Inequalities in Stroke Patients' Management in English Public Hospitals: A Survey on 200,000 Patients

Abstract

BackgroundAccording to clinical guidelines, every patient affected by stroke should be given a brain-imaging scan (BIS) - Computerized Tomography or Magnetic Resonance Imaging - immediately after being admitted to hospital.Aim of the studyTo describe the variation in use of BIS among English public hospitals and identify any patient groups being excluded from appropriate care.MethodsWe collected hospital administrative data for all patients admitted to any English public hospital with a principal diagnosis of stroke from 2006 to 2009. We calculated the proportion of patients treated with BIS in the whole sample and after stratification by hospital. We compared hospitals' performance using funnel plots. We performed a multiple logistic regression analysis using BIS as outcome and age, gender, socio-economic deprivation, and comorbidity as covariates.ResultsIn English public hospitals there are about 70,000 emergency admissions for stroke per year. Nationally, only 35% receive a BIS immediately, and only 84% receive it within the admission. There is large variation in the use of BIS for stroke patients among English public hospitals, with some of them approaching the recommended 100% and some having very low rates. Young (P<0.001), male (P = 0.012), and least socio-economically deprived patients (P = 0.001), as well as patients with fewer comorbidities (P<0.001) appear to have more chance of being selected for a brain scan.ConclusionSome English public hospitals appear to be falling well below the clinical guideline standards for scanning stroke patients and inappropriate patient selection criteria may be being applied, leading to health inequalities.

Age, Sex, and Racial Differences in Neuroimaging Use in Acute Stroke: A Population-Based Study

“…15,19 Large variation was reported among English public hospitals, where younger patients, men, and patients of higher socioeconomic status were more likely to undergo brain imaging (NCCT or MR imaging). 11 A study using the Canadian Stroke Registry found that very elderly patients were less likely to undergo carotid imaging compared with younger patients with acute ischemic stroke, though there was no association between age and the quality of stroke care. 17 In our analysis, a higher proportion of the older patients underwent carotid sonography rather than CTA or MRA, compared with younger patients.…”

“…Previous studies have shown compelling sex, racial, and socioeconomic disparities in the treatment and outcomes among patients with acute stroke. [5][6][7] Generally, racial minorities and women with acute stroke have lower quality hospital care, 5,[8][9][10][11][12][13] including the use of imaging. These disparities can contribute to inequality in stroke outcomes and are a top research priority of the National Institute of Neurologic Disorders and Stroke.…”

Socioeconomic Status and Stroke

“…Differences in receipt of evidence-based care occur not only between HIC and LMIC, but also within countries with universal access to health care. 39 Patients of higher SES were more likely to receive postacute stroke rehabilitation in a US cohort study. 40 Using routinely collected data from English public hospitals, patients with stroke from more deprived areas were less likely to receive a brain scan on the same day of admission.…”

“…40 Using routinely collected data from English public hospitals, patients with stroke from more deprived areas were less likely to receive a brain scan on the same day of admission. 39 Regarding secondary stroke prevention, patients with lower income and those without medical insurance were less likely to receive antithrombotic therapy after stroke in China. 41 Patients with a higher level of education were more likely to undergo echocardiography and have speech therapy during admission compared with patients with no basic education in Austria.…”

The effects of socioeconomic status on stroke risk and outcomes

“…58 Stroke audit data across England (including data on around 70,000 people admitted to hospital with stroke) found wide variation in appropriate brain imaging, but found that it was not explained by deprivation. 59 In Sweden, using data from 319,240 stroke patients recorded in the nationwide Riks-Stroke register between 1995 and 2009 small significant differences in admission to stroke units were found by level of education (highest educational attainment: secondary OR 1.04, 95% CI 10.1 to 1.07; university OR 1.06, 95% CI 1.01 to 1.10; all versus primary). 60 However, as in London over the same time period, the difference diminished over time as stroke unit capacity increased.…”