title: Socioeconomic differences in one-year survival after ischemic stroke: the effect of acute and post-acute care-pathways in a cohort study.
abstract: The reasons for socioeconomic inequity in stroke mortality are not well understood. The aim of this study was to explore the role of ischemic stroke care-pathways on the association between education level and one-year survival after hospital admission.
  
  
  
  Hospitalizations for ischemic stroke during 2011/12 were selected from Lazio health data. Patients' clinical history was defined by retrieving previous hospitalizations and drugs prescriptions. The association between education level and mortality after stroke was studied for acute and post-acute phases using multilevel logistic models (Odds Ratio (OR)). Different scenarios of quality care-pathways were identified considering hospital performance, access to rehabilitation and drug treatment post-discharge. The probability to survive to acute and post-acute phases according to education level and care-pathway scenarios was estimated for a "mean-severity" patient. One-year survival probability was calculated as the product of two probabilities. For each scenario, the 1-year survival probability ratio, university versus elementary education, and its Bootstrap Confidence Intervals (95 % BCI) were calculated.
  
  
  
  We identified 9,958 patients with ischemic stroke, 53.3 % with elementary education level and 3.2 % with university. The mortality was 14.9 % in acute phase and 14.3 % in post-acute phase among survived to the acute phase. The adjusted mortality in acute and post-acute phases decreased with an increase in educational level (OR = 0.90 p-trend < 0.001; OR = 0.85 p-trend < 0.001). For the best care-pathway, the one-year survival probability ratio was 1.06 (95 % BCI = 1.03-1.10), while it was 1.17 (95 % BCI = 1.09-1.25) for the worst.
  
  
  
  Education level was inversely associated with mortality both in acute and post-acute phases. The care-pathway reduces but does not eliminate 1-year survival inequity.
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Belleudi
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Sciattella
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy. n.agabiti@deplazio.it.
authors.forename: Nera
authors.initials: N
authors.lastname: Agabiti
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
authors.forename: Mirko
authors.initials: M
authors.lastname: Di Martino
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Di Domenicantonio
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
authors.forename: Marina
authors.initials: M
authors.lastname: Davoli
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
authors.forename: Danilo
authors.initials: D
authors.lastname: Fusco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010351:Patient Discharge / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012720:Severity of Illness Index; D012959:Socioeconomic Factors; D020521:Stroke / Q000401:mortality*; D019467:Subacute Care / Q000706:statistics & numerical data*
keywords: Pathway-analysis; Socioeconomic-position; Stroke; Survival