors, obesity, hypertension, and diabetes (Karp et al, 2016;Labarthe et al, 2016;Rosenberg et al, 2016).…”

Section: Discussionmentioning

confidence: 99%

The Association of Early Life Factors and Declining Incidence Rates of Dementia in an Elderly Population of African Americans

Hendrie

Smith-Gamble

Lane

et al. 2018

The Journals of Gerontology: Series B

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Objectives To explore the possible association of childhood residence, education levels, and occupation with declining incidence rates of dementia in 2 cohorts of elderly African Americans. Methods African Americans residing in Indianapolis without dementia were enrolled in 1992 and 2001 and evaluated every 2–3 years. The cohorts consist of 1,440 participants in 1992 and 1,835 participants in 2001 aged 70 years and older. Cox proportional hazard regression models were used to compare cohort differences in dementia and Alzheimer’s disease (AD) risk. Results The 2001 cohort had significantly decreased risk of both incident dementia and AD (hazard ratio [HR]: 0.62/0.57 for dementia/AD). Years of education was associated with decreased risk of dementia (HR = 0.93; p = .0011). A significant interaction (p = .0477) between education and childhood rural residence was found for the risk of AD that higher education level is significantly associated with reduced AD risk (HR = 0.87) in participants with childhood rural residence, but no association in those with urban upbringing. The cohort difference for dementia rates were attenuated by adjusting for the 3 risk factors but remained significant (HR = 0.75; p = .04). Discussion These results emphasize the importance of early life factors including rural residence and education for the risk for dementia later in life.

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“…In contrast to our findings, a higher stroke incidence was found in the southeastern United States, which has been widely acknowledged as 'the Stroke Belt' due to higher mortality of stroke in comparison with other regions. [18][19][20] Prior studies also indicated "the Stroke Belt" was a result of a significant number of rural residents, African American, residents with a higher prevalence of traditional stroke risk factors, inflammation and infection, as well as socio-economically deprived individuals. 18,19,[21][22][23] However, it should be noted that findings from western nations may not be general- ized to eastern countries since culture and social structure differ substantially.…”

Section: Comparison With Existing Researchmentioning

confidence: 99%

Geographic Variations of Stroke Incidence in Chinese Communities: An 18-Year Prospective Cohort Study from 1997 to 2015

Xia

et al. 2020

J Stroke

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Background and Purpose As a leading cause of disability and death in China, stroke as well as its epidemiologic features have gained increasing attention. Prior studies, however, have overgeneralized the north-to-south gradient in China. Whether the differences exist across urban and rural areas remains unexplored. This study therefore aims to investigate the north-to-south gradient in stroke incidence across urban and rural China.Methods The present prospective cohort study analyzed data from the China Health and Nutrition Survey 1997 to 2015. By including 16,917 individuals from diverse social contexts, we calculated the age-standardized incidence of stroke across regions and the age-adjusted risk ratio (aRR). Cox proportional hazards models with time-varying covariates were employed to analyze variations in incident stroke.Results During the follow-up, age-standardized incidence of stroke ranged from 4.17 per 1,000 person-years (95% confidence interval [CI], 3.38 to 4.96) in the north region to 1.95 (95% CI, 1.60 to 2.30) in the south region (aRR, 2.04; 95% CI, 1.58 to 2.64; <i>P</i><0.001). The north-to-south gradient of stroke incidence was observed only in rural areas, but not in urban areas. Hierarchical modelling analyses further indicated that the regional differences could be mostly explained by the disparities in the prevalence of hypertension.Conclusions The present study extends the current evidence on the north-to-south gradient by demonstrating that the difference varied across urban and rural China. Our findings highlight the importance of hypertension management as the measure for alleviating regional differences in stroke incidence.

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Incidence and Case Fatality at the County Level as Contributors to Geographic Disparities in Stroke Mortality

Cited by 17 publications

References 19 publications

Contributors to the Excess Stroke Mortality in Rural Areas in the United States

Contributors to the Excess Stroke Mortality in Rural Areas in the United States

The Association of Early Life Factors and Declining Incidence Rates of Dementia in an Elderly Population of African Americans

Geographic Variations of Stroke Incidence in Chinese Communities: An 18-Year Prospective Cohort Study from 1997 to 2015

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