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) using 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.