(Stroke. 2000;31:1583.)
© 2000 American Heart Association, Inc.
Original Contributions |
Trends in Stroke Incidence and Acute Case Fatality in a Japanese Rural Area
The Oyabe Study
From Kanazawa Medical University (Y.M., H.N., M.N., K.M., M.T., W.H.), Ishikawa-ken; Toyama Medical and Pharmaceutical University (Y.N., S.K.), Toyama-ken; Tonami Public Health Center (M.H.), Toyama-ken; and Notre Dame Seishin University (K.Y., K.H.), Okayama-ken, Japan.
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Abstract |
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Background and Purpose—Stroke mortality in Japan has significantly declined during recent decades. To determine the cause of this decrease, we studied the trends in stroke incidence and case fatality within 28 days after stroke in a rural area in Japan.
Methods—We used a population-based registry during 1977–1991 in Oyabe, a rural area in the central part of Japan. The average population aged 25 years and older numbered 32 859 persons. Changes in age-standardized stroke incidence rate were calculated and compared between the 3 periods 1977–1981, 1982–1986, and 1987–1991. The 28-day case fatality rate was evaluated and also compared between the 3 periods by onset year.
Results—The total number of strokes was 2068. The age-standardized incidence rate of all strokes decreased during the 15-year period, from 605 to 417 per 100 000 in men and from 476 to 329 per 100 000 in women. A marked decline was found during 1977–1986 but was not apparent during 1987–1991. Moreover, there was an increase in the group aged 75 years and older. The 28-day case fatality rates for all strokes improved from 18.0% to 14.2% in men and from 26.8% to 19.1% in women during the observation period.
Conclusions—These data indicate that declines in the stroke incidence and the 28- day case fatality have been associated with a marked decrease in stroke-related mortality in Japan.
Key Words: epidemiology • incidence • Japan • stroke outcome
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Introduction |
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Stroke is one of the major causes of death and disability in most developed countries.1 Stroke mortality in Japan had been higher than that in other developed countries1 2 but has significantly declined during recent decades, and by 1990 stroke-related deaths were only 40% of those of 1965.3 Measurement of community trends in incidence and case fatality is necessary to determine whether mortality is falling because there are fewer events occurring or because survival after the event has improved. No nationwide study of stroke incidence in Japan is available. By some studies of model districts, a decline in stroke incidence was reported.4 5 6 7 8 However, information about secular trends in incidence and case fatality is still inadequate. Additionally, few studies have been conducted on the survival rate of stroke patients in a whole population in Japan.
The purpose of our study was to reveal the trends of stroke incidence and survival rate from the data of a community-based stroke registry in a rural area in Japan. This area is a valuable one in which a population-based registry system of stroke was established and has been maintained for a relatively long period.
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Subjects and Methods |
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We used a population-based registry in the jurisdiction of the Oyabe Public Health Center and determined the trend in stroke incidence during 1977–1991 and acute fatal rate within 28 days after stroke. The jurisdiction of Oyabe Public Health Center is a semirural area located in Toyama prefecture, in the central part of Japan. It comprises the city of Oyabe and the town of Fukuoka and has an area of 191 km2. The average population aged 25 years and older during the observational period was 32 859 persons (15 558 men and 17 301 women). General practitioners and several general hospitals in this area and neighboring areas are the main providers of medical care.
We requested 3 general hospitals in this area and neighboring areas and all general practitioners in this area to notify us of patients suspected of having stroke. The number of general practitioners was 25 in 1977 and 31 in 1991. Six of them had facilities for admission. The 3 general hospitals mainly reported hospitalized cases. The general practitioners reported outpatients and hospitalized cases. The physicians reported the events in a prescribed form with items related to neurological deficit, trends of symptom, and past history. To complete the registration, information was also gathered by public health nurses, local associations, and groups for the support of patients with stroke. We also regularly checked death certificates, social insurance records, and registers of calls for ambulance service. In cases in which the information from physicians was insufficient and in cases from other resources, medical records were gathered and checked. Additionally, public health nurses held interviews with the patients regarding the medical and social facts surrounding the events, except for fatal cases and severely disabled patients. The study team members checked the accuracy of the diagnosis of stroke and registered the cases.
Stroke was defined according to the World Health Organization (WHO) criteria2 as "rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin." The definition includes most cases of subarachnoid hemorrhage, intracranial hemorrhage, and cerebral infarction but no cases of transient ischemic attacks or those with asymptomatic lesions detected by brain imaging (silent infarction). Only patients with first-ever stroke during the study periods were registered and counted for the measurement of stroke incidence and the 28-day case fatality rate. The classification of the type of stroke was done according to the criteria of the Stroke Committee established by the Japanese Ministry of Education,9 which modified the diagnostic criteria of the ad hoc committee established by the Advisory Council for the National Institute of Neurological Diseases and Blindness, Public Health Service.10 This classification depends mainly on symptoms and past history. However, since CT scanning and other neuroimaging methods have been used for diagnosis in this area since 1985, these findings were preferred for the diagnosis.
The analysis included the following 3 periods: first period, 1977–1981; second period, 1982–1986; and third period, 1987–1991. During 1977–1991, 2068 stroke cases were identified among the inhabitants aged 25 years and older. Among the 2068 cases, 1175 cases (57%) were obtained from the physicians, 631 from general hospitals, and 544 from general practitioners. Seven hundred three cases (34%) were obtained from searches of death certificates. Others (9%) were obtained from other community-based sources. The proportion of events identified from general hospitals among all events showed an increase in recent years: 19% in 1977–1981, 33% in 1982–1986, and 41% in 1987–1991. By contrast, the proportion identified from death certificates decreased recently: 37.6% in 1977–1981, 39.2% in 1982–1986, and 25.5% in 1987–1991.
The age-standardized incidence rate was calculated by an indirect
method, with the mean population during the observational period of the
jurisdiction of the Oyabe Health Center used as a standard population.
The case fatality rates are the proportion of registered stroke
patients who died within 28 days after the first event. The
Mantel-Haenszel 
2 test was used when
appropriate.
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Results |
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Trend of Stroke Incidence
During 1977–1991, 2068 stroke cases, 1117 men and 951 women, were identified among the inhabitants aged 25 years and over. The numbers of events determined by the 3 periods—1977–1981, 1982–1986, and 1987–1991—were 740, 627, and 701, respectively. Mean age at onset among male patients was lower than that of female patients. The mean age of male patients was 67.8 years in 1977–1981, 68.7 years in 1982–1986, and 70.1 years in 1987–1991. The mean age of women was 71.5 years in the first period, 74.6 years in the second period, and 75.2 years in the third period, showing a tendency toward older age of onset in both sexes.
The proportion of type of stroke is shown in Table 1
. During the 15-year period, the
proportion of cerebral hemorrhage among all strokes decreased
from 23.6% to 16.4%. Additionally, the proportion of undetermined
type decreased from 11.5% to 2.3%. In contrast, the proportion of
cerebral infarction increased from 61.1% to 73.6%, and that of
subarachnoid hemorrhage increased from 3.8% to
7.7%.
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The age- and sex-specific crude incidence rates and age-standardized
incidence rates of strokes are shown in Tables 2 and 3.
Incidence rates for men and women rose steeply with each decade of age
in all 3 periods. Age-specific rates of men were higher than those of
women in all 3 periods. The age-standardized incidence rate of stroke
decreased significantly from 1977–1981 to 1982–1986; the rate was 605
per 100 000 for 1977–1981 and 455 for 1982–1986 in men and 476 per
100 000 for 1977–1981 and 322 for 1982–1986 in women. There was a
25% reduction in the age-standardized incidence rate in men and a 30%
reduction in women between 1977–1981 and 1982–1986. However, no such
decreasing trend of stroke incidence rate was apparent from 1982–1986
to 1987–1991. Moreover, there was an increase in the age-standardized
incidence rate among people aged 75 years and older from 1982–1986 to
1987–1991.
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Trends in the 28-Day Case Fatality Rate of Stroke Patients
The 28-day case fatality rates by the observational periods are
shown in Table 4. Case fatalities of
strokes of female patients were higher than those of male patients in
each period. The difference between the sexes was statistically
significant among the patients aged 65 to 74 years in 1977–1981 and
1982–1986 and the patients younger than 65 years in 1987–1991. The
28-day case fatality rates for stroke tended to improve during the
observation period. The proportion of decline of case fatality was 23%
in men and 29% in women during the 15-year period. The decline of case
fatality was statistically significant in women aged 75 years and
older.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The target population of our study is a valuable one to elucidate the long-term trend of stroke incidence in Japan. Our target district is located in a rural area in Japan. The standardized mortality ratio of stroke of this district compared with the national mean in 1989–1993 was 132.8 for men and 128.1 for women in the city of Oyabe and 96.1 for men and 105.6 for women in the town of Fukuoka.11 Therefore, the mortality rate of the city of Oyabe was higher than that of the national mean. A decline in the mortality of stroke has also been noted in this area, reflecting the national trend.
For an epidemiological study of stroke, completeness of case ascertainment and accuracy of diagnosis are needed.12 13 14 Population-based stroke registers in this area were established in 1977. To ensure the completeness of case ascertainment, multiple sources of information, such as physicians’ reports, death certificates, social insurance records, and reports from public health nurses and public emergency services, were used. In our registration, the proportion of patients identified from death certificates was high compared with other reports, particularly in the earlier years. Mainly, the lower number of reports from general practitioners caused the high proportion of cases from death certificates. With the increase in the reports from general hospitals, the proportion of cases from general practitioners and death certificates decreased. This is attributable to the fact that stroke patients have recently preferred to attend general hospitals.
The WHO Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) Project identified several keys that indicate the data quality of stroke registration,12 such as the ratio of fatal cases in the registration to acute stroke deaths in routine mortality statistic and the 28-day case fatality rate. Unfortunately, we could not obtain the routine statistics of acute stroke deaths (International Classification of Diseases [ICD] 430 to 434, 436) during the whole observational period. Instead, we were able to determine the ratio between the number of stroke deaths in those who were registered in our system and the number of stroke deaths in routine mortality statistics (ICD 430 to 438). The annual ratio was distributed from 0.4 to 1.5 during the 15-year period. Although the ratio was <1.0 during 1977–1981, it was >1.0 after 1982. The number of deaths in routine statistics in earlier years would contain the deaths after stroke that occurred before 1977. In addition, the 28-day case fatality rate was <30% during the observational period. This rate is not as high as those in other reports.12 We therefore considered that we could obtain sufficient data quality for an epidemiological study.
Incidence rates of our target population were similar to those in the same years of other populations in Japan.4 5 6 7 8 However, the incidence rates of our study area were higher than those of other developed countries in the 1980s.15 16 17 18 Incidence rates of stroke in our target population declined during the observational period. A marked decline was evident in the first half of this 15-year period, during 1977–1981 through 1982–1986. In this period the decline of the incidence rate was seen for both sexes, for all age classes. This reincrease of stroke, particularly cerebral infarction, was also reported from other districts in Japan.19 20 It is suggested that some part of this trend is associated with the widespread use of CT scanning and changes in diagnostic methods. Additionally, in our target area, greater use of CT started after 1985. However, because we did not include cases only identified by such scanning without clinical evidence of stroke, we consider that the trend of all strokes was not significantly influenced by the development of neuroimaging. On the other hand, it would affect the classification of stroke type, as shown in the decrease in the proportion of underestimated type in our report. The impact of CT on the diagnosis of stroke type cannot be ignored.13 21
The case fatality at 28 days also improved during the 15-year period, being similar to or lower than that of other developed countries.16 22 23 24 25 For reference, the age-standardized case fatality of our data was calculated according to the method of the WHO MONICA Project,16 which weighs 1, 3, and 7 for the age groups 35 to 44, 45 to 54, and 55 to 64 years, respectively. The fatality of our study cases aged 35 to 64 years ranged from 16.4% in 1977–1981 to 7.4% in 1987–1991 among male patients and from 20.6% in 1977–1981 to 12.4% in 1982–1986 among female patients. These are lower than the 28-day case fatality rates of the WHO MONICA populations.16
Stroke incidence and acute fatal rate decreased during the observational period in a rural area in Japan. It is considered that these trends caused a marked decline in stroke mortality in Japan. However, the decline of incidence of stroke has recently been attenuated. Lack of decrease and reincrease of stroke incidence have also been reported from some other developed countries.23 26 27 28 The incidence rates of our population are higher than those of other industrialized countries. The decreasing trend has been attenuated before it reached the level of other developed countries. We therefore need to identify appropriate strategies for the prevention of stroke.
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Acknowledgments |
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We wish to thank coworker Tomiko Yoshii for supporting the stroke registration system as a leader of public health nurses for many years. We also thank the persons in the registration system in Oyabe Public Health Center, the city of Oyabe, the town of Fukuoka, and general practitioners and hospitals for supporting the stroke registration and data collection for many years.
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Footnotes |
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Reprint requests to Yuko Morikawa, Department of Public Health, Kanazawa Medical University, 1-1 Daigaku, Uchinada-machi, Kahoku-gun, Ishikawa-ken, Japan 920-0293.
Received December 27, 1999; revision received April 3, 2000; accepted April 3, 2000.
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References |
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