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Health at a Glance 2011: OECD Indicators
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branch 5. Quality of Care
branch Care for acute exacerbation of chronic conditions
    branch 5.4. In-hospital mortality following stroke

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., 2007).

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 countries.

Information on data for Israel: http://dx.doi.org/10.1787/888932315602.

 
Indicator in PDF Acrobat PDF page

Figures
5.4.1 In-hospital case-fatality rates within 30 days after admission for ischemic stroke, 2009 (or nearest year) Figure in Excel
In-hospital case-fatality rates within 30 days after
 admission for ischemic stroke, 2009 (or nearest year)
5.4.2 In-hospital case-fatality rates within 30 days after admission for hemorrhagic stroke, 2009 (or nearest year) Figure in Excel
In-hospital case-fatality rates within 30 days after
 admission for hemorrhagic stroke, 2009 (or nearest year)
5.4.3 Reduction in in-hospital case-fatality within 30 days after admission for ischemic stroke, 2000-09 (or nearest year) Figure in Excel
Reduction in in-hospital case-fatality within 30 days
 after admission for ischemic stroke, 2000-09 (or nearest year)
 



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