Neighborhood Type Tied to Post-Stroke Mortality Risk

Batya Swift Yasgur, MA, LSW

February 22, 2023

Individuals living in disadvantaged neighborhoods may be at increased risk for death during the month following a hospitalization for stroke, epilepsy, or other neurologic conditions, new research suggests.

In a study of more than 900,000 older individuals, results showed that participants from the most disadvantaged neighborhoods who had been hospitalized for stroke had a 23% higher risk of dying within a month compared with those from the most advantaged neighborhoods. The difference was even higher in those hospitalized for trauma-related coma, neurodegenerative conditions, and epilepsy (44%, 38%, and 34%, respectively).

The most dramatic difference was in non–trauma-related coma, with a staggering 146% higher mortality risk in those from the most disadvantaged vs the most advantaged neighborhoods.

Senior author Bradley Hammill, DrPH, associate professor, Duke University School of Medicine, Durham, North Caroline, told Medscape Medical News that "clinicians need to recognize and appreciate" that the socioeconomic status (SES) of their patients and where they come from are important.

"It's been shown time and again that a hospital's direct impact on patient outcomes is less than the risk patients encounter once they leave the hospital," Hammill said.

The findings were published online February 15 in Neurology.

Public Policy, Clinical Implications

"No studies have evaluated the contribution of neighborhood socioeconomic status for several common neurological conditions, after adjusting for key risk factors," the investigators write.

However, understanding the contribution of neighborhood socioeconomic deprivation to outcomes for patients with neurologic diseases "would have significant public policy and clinical practice implications," they add.

Hammill said he and his colleagues were "really interested in why some hospitals seem to perform better than other hospitals."

There are many hospital performance rating and ranking systems that measure this type of question. However, "few, if any, account for the social risk of the patient population served by the hospital," Hammill noted.

"Unsurprisingly, the hospitals that treat more patients with high SES tend to perform better than safety net hospitals, which treat more patients with low SES," he said. "We wondered what portion of health outcomes like mortality and readmission might be attributable not to the care received in the hospital but to the risk that patients bring with them to the hospital."

To investigate the question, the researchers retrospectively studied nationwide Medicare claims from 2017 to 2019. They included patients aged 65 years or older who had been hospitalized for an array of neurologic disorders.

Neighborhood SES was measured by the Area Deprivation Index (ADI), which uses 17 socioeconomic indicators to estimate area-level socioeconomic deprivation. These indicators included educational attainment, unemployment, infrastructure access, and income.

Participants were classified into high, middle, or low SES on the basis of their ADI score.

The researchers analyzed mortality (n = 905,784 patients) as well as unplanned readmissions to the hospital (n = 915,993 patients) during the 30 days following discharge.

Covariates included demographics, Medicaid dual-eligibility status, end-stage renal disease status, discharge, year, and 29 comorbidities.

Multiple Mechanisms?

In both cohorts, groups with low ADI (meaning high neighborhood SES) were older, had a higher percentage of male beneficiaries, a lower percentage of patients dually eligible for Medicare and Medicaid, and fewer comorbidities compared with groups who had high ADI (meaning low neighborhood SES) (P < .001).

The adjusted analysis showed that patients from low SES neighborhoods had higher 30-day mortality rates for all disease categories, except for multiple sclerosis, compared with those from high SES neighborhoods.

Disease Category

Low SES Odds Ratio (95% CI)

P Value

Multiple sclerosis and cerebellar ataxia

1.42 (.59-3.40)



1.23 (1.19-1.28)

< .001

Degenerative nervous system disorders

1.38 (1.25-1.53)

< .001


1.34 (1.20-1.50)

< .001

Nontraumatic disorders of consciousness

2.46 (1.60-3.78)

< .001

Traumatic disorders of consciousness

1.44 (1.34-1.56)

< .001


By contrast, none of the groups showed significant differences in readmission rates.

"Unfortunately, it's not totally clear what the mechanism is between mortality risk and a person's neighborhood, but it is almost certainly multifactorial," Hammill said.

"Some of the disparity in mortality we observed may be due to prehospitalization risk. Patients from disadvantaged neighborhoods arrive at the hospital with more severe disease because of inadequate healthcare resources to manage the disease," he noted.

In addition, some of the disparity in mortality risk may be due to differences in post-hospitalization risk. Patients from disadvantaged neighborhoods may not be able to get the care they need following discharge from the hospital, such as access to nursing or home healthcare, access to prescription drugs, or the ability to get to follow-up appointments, he added.

Hammill pointed out that many states have programs intended to help patients connect to public resources for food insecurity, housing instability, lack of transportation access, or other nonmedical needs.

"Educating clinicians on the availability of resources like this might help to get the information disseminated to patients who need it, which might help them mitigate the neighborhood-based risks we're talking about," he said.

'Intentional Push' Needed

Commenting for Medscape Medical News, William J. Hicks, II, MD, volunteer president, Midwest Affiliate, American Heart Association, said the research "adds to the burgeoning study of social determinants of health, suggesting most common neurological conditions fare no better than the other chronic medical conditions previously studied."

Hicks, who is also co-director of the Comprehensive Stroke Program, Ohio Health Riverside Methodist Hospital, Columbus, was not involved with the study.

He suggested that "understanding the key factors encompassing the social determinants of health will clarify the persistent health disparities we see with neurological patients from certain zip codes."

Discharge plans "can aim to provide a wraparound care plan to those patients from low SES communities. But the most impactful help would occur decades prior to one's hospitalization," Hicks said.

"Until there is an intentional push to fight against the generational injustices embedded within these particular areas, we cannot expect these findings to ever be rectified," he added.

The study was internally funded by the Duke University Health System. The investigators report no relevant financial relationships. Hicks reports having previously received honoraria from AstraZeneca and Pfizer/BMS, received expert testimony payment from the state of Ohio, and has served in leadership roles for the American Heart Association, the Columbus Foundation, and OhioHealth.

Neurology. Published online February 15, 2023. Abstract

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom(the memoir of two brave Afghan sisters who told her their story).

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