Influence of socioeconomic status on functional outcomes after stroke: a systematic review and meta-analysis

Background Despite advances in stroke treatment and rehabilitation, socioeconomic factors have an important impact on recovery from stroke. This review aimed to quantify the impact of socioeconomic status (SES) on functional outcomes from stroke and identify the SES indicators that exhibit the highest magnitude of association. Methods We performed a systematic literature search across Medline and Embase databases up to May 2022, for studies fulfilling the following criteria: observational studies with ≥100, patients aged ≥18 years with stroke diagnosis based on clinical examination or in combination with neuroimaging, reported data on the association between SES and functional outcome, assessed functional outcomes with the modified Rankin Scale (mRS) or Barthel index tools, provided estimates of association (odds ratios [OR] or equivalent), and published in English. Risk of bias was assessed using the modified Newcastle Ottawa Scale. Findings We identified 7,698 potentially eligible records through the search after removing duplicates. Of these, 19 studies (157,715 patients, 47.7% women) met our selection criteria and were included in the meta-analyses. Ten studies (53%) were assessed as low risk of bias. Measures of SES reported were education (11 studies), income (8), occupation (4), health insurance status (3), and neighbourhood socioeconomic deprivation (3). Random-effect meta-analyses revealed low SES was significantly associated with poor functional outcomes: incomplete education or below high school level versus high school attainment and above (OR [95% CI]: 1.66 [1.40, 1.95]), lowest income versus highest income (1.36 [1.02, 1.83], a manual job/unemployed versus a non-manual job/employed (1.62 [1.29, 2.02]), and living in the most disadvantaged socioeconomic neighbourhood versus the least disadvantaged (1.55 [1.25, 1.92]). Low health insurance status was also associated with an increased risk of poor functional outcomes (1.32 [0.95, 1.84]), although not statistically significant. Conclusions Socioeconomic disadvantage remains a risk factor for poor functional outcomes after an acute stroke. Further research is needed to better understand causal mechanisms and disparities. Funding This study is supported by an NHMRC Investigator grant (APP1195237).