Trends in the Prevalence of Stroke Among Community-Dwelling Individuals in the US, 1999-2018

Wells Andres; Aaron Rothstein; Holly Elser; Kelly L Sloane; Rebecca F Gottesman; Scott E Kasner; Andrea L C Schneider

doi:10.1001/jamaneurol.2023.0742

. 2023 Apr 24;80(6):646–648. doi: 10.1001/jamaneurol.2023.0742

Trends in the Prevalence of Stroke Among Community-Dwelling Individuals in the US, 1999-2018

Wells Andres ¹, Aaron Rothstein ¹, Holly Elser ¹, Kelly L Sloane ¹, Rebecca F Gottesman ², Scott E Kasner ^1,³, Andrea L C Schneider ^1,^3,^✉

¹Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia

²Stroke Branch, National Institute of Neurologic Disorders and Stroke Intramural Research Program, Bethesda, Maryland

³Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia

Accepted for Publication: February 6, 2023.

Published Online: April 24, 2023. doi:10.1001/jamaneurol.2023.0742

^✉

Corresponding Author: Andrea L. C. Schneider, MD, PhD, Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, 51 N 39th St, Andrew Mutch Building 416, Philadelphia, PA 19104 (andrea.schneider@pennmedicine.upenn.edu).

Author Contributions: Drs Rothstein and Schneider had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Andres and Rothstein are co–first authors and contributed equally.

Study concept and design: Rothstein, Gottesman, Schneider.

Acquisition, analysis, or interpretation of data: Andres, Rothstein, Elser, Sloane, Kasner, Schneider.

Drafting of the manuscript: Andres.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rothstein, Schneider.

Administrative, technical, or material support: Sloane.

Study supervision: Schneider.

Conflict of Interest Disclosures: Dr Kasner has received grants from Genentech and Diamedica as well as personal fees from Bristol Myers Squibb, Medtronic, and AstraZeneca outside the submitted work. Dr Schneider has received grants from the US Department of Defense and is Associate Editor of Neurology outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Schneider is supported by grant K23NS123340 from the National Institute of Neurological Disorders and Stroke. Dr Rothstein is supported by grant T32NS061779 from the National Institute of Neurological Disorders and Stroke. Dr Gottesman is supported by the National Institute of Neurological Disorders and Stroke Intramural Research Program.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This paper was presented at AAN 2023 Annual Meeting; April 24, 2023; Boston, Massachusetts.

Data Sharing Statement: See the Supplement.

^✉

Corresponding author.

PMCID: PMC10126939 PMID: 37094376

Abstract

This cross-sectional study estimates trends in stroke prevalence representative of the noninstitutionalized civilian population of US adults 20 years and older using data from the 1999 to 2018 National Health and Nutrition Examination Surveys.

Representative estimates of stroke prevalence inform public health interventions and guide resource allocation. There is a need for updated data on stroke prevalence among community-dwelling individuals in the US. We present data from the 1999 to 2018 National Health and Nutrition Examination Surveys (NHANES) to estimate trends in stroke prevalence representative of the noninstitutionalized civilian population of US adults 20 years and older.

Methods

The NHANES is a series of nationally representative cross-sectional surveys administered biennially.¹ Participants are selected from among the noninstitutionalized US population using a complex, stratified, multistage, probability-clustered sampling design. This analysis includes all (n = 2197) participants from the 1999-2018 survey cycles 20 years and older who self-reported a history of stroke, ascertained using the question, “Has a doctor or other health professional ever told you that you had a stroke?”² The NHANES are approved by the National Center for Health Statistics Ethics Review Board.

Data were grouped into 4-year epochs to improve the precision of estimates.¹ Within each epoch, stroke prevalence was calculated overall and stratified by sex, self-reported race and ethnicity, and age group. Prevalence estimates were age-standardized to the 2017 to 2018 American Community Survey–Public Use Microdata Sample (ACS-PUMS) using the following age categories: 20 to 39 years, 40 to 59 years, and 60 years or older. We applied our stroke prevalence estimates to the Current Population Surveys and the ACS-PUMS to calculate the number of affected individuals with stroke. P values for linear trend over time were calculated using logistic regression models. In accordance with NHANES recommendations, analyses incorporated survey weights to account for the sampling design and the Taylor series (linearization) method was used to obtain standard errors.¹ A 2-tailed P value less than .05 was considered statistically significant, and all analyses were performed using Stata SE version 17 (StataCorp).

Results

From 1999 to 2018, the overall crude and age-standardized prevalence of stroke was 2.84% (95% CI, 2.67-3.02) and 3.10% (95% CI, 2.92-3.29), respectively. This corresponds to an estimated 7.3 million (95% CI, 6.9 million-7.8 million) affected individuals. The overall prevalence of stroke was stable from 1999-2002 to 2015-2018 (Table). Crude estimates of the number of affected individuals with stroke increased over time, while age-standardized estimates were stable (Figure).

Table. Self-Reported Stroke Prevalence Overall and Stratified by Sex, Race and Ethnicity, and Age Group.

Measure	Prevalence (95% CI)						P for trend^a
Measure	Overall, 1999-2018	1999-2002	2003-2006	2007-2010	2011-2014	2015-2018	P for trend^a
Unweighted total, No.	2197	394	405	485	431	482	NA
Overall
Crude	2.84 (2.67-3.02)	2.50 (2.18-2.87)	2.82 (2.39-3.31)	2.91 (2.52-3.36)	2.86 (2.53-3.23)	3.05 (2.68-3.47)	.07
Age standardized^b	3.10 (2.92-3.29)	2.95 (2.56-3.38)	3.27 (2.85-3.73)	3.23 (2.80-3.72)	3.02 (2.69-3.39)	3.08 (2.72-3.48)	.07
Stratified by sex
Men
Crude	2.55 (2.36-2.77)	2.29 (1.94-2.71)	2.32 (1.88-2.85)	2.62 (2.26-3.05)	2.53 (2.06-3.11)	2.94 (2.50-3.46)	.04
Age standardized^b	2.95 (2.73-3.18)	2.91 (2.49-3.39)	2.96 (2.50-3.49)	3.03 (2.65-3.48)	2.81 (2.27-3.46)	3.08 (2.63-3.60)	.04
Women
Crude	3.10 (2.85-3.37)	2.69 (2.21-3.28)	3.28 (2.73-3.93)	3.18 (2.58-3.92)	3.17 (2.69-3.72)	3.15 (2.62-3.79)	.39
Age standardized^b	3.24 (2.99-3.52)	2.99 (2.46-3.63)	3.56 (3.03-4.19)	3.39 (2.74-4.18)	3.22 (2.76-3.76)	3.09 (2.57-3.71)	.39
Stratified by race and ethnicity
Mexican American
Crude	1.51 (1.28-1.78)	1.09 (0.81-1.46)	1.62 (1.1-2.36)	1.29 (0.83-2.00)	1.94 (1.31-2.86)	1.51 (1.15-1.99)	.15
Age standardized^b	2.60 (2.28-2.97)	2.58 (2.12-3.14)	3.22 (2.37-4.35)	2.29 (1.67-3.14)	2.94 (2.07-4.17)	2.25 (1.82-2.78)	.15
Non-Hispanic Asian^c
Crude	1.34 (0.96-1.85)	NA	NA	NA	1.68 (1.10-2.57)	1.04 (0.64-1.68)	NA
Age standardized^c	1.74 (1.29-2.35)	NA	NA	NA	2.32 (1.62-3.32)	1.28 (0.81-2.03)	NA
Non-Hispanic Black
Crude	3.82 (3.49-4.17)	3.38 (2.73-4.17)	3.38 (2.71-4.21)	4.12 (3.44-4.92)	3.70 (3.01-4.55)	4.39 (3.69-5.21)	.05
Age standardized^b	4.66 (4.29-5.01)	4.45 (3.60-5.49)	4.60 (3.80-5.54)	4.99 (4.18-5.94)	4.39 (3.59-5.36)	4.91 (4.21-5.73)	.05
Non-Hispanic White
Crude	2.95 (2.72-3.18)	2.59 (2.17-3.07)	2.94 (2.44-3.55)	3.09 (2.56-3.72)	2.95 (2.57-3.39)	3.14 (2.62-3.75)	.18
Age standardized^b	2.92 (2.71-3.16)	2.81 (2.34-3.37)	3.11 (2.63-3.67)	3.11 (2.57-3.75)	2.81 (2.47-3.19)	2.84 (2.39-3.37)	.18
Other^d
Crude	2.46 (2.00-3.02)	2.03 (1.22-3.34)	2.14 (1.18-3.86)	1.87 (1.28-2.70)	2.69 (1.81-3.97)	3.48 (2.29-5.25)	.08
Age standardized^b	3.47 (2.84-4.23)	2.66 (1.60-4.39)	3.62 (2.10-6.17)	2.91 (2.06-4.09)	3.89 (2.73-5.51)	4.26 (2.80-6.43)	.08
Stratified by age, y^e
20-39	0.42 (0.33-0.54)	0.46 (0.27-0.79)	0.41 (0.23-0.75)	0.46 (0.27-0.80)	0.38 (0.23-0.64)	0.38 (0.21-0.68)	.60
40-59	2.01 (1.77-2.29)	1.67 (1.19-2.34)	1.91 (1.36-2.68)	2.11 (1.67-2.66)	1.97 (1.48-2.61)	2.37 (1.82-3.07)	.14
≥60	7.71 (7.22-8.24)	7.54 (6.59-8.61)	8.41 (7.36-9.60)	7.99 (6.69-9.51)	7.54 (6.60-8.61)	7.28 (6.28-8.42)	.35

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Abbreviation: NA, not applicable.

^{^a}

P values for linear trend across 4-year epochs from logistic regression models.

^{^b}

Age standardized to the 2017-2018 American Community Survey–Public Use Microdata Sample using the following age categories: 20 to 39 years, 40 to 59 years, and 60 years and older.

^{^c}

Representative information for Asian American individuals available from 2011 to 2018.

^{^d}

The other category includes other Hispanic and other race, including multiracial.

^{^e}

Crude and age-standardized estimates are equivalent when age stratified using the categories of 20 to 39 years, 40 to 59 years, and 60 years and older.

Figure. — A, Crude stroke prevalence estimates were applied to the 1999 to 2002 Current Population Survey (CPS), 2003 to 2006 CPS, 2007 to 2010 CPS and American Community Survey–Public Use Microdata Sample (ACS-PUMS), 2011 to 2014 ACS-PUMS, and 2015 to 2018 ACS-PUMS to calculate the number of affected individuals with stroke in each 4-year epoch. B, Stroke prevalence estimates were age-standardized to the 2017-2018 ACS-PUMS using the following age categories: 20 to 39 years, 40 to 59 years, and 60 years and older. Age-standardized stroke prevalence estimates were then applied to the 2017-2018 ACS-PUMS to calculate the age-standardized number of affected individuals with stroke in each 4-year epoch. Error bars indicate 95% CIs.

The age-standardized prevalence of stroke was higher among non-Hispanic Black individuals compared with other racial and ethnic groups and was similar by sex. The prevalence was higher among older compared with younger individuals. The prevalence of stroke in each age and racial and ethnic group was stable from 1999-2002 to 2015-2018 but increased over time among men (from 2.29% [95% CI, 1.94-2.71] in 1999-2002 to 2.94% [95% CI, 2.50-3.46] in 2015-2018; P for trend = .04) (Table).

Discussion

Using a nationally representative sample of community-dwelling adults, we show that the prevalence of self-reported stroke remained stable in the US between 1999 and 2018 overall and by racial and ethnic group and age group and increased among men. Estimates herein underestimate the total burden of stroke in the US as NHANES does not include individuals residing in rehabilitation, long-term care, or other institutional settings. Stroke was self-reported in NHANES, which has high negative predictive value but modest positive predictive value^3,4; it is possible that the validity of self-reported stroke has changed over time. Importantly, we presented both crude and age-standardized prevalence estimates to account for changes in the age structure of the US population over the study period.

We report a crude stroke prevalence of 2.8% and an age-standardized stroke prevalence of 3.1% from 1999 to 2018, which is slightly higher than the 2006 to 2010 prevalence data from the Behavioral Risk Factor Surveillance System (BRFSS; 2.6% to 2.7%).⁵ Both prevalence estimates, that of our study and BRFSS, are higher than the 1973 to 1991 NHANES estimates, which showed that prevalence increased from 1.41% to 1.87%.⁶ Taken together, although the burden of stroke has increased since 1973 to 1991, it has stabilized in recent years.

Supplement.

Data Sharing Statement

Click here for additional data file.^{(16.9KB, pdf)}

References

1.Johnson CL, Paulose-Ram R, Ogden CL, et al. National health and nutrition examination survey: analytic guidelines, 1999-2010. Vital Health Stat 2. 2013;(161):1-24. [PubMed] [Google Scholar]
2.National Health and Nutrition Examination Survey . 2017-2018 Data Documentation, Codebook, and Frequencies. Accessed March 13, 2023. https://wwwn.cdc.gov/Nchs/Nhanes/2017-2018/MCQ_J.htm#MCQ160f
3.Engstad T, Bonaa KH, Viitanen M. Validity of self-reported stroke: the Tromso Study. Stroke. 2000;31(7):1602-1607. doi: 10.1161/01.STR.31.7.1602 [DOI] [PubMed] [Google Scholar]
4.Reitz C, Schupf N, Luchsinger JA, et al. Validity of self-reported stroke in elderly African Americans, Caribbean Hispanics, and Whites. Arch Neurol. 2009;66(7):834-840. doi: 10.1001/archneurol.2009.83 [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Fang J, Shaw KM, George MG; Centers for Disease Control and Prevention (CDC) . Prevalence of stroke—United States, 2006-2010. MMWR Morb Mortal Wkly Rep. 2012;61(20):379-382. [PubMed] [Google Scholar]
6.Muntner P, Garrett E, Klag MJ, Coresh J. Trends in stroke prevalence between 1973 and 1991 in the US population 25 to 74 years of age. Stroke. 2002;33(5):1209-1213. doi: 10.1161/01.STR.0000015031.57955.D1 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

Data Sharing Statement

Click here for additional data file.^{(16.9KB, pdf)}

[nld230001r1] 1.Johnson CL, Paulose-Ram R, Ogden CL, et al. National health and nutrition examination survey: analytic guidelines, 1999-2010. Vital Health Stat 2. 2013;(161):1-24. [PubMed] [Google Scholar]

[nld230001r2] 2.National Health and Nutrition Examination Survey . 2017-2018 Data Documentation, Codebook, and Frequencies. Accessed March 13, 2023. https://wwwn.cdc.gov/Nchs/Nhanes/2017-2018/MCQ_J.htm#MCQ160f

[nld230001r3] 3.Engstad T, Bonaa KH, Viitanen M. Validity of self-reported stroke: the Tromso Study. Stroke. 2000;31(7):1602-1607. doi: 10.1161/01.STR.31.7.1602 [DOI] [PubMed] [Google Scholar]

[nld230001r4] 4.Reitz C, Schupf N, Luchsinger JA, et al. Validity of self-reported stroke in elderly African Americans, Caribbean Hispanics, and Whites. Arch Neurol. 2009;66(7):834-840. doi: 10.1001/archneurol.2009.83 [DOI] [PMC free article] [PubMed] [Google Scholar]

[nld230001r5] 5.Fang J, Shaw KM, George MG; Centers for Disease Control and Prevention (CDC) . Prevalence of stroke—United States, 2006-2010. MMWR Morb Mortal Wkly Rep. 2012;61(20):379-382. [PubMed] [Google Scholar]

[nld230001r6] 6.Muntner P, Garrett E, Klag MJ, Coresh J. Trends in stroke prevalence between 1973 and 1991 in the US population 25 to 74 years of age. Stroke. 2002;33(5):1209-1213. doi: 10.1161/01.STR.0000015031.57955.D1 [DOI] [PubMed] [Google Scholar]

PERMALINK

Trends in the Prevalence of Stroke Among Community-Dwelling Individuals in the US, 1999-2018

Wells Andres, MD

Aaron Rothstein, MD

Holly Elser, MD, PhD

Kelly L Sloane, MD

Rebecca F Gottesman, MD, PhD

Scott E Kasner, MD, MSCE

Andrea L C Schneider, MD, PhD

Abstract

Methods

Results

Table. Self-Reported Stroke Prevalence Overall and Stratified by Sex, Race and Ethnicity, and Age Group.

Figure. Crude and Age-Standardized Estimated Number of US Adults 20 Years or Older With Self-Reported Stroke.

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

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Cite

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PERMALINK

Trends in the Prevalence of Stroke Among Community-Dwelling Individuals in the US, 1999-2018

Wells Andres, MD

Aaron Rothstein, MD

Holly Elser, MD, PhD

Kelly L Sloane, MD

Rebecca F Gottesman, MD, PhD

Scott E Kasner, MD, MSCE

Andrea L C Schneider, MD, PhD

Abstract

Methods

Results

Table. Self-Reported Stroke Prevalence Overall and Stratified by Sex, Race and Ethnicity, and Age Group.

Figure. Crude and Age-Standardized Estimated Number of US Adults 20 Years or Older With Self-Reported Stroke.

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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