Eighteen-year trends in stroke mortality and the prognostic influence of comorbidity

Schmidt, Morten; Jacobsen, Jacob; Johnsen, Søren Paaske; Bøtker, Hans Erik; Sørensen, Henrik Toft

doi:10.1212/wnl.0000000000000062

Cited by 130 publications

(146 citation statements)

References 41 publications

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“…Poor communication between patients and professionals was a common experience, exacerbated by fragmentation of health services and poor communication between healthcare providers themselves, aspects of stroke care likely to be exacerbated by multimorbidity [24][25][26]. Surprisingly, there has been limited exploration of multimorbidity or polypharmacy in people with stroke, the field being characterised by small-scale studies and a small number of conditions under examination [19,[27][28][29][30][31][32][33][34][35][36]. Those studies that have examined stroke in relation to other longterm conditions have suggested that stroke is one of the diseases most significantly associated with polypharmacy [19,33], but there is a lack of large-scale studies examining a broad range of medications and comorbidities.…”

Section: Introductionmentioning

confidence: 99%

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden

Batty

McLean

et al. 2014

BMC Medicine

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Background: The prevalence of multimorbidity (the presence of two or more long-term conditions) is rising internationally. Multimorbidity affects patients by increasing their burden of symptoms, but is also likely to increase the self-care demands, or treatment burden, that they experience. Treatment burden refers to the effort expended in operationalising treatments, navigating healthcare systems and managing relations with healthcare providers. This is an important problem for people with chronic illness such as stroke. Polypharmacy is an important marker of both multimorbidity and burden of treatment. In this study, we examined the prevalence of multimorbidity and polypharmacy in a large, nationally representative population of primary care patients with and without stroke, adjusting for age, sex and deprivation. Methods: A cross-sectional study of 1,424,378 participants aged 18 years and over, from 314 primary care practices in Scotland that were known to be demographically representative of the Scottish adult population. Data included information on the presence of stroke and another 39 long-term conditions, plus prescriptions for regular medications. Results: In total, 35,690 people (2.5%) had a diagnosis of stroke. Of the 39 comorbidities examined, 35 were significantly more common in people with stroke. Of the people with a stroke, the proportion that had one or more additional morbidities present (94.2%) was almost twice that in the control group (48%) (odds ratio (OR) adjusted for age, sex and socioeconomic deprivation 5.18; 95% confidence interval (CI) 4.95 to 5.43). In the stroke group, 12.6% had a record of 11 or more repeat prescriptions compared with only 1.5% of the control group (OR adjusted for age, sex, deprivation and morbidity count 15.84; 95% CI 14.86 to 16.88). Limitations include the use of data collected for clinical rather than research purposes, a lack of consensus in the literature on the definition of certain long-term conditions, and the absence of statistical weighting in the measurement of multimorbidity, although the latter was deemed suitable for descriptive analyses. Conclusions: Multimorbidity and polypharmacy were strikingly more common in those with a diagnosis of stroke compared with those without. This has important implications for clinical guidelines and the design of health services.

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Section: Introductionmentioning

confidence: 99%

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden

Batty

McLean

et al. 2014

BMC Medicine

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“…3 A recent study found that older adults with prior stroke were more likely to have other CCs than those without prior stroke. 4 Comorbid CCs are associated with greater short-and long-term stroke mortality, 5,6 worse rehabilitation outcomes, 7,8 and reduced use of secondary prevention. 9 Most research has focused on concordant comorbid conditions (those related to stroke) and outcomes such as stroke mortality, recurrence, rehabilitation, or stroke-specific health care costs.…”

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confidence: 99%

Increasing comorbidity and health services utilization in older adults with prior stroke

et al. 2016

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Objective: To characterize comorbid chronic conditions, describe health services use, and estimate health care costs among community-dwelling older adults with prior stroke.Methods: This is a retrospective cohort study using administrative data from Ontario, Canada. We identified all community-dwelling individuals aged 66 and over on April 1, 2008 (baseline), who had experienced a stroke at least 6 months prior. We estimated the prevalence of 14 comorbid conditions at baseline; we captured all physician visits, emergency department visits, hospital admissions, home care contacts, and associated costs over 5 years stratifying by number of comorbid conditions. Where possible, we distinguished between health services use for stroke-and non-stroke-related reasons.Results: A total of 29,673 individuals met our criteria. Only 1% had no comorbid conditions, while 74.9% had 3 or more. The most common conditions were hypertension (89.8%) and arthritis (65.8%); 5 other conditions had a prevalence of 20% or more (ischemic heart disease, diabetes, chronic obstructive pulmonary disease, inflammatory bowel disease, and dementia). Use of all health services doubled with increasing comorbidity and was largely attributed to non-strokerelated reasons. Total and per-patient costs increased with comorbidity. Main cost drivers shifted from physician and home care visits to hospital admissions with greater comorbidity.Conclusions: Our findings demonstrate the importance of community-based patient-centered care strategies for stroke survivors that address their range of health needs and prevent more costly acute care use.

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“…In fact, most frequencies of comorbidities prior to the index event exceeded the rates previously described in previous stroke cohorts [11,12,14,26,27]. A quarter of our patients were classified as having a very severe burden of comorbidities (CCI), which resulted in the maximum mortality risk along the follow-up.…”

Section: Discussionmentioning

confidence: 58%

“…Despite the high burden of clinical comorbidities associated to cerebrovascular disease [3,7,8,9,] few prospective studies reported the prognostic value of comorbidities in long-term stroke survival [10,11,12]. In this context, the Charlson Comorbidity Index (CCI) [13] is one of the most often used comorbidity score employed in longitudinal studies to evaluate prognosis [11,12,14,15,16,17,18,19,20].…”

Section: Introductionmentioning

confidence: 99%

“…In this context, the Charlson Comorbidity Index (CCI) [13] is one of the most often used comorbidity score employed in longitudinal studies to evaluate prognosis [11,12,14,15,16,17,18,19,20]. A modified version of Charlson index was adapted by Goldstein et al [14] for predicting functionality at hospital discharge and 1-year mortality in ischaemic stroke (IS) patients.…”

Section: Introductionmentioning

confidence: 99%

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Multimorbidities Are Associated to Lower Survival in Ischaemic Stroke: Results from a Brazilian Stroke Cohort (EMMA Study)

Castro¹,

Alencar²,

Benseñor³

et al. 2017

Cerebrovasc Dis

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Background: Stroke prognosis is related to the multimorbidity profile. Moreover, performing an individual evaluation of most common cerebrovascular risk factors (CVRF) not always identifies patients with poor prognosis. Thus, we decided to evaluate multimorbidity profile, focusing on the Charlson Comorbidity Index (CCI) validated by Goldstein for ischaemic stroke (IS) patients, a score that measures a burden of comorbidities and its related mortality in the long-term survival of the EMMA Study (Study of Stroke Mortality and Morbidity). Methods: Nine hundred fifty-nine individuals (median age 70 years) had validated data on the diagnosis of IS, main CVRF and clinical comorbidities pre index event such as atrial fibrillation (AF), stroke recurrence, diabetes, hypertension, heart failure and cancer. CCI modified by Goldstein was calculated, which includes 17 clinical conditions with scores ranging from 1 to 6 (0-31 points). Survival analyses were performed by Kaplan-Meier curves and Cox logistic regression models (cumulative hazard ratio [HR] with [95% CI]) for all-cause mortality at 180 days, and every 3 years up to 9-year follow-up. Mortality analyzes were performed by CCI categorized according to weight added to comorbidities (Reference group: zero, moderate: 1, severe: 2 and very severe: ≥3 points). We also tested the modification effect of AF and stroke recurrence including these conditions in the CCI. Results: The overall survival rate was 47% (508 deaths/959). The worst survival (577, 95% CI 381-773 days) and the highest risk of death after stroke were observed in the very severe CCI group (HR 3.18; 95% CI 2.16-4.69) up to 9 years. The inclusion of previous AF and stroke in the CCI slightly increased the risk of death for very severe CCI (HR 3.27; 95% CI 2.07-5.18). Conclusions: A high burden of comorbidities represented an independent predictor of poor prognosis increasing the risk of dying by 2 to 3 times among IS up to 9 years in the EMMA study. The inclusion of other CVRF such as AF and stroke recurrence slightly modified all-cause mortality risk.

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Eighteen-year trends in stroke mortality and the prognostic influence of comorbidity

Abstract: Short- and long-term mortality improved considerably between 1994 and 2011 for all types of stroke. Short-term mortality improved regardless of comorbidity burden. However, comorbidity burden was a strong prognostic factor for both short- and long-term mortality.

Cited by 130 publications

References 41 publications

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden

Increasing comorbidity and health services utilization in older adults with prior stroke

Multimorbidities Are Associated to Lower Survival in Ischaemic Stroke: Results from a Brazilian Stroke Cohort (EMMA Study)

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