Temporal Trends and Drivers of Socioeconomic Inequalities in Stroke Care, Survival, and Long‐Term Outcomes

BACKGROUND: Stroke disproportionately affects individuals with lower socioeconomic status (SES). This study investigates socioeconomic inequalities in stroke care and long-term outcomes since 1995. METHODS: Using the South London Stroke Register (1995-2024), SES was measured at the area-level (Index of Multiple Deprivation [IMD]) and individual-level (occupation). Associations between SES and stroke unit admission, thrombolysis, and poststroke disability (Barthel Index/0-14), dependency (Frenchay Activities Index/0-15), and depression (Hospital Anxiety and Depression Scale/8-21) were estimated using multivariable logistic regression; and SES-effect on 5-year survival was estimated using Kaplan-Meier and Cox Proportional-hazard models. RESULTS: A total of 7714 participants were included (median age [interquartile range]: 70.9 years [59.0-80.8 years]; women: N=3677 [47.7%]). SES was not associated with stroke unit admission (IMD 1 (most deprived) versus IMD 3/4/5 (least deprived): odds ratio 0.90 [95% CI 0.76-1.08]; routine/manual versus nonroutine/nonmanual occupation: 1.04 [0.92-1.17]) or thrombolysis (0.91 [0.66-1.25]; 0.94 [0.75-1.16], respectively). Poorer survival of participants with lower SES in 1995 to 2003 (IMD 1 versus IMD 3/4/5: hazard ratio 2.24 [95% CI 1.81-2.76]; routine/manual versus nonroutine/nonmanual: 1.09 [0.98-1.24]) was not observed in 2013 to 2022 (1.02 [0.82-1.26]; 0.97 [0.82-1.15]). A total of 3944 completed 3-month (64.8% of alive) and 2364 5-year follow-ups (69.4%). In stroke-year/age/sex-adjusted analyses, participants with lower SES persistently experienced higher rates of 3-month and 5-year disability and dependency and 5-year depression. Further adjustments for ethnicity, vascular risk factors, stroke type/severity and acute interventions had minor attenuating effects. CONCLUSIONS: Access to key acute interventions was equitable and the survival disadvantage of participants with lower SES declined. Persistent inequalities in functional and mental health outcomes might be driven by factors beyond acute interventions (eg, rehabilitation access or post-acute social support), requiring integrated care approaches addressing clinical and social determinants of stroke recovery.