Stroke and other cerebrovascular
disease is the fourth most common cause of death in OECD countries, accounting for over 8%
of all deaths on average (OECD, 2011a). Estimates suggest that it accounts for 2-4% of
health care expenditure and also significant costs outside of the health care system due
to its impact on disability (OECD, 2003a). In ischemic stroke, representing about 85% of
cases, the blood supply to a part of the brain is interrupted, leading to a necrosis of
the affected part, while in hemorrhagic stroke, the rupture of a blood vessel causes
bleeding into the brain, usually causing more widespread damage.
Treatment for ischemic stroke has
advanced dramatically over the last decade. Until the 1990s, it was largely accepted that
the damage to the brain was irreversible and treatment focused on prevention of
complications and rehabilitation. But following the spectacular improvements in
AMI survival rates that were achieved with early thrombolysis, clinical trials
demonstrated clear benefits of thrombolytic treatment for ischemic stroke in Japan (Mori
et al., 1992), the United States (e.g. NINDS, 1995) and European countries (e.g. Hacke et al., 1995).
Dedicated stroke units were introduced in many countries, to facilitate timely and
aggressive diagnosis and therapy for ischemic and haemorrhagic stroke victims, achieving
better survival than after usual care (Seenan et al.,
Stroke survival reflects quality of
acute care, particularly effective treatment methods such as thrombolysis and prompt and
adequate care delivery. Consequently, stroke case-fatality rates have been used for
hospital benchmarking within and between OECD countries.
While the standardised case-fatality
rate for ischemic stroke was about 5% on average across OECD countries in 2009, there were
large differences between the highest rate in Mexico (17.6%) and Slovenia (9.7%) and the
lowest rates in Korea and Japan (1.8%) (Figure 5.4.1). The average
standardised rate for hemorrhagic stroke is 19% (Figure 5.4.2), about four times greater than the rate for ischemic stroke,
reflecting the more severe effects of intracranial bleeding. The cross-country difference
ranges between 6.5% in Finland and 38.6% in Belgium. Countries that achieve better
survival for one type of stroke tend to do well for the other type. Given the initial
steps of care for stroke patients are similar, this suggests that system-based factors
play a role in explaining differences across countries. For example, Nordic countries
(Denmark, Finland, Iceland, Norway and Sweden) have been at the forefront of establishing
dedicated stroke units in hospitals, contributing to the below-average case-fatality rates
for both ischemic and hemorrhagic stroke. Other factors such as patterns of hospital
transfers, average length of stay, emergency retrieval times and average severity of
stroke may also influence the rates.
Case-fatality rates for ischemic
stroke have declined by 26% on average across OECD countries between 2000 and 2009 (Figure 5.4.3). The trend is similar for hemorrhagic stroke with an average
reduction of 17% during the same period. These reductions suggest widespread improvement
in the quality of care for stroke patients.
Definition and comparability
In-hospital case-fatality rate
following ischemic and hemorrhagic stroke is defined as the number of people who die
within 30 days of being admitted (including same day admissions) to hospital. Ideally,
rates would be based on individual patients; however, not all countries have the
ability to track patients in and out of hospitals, across hospitals or even within the
same hospital because they do not currently use a unique patient identifier.
Therefore, this indicator is based on unique hospital admissions and restricted to
mortality within the same hospital, so differences in practices in discharging and
transferring patients may influence the findings.
The Czech Republic, Denmark,
Finland, Korea, Luxembourg, New Zealand, the Netherlands, Poland, Slovenia, Sweden and
the United Kingdom also provided patient-based (in and out of hospitals) data. Their
relative performance is generally similar as the case-fatality rate within the same
hospital, although the rates are obviously higher.
Both crude and age and sex
standardised rates are presented. Standardised rates adjust for differences in age
(45+ years) and sex and facilitate more meaningful international comparisons. Crude
rates are likely to be more meaningful for internal consideration by individual