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Socioeconomic status and survival after stroke - Using mediation and sensitivity analyses to assess the effect of stroke severity and unmeasured confounding

Lindmark, Anita ; Norrving, Bo LU and Eriksson, Marie (2020) In BMC Public Health 20(1).
Abstract

Background: Although it has been established that low socioeconomic status is linked to increased risk of death after stroke, the mechanisms behind this link are still unclear. In this study we aim to shed light on the relationship between income level and survival after stroke by investigating the extent to which differences in stroke severity account for differences in survival. Methods: The study was based on patients registered in Riksstroke (the Swedish stroke register) with first time ischemic stroke (n = 51,159) or intracerebral hemorrhage (n = 6777) in 2009-2012. We used causal mediation analysis to decompose the effect of low income on 3-month case fatality into a direct effect and an indirect effect due to stroke severity.... (More)

Background: Although it has been established that low socioeconomic status is linked to increased risk of death after stroke, the mechanisms behind this link are still unclear. In this study we aim to shed light on the relationship between income level and survival after stroke by investigating the extent to which differences in stroke severity account for differences in survival. Methods: The study was based on patients registered in Riksstroke (the Swedish stroke register) with first time ischemic stroke (n = 51,159) or intracerebral hemorrhage (n = 6777) in 2009-2012. We used causal mediation analysis to decompose the effect of low income on 3-month case fatality into a direct effect and an indirect effect due to stroke severity. Since causal mediation analysis relies on strong assumptions regarding residual confounding of the relationships involved, recently developed methods for sensitivity analysis were used to assess the robustness of the results to unobserved confounding. Results: After adjustment for observed confounders, patients in the lowest income tertile had a 3.2% (95% CI: 0.9-5.4%) increased absolute risk of 3-month case fatality after intracerebral hemorrhage compared to patients in the two highest tertiles. The corresponding increase for case fatality after ischemic stroke was 1% (0.4-1.5%). The indirect effect of low income, mediated by stroke severity, was 1.8% (0.7-2.9%) for intracerebral hemorrhage and 0.4% (0.2-0.6%) for ischemic stroke. Unobserved confounders affecting the risk of low income, more severe stroke and case fatality in the same directions could explain the indirect effect, but additional adjustment to observed confounders did not alter the conclusions. Conclusions: This study provides evidence that as much as half of income-related inequalities in stroke case fatality is mediated through differences in stroke severity. Targeting stroke severity could therefore lead to a substantial reduction in inequalities and should be prioritized. Sensitivity analysis suggests that additional adjustment for a confounder of greater impact than age would be required to considerably alter our conclusions.

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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Direct effect, Income, Indirect effect, Mediation, Sensitivity analysis, Socioeconomic factors, Stroke, Unmeasured confounding
in
BMC Public Health
volume
20
issue
1
article number
554
publisher
BioMed Central (BMC)
external identifiers
  • pmid:32334556
  • scopus:85084031107
ISSN
1471-2458
DOI
10.1186/s12889-020-08629-1
language
English
LU publication?
yes
id
dec7f832-20bd-43c9-948d-203da60f86d8
date added to LUP
2020-05-20 08:36:32
date last changed
2020-05-21 03:00:11
@article{dec7f832-20bd-43c9-948d-203da60f86d8,
  abstract     = {<p>Background: Although it has been established that low socioeconomic status is linked to increased risk of death after stroke, the mechanisms behind this link are still unclear. In this study we aim to shed light on the relationship between income level and survival after stroke by investigating the extent to which differences in stroke severity account for differences in survival. Methods: The study was based on patients registered in Riksstroke (the Swedish stroke register) with first time ischemic stroke (n = 51,159) or intracerebral hemorrhage (n = 6777) in 2009-2012. We used causal mediation analysis to decompose the effect of low income on 3-month case fatality into a direct effect and an indirect effect due to stroke severity. Since causal mediation analysis relies on strong assumptions regarding residual confounding of the relationships involved, recently developed methods for sensitivity analysis were used to assess the robustness of the results to unobserved confounding. Results: After adjustment for observed confounders, patients in the lowest income tertile had a 3.2% (95% CI: 0.9-5.4%) increased absolute risk of 3-month case fatality after intracerebral hemorrhage compared to patients in the two highest tertiles. The corresponding increase for case fatality after ischemic stroke was 1% (0.4-1.5%). The indirect effect of low income, mediated by stroke severity, was 1.8% (0.7-2.9%) for intracerebral hemorrhage and 0.4% (0.2-0.6%) for ischemic stroke. Unobserved confounders affecting the risk of low income, more severe stroke and case fatality in the same directions could explain the indirect effect, but additional adjustment to observed confounders did not alter the conclusions. Conclusions: This study provides evidence that as much as half of income-related inequalities in stroke case fatality is mediated through differences in stroke severity. Targeting stroke severity could therefore lead to a substantial reduction in inequalities and should be prioritized. Sensitivity analysis suggests that additional adjustment for a confounder of greater impact than age would be required to considerably alter our conclusions.</p>},
  author       = {Lindmark, Anita and Norrving, Bo and Eriksson, Marie},
  issn         = {1471-2458},
  language     = {eng},
  month        = {04},
  number       = {1},
  publisher    = {BioMed Central (BMC)},
  series       = {BMC Public Health},
  title        = {Socioeconomic status and survival after stroke - Using mediation and sensitivity analyses to assess the effect of stroke severity and unmeasured confounding},
  url          = {http://dx.doi.org/10.1186/s12889-020-08629-1},
  doi          = {10.1186/s12889-020-08629-1},
  volume       = {20},
  year         = {2020},
}