How Are Household Economic Circumstances Affected After a Stroke? The Psychosocial Outcomes In StrokE (POISE) Study
Background and Purpose—Stroke is associated with severe economic consequences. This is the first study to investigate in younger survivors the household economic burden of stroke.
Methods—A multicenter, 3-year prospective cohort study was conducted of younger (18–65 years) survivors in Australia. Pre- and poststroke patterns of income and hardship were evaluated and multivariable logistic regression identified the predictors of economic hardship after stroke.
Results—Four hundred fourteen participants were followed up over 12 months after stroke. The variables that independently predicted economic hardship after stroke were: female (OR, 2.94; 95% CI, 1.52–5.70), hazardous alcohol consumption (OR, 2.28; 95% CI, 1.00–5.20), manual occupation (OR, 1.88; 95% CI, 1.07–3.30), lack of health insurance (OR, 2.01; 95% CI, 1.12–3.60), and prior hardship (OR, 3.93; 95% CI, 2.12–7.29), whereas concessional status (OR, 0.50; 95% CI, 0.26–0.95) and more social contacts per week (OR, 0.99; 95% CI, 0.98–1.00) reduced hardship likelihood.
Conclusions—Higher prestroke income did not buffer hardship after stroke nor did clinical, health service, or disability factors. Policies to reduce inequalities after stroke would be best aimed at socioeconomic targets.
Working-aged people constitute approximately 20% of all stroke cases in high-income countries.1 Among this group, the economic consequences include unemployment, reduction in paid employment, and changes in career for the person and often a family caregiver.2–4 There are also unbudgeted out-of-pocket costs associated with medical care, medications, medical equipment, home modifications, transport, and paid care. In most developed countries like Australia, where national health insurance schemes are in place, protection against most out-of-pocket expenses for medical treatment is widely available (see online-only Data Supplement). Nevertheless, protection is rarely complete and there are often significant health-related costs to be managed, compounding the reduction in work capacity and income. Supplementary private health insurance is held by 53.2% (12.2 million) of Australians,5 but the extent to which it offsets the economic impact of major illnesses such as stroke is not known.
We measured the patterns of income and economic hardship before and after stroke and identified the determinants of economic hardship in younger stroke survivors.
Design and Overview
The Psychosocial Outcomes in Stroke (POISE) study was a 3-year prospective multicenter observational study that consecutively recruited English-speaking individuals (or their proxy) between the ages of 18 and 65 years within 28 days of stroke from the Stroke Services New South Wales network in Australia.6 Consented participants were interviewed by telephone at 28 days (baseline) and 6 and 12 months after stroke. A description of the information collected at each interview is provided in the online-only Data Supplemental Methods. The Sydney South West Area Health Service’s Human Research Ethics Committee approved the study and written informed consent was obtained from all participants or their proxy.
The main outcome in the analysis was household economic hardship (hardship hereafter) after stroke. Hardship was ascertained for the 3 months before, and prospectively, at 6 and 12 months after, stroke. It was defined as either an instance of a household’s inability to make a necessary household payment (financial stress) or the deployment of dissaving behavior (borrowing or use of savings) after stroke.7
The second outcome measured changes in income after stroke. Equivalized household income, weighting for household composition, was grouped into the following categories: low income (<USD $550), middle income (USD $550 to USD $917), and high income (>USD $917 per week; USD $1 = AUD $1.09, 2010).
Univariate analyses were used to determine the association between hardship after stroke and various baseline characteristics and multivariate logistic regression was used to identify the predictors of hardship after stroke. Data analyses were conducted using SAS Version 9.2. The full modeling strategy is described in the online-only Data Supplemental Methods. A χ2 test was used to assess the change in the proportions in each income category after stroke.
The baseline study population included 414 participants (online-only Data Supplement Figure I). The Table shows their 28-day poststroke characteristics and the associations with poststroke hardship.
Thirty-six percent (n=150) of participants reported hardship before stroke. In the 12 months after stroke, 61% (n=254) of participants had hardship. This reflects a significant increase in the proportion reporting each of the financial stressors and dissaving behaviors, most of which continued to increase significantly by 12 months (Figure 1). The independent predictors of hardship in the 12 months after stroke from the multivariate backward selection regression model (Figure 2) were female sex, hazardous alcohol consumption, manual occupation, lack of health insurance, and hardship before stroke. The factors that decreased the likelihood of hardship after stroke were concessional status (ie, receiving government financial support for living and medical expenses) and the number of social contacts per week. The final model fit the data well (χHL2: 8.48, P=0.39; c=0.76). In a sensitivity analysis that only included the participants who had been working before stroke, returning to work by 28 days reduced the likelihood of hardship after stroke (OR, 0.32, 95% CI, 0.16–0.62).
There was a decrease in the proportion of participants in the highest income bracket from baseline to 12 months (59%–44%; online-only Data Supplement Figure II). Among those who reported high income before stroke, 11% (n=19) reported low income at 12 months after stroke. Among the middle income earners before stroke, only 35% (n=21) remained at this income level at 12 months with 35% (n=21) reporting low income. Most of the low-income earners before stroke remained at this income level after stroke (80%, n=51).
This is the first study designed to measure, in a large consecutively recruited cohort of younger stroke survivors, the economic burden experienced after stroke. Prestroke levels of hardship were significantly greater than the levels typically found in the Australian adult population,7 suggesting that this cohort had worse economic circumstances to begin with. However, the levels of hardship after stroke in this population increased significantly and are consistent with the estimates reported for other chronically ill patient populations in Australia8 and internationally.9,10 However, actual income per se had no independent buffering effect. Females, manual laborers, and heavy drinkers, all potential surrogates for lower socioeconomic status, faced a greater risk of poor economic outcomes after stroke. This association is only partly due to poorer economic circumstances before stroke in these groups being exacerbated in the aftermath of stroke, because the effect was independent of income. This has important implications for adherence to rehabilitation and medical care, because previous studies indicate that adherence suffers when patients experience financial problems.10,11
We identified policy supports within an Australian context that buffer stroke survivors from hardship. Concessional status before stroke reduced the likelihood of hardship after stroke by 50%. Timely access to these support programs and other more targeted strategies are needed, particularly for those who are unable to return to work after stroke. This might involve temporary safety net mechanisms or more rapid access to income support programs immediately after stroke. Finally, participants without private health insurance coverage were twice as likely to have hardship after stroke. The support offered by private health insurance may help to offset the medical expenses associated with rehabilitation. However, the higher risk of hardship for the uninsured may also reflect private health insurance status being a marker of higher socioeconomic status in this population.
Economic hardship is common in younger stroke survivors, with two thirds reporting hardship in the 12 months after stroke despite Social Security and national health insurance systems in Australia that are generally considered universal. These findings can help inform strategies to identify survivors who are most at risk of hardship soon after diagnosis to link them into targeted support programs early.
Sources of Funding
National Health and Medical Research Council (NHMRC) of Australia (512429); Canadian Institutes of Health Research Doctoral Research Award and NHMRC scholarship (Dr Essue); NHMRC Career Development Award, 2010–2013 (632925; Dr Hackett); NHMRC Senior Research Fellowship, 2012–2016 (1020403; Dr Jan); infrastructure grants from New South Wales Health and the Commonwealth of Australia and the Moran Foundation for Older Australians (Dr Lindley). No funding bodies had a role in the conduct or reporting of this study.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.112.666453/-/DC1.
- Received June 22, 2012.
- Revision received August 15, 2012.
- Accepted August 20, 2012.
- © 2012 American Heart Association, Inc.
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- 5.↵Private Health Insurance Administration Council. Quarterly Statistics 2010. Canberra, Australia: PHIAC; March 2012.
- 7.↵Australian Bureau of Statistics. 2010 General Social Survey: Summary Results. 4159.0. Canberra, Australia: ABS; 2011.
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