Cardiovascular

Factors Underlying Stroke Recovery Variation by Neighborhood Socioeconomic Status.

TL;DR

Higher neighborhood socioeconomic status was associated with better stroke recovery outcomes, but these differences were not significantly mediated by hyperacute treatment, postacute care resource density, transportation access, or walkability.

Key Findings

Higher neighborhood socioeconomic status (nSES) was significantly associated with better outcomes across all three recovery measures at 90 days post-stroke.

  • PHQ-8 depressive symptom score: β = -1.21 (95% CI, -1.86 to -0.56), indicating fewer depressive symptoms with higher nSES
  • ADL-IADL functional status score: β = -0.20 (95% CI, -0.27 to -0.13), indicating better functional status with higher nSES
  • SS-QoL quality of life score: β = 0.20 (95% CI, 0.11 to 0.29), indicating better quality of life with higher nSES
  • Associations were assessed using generalized estimating equations in a population-based cohort from Nueces County, Texas (2009–2022)

The combined set of candidate mediators explained only a modest and statistically non-significant portion of the nSES-outcome association.

  • Shifting all mediator distributions from low-nSES to high-nSES neighborhoods attenuated the association with PHQ-8 score by 14.1% (95% CI, -36.3% to 64.5%)
  • The mediators accounted for 15.1% (95% CI, -11.0% to 41.2%) of the association with ADL-IADL score
  • The mediators accounted for 5.6% (95% CI, -25.4% to 36.6%) of the association with SS-QoL score
  • No individual evaluated factor was a statistically significant mediator
  • Causal mediation analyses were used to assess mediation

The study cohort consisted of 2203 individuals with 90-day outcomes drawn from 77 census tracts in a biethnic urban population.

  • 1044 participants (47.4%) were female
  • Median (IQR) age was 66 (57 to 75) years
  • Median (IQR) acute NIH Stroke Scale score was 3 (1 to 6), reflecting predominantly mild strokes
  • Participants were aged 45 years or older and were community-dwelling at 90-day follow-up
  • Enrollment spanned 2009 to 2022 in Nueces County, Texas as part of the BASIC (Brain Attack Surveillance in Corpus Christi) study

Candidate mediators evaluated included receipt of hyperacute treatment, neighborhood density of home health services, density of rehabilitation clinics, density of recreation centers, transportation access, and walkability.

  • Mediator data were derived from BASIC records, Redfin, or the National Neighborhood Data Archive
  • Participants' census tracts at time of stroke were used to define neighborhoods
  • nSES was defined as a validated index of neighborhood deprivation
  • The study followed participants from time of stroke to 90 days after stroke

The authors identified several factors not examined in this study that may underlie nSES-associated stroke recovery differences and warrant future investigation.

  • Future studies should evaluate time to hyperacute treatment, postdischarge disposition, and poststroke therapy intensity
  • Other unspecified factors may also contribute to recovery differences by nSES
  • The current study could not fully explain the nSES-outcome association with the mediators assessed
  • The wide confidence intervals around mediation estimates indicate substantial uncertainty in the mediation proportions

What This Means

This research suggests that people who live in wealthier, more resource-rich neighborhoods tend to recover better after a stroke than those living in poorer neighborhoods — showing fewer depressive symptoms, better ability to perform daily activities, and higher quality of life at 90 days after their stroke. This finding comes from a large, long-running study of over 2,200 stroke patients in Corpus Christi, Texas, followed between 2009 and 2022. The study specifically tried to understand why this neighborhood wealth gap in stroke recovery exists by testing whether several practical factors — such as access to clot-busting treatments during a stroke, proximity to rehabilitation clinics or home health services, access to transportation, and neighborhood walkability — could explain the difference. Surprisingly, none of these factors turned out to be significant explanations. Even when researchers theoretically 'improved' all of these factors to match what wealthier neighborhoods offer, it only explained about 5–15% of the gap, and even that modest explanation was statistically uncertain. This research suggests that the reasons why neighborhood poverty leads to worse stroke recovery remain largely unknown and likely involve factors not yet studied, such as how quickly patients get treated after stroke symptoms begin, where patients go after leaving the hospital, or how much rehabilitation therapy they actually receive. The findings point to the need for future research to identify the specific, modifiable causes of these disparities so that effective interventions can be developed to help all stroke survivors recover equally well regardless of where they live.

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Citation

Stulberg E, Miller R, Hartman N, Risk M, Wing J, Schneider A, et al.. (2026). Factors Underlying Stroke Recovery Variation by Neighborhood Socioeconomic Status.. JAMA network open. https://doi.org/10.1001/jamanetworkopen.2026.16362