Summary
Background and purpose
Little information is available on the effects of age on health care and outcomes of ischemic stroke (IS) in China. Our aim was to evaluated risk factors, health care, and outcomes among age groups including ≤45, 46–65, 66–79, and ≥80 years and to find whether the outcome was affected by age and health care.
Methods
CNSR is a nationwide prospective registry for patients admitted with acute stroke and prospectively followed up 12‐month outcomes. Demographics, socioeconomics, risk factors, health care, and outcomes were analyzed among age groups, and multivariate regression analysis was used to determine the association of outcome and age and health care.
Results
We identified 12,415 acute IS patients for analysis. Of 1179 (9.50%) were aged ≥80 years. In terms of risk factors, cardiac diseases were significantly more frequent in patients ≥80 years, behavioral risk factors were more common in younger patients, and hypertension, hyperlipidemia, and diabetes were more seen in 46–79 patients. The use of health care varied among groups and was significantly lower in ≥80 years especially in secondary prevention. The very old patients had the worst outcomes even after adjusting by prognostic factors; however, adjusting forward by health care, the extent of differences decreased.
Conclusions
In CNSR, differences in stroke clinic characteristics and health care were observed among various age groups, and the old patients, receiving lower levels of stroke care, had the worst outcomes. Knowledge of the age differences in ischemic stroke may be helpful to appropriately allocate the limited health resources and to improve stroke outcomes.
Keywords: China, Health care, Ischemic stroke, Outcome, Risk factor
Introduction
Unlike in western countries, stroke is a leading cause of death, and the number of patients who die from stroke is three times more than that from coronary heart disease in China 1. Furthermore, with the demographic trends of population aging, stroke patients and stroke‐related disability will significantly increase 2. Although a number of guidelines 3, 4, 5, 6, 7, 8 have been developed to prevent stroke and improve stroke outcomes, age differences in receiving guideline‐recommended diagnostic tools and treatments still exist and vary between developed countries, developed and developing countries 9, 10, 11, 12, 13. Recent studies have also shown age differences in risk factors, stroke mechanisms, and outcomes 9, 14.
Using data from CNSR, we examine the extent to which age‐related differences exists in demographics, risk factors, health care, and outcomes among IS patients to provide reliable information in China.
Method
Study Design and Data Sources
Details of the design and conduct of the CNSR program have been previously described 15. In brief, the CNSR is a nationwide prospective registry for patients presented to hospitals with acute cerebrovascular events sponsored by the Ministry of Health, with the goal to help to develop strategies based on evidence observed through the registry, to improve stroke care in China.
The registry recruited consecutive patients between September 2007 and August 2008 who met the following criteria: (1) older than 18; (2) acute stroke including IS, transient ischemic attack (TIA), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) within 14 days of the index event; (3) direct admission based on physician evaluation or arrival through the emergency department; (4) written informed consent available from the patient or legally authorized representative (primarily spouse, parents, adult children, otherwise indicated) to provide informed consent; and (5) eligible events were confirmed by brain CT or MRI within 14 days after the onset of symptom. Acute ischemic stroke was defined according to the World Health Organization 16. Instead, patients with one of the following conditions were excluded: (1) silent cerebral infarction patients without symptom; (2) onset‐to‐door time more than 14 days; and (3) refused to participate in the research.
Data were collected by trained investigators by filling paper‐based registry forms (PRF) developed by the expert advisory panel in each center. Patients were evaluated in the acute phase, and the follow‐up was completed over the telephone by trained research personnel at 12 months after disease onset. The complete description of all the study variables is given in detail elsewhere. Those germane to this article include the following:
Demographic: age, gender, education, living condition, marital status, and insurance (including Basic Health Insurance Scheme [BHIS] for urban and governmental employees and urban residents, which is jointly funded by the government, employers, and employees; New Cooperative Medical System [NCMS] provided by the Chinese government to rural residents; commercial insurance; self‐payment [no insurance coverage]) 15.
Vascular risk factors and complication conditions: currently smoking; moderate or heavy alcohol consumption (≥2 standard alcohol consumption per day), history of stroke (defined as a medical chart confirmed history of IS, TIA, ICH, or SAH, hypertension (including self‐reported history of hypertension, oral antihypertension drugs); atrial fibrillation (AF) (history of AF, confirmed by at least one electrocardiogram, or the presence of the arrhythmia during hospitalization); diabetes (including history of diabetes mellitus, or hypoglycemic medications at discharge); dyslipidemia (self‐reported history of all types of dyslipidemia, oral antidyslipidemia drugs, or oral antidyslipidemia drugs at discharge); and clinically evident coronary heart disease (CHD), valvular heart disease, contraceptive pill use, homocysteine (HCY), body mass index (BMI), and family history of stroke.
Baseline severity was estimated according to National Institutes of Health Stroke Scale (NIHSS) 17 on admission and categorized as mild (NIHSS<4), moderate (NIHSS 4–14), and severe (NIHSS ≥15) stroke. Neurological and other complications during hospitalization were also identified. The modified Rankin scale 18 was used to assess disability at prestroke, discharge, and follow‐up, and moderate/severe disability was defined as modified Rankin scale ≥3. Clinical subtypes of ischemic stroke were rated according to Oxfordshire Community Stroke Project (OCSP) 19 criteria. We assessed etiologic stroke subtype according to the TOAST criteria (trial of ORG 10172) 20.
Approval for the CNSR was obtained from the Research Ethics Board at each participating institution, and all patients or their designated relatives gave informed consent.
Performance Indicators of Quality of Stroke Care
Among indicators proposed by the Steering Committee of CNSR, we selected key performance indicators developed by the GWTG‐Stroke Program 21. The indicators include the following: (1) acute performance measures: thrombolytic therapy; early antithrombotics and deep venous thrombosis (DVT) prophylaxis and (2) discharge performance measures: antithrombotics, statins, anticoagulation for AF, and smoking cessation. Definitions and domains of selected performance measures of stroke care were shown in Table 1.
Table 1.
Definitions and domains of selected performance indicators of stroke care
| Indicator | Definition |
|---|---|
| Thrombolytic therapy | Ischemic stroke patients treated with recombinant tissue plasminogen activator within 3 h after onset/patients admitted for an ischemic stroke |
| Early antithrombotics | Ischemic stroke patients treated with antithrombotic therapy within 48 h of hospitalization/ patients admitted for an ischemic stroke |
| DVT prophylaxis | Ischemic stroke patients at risk for DVT (non‐ambulatory) receiving DVT prophylaxis by the end of hospital day two/patients admitted for an ischemic stroke with a risk for DVT (nonambulatory) |
| Antithrombotics at discharge | Ischemic stroke patients prescribed aspirin, clopidogrel, dipyridamole, or oral anticoagulants at discharge/patients admitted for an ischemic stroke, not dead at discharge |
| Statins at discharge | Ischemic stroke patients prescribed statins at discharge if LDL ≥100 mg/dL, or LDL not documented/patients admitted for an ischemic stroke with LDL ≥100 mg/dL, or LDL not documented, not dead at discharge |
| Anticoagulation for AF | Ischemic stroke patients prescribed anticoagulation at discharged if AF/ischemic stroke survivors with AF |
| Smoking cessation | Ischemic stroke patients receiving smoking cessation intervention (counseling or medication) prior to discharge for current or recent smokers/ischemic stroke survivors being current or recent smokers |
DVT, deep venous thrombosis; LDL, low‐density lipoprotein; AF, atrial fibrillation.
Clinical Outcomes
The outcomes, including disability, mortality, and recurrence of stroke (aggravated primary neurological deficit, new signs, or rehospitalization with the diagnosis of IS, ICH, or SAH), were assessed at discharge and 3, 6, and 12 months after disease onset. Death was assessed by vascular death (including fatal stroke, fatal myocardial infarction (MI), and other cardiovascular death) or death for any causes. The presence of disabilities was defined as mRS 3–5. Follow‐up was implemented by trained research personnel at Beijing Tiantan Hospital using standard scripts to collect study data at 12 months after disease onset.
Statistical Analysis
Patients were categorized into four groups: ≤45, 46–65, 66–79, and ≥80 years. Baseline characteristics, the use of performance measures of stroke care, and stroke outcomes were compared in patients of different age groups using chi‐squared tests for categorical variables. Analysis of variance or Kruskal–Wallis tests were used to compare mean and median differences for continuous variables. Multivariate regression analysis was used to determine the association of prognostic factors (gender, smoking, heavy drinking, hypertension, hyperlipidemia, diabetes, CHD, AF, and NIHSS score) with stroke outcomes and prognostic factors and health care with stroke outcomes. All tests were 2‐tailed, and P < 0.05 was considered significant. Statistical analysis was performed using a commercially available software package (SAS statistical software version 9.2; SAS Institute Inc., Cary, NC, USA).
Results
During the 12‐month study period, 22,216 consecutive stroke patients were registered in the participating hospitals. Excluding patients with hemorrhagic stroke (HS), TIA and unspecified stroke and those missing baseline or no consent for follow‐up or transferred from other hospitals, 12,415 were left for this study (Figure 1). Of them, 782 (6.30%) were 45 years or younger, and 1179 (9.50%) were aged 80 years or older. Demographics and socioeconomic status are shown in Table 1. Compared with other age groups, the very old patients were more often women (51.57%), more often lived alone and have lower level of education. However, the proportion of having insurance increased with age.
Figure 1.
Flow diagram defining the studying patients with IS. CNSR, indicates China National Stroke Registry; ICH, intracerebral haemorrhage; IS, ischemic stroke; TIA, transient ischemic attack.
Stroke risk factors according to age group are demonstrated in Table 2. Older patients had a higher frequency of cardiac risk factors such as AF and CHD. Smoking, heavy drinking, and family history of stroke occurred more often in younger than 45 years. Other risk factors, including hypertension, hyperlipidemia, and diabetes, were more often in 46–79 age groups, whereas the proportion of overweight or obesity and waist circumference decreased with age. The very old patients also had a high risk of disability before stroke and suffered from complications. Hyperhomocysteine(HCY ≥ 15) was seen in more than 50% of patients who had the homocysteine test in every age group. Record of contraceptive pill use was seen in only nine patients (7 in ≤45 group and 2 in 46–65 group).
Table 2.
Demographics, socioeconomic status, and medical history according to age group
| Variable, num (%) | Age group | P | |||
|---|---|---|---|---|---|
| ≤45 | 46–65 | 66–79 | ≥80 | ||
| n = 782 (6.30) | n = 5013 (40.38) | n = 5441 (43.83) | n = 1179 (9.50) | ||
| Gender, male | 570 (72.89) | 3426 (68.34) | 3091 (56.81) | 571 (48.43) | <0.0001 |
| Marital status | |||||
| Single | 39 (4.99) | 48 (0.96) | 44 (0.81) | 10 (0.86) | <0.0001 |
| Married | 725 (92.83) | 4807 (96.27) | 4790 (88.57) | 767 (65.61) | |
| Divorced/widowed/remarried | 17 (2.18) | 138 (2.76) | 574 (10.61) | 392 (33.53) | |
| Living status | |||||
| Alone | 22 (2.84) | 104 (2.09) | 239 (4.43) | 78 (6.72) | <0.0001 |
| With others | 754 (97.16) | 4867 (97.81) | 5120 (95.01) | 1067 (91.90) | |
| In gerocomium | 0 (0) | 5 (0.10) | 30 (0.56) | 16 (1.38) | |
| Education | |||||
| Elementary or below | 96 (12.28) | 1647 (32.97) | 3101 (57.18) | 816 (69.51) | <0.0001 |
| Middle school | 246 (31.46) | 1704 (34.11) | 1080 (19.92) | 174 (14.82) | |
| High school or above | 440 (56.27) | 1644 (32.91) | 1242 (22.90) | 184 (15.67) | |
| Insurance | |||||
| BHIS | 308 (40.85) | 2721 (55.61) | 3605 (68.17) | 800 (69.99) | <0.0001 |
| NCMS | 185 (24.54) | 1046 (21.38) | 690 (13.05) | 120 (10.50) | |
| Self‐payment | 235 (31.17) | 1038 (21.21) | 861 (16.28) | 185 (16.19) | |
| Commercial | 26 (3.45) | 88 (1.80) | 132 (2.50) | 38 (3.32) | |
| Risk factors | |||||
| Current smoker | 404 (51.73) | 2440 (48.67) | 1821 (33.48) | 269 (22.82) | <0.0001 |
| Heavy drinking | 157 (20.08) | 705 (14.06) | 280 (5.15) | 29 (2.46) | <0.0001 |
| Family history of stroke | 135 (17.26) | 834 (16.64) | 494 (9.08) | 56 (4.75) | <0.0001 |
| History of hypertension | 425 (54.35) | 3506 (69.94) | 4027 (74.01) | 850 (72.09) | <0.0001 |
| Hyperlipidemia | 82 (10.49) | 653 (13.03) | 589 (10.83) | 66 (5.60) | <0.0001 |
| Diabetes mellitus | 107 (13.68) | 1318 (26.29) | 1585 (29.13) | 206 (17.47) | <0.0001 |
| CHD | 21 (2.69) | 463 (9.24) | 1074 (19.74) | 284 (24.09) | <.0001 |
| AF | 39 (4.99) | 296 (5.90) | 715 (13.14) | 276 (23.41) | <0.0001 |
| Valvular heart disease | 36 (4.64) | 119 (2.39) | 123 (2.29) | 22 (1.89) | 0.0005 |
| HCY | |||||
| ≥15 | 108 (51.92) | 505 (51.37) | 574 (59.05) | 84 (58.33) | 0.0044 |
| <15 | 100 (48.08) | 478 (48.63) | 398 (40.95) | 60 (41.67) | |
| Body mass index | |||||
| <25 | 408 (56.28) | 2611 (56.84) | 3079 (63.31) | 717 (70.78) | <0.0001 |
| 25–30 | 261 (36.00) | 1750 (38.09) | 1525 (31.36) | 252 (24.88) | |
| >30 | 56 (7.72) | 233 (5.07) | 259 (5.33) | 44 (4.34) | |
| Waist circumference | |||||
| Median(IQR) | 85 (79–93) | 86 (80–93) | 85 (79–93) | 83 (75–91) | <0.0001 |
| Mean ± SE | 86.73 ± 16.41 | 86.53 ± 12.64 | 85.78 ± 13.36 | 83.33 ± 13.98 | |
| mRS before stroke | |||||
| ≤2 | 765 (98.58) | 4772 (96.52) | 5034 (93.81) | 1036 (89.62) | <0.0001 |
| >2 | 11 (1.42) | 172 (3.48) | 332 (6.19) | 120 (10.38) | |
Numbers in columns represent numbers and percentages unless otherwise specified.
BHIS, basic health insurance scheme; NCMS, new cooperative medical system; CHD, coronary heart disease; AF, coronary heart disease; HCY, homocysteine; IQR, represents interquartile range; mRS, modified Rankin scale.
Stroke severity according to NIHSS was showed in Table 3. Severity increased with age, with the proportion of severe stroke (NIHSS ≥15) twice as much in the very old as that in other age groups. Stroke etiology according to TOAST classification by age group was listed in Table 3. Stroke because of large artery disease was the most common in all age groups; however, stroke because of cardioembolic disease was more common in the older group (11.62%). This may mostly be explained by the more frequent risk factors of AF and CHD in this age group. In terms of OCSP classification, TACI was significantly more frequent in the older subjects, while POCI was more common in younger than 65 years.
Table 3.
The severity, complications, stroke pathological types, and clinical syndromes by age group
| Characteristic, num(%) | 18–45 | 46–65 | 66–80 | ≥80 | P |
|---|---|---|---|---|---|
| Score on NIHSS on admission | |||||
| Median (IQR) | 4 (2–8) | 4 (2–8) | 5 (2–10) | 7 (3–14) | <0.0001 |
| <4 | 267 (44.63) | 1383 (44.42) | 1132 (38.89) | 175 (30.79) | |
| 4–14 | 299 (47.44) | 1377 (46.66) | 1296 (47.91) | 294 (44.70) | |
| ≥15 | 69 (7.93) | 298 (8.92) | 401 (13.20) | 173 (24.51) | |
| Score on NIHSS at discharge | |||||
| Median (IQR) | 2 (1–2) | 2 (2–2) | 2 (2–3) | 2 (2–4) | <0.0001 |
| <4 | 632 (81.55) | 4031 (81.09) | 4189 (77.65) | 853 (73.16) | |
| 4–14 | 123 (15.87) | 825 (16.60) | 995 (18.44) | 227 (19.47) | |
| ≥15 | 20 (6.30) | 115 (2.31) | 211 (3.91) | 86 (7.38) | |
| TOAST criteria | |||||
| Large vessel disease | 312 (39.90) | 2310 (46.08) | 2473 (45.45) | 492 (41.73) | <0.0001 |
| Small vessel disease | 118 (15.09) | 885 (17.65) | 934 (17.17) | 153 (12.98) | |
| Cardioembolic | 39 (4.99) | 198 (3.95) | 389 (7.15) | 137 (11.62) | |
| Other determined | 32 (4.09) | 55 (1.10) | 45 (0.83) | 9 (0.76) | |
| Undetermined | 281 (35.93) | 1565 (31.22) | 1600 (29.41) | 388 (32.91) | |
| Oxfordshire stroke classification | |||||
| PACI | 445 (62.32) | 2661 (59.00) | 2985 (60.57) | 663 (62.08) | <0.0001 |
| TACI | 74 (10.36) | 400 (8.87) | 479 (9.72) | 148 (13.86) | |
| LACI | 63 (8.82) | 562 (12.46) | 607 (12.32) | 117 (10.96) | |
| POCI | 132 (18.49) | 887 (19.67) | 857 (17.39) | 140 (13.11) | |
| Neurological complication | |||||
| New stroke | 14 (1.79) | 180 (3.59) | 213 (3.91) | 45 (3.82) | 0.0301 |
| TIA | 18 (2.30) | 64 (1.28) | 55 (1.01) | 10 (0.85) | 0.0105 |
| Seizure | 13 (1.66) | 42 (0.84) | 61 (1.12) | 23 (1.95) | 0.0046 |
| Hydrocephalus | 0 (0) | 12 (0.24) | 41 (0.75) | 14 (1.19) | <0.0001 |
| Other complication | |||||
| Atrial fibrillation | 31 (3.96) | 199 (3.97) | 509 (9.35) | 215 (18.24) | <0.0001 |
| Myocardial Infarction | 1 (0.13) | 18 (0.36) | 44 (0.81) | 16 (1.36) | <0.0001 |
| Urinary tract infection | 11 (1.41) | 102 (2.03) | 269 (4.94) | 92 (7.80) | <0.0001 |
| Pneumonia | 30 (3.84) | 322 (6.42) | 762 (14.00) | 325 (27.57) | <0.0001 |
| Gastrointestinal hemorrhage | 14 (1.79) | 93 (1.86) | 162 (2.98) | 53 (4.50) | <0.0001 |
| Injury | 3 (0.38) | 4 (0.08) | 17 (0.31) | 12 (1.02) | <0.0001 |
| Cardiac or respiratory arrest | 7 (0.90) | 58 (1.16) | 129 (2.37) | 63 (5.34) | <0.0001 |
| DVT | 0 (0) | 13 (0.26) | 31 (0.57) | 7 (0.59) | 0.0157 |
| Depression | 13 (1.66) | 94 (1.88) | 128 (2.35) | 20 (1.70) | 0.2076 |
| Decubitus ulcer | 1 (0.13) | 16 (0.32) | 56 (1.03) | 24 (2.04) | <0.0001 |
Numbers in columns represent number and percentages unless otherwise specified.
NIHSS, national institutes of health stroke scale; IQR, represents interquartile range; LACI, lacunar stroke; PACS, partial anterior circulation stroke; POCS, posterior circulation stroke; TACS, total anterior circulation stroke; TIA, transient ischemic attack; DVT, deep venous thrombosis.
Medical complications during hospitalization including new stroke, TIA, seizure, hydrocephalus, AF, myocardial infarction, urinary tract infection, pneumonia, gastrointestinal hemorrhage, injury, cardiac or respiratory arrest, DVT, depression, and decubitus ulcer were also identified (Table 3). The very old patients had a high risk of suffering from complications especially pneumonia and AF.
Performance Indicators of Quality of Stroke Care
Although the very old patients were more frequently transferred to hospital by ambulance (11%, 11.85%, 17.28%, 28.24%, respectively, according age group) and the time from symptom onset to arrival was shorter in them (the proportion of onset to door time <180 min being 14.55%, 20.32%, 22.17%, 28.56%, respectively, according age group), the proportion of use of most indicators was lower compared with other age groups as shown in Table 4. Overall, the largest differences were seen in the proportion treated with intravenous tPA and secondary stroke prevention. The prevalence of AF was significantly higher in the very old; however, the proportion of anticoagulation use at discharge decreased significantly with age. Although age alone should not be a barrier to the use of tPA 22, only six patients accepted it in the very old.
Table 4.
Performance indicators of stroke care by age group
| Indicators, num(%) | ≤45 | 46–65 | 66–79 | ≥80 | P |
|---|---|---|---|---|---|
| Acute performance | |||||
| Thrombolytic therapy | 20 (2.56) | 96 (1.92) | 110 (2.02) | 6 (0.51) | 0.0021 |
| Early antithrombotics | 628 (80.31) | 4059 (80.97) | 4292 (78.88) | 841 (71.33) | <0.0001 |
| DVT prophylaxis | 150 (65.79) | 979 (63.82) | 1313 (62.52) | 349 (56.66) | 0.0112 |
| Discharge performance | |||||
| Antithrombotic at discharge | 570 (72.89) | 3616 (72.13) | 3697 (67.95) | 634 (53.77) | <0.0001 |
| Statins at discharge | 278 (35.55) | 1845 (36.80) | 1933 (35.53) | 305 (25.87) | <0.0001 |
| Anticoagulation for AF | 21 (53.85) | 103 (34.80) | 173 (24.20) | 38 (13.77) | <0.0001 |
| Smoking cessation | 270 (34.53) | 1330 (26.53) | 677 (12.44) | 60 (5.09) | <0.0001 |
Numbers in columns represent number and percentages unless otherwise specified.
DVT, deep venous thrombosis; AF, atrial fibrillation.
Disability, Fatality, and recurrence after Stroke
Disability and mortality at discharge significantly increased with age, with 22.58%, 25.09%, 32.35%, and 44.92% disability and 1.15%, 1.46%, 3.31%, and 7.63% in‐hospital mortality according to age group (P < 0.0001). The cumulative dependency, mortality, and recurrence by age group at 12 months were represented in Figure 2. Disability, mortality, and stroke recurrence at 12 months were significantly higher in those aged 80 years and older compared with their younger counterparts. After adjusting by prognostic factors, 12‐month disability, mortality, and recurrence still increased with age, with OR (95% CI) being 3.953 (3.293–4.745), 4.451 (3.719–5.327), and 2.318 (1.982–2.712) in ≥80 age group, 46–64 group as reference. However, after adjusting by prognostic factors and health care, the extent of differences decreased, with OR (95% CI) being 3.207 (1.923–5.350), 4.307 (2.541–7.299), and 1.944 (1.247–3.030). The length of stay in older patients was also slightly longer than others, but had no significant difference, with 18, 17, 19, and 20 days, respectively, according to ≤45, 46–65, 66–79, ≥80 group. Outcomes in 3 and 6 months after onset also got worse with age increasing, with 13.87%, 20.50%, 32.87%, and 49.35% disability, 2.99%, 5.21%, 9.51%, and 21.77% mortality, and 7.28%, 10.21%, 13.30%, and 19.57% recurrence according to age group in 3 months, and 11.45%, 18.19%, 31.10%, and 45.81% disability, 3.89%, 6.19%, 12.84%, and 29.15% mortality, and 8.96%, 12.25%, 17.14%, and 26.19% recurrence according to age group in 6 months.
Figure 2.
Outcomes of 12‐month after onset according to age group.
Discussion
Our registry is the first countrywide study of stroke in China. Previous multicenter studies of stroke in China have been published 23, 24. The proportion of older patients observed in our study is lower than that in western countries where about one‐third of ischemic stroke occurred in subjects over 80 25. In the RCSN(The Registry of the Canadian Stroke Network) 11, for example, the proportion of the very old is 33.6%. The lower proportion of older patients in our cohort may be partly explained by the lower expected lifetime in China.
As expected, epidemiology of ischemic stroke among age groups including gender, the prevalence of risk factors was similar to other studies. Male patients accounted for most part in younger than 79 year, whereas female patients were a little more often in the very old, which may be related to the longer life expectancy in women. The proportion of patients with behavioral risk factors including smoking and heavy drinking in ≤45 group was highest. Hypertension, hyperlipidemia, and diabetes were more seen in 46–79 group, and cardiac diseases were the main stroke risk factors in ≥80 group patients. The distribution of risk factors in different age groups was similar to that in other studies 9, 10, 14 excluding lower incidence of hyperlipidemia and AF, which may be related to the less use of related examination in our study.
In recent years, the impact of age on stroke care delivery and the impact of age associated with different access to stroke care on outcomes have been paid close attention to. The access to stroke care in different ages is controversy in different reports. In the 2004 National Stroke Audit in England, Wales, and Northern Ireland, older patients were significantly less likely to receive secondary prevention 26, which is in line with that in our study. On the other hand, in RCSN 11 study in Canada, the use of performance measure including thrombolysis, stroke unit care, and secondary stroke prevention is at a similar rate to those seen in younger individuals. In DNIP(the Danish National Indicator Project) study 27 and GWTG‐Stroke(the Get With the Guidelines–Stroke) study 28, the age‐related differences are modest for most examined quality‐of‐care criteria and do not appear to explain the poorer outcome among older patients.
It is worth noting that, although the overall level of stroke management in China have improved than that reported in 1997 29, it is still significantly lower in all age groups in our study than that in western countries 9, 11, 27, 28. This may be partly explained by less use of stroke units, which have been shown to provide higher standards of care for all patients. In our study, the stroke units' use was only seen in <20% patients, whereas up to over 40% in other studies in western countries 11, 26, 30. Although reports have demonstrated that early IV rtPA is helpful to improve outcomes in any age group 31, the use of IV rtPA was significantly lower in our study. The use of secondary stroke prevention in our study, which is in line with other reports in China 32, was also significantly lower than those contemporary in western countries 9, 11, and age‐related treatment gaps were still distinct, which may be the reason of high risk of recurrence after stroke in our cohort especially in the very old.
In terms of outcomes, older patients were associated with higher disability, mortality, and recurrence at 12‐month follow‐up and a longer in‐hospital stay, which are consistent with other reports 33, 34, 35, 36. However, overall in‐hospital mortality (2.84%) and 12 months mortality (13.4%) in our cohort are lower than that in developed countries, for example, RCSN 11 and GWTG‐Stroke program 28, which may be explained by lower mean age in stroke patient and lower proportion of the very old patient in our study because in‐hospital and 12‐month mortality in the very old patients is alike or higher than that in developed countries. In our cohort, the risk of recurrent stroke was higher than that in western countries 37, which may be related to the less use of secondary prevention.
Some study limitations deserve comment. First, our study includes only patients admitted to participating hospitals that are mainly in urban and may not be representative of the management and outcomes seen in different types of facilities across the country. It is possible that the level of stroke management may be lower, and age disparities may be either more noticeable in rural hospitals. Second, as the participation in CNSR was voluntary, we cannot rule out the possibility of selection bias.
Despite these limitations, CNSR is a nationwide, prospective, multicenter, and comprehensive registry designed to observe the characteristics and outcomes of stroke patient, to evaluate current stroke care delivery at the national level. Our findings call the attention of policymakers to develop strategies to improve quality of stroke management according to age group, and the attention of clinical physicians to pay more attention to older patients to eliminate the age gaps in stroke management. Further analysis will be needed to investigate the determinants of outcomes in different age groups to provide optimal stroke treatment and second prevention in different ages.
In conclusion, we found that age‐dependent differences existed in risk factors, health care, and outcomes among IS patients in china. Behavioral factors, metabolic diseases, and cardiac diseases are, respectively, the main stroke risk factors of ≤45, 46–79, and ≥80 group. The very old patients received a significantly poorer quality of care than do younger patients, especially in secondary stroke prevention. The very old patients had the worst outcomes, which may be partly explained by low level of health care found in the examined indicators. Continuous efforts are needed to ensure patients with stroke optimal care irrespective of age.
Conflict of Interest
The authors declare no conflict of interest.
Acknowledgments
We thank all participating colleagues contributed to this study. This study was funded by the Ministry of Science and Technology and the Ministry of health of the People's Republic of China. The Grant Nos. are National Science and Technology Major Project of China (2008ZX09312‐008), The National Science Foundational (Grant no. 81071115), National S & T Major Project of China (2011BAI08B02), The Beijing Science and Technology Committee (Grant no. 7102050), The Research Special Fund For Public Welfare Industry of Health (200902004), Beijing Health System High Level Health Technology Talent Cultivation Plan (Grant no. 2001‐3‐023), and The Beijing Science and Technology Committee (Grant no. D101107049310005).
The first two authors contributed equally to this work.
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