Multi-year study reveals decrease in stroke fatalities, improvements in systems of care

Acute stroke case fatality decreased substantially between 2003 and 2017 at the same time that discharge to home or rehabilitation increased and long-term care admissions decreased, according to a Canadian study.

The findings, which were published in Neurology, indicate “continuous improvements” to stroke systems of care over the 15-year study period.

“We developed this research project to understand whether outcomes among patients with acute stroke were changing over time in the last 2 decades. Other studies from developed countries have generally found that case fatality after acute stroke is going down with time,” Raed Joundi, a master’s student and stroke fellow at the University of Calgary Cumming School of Medicine, told Healio. “However, some studies have found that case fatality is decreasing after ischemic stroke, but not intracerebral hemorrhage. In addition, it is possible that the increased use of life-sustaining care may lower case fatality only in the short-term, and result in an increase in people surviving with severe disability. To address these unanswered questions, we used administrative data linkages in the entire population of Ontario, Canada.”

In this population-based study, Joundi and colleagues examined trends in acute stroke case fatality, discharge destination and long-term care admission from 2003 to 2017 for all ED visits and hospital admissions for first-ever ischemic stroke or intracerebral hemorrhage in Ontario, Canada. The researchers determined crude and standardized (according to age and sex) risk for death at 30 days and 1 year after the index stroke. They also examined trends in rates of discharge to home or to rehabilitation from acute care, as well as admission to long-term care, within 1 year after acute care discharge. Finally, Joundi and colleagues determined whether these outcome trends remained after adjusting for baseline characteristics, estimated stroke severity and use of life-sustaining care.

During the study period, 163,574 patients experienced an acute stroke, including intracerebral hemorrhage (12.4%) and ischemic stroke (87.6%). The researchers observed an increase in the number of patients over 60 years of age in the ischemic stroke group, as well as an increase in patients with hypertension, diabetes and those receiving intensive care or mechanical ventilation in both groups. They also noted a decrease in 30-day hazard of death for all patients every year of the study, with HRs that remained “virtually unchanged” after adjustment for demographics, comorbidity and type of care, while the number of patients discharged to the home or rehabilitation increased. Specifically, age/sex-standardized 30-day stroke case fatality decreased from 20.5% to 13.2% and from 32.2% to 22.8% at 1 year. Reductions in fatality occurred regardless of age or sex.

“One of the most striking results was the large decrease in case fatality after intracerebral hemorrhage. Thirty-day case fatality dropped from 45% to 30% over 15 years,” Joundi said. “This is interesting because, while hyperacute therapies for ischemic stroke (thrombolysis and thrombectomy) have become more widespread, there have been limited therapeutics for the treatment of acute intracerebral hemorrhage. The changes observed may be due to improvement in multidisciplinary stroke care, which benefits patients with both ischemic stroke and intracerebral hemorrhage.”

Joundi called the results “very encouraging.”

“Our findings ... show that efforts to improve care of those with stroke, which have spanned decades, have yielded improved outcomes,” he said. “This success should be celebrated but should also stimulate further initiatives to continuously refine and improve access to best care for all stroke patients.”