Cross-level interaction between individual socioeconomic status and regional deprivation on overall survival after onset of ischemic stroke: National health insurance cohort sample data from 2002 to 2013

Introduction: The literature on stroke mortality and neighborhood effect is characterized by studies that are oftenWestern society-oriented, with a lack of racial and cultural diversity.We estimated the effect of cross-level interaction between individual and regional socioeconomic status on the survival after onset of ischemic stroke. Methods: We selected newly diagnosed ischemic stroke patients from 2002 to 2013 using stratified representative sampling data of 1,025,340 subjects. A total of 37,044 patients over the 10 years from 2004 to 2013 had newly diagnosed stroke. We calculated hazard ratios (HR) of 12- and 36-month mortality using the Cox proportional hazard model, with the reference group as stroke patients with high income in advantaged regions. Results: For the middle incomelevel, the patients inadvantagedregions showed lowHRs for overallmortality (12-month HR 1.27; 95% confidence interval [CI], 1.13-1.44; 36-month HR 1.25; 95% CI, 1.14-1.37) compared to the others in disadvantaged regions (12-month HR 1.36; 95% CI,1.19-1.56; 36-month HR 1.30; 95% CI,1.17 -1.44). Interestingly, for the lowincomelevel, the patients in advantaged regions showed highHRs for overall mortality (12-monthHR1.27; 95% CI,1.13-1.44; 36-monthHR1.33; 95% CI,1.22-1.46) compared to the others in disadvantaged regions (12-month HR 1.25; 95% CI, 1.09-1.43; 36-month HR 1.30; 95% CI, 1.18-1.44). Conclusion: Although we need to perform further investigations to determine the exact mechanisms, regional deprivation, as well as medical factors, might be associated with survival after onset of ischemic stroke in low-income patients.