Social inequality in rehabilitation after stroke: a health care gap approach

Objectives

Stroke remains one of the largest burdens of disease in the world. Rehabilitation is an essential component of the treatment, with the potential to remedy the individual consequences and societal costs.

Much effort has been put into securing timely assessment of rehabilitation needs and providing information to patients and professionals about the importance. Despite this, less than half of stroke patients participate in rehabilitation and little is known about why. This study aims to investigate patient and provider triggers for this potential inequality.

Study design

Register-based study on population-based data.

Methods

This study includes all stroke patients in Denmark between 2014 and 2018 (N ∼ 70,000), for which we conduct individual-level linkage to register data on patient characteristics, health service utilisation, as well as sociodemographic information. Provider-side rehabilitation is signalled by the issuing of a rehabilitation plan, while demand (compliance) is defined as units of rehabilitation services utilized by the patient. The Danish Stroke Register holds information on injury-related factors, e.g. severity, and allows us to derive a measure of the need for rehabilitation. Thus, we can estimate the expected need for rehabilitation and apply the health care gap (HCG) approach to analyse the socioeconomic patient-level and provider-level drivers of potential inequality in rehabilitation.

Results

There were 70,173 stroke events during the five years of study, of which 41 % received a rehabilitation plan upon discharge. In the group who received a rehabilitation plan, 81 % attended rehabilitation. High severity, Danish origin, living outside the capital area, and being an age pensioner increased the provider health care gap; while young age, male gender, longer length of stay, living in the capital area and employment increased the attendance-gap.

Conclusions

We find that age and severity along with sociodemographic characteristics (education and place of residence) impact both provider-health care gap and attendance-health care gap. There appears to be a potential for improving both provision and participation in rehabilitation after a stroke. Some sociodemographic characteristics may act as barriers to rehabilitation and should be focused on in the planning of rehabilitation services.