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.

研究目标：基于大型人群队列，明确急性缺血性脑卒中（acute ischemic stroke）与脑内出血（intracerebral hemorrhage, ICH）后患者的病死率、出院去向以及长期照护入住率的当代流行趋势。

研究方法：我们采用关联行政数据，识别2003年至2017年间加拿大安大略省所有因首次发作缺血性脑卒中或脑内出血就诊于急诊科及住院的患者。我们计算了脑卒中发病后30天及1年的粗病死率与年龄/性别标准化死亡风险。我们按脑卒中类型、年龄及性别对粗病死率趋势进行分层，并采用肯德尔τ-b相关系数（Kendall τ-b correlation coefficient）评估趋势的统计学显著性。我们分析了发病1年后患者出院回家、转入康复机构以及入住长期照护机构的趋势变化。我们采用Cox比例风险模型（Cox proportional hazard model）与logistic回归模型（logistic regression model），在校正基线因素、估算的卒中严重程度以及生命支持治疗使用情况后，评估结局趋势是否依然存在。

研究结果：研究周期内共纳入163574例急性缺血性脑卒中或脑内出血患者。2003年至2017年间，年龄/性别标准化后的脑卒中30天病死率从20.5%降至13.2%（绝对下降7.3个百分点，相对下降36%）；1年病死率从32.2%降至22.8%（绝对下降9.3个百分点，相对下降29%）。上述结果在不同年龄、性别及脑卒中类型的患者中均保持一致，在校正合并症、卒中严重程度与生命支持治疗使用情况后结果依然稳定。缺血性脑卒中患者的长期照护入住率有所下降，两种脑卒中类型患者的出院回家或转入康复机构的比例均有所上升。

研究结论：2003年至2017年间，急性脑卒中患者的病死率显著降低，同时出院回家或转入康复机构的比例上升，长期照护入住率下降，提示脑卒中医疗照护体系在持续优化完善。