Admission Rates, Time Trends, Risk Factors, and Outcomes of Ischemic and Hemorrhagic Stroke From German Nationwide Data

Abstract

Background and objectives:In the last decade, there have been major improvements in the control of risk factors, acute stroke therapies and rehabilitation following the availability of high-quality evidence and guidelines on best practices in the acute phase. In this changing landscape, we aimed to investigate the stroke admission rates, time-trends, risk factors, and outcomes during the period of 2014-2019 using German nationwide data.Methods:We obtained data of all acute stroke hospitalizations by the Federal Statistical Office. All hospitalized cases of adults (age ≥ 18 years) with acute stroke from the years 2014-2019 were analyzed regarding time trends, risk factors, treatments, morbidity and in-hospital mortality according to stroke subtype (all-cause/ischaemic/haemorrhagic).Results:Between 2014 and 2019, overall stroke hospitalizations in adults (median age = 76 years, [IQR: 65-83 years]) initially increased from 306,425 in 2014 to peak at 318,849 in 2017 before falling to again to 312,692 in 2019, whereas percentage stroke hospitalizations that resulted in death remained stable during this period at 8.5% in 2014 and 8.6% in 2019. In a multivariate model of 1,882,930 cases, the strongest predictors of in-hospital stroke mortality were haemorrhagic subtype (Adjusted OR [aOR] = 3.06, 95% CI 3.02-3.10; p<0.001), cancer (aOR = 2.11, 2.06-2.16; p<0.001), congestive heart failure (aOR = 1.70, 1.67-1.73; p<0.001), and lower extremity arterial disease (aOR =1.76, 1.67-1.84; p<0.001).Discussion:Despite recent advances in acute stroke care over the last decade, the percentage of stroke hospitalizations resulting in death remained unchanged. Further research is needed to determine how best to optimize stroke care pathways for multimorbid patients.

Temporal Trends in Stroke Hospitalizations, Treatment Modalities, and Mortality

“…In addition, previous studies of temporal trends in stroke incidence over time have used a stable definition of stroke, independent of changes in imaging utilization. 3 Specifically, increased use of MRI over time could have affected the findings of Kelly et al 2 Finally, this study does not report the race and ethnicity of patients or data on social determinants of health, though disparities in access to care may be less of a contributor to stroke outcomes in Germany, a country with universal health care.…”

“…In addition, previous studies of temporal trends in stroke incidence over time have used a stable definition of stroke, independent of changes in imaging utilization. 3 Specifically, increased use of MRI over time could have affected the findings of Kelly et al 2 Finally, this study does not report the race and ethnicity of patients or data on social determinants of health, though disparities in access to care may be less of a contributor to stroke outcomes in Germany, a country with universal health care. Despite these limitations, in addition to being a large population-based investigation across an entire country, an important strength of the study conducted by Kelly et al 2 is the analysis of treatment utilization rates over time in the era of mechanical thrombectomy.…”

“…Despite these limitations, in addition to being a large population-based investigation across an entire country, an important strength of the study conducted by Kelly et al 2 is the analysis of treatment utilization rates over time in the era of mechanical thrombectomy. For example, ischemic stroke hospitalizations, rates of carotid stenting, intracranial thrombectomy, and systemic thrombolysis increased over time.…”

“…In summary, updated population-level data on temporal trends from Germany, 2 a country where health care is broadly available, indicate that hospitalizations and mortality for acute stroke have not decreased across a 6-year period from 2014 through 2019 despite some increases in the use of acute revascularization interventions. Furthermore, mortality for intracranial hemorrhage particularly continues to increase.…”

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Stroke remains a leading cause of morbidity and is the second leading cause of death globally 1 despite advances in treatment and prevention over the past decade. In this issue of Neurology ® , Kelly et al 2 use administrative data on acute stroke hospitalizations among adults aged 18 years or older in Germany between 2014 and 2019 to describe updated trends in stroke admissions, treatment modalities, and mortality nationally. Using population-level data from the Federal Statistics Office in Germany, study authors calculated frequencies of hospitalizations for acute stroke over a 6-year period.

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