Factors Underlying Stroke Recovery Variation by Neighborhood Socioeconomic Status.

Importance: Lower neighborhood socioeconomic status (nSES) is associated with worse stroke recovery. It remains unclear what factors could be targeted therapeutically to mitigate nSES-associated poststroke recovery differences. Objective: To identify the extent with which receipt of hyperacute treatment, neighborhood density of home health services, density of rehabilitation clinics, density of recreation centers, transportation access, and walkability mediate the association between nSES and stroke recovery. Design, Setting, and Participants: The population-based stroke cohort Brain Attack Surveillance in Corpus Christi (BASIC) enrolled individuals between 2009 and 2022 in Nueces County, Texas. Candidate mediators were derived from BASIC, Redfin, or the National Neighborhood Data Archive. Causal mediation analyses were performed. Participants were followed from time of stroke to 90 days after stroke. Participants' census tracts at time of stroke were used to define neighborhoods. Individuals aged 45 years or older with completed baseline and community-dwelling 90-day assessments were included. Data analysis was performed from January 2024 to April 2026. Exposure: nSES, a validated index of neighborhood deprivation. Main Outcomes and Measures: The primary outcomes were 90-day functional status (activities of daily living [ADL] and instrumental ADL [IADL] questionnaire score), depressive symptom burden (Patient Health Questionnaire [PHQ]-8 Score), and quality of life (Stroke-Specific Quality-of-life questionnaire [SS-QoL] score). Associations between nSES and the outcomes were assessed using generalized estimating equations. Results: Among the 2203 individuals with 90-day outcomes from 77 census tracts, 1044 (47.4%) were female, the median (IQR) acute National Institute of Health Stroke Scale score was 3 (1 to 6), and the median (IQR) age was 66 (57 to 75) years. Higher nSES was associated with better outcomes across all measures (PHQ-8 score, β = -1.21 [95% CI, -1.86 to -0.56]; ADL-IADL score, β = -0.20 [95% CI, -0.27 to -0.13]; SS-QoL score, β = 0.20 [95% CI, 0.11 to 0.29]). Shifting all mediator distributions from low-nSES to high-nSES neighborhoods modestly attenuated the association of nSES with PHQ-8 score by 14.1% (95% CI, -36.3% to 64.5%) and accounted for 15.1% (95% CI, -11.0% to 41.2%) of the association of nSES with ADL-IADL score and 5.6% (95% CI, -25.4% to 36.6%) of the association of nSES with SS-QoL score. However, no evaluated factors were statistically significant mediators. Conclusions and Relevance: In this cohort study of a biethnic urban population with predominantly mild strokes, higher nSES was associated with better outcomes. These differences were not significantly mediated by hyperacute treatment, postacute care resource density, transportation access, or walkability. Future studies should evaluate to what extent time to hyperacute treatment, postdischarge disposition, poststroke therapy intensity, and other factors may underlie differences in stroke recovery by nSES.