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(Stroke. 2008;39:3360.)
© 2008 American Heart Association, Inc.

Original Contributions

Socioeconomic Status, Hospital Volume, and Stroke Fatality in Canada

Gustavo Saposnik, MD, MS, FAHA; Thomas Jeerakathil, MD, MSc, FRCPC; Daniel Selchen, MD, FRCPC; Akerke Baibergenova, MD, PhD; Vladimir Hachinski, MD, DSc, FRCPC; Moira K. Kapral, MD, MSc, FRCPC for the Stroke Outcome Research Canada (SORCan) Working Group

From the Stroke Research Unit (G.S.), South East Toronto Regional Stroke Center, Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto; Division of Neurology (T.J.), Department of Medicine, University of Alberta, Edmonton; Division of Neurology, Department of Medicine (D.S.), St. Michael’s Hospital, University of Toronto, Ontario, Canada; Department of Medicine (A.B.), University of Toronto, Toronto; Department of Clinical Neurological Sciences (V.H.), London Health Sciences Center, University of Western Ontario, London; Department of Health Policy, Management, and Evaluation (G.S.), University of Toronto, Toronto, Canada; Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine (M.K.K.), University Health Network, Toronto, Ontario, Canada; and University Health Network Women’s Health Program Toronto (M.K.K.), Ontario, Canada.

Correspondence to Dr Gustavo Saposnik, Director of Stroke Research Unit, 55 Queen St E, Rm 931, Toronto (M5C 1R6), Canada. E-mail saposnikg{at}smh.toronto.on.ca

Background and Purpose— Low socioeconomic status is associated with stroke fatality; however, the mechanism behind this association is uncertain. We sought to determine whether residence in a low-income neighborhood was associated with admission to low-volume facilities and whether this contributed to differences in fatality after stroke.

Methods— All hospitalizations for ischemic stroke from April 2003 to March 2004 were identified from a national administrative database containing patient-level sociodemographic, diagnostic, procedural, and administrative information. Patients were assigned to income quintiles based on the median income of their primary neighborhood of residence and then categorized as low income (quintiles 1 and 2) or high income (quintiles 3 through 5). Hospitals were categorized as low or high volume on the basis of their annual number of stroke admissions. Multivariable analyses were performed to compare stroke fatality at 7 days and at discharge in patients in low- and high-income groups seen at low- and high-volume facilities.

Results— Overall, 25 228 patients with ischemic stroke were included in the analysis. Those from high-income areas were more likely to be admitted to high-volume hospitals. Fatality at 7 days was 8.4%, 8.2%, 7.7%, 7.1, and 6.6% (²=0.002) for income quintiles 1 (lowest) to 5 (highest), respectively. Low-income patients admitted to low-volume hospitals had the highest risk-adjusted stroke fatality.

Conclusions— Patients from low-income areas presenting with acute stroke are more likely to be seen in low-volume facilities. This subgroup of patients had a higher risk-adjusted fatality than those from high-income areas seen at high-volume facilities. Understanding the pathways through which socioeconomic status affects health care may lead to strategies for quality improvement.

Key Words: stroke • socioeconomic status • mortality • hospital volume • outcomes research • health services research • health policy

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