Temporal trends in case fatality, discharge destination, and admission to long-term care after acute stroke

Objective:  To determine contemporary trends in case fatality,
discharge destination, and admission to long-term care after acute
ischemic stroke and intracerebral hemorrhage (ICH) in a large,
population-based cohort. Methods: We used linked administrative data to
identify all emergency department visits and hospital admissions for
first-ever ischemic stroke or ICH in Ontario, Canada from
2003-2017.  We calculated crude and age/sex-standardized risk of
death at 30 days and 1 year from stroke onset.  We stratified
crude trends by stroke type, age, and sex and used the Kendall τ-b
correlation coefficient to evaluate the significance of trends. 
We determined trends in discharge home and to rehabilitation, and
admission to long-term care at 1 year. We used Cox proportional hazard and
logistic regression models to assess whether trends in outcomes persisted
after adjustment for baseline factors, estimated stroke severity, and use
of life-sustaining care.  Results: There were 163,574 people with
acute ischemic stroke or ICH across the study period.  Between
2003 and 2017, age/sex-standardized 30-day stroke case fatality decreased
from 20.5% to 13.2% (7.3% absolute and 36% relative reduction) while that
at 1 year decreased from 32.2 to 22.8 (9.3% absolute and 29% relative
reduction).  Findings were consistent across age, sex, and stroke
type, and after adjustment for comorbid conditions, stroke severity and
use of life-sustaining care.  There was a reduction in long-term
care admission after ischemic stroke, and an increase in discharge home or
to rehabilitation for both stroke types. Conclusion:  We observed
substantial reductions in acute stroke case fatality from 2003-2017 with a
concurrent increase in discharge to home or rehabilitation and a decrease
in long-term care admissions, suggesting continuous improvements in stroke
systems of care.