(Stroke. 1996;27:1215-1220.)
© 1996 American Heart Association, Inc.
Articles |
Hospitalization and Case-Fatality Rates for Stroke in Canada From 1982 Through 1991
The Canadian Collaborative Study Group of Stroke Hospitalizations1
the Division of Clinical Epidemiology, Royal Victoria Hospital, Montreal, Quebec, Canada (N.E.M.).
Correspondence to Dr Nancy E. Mayo, Division of Clinical Epidemiology, Ross Pavillion, 4th Floor, Royal Victoria Hospital, 687 Pine Ave W, Montreal, Quebec, H3A 1A1, Canada. E-mail mdnm@musica.mcgill.ca.
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Abstract |
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Background and Purpose The purpose of this study was to estimate rates of hospitalization and in-hospital case-fatality for cerebral infarction and intracerebral hemorrhage in Canada and to describe variation in rates by age, sex, and calendar period.
Methods Data were obtained from hospitalization databases for each of Canada's 10 provinces for the 10 fiscal years of 1982 through 1991. All hospitalizations of persons 15 years of age or older with a primary diagnosis at discharge coded 431, 434, or 436 according to the International Classification of Disease, 9th Revision, were included. Rates per 100 000 population were calculated for intracerebral hemorrhage and cerebral infarction, for men and women, and for five age groups. Annual age- and sex-specific, 30-day, in-hospital case-fatality rates were also calculated.
Results A total of 335 283 discharges for stroke were enumerated over the 10-year period (309 631 cerebral infarctions and 25 652 intracerebral hemorrhages). A significant decline of approximately 1% per year was observed for the rate of cerebral infarctions. For hemorrhages, the reverse was seen. For men there was a 44% increase over the 10-year period, and for women there was a 34% increase. In-hospital case-fatality rates for cerebral infarctions increased with age but did not differ by sex when age was considered. For the five age groups of 15 to 54, 55 to 64, 65 to 74, 75 to 84, and 
85 years, rates were 6%, 8%, 12%, 18%, and 27%, respectively. For intracerebral hemorrhage, the in-hospital case-fatality rates declined significantly over time from approximately 36% to 29%, 55% to 37%, 49% to 41%, 66% to 45%, and 72% to 59% for the five age groups, respectively.
Conclusions The possibility that these changes are artifactual could not be ruled out, but because there is no obvious risk in assuming that they are not, it would be prudent to investigate their causes further.
Key Words: cerebral infarction • cerebral hemorrhage • epidemiology • hospitalization • mortality
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Introduction |
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Few diseases have as great an impact on society as stroke. Stroke is more disabling than any other chronic condition,1 and yet the number of Canadians affected by stroke each year is unknown. Today, estimates for the Canadian population are derived from estimates outside Canada or from examination of historical data.2 A strategy for stroke surveillance in Canada is therefore a crucial step in understanding this important disease, particularly because there is recent evidence from the United States, Canada, and Sweden that the incidence of stroke may no longer be declining.3 4 5 6
For example, one report from Rochester, Minn, found that the age-standardized incidence of acute stroke was 17% higher for the period of 1980 to 1984 compared with 1975 to 1979.4 The National Hospital Discharge Survey5 from the United States reported a similar rise in the hospitalization rate for cerebrovascular disease in general over the period of 1979 to 1983. In this study, the whole range of administrative diagnostic codes for cerebrovascular disease were included, precluding the examination of rates for acute stroke specifically. However, neither of these studies could rule out the possibility that the increases were artifacts arising from changes in admission practices or changes in the use of diagnostic technology such as CT or MRI, procedures that can improve the detection of mild strokes. A study from Sweden6 found a significant rise in the incidence of acute stroke among women for 1983 to 1986 compared with 1975 to 1978; however, no specific mechanism contributing to this increase was identified. The rise probably was not due to changes in diagnostic practice favoring detection of milder strokes because the case-fatality rates were stable over this period. Data from the World Health Organization MONICA project in Sweden, covering the years 1985 to 1991 and specific to acute stroke, indicated a declining rate in stroke occurrence for men and women aged 35 to 64 years and an increasing rate among persons 65 to 74 years of age.7 The proportion of stroke patients who underwent CT scan increased substantially over this period, from 46% in 1985 to 75% in 1991.7 Slight declines in case-fatality rates were seen during this period, but these reached statistical significance only among women. There was some evidence that the severity of stroke decreased over time in the older age group, as the proportion of persons presenting with severe motor deficits declined significantly from 50% to 46%. The other two indicators of stroke severity, proportion presenting with lowered consciousness and proportion presenting with aphasia or dysphasia, did not decline significantly.
In an earlier study of stroke in Quebec,3 the overall rate of hospitalization attributed to stroke increased from 1981 to 1989, with dramatic increases observed in the rates of hemorrhagic stroke. This Quebec study relied on administrative codes for the identification of stroke but restricted the choice of codes to those more reliable for acute stroke. Most recently in the United States, May and Kittner8 reported a decline in the hospitalization rate for cerebrovascular disease (defined using administrative codes) among Medicare registrants over the age of 70 years from 1985 to 1989 and then a dramatic upswing from 1989 to 1991.
In the absence of a population-based registry, one way of improving the information on the occurrence of stroke in Canada was to make use of routinely collected hospital discharge data as a proxy for incidence, and a number of studies have taken this approach.3 4 5 6 8 Hospitalization data do not measure incidence directly, but a change in the incidence of stroke in the population is likely to be reflected in a change in the hospitalization rate for stroke. One of the downfalls of this use of data is that it does not capture persons not admitted to the hospital for stroke. Although there are no Canadian data published on the proportion of all strokes admitted to hospitals, there are data from other countries with similar healthcare systems. For example, in most European countries, over 95% of stroke patients were admitted to a hospital,9 10 11 12 with the lowest rate reported at 85%.13 Because of universal access to health care in Canada, the decision to admit a patient to the hospital or to apply certain diagnostic tests is not based on ability to pay; thus, estimates derived from hospitalization records will represent the entire population. In addition, sudden death from stroke is rare, and most persons will survive long enough to be admitted.
Three independent validation studies conducted recently in Canada, which compared diagnostic information in hospital discharge records to that contained in hospital charts, identified those codes that were accurate for distinguishing episodes of acute cerebrovascular accident from other forms of cerebrovascular disease.14 Recently published data from the United States have confirmed the positive predictive value of selective diagnostic codes from the ICD-9 in identifying acute stroke events recorded in hospital separation abstracts.15
Given the impact of stroke on the individual, the family, and society, a survey of hospital discharges for stroke in Canada was undertaken. The purpose of this study was to estimate hospitalization and in-hospital case-fatality rates for intracerebral hemorrhage and cerebral infarction in Canada and to describe variation in rates by age, sex, and calendar period.
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Methods |
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Data were obtained from hospitalization databases for each of Canada's 10 provinces for the 10 fiscal years of 1982 through 1991. (Data were not obtained from the two northern territories.) In these databases, diagnoses at discharge are coded according to the ICD-9. Some provinces use the ICD-9 Clinical Modification coding scheme, but at the three-digit level these two coding schemes are identical.
Only primary-discharge diagnoses were used, which were restricted to codes previously demonstrated to yield a high proportion of true strokes14 : ICD-9 431 for intracerebral hemorrhage and ICD-9 434 and 436 for cerebral infarction.
For each province, records were obtained for all residents 15 years of age and over who were discharged, deceased or alive, from acute care hospitals. Discharges from long-term care hospitals, long-term care units within acute care hospitals, and rehabilitation hospitals were excluded. Data from one province (British Columbia) were not available for the first year of study.
For the determination of rates, discharge records were consolidated when a patient was transferred from one hospital to another for management of the same event. For provinces that did not transmit a unique patient identifier (Quebec and Ontario), an algorithm was developed to operationalize this process. When the listings of destination hospital, date of discharge, age, and sex on one record were identical to the admitting hospital, date of admission, age, and sex on another record, the latter record was assumed to represent the same individual, and the records were consolidated. Approximately 6% of records were considered to be interhospital transfers.
Annual rates of hospital separation for intracerebral hemorrhage and cerebral infarction were calculated for women and men and for five age groups. The numerators used to calculate the rates were the numbers of discharges from acute care hospitals. The denominators were the numbers of persons in each age-sex stratum as determined for each province from the 1981, 1986, and 1991 censuses of the entire Canadian population.16 The size of the population for the intercensus years was interpolated by determining the percent change in population between 1981 and 1986 and between 1986 and 1991 and apportioning those changes evenly over the intervening years. To facilitate comparison of sex-specific rates over time, rates were directly standardized to the total 1991 Canadian population of men and women.
Poisson regression17 was used to model the natural logarithm of the age- and sex-specific rates of hospital discharge for cerebral infarction and intracerebral hemorrhage as a function of year. Goodness-of-fit of year, both as a continuous and a categorical variable with 10 levels, was examined, as were plots of the stratum-specific rates over time. Both methods supported including year as a continuous variable with a linear relationship.
The exponent of the regression coefficient for year (ßi) from each of the Poisson models was used as an estimate of the annual change in the rate of hospital discharge. A smoothed estimate of the total percent change in the stratum-specific rates over the 10 years of study was calculated as 100x[{exp[10xßi]}-1], where i indicates the ith type-, age-, and sex-specific stratum. CIs (95%) were calculated from the standard error of the regression coefficient.
Annual age- and sex-specific, 30-day, in-hospital case-fatality rates were calculated as the proportion of all discharges in each stratum that ended in death within 30 days. For these rates, contiguous hospitalizations were combined into one discharge record. Logistic regression was used to determine whether there were differences in the in-hospital case-fatality rate by type of stroke (cerebral infarction or intracerebral hemorrhage), age group, and sex.
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Results |
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Fig 1
shows the total number of hospital separations for cerebral infarctions (top number) and intracerebral hemorrhages (bottom number) in each province over 10 years. For the whole of Canada (excluding British Columbia for 1982 to 1983), a total of 335 283 discharges for stroke were enumerated over the 10-year period (309 631 cerebral infarctions and 25 652 intracerebral hemorrhages).
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Tables 1 and 2 present the rates and numbers of discharges for cerebral infarction and intracerebral hemorrhage by age, sex, and fiscal year. The rates for the last year of the study are presented graphically in Fig 2, according to age group. The rates are depicted on a log scale and indicate that both types of stroke vary as a log-linear function with age. The rate of infarctions was always considerably greater than the rate of hemorrhages: the ratio of infarctions to hemorrhages ranged from 3:1 to more than 20:1, depending on age and sex. The rates for men were about 30% to 50% higher than for women, and this excess was consistent across time, age group, and subtype of stroke.
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The effect of time on hospitalization rates is shown in Fig 3, where age-standardized rates of infarction and hemorrhage for men and for women are plotted against year. The rate of infarctions is indicated on the left (y1 axis) and the rate of hemorrhages on the right (y2 axis). The estimated change in these rates over the 10-year period is indicated on the graph. For infarctions, a significant decline of approximately 1% per year was observed, which translates into a decline for men of approximately 11% over the 10-year study period (95% CI, 9% to 12%); for women, a 7% decline (95% CI, 5% to 8%) was observed. For hemorrhages, the reverse was seen: for men there was a 44% increase over the 10-year period (95% CI, 35% to 53%), and for women there was a 34% increase (95% CI, 26% to 42%).
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indicates estimated change from 1982-1983 to 1991-1992.
In-hospital case-fatality rates for cerebral infarctions varied by age and sex. For persons aged 65 to 74 years, the annual in-hospital case-fatality rate after infarction was approximately 12% over the 10-year period. Younger persons had significantly lower rates. The OR for fatality for persons 15 to 54 years (compared with persons in the reference stratum of 65 to 74 years) was 0.42 (95% CI, 0.39 to 0.44); for persons 55 to 64 years, the corresponding OR was 0.65 (95% CI, 0.62 to 0.67). The in-hospital case-fatality rates for persons in the two oldest age strata were approximately 18% and 27%, respectively, which are significantly higher than those in the reference age category (OR for 75 to 84 years, 1.61; 95% CI, 1.56 to 1.65; OR for 85 years, 2.77; 95% CI, 2.70 to 2.85). After adjustment for age, there was no difference between the sexes in the in-hospital case-fatality rate (OR, 0.99; 95% CI, 0.97 to 1.01).
The age-specific in-hospital case-fatality rates for cerebral infarction and for intracerebral hemorrhage for the first (1982 to 1983) and the last (1991 to 1992) years of study are given in Table 3 along with the estimated percent change and 95% CI. For cerebral infarction, the sex-adjusted declines ranged from 11% to 17% and were significant for all age strata, except the youngest.
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For intracerebral hemorrhage, the in-hospital case-fatality rate also varied by age but not by sex. Relative to the age group 65 to 74 years, the OR for fatality for persons 15 to 54 years of age was 0.63 (95% CI, 0.59 to 0.68); the OR for persons 55 to 64 years was 0.86 (95% CI, 0.80 to 0.92). The corresponding ORs (95% CIs) for the two oldest strata 75 to 84 and 85 years were 1.33 (1.24 to 1.43) and 1.91 (1.73 to 2.12), respectively. The in-hospital case-fatality rate was about 4% higher in men than in women (OR, 1.04; 95% CI, 0.99 to 1.09).
In-hospital case-fatality rates for hemorrhages were considerably higher than for infarctions, with ratios ranging from 2 for the oldest age group to 5 for the youngest age group; the relative reductions between 1982 and 1991 were greater than for cerebral infarction, ranging from 38% to 51%.
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Discussion |
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This study used secondary data based on hospital separation abstracts to describe the occurrence of stroke in an entire population over a decade, something that would not have been possible with any other surveillance strategy.
To minimize some of the obvious limitations of this type of data, only stroke codes previously shown to be valid for identifying acute strokes from other types of cerebrovascular disease were used.16 Although this makes comparison with rates derived from administrative sources that routinely use the entire rubric of ICD-9 codes for cerebrovascular disease difficult,18 this procedure provides estimates for the occurrence of all strokes that are close to what would be derived from a retrospective hospital-based registry. The inability to discriminate first-ever from recurrent stroke remains a limitation for some uses but not for others. In terms of public health policy regarding the importance of stroke as a contributor to morbidity and mortality and the need to continue an aggressive educational policy for reducing stroke, it is less important that this distinction is made, since many of the risk factors for first stroke are also risk factors for recurrent stroke.19 For planning healthcare resources, the distinction is irrelevant. Another potential limitation, double counting of admissions because of interhospital transfers, was controlled by the accumulation of contiguous records.
These types of data also do not permit follow-up of persons beyond hospital discharge; thus, the case-fatality rates refer only to in-hospital case-fatality. However, because of the long length of stay for stroke in Canadian hospitals (on average, 27 days for the population in this study), most persons would be under observation for the 30-day period. In fact, persons discharged alive after an intracerebral hemorrhage had an average length of stay of 29 days; for persons discharged alive after a cerebral infarction, the length of stay was an average of 26 days. In addition, it has been our experience that shorter lengths of stay are observed for persons with milder strokes and less comorbidity; thus, it is unlikely that many persons died out of the hospital during the first 30 days.
Although there are limitations to this type of data, several well-known features of the epidemiology of stroke emerged: the almost 10-fold predominance of cerebral infarctions over intracerebral hemorrhages, the higher rate of both types of stroke among men, the dramatic increase in rates with age, and the high in-hospital case-fatality rate, particularly for hemorrhagic strokes. The age-standardized rates of cerebral infarction for 1991 to 1992 were 167 per 100 000 men and 158 per 100 000 women; for cerebral hemorrhage, the corresponding rates were 17 and 15 per 100 000 men and women, respectively. This places Canada about midway between the highest- and lowest-incidence countries in terms of stroke occurrence20 but somewhat lower in incidence than that reported from the United States.21
Of more direct interest is the changing pattern of hospitalization for stroke over time, with a slight decline observed for infarctions but a much more dramatic increase observed for hemorrhages. It is not possible with this source of data to rule out that these changes are artifactual, caused by changes in admission policy or in diagnostic accuracy. If changes in admission policy contributed to the temporal pattern, it is likely that over this time period more stroke patients were admitted to take advantage of advances in the treatment for stroke, such as use of anticoagulation and antithrombotic agents. This policy would have tended to increase the rates of hospitalization, not decrease them, as was observed for cerebral infarctions.
If changes in the utilization of advanced diagnostic technology contributed to the change, then an increase in the rate of hemorrhagic strokes would be expected, since mild hemorrhagic strokes are the ones most often misclassified as cerebral infarctions using clinical features alone.22 Assuming this type of misclassification occurred, then over time the hemorrhagic category would include more mild strokes. Because persons with this type of stroke would be at low risk of dying, the in-hospital case-fatality rate for hemorrhagic strokes would decrease over time. Since the infarction category is large in comparison with the hemorrhagic category, the impact of including some hemorrhagic strokes on the in-hospital case-fatality rate for cerebral infarctions would be less dramatic. Thus, a decline in the in-hospital case-fatality rate would be compatible with this hypothesis, but, as pointed out by Newman,23 the decline in the case-fatality rate for infarctions is likely to have occurred owing to improvements in therapy for acute stroke.
Because of the limitations of this type of data, the course of action is open to debate. One choice is to consider the changes in rates to be artifactual and take no further action to investigate the occurrence of stroke. A second option is to act as if the changes in rates were real and pursue other avenues of inquiry. For example, what are the causes of hemorrhagic stroke? More specifically, could an increased use of antiplatelet agents be a causal factor in hemorrhagic stroke? What are the factors contributing to case-fatality? Although a stroke registry would provide much useful data, particularly as to the occurrence of specific subtypes of stroke, answers to the more specific questions will be found only through the application of analytical methodologies, not through refinements of case-ascertainment strategies.
Conclusion
Ten years of surveillance data on stroke in Canada indicate that the rates of cerebral infarction declined slightly but that the rates of intracerebral hemorrhage increased substantially. However, the increase in rates of intracerebral hemorrhage was more than offset by the decline in cerebral infarctions. As the case-fatality rate for these two types of strokes also declined, the prevalence of stroke in the population is likely to rise. The possibility that these changes are artifactual cannot be ruled out, but because there is no obvious risk in assuming that they are not, it would be prudent to investigate their causes further.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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The authors are grateful to Health Canada for research funds under the National Health Research Development Program (project #6605-392-57). The authors also would like to thank Drs Leslie Roos (Winnipeg, Manitoba), David McLean (Halifax, Nova Scotia), and Howard Brunt (Victoria, British Columbia) for their assistance in obtaining funding. In addition, the authors wish to thank the following persons who assisted with analyzing data: Shelley Derkson (Manitoba), Alison Edwards (Newfoundland), Nicole Hollet (Nova Scotia), and Liyan Liu (Saskatchewan).
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Footnotes |
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1 Principal Investigator: Nancy E. Mayo, PhD (Quebec). Coinvestigators: Doreen Neville, ScD (Newfoundland); Susan Kirkland, PhD (Nova Scotia); Truls Ostbye, MD, MPH (Ontario); Cameron A. Mustard, ScD (Manitoba); Bruce Reeder, MD, FRCP (Saskatchewan); Michel Joffres, MD, PhD (Alberta); Gerhard Brauer, MA (British Columbia); Adrian R. Levy, MSc (Quebec).
Received January 29, 1996; revision received March 28, 1996; accepted April 1, 1996.
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