A comprehensive study leveraging data from a nationally representative sample across Chinese hospitals in 2005, 2010, and 2015 reveals significant progress in the management of ischemic stroke. This research highlights improvements in hospital admissions and adherence to guideline-recommended treatments. Parallel to these advancements, a notable decrease in Discharge Against Medical Advice (DAMA) cases and enhanced in-hospital mortality rates, both independently and combined with DAMA, were observed. While disparities between rural and urban healthcare facilities have narrowed, they remain a point of concern, indicating areas for continued improvement, especially in leveraging Online resources to bridge the gap.
The upward trend in ischemic stroke cases and the increasing prevalence of associated risk factors in China mirrors patterns observed in the United States and within the realm of ST-segment elevation myocardial infarction, as documented in the China PEACE Study. This convergence is likely influenced by several interconnected factors. Firstly, the growing occurrence of cerebrovascular risk factors, including hypertension, diabetes mellitus, and dyslipidemia, is largely attributed to shifts in lifestyle. This has contributed to a rapid surge in stroke incidence across China, necessitating increased access to healthcare services, including hospitalization, and a greater emphasis on public health education, potentially enhanced through online platforms and digital campaigns. To meet this escalating demand, China has significantly expanded its healthcare infrastructure, with a 118% increase in hospital beds between 2005 and 2015.
The rise in hospital admissions may also be linked to current reimbursement policies that favor inpatient care, which constitutes a significant portion of services covered by insurance premiums. Furthermore, improved access to and availability of high-quality healthcare over time plays a crucial role. However, the Chinese healthcare system is characterized by a structure that prioritizes acute hospital care over long-term management and community-based primary care for risk factor control. Reforming this structure to place greater emphasis on primary care and preventative measures, potentially through online education and remote monitoring programs, could be instrumental in reducing stroke morbidity and the need for hospitalization.
This study’s findings indicate an overall improvement in the physical condition of stroke patients upon hospital admission, evidenced by reduced instances of coma, limb weakness, aphasia, or dysarthria, alongside better management of systolic blood pressure, blood lipid levels, and kidney function over the study period. This suggests an increasing public awareness of risk factor management and a growing inclination to seek timely medical attention even for milder symptoms, possibly facilitated by greater access to online health information and symptom checkers. Concurrently, the quality of stroke care, assessed through performance indicators such as diagnostic tests, acute therapies, and secondary prevention treatments, has shown improvement over the past decade. For instance, the utilization of Holter monitoring, a standard diagnostic tool for detecting atrial fibrillation post-stroke, has increased, although it remained relatively low at 11.6% in 2015 within this study. This may partially explain the lower prevalence of comorbid atrial fibrillation observed in this study (5.6% in 2015) compared to figures reported in the US population (17.1%).
The administration rate of recombinant tissue plasminogen activator (rt-PA) has seen a sevenfold increase over the decade, yet it still lags significantly behind utilization rates in the USA and Europe. This disparity is largely due to the fragmented and underutilized emergency stroke care system in China, often leading to prolonged pre-hospital and in-hospital delays. Furthermore, the lack of comprehensive health insurance coverage for alteplase costs remains a barrier. In response to advocacy from stroke specialists, a large-scale initiative to establish specialized stroke centers was launched in 2015. Notably, within these stroke centers, rt-PA utilization rates saw a 60% increase between 2015 and 2019, demonstrating the impact of focused, specialized care, potentially further enhanced by online training and collaborative platforms for these centers.
The combined use of aspirin and clopidogrel witnessed a substantial rise from 1.2% in 2005 to 18.0% in 2015. This increase is likely attributable to the publication of the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial results in 2013 and the subsequent update to Chinese stroke guidelines in 2014. Similarly, the use of anticoagulants for atrial fibrillation has increased over time. However, the use of hypoglycemic drugs for diabetes post-stroke remained at 69.5% in 2015, and the prescription of antihypertensives actually decreased over time, reaching only 64.9% in 2015, down from 72.4% in 2005. These findings align with data from the China National Stroke Registries, indicating persistent gaps and challenges in achieving optimal stroke care. These challenges likely stem from the need to balance treatment benefits against potential risks and financial considerations, issues that could be addressed through better online access to comprehensive treatment information and cost-benefit analyses for both clinicians and patients.
On a positive note, this study reveals a decrease in DAMA cases between 2005 and 2015, alongside improvements in in-hospital mortality and the composite outcome of in-hospital mortality or DAMA in the years 2010 and 2015, although the temporal trend was not statistically significant. While the non-significant temporal trends for in-hospital mortality and the composite outcome do not definitively prove improvement, they also do not exclude the possibility of meaningful progress, as temporal trend analysis may not capture variations in improvement rates across different intervals. Supporting this, a prior study using data from tertiary hospital medical records also reported a decrease in in-hospital mortality for ischemic stroke from 2.48% in 2007 to 1.47% in 2010. The ‘Get With The Guidelines-Stroke’ program has also shown similar reductions in in-hospital mortality in the USA over time. Key factors contributing to reduced stroke mortality in China likely include the ongoing national healthcare reform plan, improved healthcare coverage, the introduction of new treatment options, and advancements in medical technology. The in-hospital mortality rates reported in this study are notably lower than those reported in studies from Western countries. One potential explanation is the practice of treatment withdrawal at terminal stages, possibly influenced by affordability or cultural factors. To account for this unique discharge pattern in China, the composite outcome of in-hospital mortality or DAMA was reported.
In contrast to the China PEACE Study, rural–urban disparities in this study were primarily observed for diabetes, rather than hypertension, dyslipidemia, or several other risk factors. Rural–urban differences persist in the utilization of diagnostic tests, including brain MRI and cerebrovascular assessments, and in the prescription of preventive drugs, such as clopidogrel and anticoagulants for atrial fibrillation. Greater resources and focused attention are needed for rural hospitals, potentially through the implementation of telemedicine and online consultation platforms to improve access to specialist expertise and standardized treatment protocols. While no significant rural-urban discrepancies were found for DAMA and the composite outcome of in-hospital mortality or DAMA, these disparities showed an increase from 2005 to 2015, indicating slower progress in rural hospitals. Differences in study hospitals, populations, and years may contribute to the variations in urban–rural disparities observed across studies.
To the best of our knowledge, China PROGRESS represents the most extensive study to date on national trends in ischemic stroke in China, employing a robust random sampling framework for a hospital-based cohort. The study placed significant emphasis on data quality, utilizing a double-blinded data reading and entry system to ensure accuracy in case ascertainment and data abstraction. The low error rate associated with this system is critical to the validity of the findings, given the retrospective nature of variable extraction. The study sample included hospitals with diverse characteristics in terms of stroke facilities, capacity, and quality of care, allowing for nationally representative findings that can inform quality improvement initiatives across a country with substantial variability in these factors across regions and hospitals. However, several limitations should be acknowledged. Firstly, the accuracy of ischemic stroke diagnoses, based on ICD-10 codes from medical record front pages, could not be definitively verified by non-stroke professionals during initial data entry. To address this, a random sample of 1400 (5%) records was reviewed by experienced stroke neurologists for final diagnosis confirmation. This review confirmed 939 (67.1%) as novel ischemic stroke, 450 (32%) as undetermined due to insufficient information, and 11 (0.8%) as misdiagnosed. Secondly, definitions of disorders and documentation completeness may vary across time and hospitals, and it remains unclear whether patients were sampled from dedicated stroke units or other neurology departments. Finally, data on post-discharge treatments and outcomes were not collected, limiting the scope of the study to in-hospital trends. Future research could leverage online patient follow-up tools to gather more comprehensive post-discharge data and further enhance our understanding of long-term stroke management in China.
