Neighborhood income inequality associated with functional independence after ischemic stroke: a cohort study

Abstract

Abstract Background Individual measures of socioeconomic status have been associated with post-stroke disability in patients with ischemic stroke. However, it is not known whether the distribution of income in a community may have an impact on stroke recovery. We hypothesized that increased neighborhood income inequality (as measured by the Gini index) may be associated with a slower recovery after stroke. Methods This was a retrospective cohort study of adult patients hospitalized at a comprehensive stroke center with acute ischemic stroke between 1/1/2018-12/31/2019. Individual patient data was abstracted from the EHR, and zip code Gini index was obtained from the US Census Bureau. Binary logistic regression was used to assess the relationship between Gini index and modified Rankin score at discharge and follow-up. A second binary regression was also performed using a subset of patients to assess possible predictors of being discharged as recommended. Results Three hundred and thirty-eight patients were included in this analysis. Zip code Gini index was not associated with functional independence at discharge but was associated with independence at follow-up such that patients from high inequality neighborhoods were less likely to be independent. Each 1% increase in neighborhood Gini index was associated with an 7% decreased likelihood of independence at follow-up. Patients living in the highest income inequality neighborhoods were 220% less likely to achieve functional independence by follow-up compared to those in the lowest inequality neighborhoods. Being discharged as recommended was associated with a higher likelihood of independence at follow-up. Greater income inequality and Asian race were associated with a lower likelihood of being discharged as recommended. Conclusion Among a cohort of patients with ischemic stroke, increased neighborhood income inequality was associated with a lower likelihood of achieving functional independence by the time of outpatient follow-up. This disparity may be driven by discharge destination and race.