Temporal trends and rural-urban disparities in cerebrovascular risk factors,in-hospital management and outcomes in ischaemic strokes in China from 2005 to 2015:a nationwide serial cross-sectional survey

Background Stroke is the leading cause of mortality in China,with limited evidence of in-hospital burden obtained from nationwide surveys.We aimed to monitor and track the temporal trends and rural-urban disparities in cerebrovascular risk factors,management and outcomes from 2005 to 2015.Methods We used a two-stage random sampling survey to create a nationally representative sample of patients admitted for ischaemic stroke in 2005,2010 and 2015.We sampled participating hospitals with an economic-geographical region-stratified random-sampling approach first and then obtained patients with a systematic sampling approach.We weighed our survey data to estimate the national-level results and assess changes from 2005 to 2015.Results We analysed 28277 ischaemic stroke admissions from 189 participating hospitals.From 2005 to 2015,the estimated national hospital admission rate for ischaemic stroke per 100000 people increased(from 75.9 to 402.7,Ptrend<0.001),and the prevalence of risk factors,including hypertension,diabetes,dyslipidaemia and current smoking,increased.The composite score of diagnostic tests for stroke aetiology assessment(from 0.22 to 0.36,Ptrend<0.001)and secondary prevention treatments(from 0.46 to 0.70,Ptrend<0.001)were improved.A temporal decrease was found in discharge against medical advice(DAMA)(from 15.2%(95%CI 13.7%to 16.7%)to 8.6%(8.1%to 9.0%);adjusted Ptrend=0.046),and decreases in in-hospital mortality(0.7%in 2015 vs 1.8%in 2005;adjusted OR(aOR)0.52;95%CI 0.32 to 0.85)and the composite outcome of in-hospital mortality or DAMA(8.4%in 2015 vs 13.9%in 2005;aOR 0.65;95%CI 0.47 to 0.89)were observed.Disparities between rural and urban hospitals narrowed;however,disparities persisted in in-hospital management(brain MRI:rural-urban difference from−14.4%to−11.2%;cerebrovascular assessment:from−20.3%to−16.7%;clopidogrel:from−2.1%to−10.3%;anticoagulant for atrial fibrillation:from−10.9%to−8.2%)and in-hospital outcomes(DAMA:from 2.7%to 5.0%;composite outcome of in-hospital mortality or DAMA:from 2.4%to 4.6%).Conclusions From 2005 to 2015,improvements in hospital admission and in-hospital management for ischaemic stroke in China were found.A temporal improvement in DAMA and improvements in in-hospital mortality and the composite outcome of in-hospital mortality or DAMA were observed.Disparities between rural and urban hospitals generally narrowed but persisted.

Secondary prevention medication persistence and prognosis of acute ischaemic stroke or transient ischaemic attack

Introduction The risk of disability and mortality is high among recurrent stroke,which highlights the importance of secondary prevention measures.We aim to evaluate medication persistence for secondary prevention and the prognosis of acute ischaemic stroke or transient ischaemic attack(TIA)in China.Methods Patients with acute ischaemic stroke or TIA from the China National Stroke Registry II were divided into 3 groups based on the percentage of persistence in secondary prevention medication classes from discharge to 3 months after onset(level I:persistence=0%,level II:0%<persistence<100%,level III:persistence=100%).The primary outcome was recurrent stroke.The secondary outcomes included composite events(stroke,myocardial infarction or death from cardiovascular cause),all-cause death and disability(modified Rankin Scale score=3–5)from 3 months to 1 year after onset.Recurrent stroke,composite events and all-cause death were performed using Cox regression model,and disability was identified through logistic regression model using the generalised estimating equation method.Results 18344 patients with acute ischaemic stroke or TIA were included,315(1.7%)of whom experienced recurrent strokes.Compared with level I,the adjusted HR of recurrent stroke for level II was 0.41(95%CI 0.31 to 0.54)and level III 0.37(0.28 to 0.48);composite events for level II 0.41(0.32 to 0.53)and level III 0.38(0.30 to 0.49);all-cause death for level II 0.28(0.23 to 0.35)and level III 0.20(0.16–0.24).Compared with level I,the adjusted OR of disability for level II was 0.89(0.77 to 1.03)and level III 0.82(0.72 to 0.93).Conclusions Persistence in secondary prevention medications,especially in all classes of medications prescribed by the physician,was associated with lower hazard of recurrent stroke,composite events,all-cause death and lower odds of disability in patients with acute ischaemic stroke or TIA.