- Email: [email protected]
National data on stroke outcomes in Thailand
Journal of Clinical Neuroscience 22 (2015) 493–497
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
National data on stroke outcomes in Thailand Kannikar Kongbunkiat a,c, Narongrit Kasemsap a, Kaewjai Thepsuthammarat b, Somsak Tiamkao a,c, Kittisak Sawanyawisuth a,d,⇑ a
Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand Clinical Epidemiology Unit, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand c North-eastern Stroke Research Group, Khon Kaen University, Thailand d The Research Center in Back, Neck, Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University, Khon Kaen, Thailand b
a r t i c l e
i n f o
Article history: Received 15 May 2013 Accepted 25 August 2014
Keywords: ICD-10 National data Outcomes Predictors Stroke Thailand
a b s t r a c t Stroke is a major public health problem worldwide. There are limited data on national stroke prevalence and outcomes after the beginning of the thrombolytic therapy era in Thailand. This study aimed to investigate the prevalence and factors associated with mortality in stroke patients in Thailand using the national reimbursement databases. Clinical data retrieved included individuals under the universal coverage, social security, and civil servant benefit systems between 1 October 2009 and 30 September 2010. The stroke diagnosis code was based on the International Classification of Diseases 10th revision system including G45 (transient cerebral ischemic attacks and related syndromes), I61 (intracerebral hemorrhage), and I63 (cerebral infarction). The prevalence and stroke outcomes were calculated from these coded data. Factors associated with death were evaluated by multivariable logistic regression analysis. We found that the most frequent stroke subtype was cerebral infarction with a prevalence of 122 patients per 100,000 of population, an average length of hospital stay of 6.8 days, an average hospital charge of 20,740 baht ($USD 691), a mortality rate of 7%, and thrombolytic prescriptions of 1%. The significant factors associated with stroke mortality were septicemia, pulmonary embolism, pneumonia, myocardial infarction, status epilepticus, and heart failure. In conclusion, the prevalence and outcomes of stroke in Thailand were comparable with other countries. The era of thrombolytic therapy has just begun in Thailand. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Stroke is one of the most important causes of death and adult disability [1]. It is estimated that stroke is the second most common cause of death worldwide [2]. Mortality data in Asian countries are varied [3]. The crude death rate was between 50–160 per 100,000 of population in 2002 [3]. Previous reports showed that the mortality rate from stroke was declining over time in the Philippines and Singapore [4,5]. The explanation for this may be lower rates of hypertension, smoking, dyslipidemia, and obesity [5,6]. In contrast, the death rates from stroke in Thailand increased from 3.7/100,000 in 1950 to 11.8/100,000 in 1983 and 77.2/ 100,000 in 2005 [7,8]. Stroke became the most common cause of death in Thailand in 2005 [8,9]. In Thailand, several studies have addressed stroke prevalence, risk factors, management, and outcomes [10–12]. The mean age of stroke patients in Thailand is approximately 65 years and there ⇑ Corresponding author. Tel.: +66 43 363 664; fax: +66 43 348 399. E-mail address: [email protected] (K. Sawanyawisuth). http://dx.doi.org/10.1016/j.jocn.2014.08.031 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
is a slight male predominance (57%). Hypertension was the most common risk factor, seen in 57% of patients, followed by smoking (29%) and diabetes (24%). Eighteen percent of acute ischemic stroke patients also had an abnormal ankle brachial index suggestive of comorbid peripheral artery disease [10]. Information regarding predictors for in-hospital mortality and the impact of serious medical and neurological complications, however, is limited [13]. A study in the USA that was conducted based on hospital databases all over the country showed that factors associated with mortality were the patient’s age, being female, not having Medicare insurance, and having a comorbid disease [13]. There are limited data from the entire country Thailand and no national database on the incidence of stroke, stroke impact, stroke outcomes, in-hospital deaths, and predictors for mortality from stroke. The in-hospital deaths after stroke probably reflect the optimized overall premorbid health status, acute stroke treatment, and acute general medical care in hospitals and the health system levels. This study aimed to identify these limited data by using the three national databases that cover 1172 hospitals in Thailand.
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The stroke patients’ baseline characteristics are shown in Table 2. The ratio of males to females in CI patients was 1.16. Stroke rates tended to be higher in older age groups in all three types of stroke. The two most common complications were pneumonia and urinary tract infection. Just over half of the TIA patients were male (54%) and the average age of the TIA patients was 63 years. The frequently found comorbid diseases in TIA patients were similar to CI patients. The average age of ICH patients was the lowest at 62 years. Patients with ICH had a higher percentage of hypertension than CI or TIA patients. Reimbursement of hospital charges is shown in Table 3. Around three-quarters of patients were in the UC system, followed by CSMBS (19%) and SS (8%). Primary, secondary and tertiary level hospitals admitted a similar proportion of patients with TIA. About 80% of ICH and CI patients were admitted to secondary and tertiary level hospitals. ICH patients had the highest mortality rate (27%) while CI had a rate of only 7%. The average hospital charges and length of stay are presented in Table 4. CI patients receiving thrombolytic agents paid the highest average hospital charge. The length of stay for patients with ICH was longer than patients with TIA. In 2010, 550 CI patients all over Thailand received thrombolytic treatment (1.05%) as shown in Table 5. The most common complication of thrombolytic treatment was ICH. Thrombolytic treatment was mostly provided in the tertiary hospitals and had a mortality rate of 6% overall. Factors associated with death of CI in-patients were calculated by univariate (Table 6) and multivariable logistic regressions (Table 7). Significant factors associated with mortality included sex, insurance scheme, hospital level, risk factors, and complications of stroke.
2. Materials and methods Data were obtained from the national database system covering 95.5% of the Thai population who were under health security schemes [14]. The first system (7.1% of the population) is the civil servant medical benefit system (CSMBS) that covers government employees and their dependents including parents, spouses and up to two children aged <20 years. The second system (13.2%) is the social security (SS) that covers private sector employees, excluding their dependents. The third system (75.2%) is the universal coverage (UC) that covers the rest of population who are not covered by SS and CSMBS. These database systems were studied because they represent almost all of the people in Thailand except those who are self-insured. This study included patients over the age of 18 years who were admitted to a hospital in Thailand due to stroke from 1 October 2009 to 30 September 2010. Clinical data were retrieved from reimbursement forms. The diagnosis of stroke was based on the International Classification of Diseases (ICD) 10th revision using the codes G45 (transient cerebral ischemic attacks [TIA] and related syndromes), I61 (intracerebral hemorrhage [ICH]), and I63 (cerebral infarction [CI]). The types of stroke were identified by CT scans of the brain. The length of hospital stay for each patient, their age, sex, comorbid diseases, complications, mortality rate, and hospital charges per admission were recorded. There are four categories of hospitals in Thailand, being primary or community, secondary, tertiary, and private hospitals. Primary or community hospitals serve people in the districts or at community levels, and usually have 10 to 30 beds. Secondary hospitals provide healthcare in the provincial areas, while tertiary hospitals receive patients via the referral system. Private hospitals are located all over the country at the provincial level, and serve 4% of the entire population. Thrombolytic prescription frequency was based on the ICD-9 code 99.10 (injection or infusion of thrombolytic agents in patients diagnosed as having CI). The percentage of stroke complications, length of hospital stay, and hospital charges were also studied in patients receiving thrombolytic therapy. Analysis of factors associated with mortality in patients with CI who received treatment at a hospital was conducted using multivariable logistic regression, with a p value <0.05 considered statistically significant.
4. Discussion This study is a compilation of national data regarding in-hospital stroke patients, outcomes and predictors associated with mortality in Thailand. The average stroke prevalence in Thailand was 122 per 100,000 of population. The prevalence was highest in the central part of the country and Bangkok where the economic status is also the highest in the country. Similarly, the diagnosis of metabolic syndrome in Thailand was commonly found in urban areas or the central part of Thailand in a national survey in 2012 [15]. A report from the Bureau of Epidemiology showed that the prevalence of metabolic syndrome was 50.56 people per 100,000 of population [15]. These data were collected from the yearly report of all hospitals all over Thailand. The prevalence seen in other countries is varied and differs from Thailand; South Asia has a prevalence of 45 to 471 per 100,000 of the adult (>18 years old) population [16], and 260 to 719 per 100,000 for all ages in China [17]. Similar to results from the USA and Canada [4,18] and Asian results from India, China, Singapore, and Indonesia [9,16,17], CI was the most common stroke subtype. In Thailand, the mean age of CI patients was 66 years and males were slightly predominant (54%). The prevalence of CI increased with age and the highest
3. Results During the 2010 fiscal year (1 October 2009 to 30 September 2010), 82,061 stroke patients were admitted to 1172 hospitals all over Thailand. This included 747 primary hospitals, 134 secondary hospitals, 120 tertiary hospitals, and 171 private hospitals. Patients were divided into 52,437 cases (63.9%) of CI, 23,366 cases (28.5%) of ICH, and 6258 cases (7.6%) of TIA. Prevalence of stroke among patients over 18 years of age was divided into regions as shown in Table 1. The central region had the highest prevalence of stroke during this period. Table 1 Prevalence of cerebrovascular diseases per 100,000 of population in Thailand Regions
Northern North-east Central Southern Total
Population
8,871,705 15,964,936 11,896,555 6,287,474 47,171,244
TIA
ICH
CI
Number
Prevalence/100,000
Number
Prevalence/100,000
Number
Prevalence/100,000
1,282 1,672 2,361 919 6,234
14 10 20 15 14
5,480 5,725 9,337 2,596 23,138
62 36 78 41 54
10,389 14,786 20,426 6,672 52,273
117 93 172 106 122
CI = cerebral infarction, ICH = intracerebral hemorrhage, TIA = transient ischemic attack.
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K. Kongbunkiat et al. / Journal of Clinical Neuroscience 22 (2015) 493–497 Table 2 Baseline characteristics of patients with cerebrovascular disease (International Classification of Diseases 10th Revision codes G45, I61, I63) Demographic factors
TIA
ICH
CI
p value
Males Age, years, mean (SD)
3,409 (54) 63 (15)
14,002 (60) 62 (15)
28,165 (54) 66 (14)
<0.001
Age group, years <35 35–44 45–54 55–64 65–74 75–84 85+
235 (3.8) 483 (7.7) 1,082 (17.3) 1,467 (23.4) 1,569 (25.1) 1,157 (18.5) 265 (4.2)
809 (3.5) 2,023 (8.7) 5,036 (21.6) 5,487 (23.5) 4,961 (21.2) 3,932 (16.8) 1,118 (4.8)
945 (1.8) 2,641 (5.0) 7,297 (13.9) 11.385 (21.7) 14.459 (27.57) 12.348 (23.6) 3,362 (6.4)
<0.001
Comorbid diseases Hypertensive diseases Disorders of lipoprotein metabolism and other lipidemias Diabetes mellitus Chronic kidney disease Atrial fibrillation and flutter Congestive heart failure Myocardial infarction HIV
2,746 (43.9) 1,896 (30.3) 1,276 (20.4) 216 (3.5) 318 (5.1) 67 (1.1) 38 (0.6) 22 (0.4)
12,459 (53.3) 2,229 (9.5) 2,801 (12.0) 809 (3.5) 397 (1.7) 185 (1.0) 120 (0.5) 88 (0.3)
23,685 (45.1) 16,424 (31.3) 12,024 (22.9) 2,404 (4.6) 4,289 (8.2) 1,136 (2.2) 523 (1.0) 216 (0.4)
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.662
Complications Pneumonia Urinary tract infection Decubitus ulcer Phlebitis and thrombophlebitis of other deep vessels Pulmonary embolism Epilepsy Status epilepticus Other septicemias Total
8 (0.1) 82 (1.3) 3 (0.05) 3 (0.05) 1 (0.01) 38 (0.6) 0 (0) 11 (0.2) 6,258
1,647 (7.1) 1,302 (5.6) 308 (1.3) 38 (0.2) 3 (0.01) 278 (1.2) 62 (0.3) 994 (4.3) 23,364
2,702 (5.2) 2,702 (5.2) 578 (1.1) 108 (0.2) 23 (0.04) 737 (1.4) 151 (0.3) 1,841 (3.5) 52,437
<0.001 <0.001 <0.001 0.083 0.097 <0.001 <0.001 <0.001
Data are presented as number (%) unless otherwise specified. CI = cerebral infarction, HIV = human immunodeficiency virus, ICH = intracerebral hemorrhage, SD = standard deviation, TIA = transient ischemic attack.
Table 3 Insurance scheme, hospital level, discharge status and brain CT scan data TIA
ICH
CI
p value
Insurance scheme CSMBS SS UC
1181 (19) 519 (8) 4,558 (73)
3,611 (15) 1,293 (6) 18,462 (80)
10,515 (20) 2,159 (4) 39,763 (76)
<0.001
Hospital level Primary Secondary Tertiary Private
2,102 (34) 1,531 (24) 2,126 (34) 499 (8)
2,315 (10) 7,142 (31) 12,292 (52) 1,617 (7)
7,284 (14) 18,402 (36) 23,913 (46) 2,838 (54)
<0.001
Discharge status Recovered and improved Not improved Dead
6,045 (97) 207 (3) 6 (0.001)
13,398 (57) 3,735 (16) 6,231 (27)
45,206 (86) 3,428 (7) 3,803 (7)
<0.001
Imaging CT scan of the brain Total
2,217 (35.4) 6,258
12,518 (53.6) 23,364
32,459 (61.9) 52,437
<0.001
CI = cerebral infarction, CSMBS = civil servant medical benefit system, ICH = intracerebral hemorrhage, SS = social security, TIA = transient ischemic attack, UC = universal coverage. Discharge status defined by the attending physician at discharge.
prevalence was found in the age group of 65–74 years. The mean age was 8 years lower than other countries where the mean age of CI was 74 years [4] and females had a slightly higher prevalence [4,19]. Some risk factors were similar to the Western countries including common comorbid diseases and stroke complications. The average length of hospital stay for ICH, CI, and TIA patients was 10.7, 6.3, and 2.7 days, respectively. The length of stay for CI patients in the USA, Canada and Germany was 4.1 days [4], 8 days [18] and 10.6 days [20], respectively. The length of stay in this analysis is comparable with previous international studies [4,18,20]. The length of stay depends on stroke subtype, with ICH
having the longest hospital stay. The highest hospital costs per admission were seen in ICH patients ($USD1717) and CI patients who received thrombolytic therapy ($USD1840). The mortality rate in the CI group was 7%. In the USA it was 9.8% in 1997–1998 and 8.8% in 2005–2006 [4]. Thailand has a slightly lower overall in-hospital stroke mortality rate of 6%. This finding may be explained by the Thai culture. Very sick patients will be taken home to die by their relatives even against medical advice. The in-hospital mortality rate may therefore be an underestimate of the true early mortality. However, the number of patients included in this ‘‘against medical advice’’ category was not high
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Table 4 Hospital costs and length of stay per admission Hospital charge per admission, THB (USD)
Length of stay per admission day
TIA
7,080 ($236)
2.7
ICH
51,618 ($1717)
10.7
CI
20,740 ($691)
6.3
CI with thrombolytic treatment
55,405 ($1840)
6.5
CI = cerebral infarction, ICH = intracerebral hemorrhage, TBH = Thai baht, TIA = transient ischemic attack, USD = United States dollars.
Table 5 Thrombolytic therapy in cerebral infarction Ischemic stroke (N = 52,437)
N (%)
Injection or infusion of thrombolytic agent
550 (1.05)
Complications Subarachnoid hemorrhage Intracerebral hemorrhage Gastrointestinal hemorrhage, unspecified Gastrointestinal bleeding + transfusion of blood and blood components
2 (0.4) 11 (2.0) 7 (1.3) 3 (0.5)
Hospital level Primary Secondary Tertiary Private
7 (1.2) 17 (3.1) 513 (93.3) 13 (2.4)
Discharge type With physician approval Transfer to other hospital Against medical advice, death
487 (89) 30 (5) 8 + 25 (6)
Table 6 Univariate analysis of factors associated with hospital mortality of cerebral infarction patients Factors
Alive
Dead
Total
p value
Male Diabetes mellitus Hypertensive diseases Dyslipidemia Chronic kidney disease Atrial fibrillation Heart failure Myocardial infarction HIV infection Pneumonia Decubitus ulcer Urinary tract infection Phlebitis and deep vein thrombosis Pulmonary embolism Epilepsy Status epilepticus Other septicemia
26,383 11,144 22,094 15,841 2,120 3,645 854 378 193 1,861 430 2,225 94 17 662 101 883
1,782 880 1,591 583 284 644 282 145 23 841 148 477 14 6 75 50 958
28,165 12,024 23,685 16,424 2,404 4,289 1,136 523 216 2,702 578 2,702 108 23 737 151 1,841
<0.001 0.765 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.072 <0.001 <0.001 <0.001 0.035 0.002 0.003 <0.001 <0.001
HIV = human immunodeficiency virus.
(Table 5). The mortality rate increases to 14% if those patients who left the hospital with a ‘‘not improved’’ condition were included. A previous study from Germany observed a mortality rate ranging from 3% to 35% depending on the population studied [20]. The mortality rate in ICH is 27% (if ‘‘not improved’’ patients were included, it would increase to 35%) similar to the USA (30.7% in 1997–1998 and 28.2% in 2005–2006) [4]. The rate of thrombolytic prescription use was much lower than in other countries. In 2010, the overall thrombolytic therapy in stroke patients in Thailand was only 1.05%. Of those, 93% of CI patients received thrombolytic therapy in tertiary care hospitals. Low thrombolytic therapy uptake in Thailand may be explained
Table 7 Multivariate logistic regression model of factors associated with hospital mortality in cerebral infarction patients Factors
Adjusted odds ratio
95% confidence interval
Demographic data Male versus Female
0.8
0.7–0.9
Insurance scheme Social security fund Universal coverage
0.7 1.3
0.5–0.9 1.2–1.4
Hospital level Secondary Tertiary Private
2.7 2.6 2.4
2.3–3.2 2.2–3.0 1.9–3.0
Risk factors Dyslipidemia Chronic kidney disease Atrial fibrillation and flutter Congestive heart failure Myocardial infarction HIV infection
0.4 1.5 1.7 2.7 3.5 1.8
0.4–0.5 1.3–1.7 1.5–1.9 2.3–3.3 2.7–4.5 1.2–2.9
1.9 4.2 1.5 4.3 2.8 11.6
1.4–2.5 3.7–4.7 1.4–1.8 1.2–14.6 1.7–4.7 10.3–13.0
Complications Decubitus ulcer Pneumonia Urinary tract infection Pulmonary embolism Status epilepticus Other septicemia HIV = human immunodeficiency virus.
by a lack of stroke knowledge in the general population, healthcare access issues, and availability of CT scans and thrombolytic drugs, particularly in primary or secondary hospitals. Thrombolytic therapy use was also low at the beginning of the era and then dramatically increased over time. About 1–2% of stroke patients in the developed world are treated with intravenous thrombolytic therapy [11], but higher treatment rates have been reported in some areas [11]. In Sweden, prescriptions of thrombolytic agents was 0.9% in 2003 and then grew to 6.6% in 2008 [21]. Similarly, a study from Israel showed that the rate of thrombolytic therapy rose from 0.4% to 5.9% within a period of 6 years [22]. It is therefore believed that there will be an increasing use of thrombolytic therapy in Thailand in the near future. Factors associated with death in CI patients were particular comorbid diseases and complications after the stroke. Having cardiovascular risks such as heart failure, myocardial infarction, or atrial fibrillation significantly increased the risk of mortality. Similar to studies from China and Germany, stroke complications and particularly infection were associated with a higher risk of death [22–24]. In this study, septicemia had the highest adjusted odds ratio for death in CI patients, followed by pneumonia and pulmonary embolism. This study was strengthened by its nationwide scope that represented 95.5% [14] of the in-patient settings of the Thai population (the other 4.5% [14] were patients without public health insurance, and those who were unregistered or waiting to establish eligibility). Data were retrieved from the reimbursement section of the Ministry of Public Health to access all three databases. The
K. Kongbunkiat et al. / Journal of Clinical Neuroscience 22 (2015) 493–497
diagnosis and type of stroke were well established by attending physicians, and not from patient self-reporting. Some issues in terms of coding related to diagnosis may have had an impact; however, there were several steps in checking this possibility before making the reimbursement. Therefore it is believed that the diagnosis and coding data should be valid. There were some limitations in this study. The data were lacking information regarding illness severity including both neurological symptoms and medical symptoms. The data resources lacked documented information on the rate of non-hospital stroke, and therefore these results may not be applicable for the outpatient setting and the many stroke-related deaths that occur out of the hospital. 5. Conclusions The incidence rate, outcome and in-hospital mortality rate of stroke in Thailand were comparable with other countries. Significant factors associated with mortality included sex, insurance scheme, hospital level, risk factors, and complications of stroke. Physicians in Thailand should be aware of these predictors for stroke mortality. Acute stroke treatment is important all over the country because it is the beginning of the thrombolytic therapy era in Thailand. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. Acknowledgements We would like to thank Prof. James A Will (University of Wisconsin) for reviewing and proof reading this manuscript. This study was supported by TRF grants from Senior Research Scholar Grant, Thailand Research Fund grant number RTA5580004 and the Higher Education Research Promotion and National Research University Project of Thailand, Office of the Higher Education Commission, Thailand through the Health Cluster (SHeP-GMS), Khon Kaen University. References [1] Bonita R, Mendis S, Truelsen T, et al. The global stroke initiative. Lancet Neurol 2004;3:391–3.
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[2] World Health Organization. The global burden of disease: 2004 update. Geneva: World Health Organization; 2008. [3] Hata J, Kiyohara Y. Epidemiology of stroke and coronary artery disease in Asia. Circ J 2013;77:1923–32. [4] Tuomilehto J, Morelos S, Yason J, et al. Trends in cardiovascular diseases mortality in the Philippines. Int J Epidemiol 1984;13:168–76. [5] Venketasubramanian N. Trends in cerebrovascular disease mortality in Singapore: 1970 to 1994. Int J Epidemiol 1998;27:15–9. [6] Hughes K. Trends in mortality from hypertensive and cerebrovascular diseases in Singapore, 1959 to 1983. Int J Epidemiol 1987;16:18–24. [7] Viriyavejakul A. Stroke in Asia: an epidemiological consideration. Clin Neuropharmacol 1990;13:S26–33. [8] Porapakkham Y, Rao C, Pattaraarchachai J, et al. Estimated causes of death in Thailand, 2005: implications for health policy. Popul Health Metr 2010;8:14. [9] Venketasubramanian N. The epidemiology of stroke in ASEAN countries – a review. Neurol J Southeast Asia 1998;3:9–14. [10] Ratanakorn D, Keandoungchun J, Tegeler CH. Prevalence and association between risk factors, stroke subtypes, and abnormal ankle brachial index in acute ischemic stroke. J Stroke Cerebrovasc Dis 2012;21:498–503. [11] Muengtaweepongsa S, Dharmasaroja P, Kummark U. Outcomes of intravenous thrombolytic therapy for acute ischemic stroke with an integrated acute stroke referral network: initial experience of a community-based hospital in a developing country. J Stroke Cerebrovasc Dis 2012;21:42–6. [12] Dharmasaroja PA, Dharmasaroja P, Muengtaweepongsa S. Outcomes of Thai patients with acute ischemic stroke after intravenous thrombolysis. J Neurol Sci 2011;300:74–7. [13] Ovbiagele B. Nationwide trends in in-hospital mortality among patients with stroke. Stroke 2010;41:1748–54. [14] Hughes D, Leethongdee S. Universal coverage in the land of smiles: lessons from Thailand’s 30 Baht health reforms. Health Aff (Millwood) 2007;26:999–1008. [15] Thonghong A, Tepsittha K, Jongpiriyaanan P, et al. Chronic diseases surveillance report, 2011. Wkly Epidemiol Surveill Rep Thai 2012;43:257–64. [16] Kulshreshtha A, Anderson LM, Goyal A, et al. Stroke in South Asia: a systematic review of epidemiologic literature from 1980 to 2010. Neuroepidemiology 2012;38:123–9. [17] Liu M, Wu B, Wang WZ, et al. Stroke in China: epidemiology, prevention, and management strategies. Lancet Neurol 2007;6:456–64. [18] Saposnik G, Jeerakathil T, Selchen D, et al. Socioeconomic status, hospital volume, and stroke fatality in Canada. Stroke 2008;39:3360–6. [19] Bhattacharya S, Saha SP, Basu A, et al. A 5 years prospective study of incidence, morbidity and mortality profile of stroke in a rural community of eastern India. J Indian Med Assoc 2005;103:655–9. [20] Heuschmann PU, Kolominsky-Rabas PL, Misselwitz B, et al. Predictors of inhospital mortality and attributable risks of death after ischemic stroke: the German Stroke Registers Study Group. Arch Intern Med 2004;164:1761–8. [21] Eriksson M, Jonsson F, Appelros P, et al. Dissemination of thrombolysis for acute ischemic stroke across a nation: experiences from the Swedish stroke register, 2003 to 2008. Stroke 2010;41:1115–22. [22] Tanne D, Koton S, Molshazki N, et al. Trends in management and outcome of hospitalized patients with acute stroke and transient ischemic attack: the National Acute Stroke Israeli (NASIS) registry. Stroke 2012;43:2136–41. [23] Wang PL, Zhao XQ, Yang ZH, et al. Effect of in-hospital medical complications on case fatality post-acute ischemic stroke: data from the China National Stroke Registry. Chin Med J (Engl) 2012;125:2449–54. [24] Rocco A, Fam G, Sykora M, et al. Poststroke infections are an independent risk factor for poor functional outcome after three-months in thrombolysed stroke patients. Int J Stroke 2013;8:639–44.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
National data on stroke outcomes in Thailand Kannikar Kongbunkiat a,c, Narongrit Kasemsap a, Kaewjai Thepsuthammarat b, Somsak Tiamkao a,c, Kittisak Sawanyawisuth a,d,⇑ a
Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand Clinical Epidemiology Unit, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand c North-eastern Stroke Research Group, Khon Kaen University, Thailand d The Research Center in Back, Neck, Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University, Khon Kaen, Thailand b
a r t i c l e
i n f o
Article history: Received 15 May 2013 Accepted 25 August 2014
Keywords: ICD-10 National data Outcomes Predictors Stroke Thailand
a b s t r a c t Stroke is a major public health problem worldwide. There are limited data on national stroke prevalence and outcomes after the beginning of the thrombolytic therapy era in Thailand. This study aimed to investigate the prevalence and factors associated with mortality in stroke patients in Thailand using the national reimbursement databases. Clinical data retrieved included individuals under the universal coverage, social security, and civil servant benefit systems between 1 October 2009 and 30 September 2010. The stroke diagnosis code was based on the International Classification of Diseases 10th revision system including G45 (transient cerebral ischemic attacks and related syndromes), I61 (intracerebral hemorrhage), and I63 (cerebral infarction). The prevalence and stroke outcomes were calculated from these coded data. Factors associated with death were evaluated by multivariable logistic regression analysis. We found that the most frequent stroke subtype was cerebral infarction with a prevalence of 122 patients per 100,000 of population, an average length of hospital stay of 6.8 days, an average hospital charge of 20,740 baht ($USD 691), a mortality rate of 7%, and thrombolytic prescriptions of 1%. The significant factors associated with stroke mortality were septicemia, pulmonary embolism, pneumonia, myocardial infarction, status epilepticus, and heart failure. In conclusion, the prevalence and outcomes of stroke in Thailand were comparable with other countries. The era of thrombolytic therapy has just begun in Thailand. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Stroke is one of the most important causes of death and adult disability [1]. It is estimated that stroke is the second most common cause of death worldwide [2]. Mortality data in Asian countries are varied [3]. The crude death rate was between 50–160 per 100,000 of population in 2002 [3]. Previous reports showed that the mortality rate from stroke was declining over time in the Philippines and Singapore [4,5]. The explanation for this may be lower rates of hypertension, smoking, dyslipidemia, and obesity [5,6]. In contrast, the death rates from stroke in Thailand increased from 3.7/100,000 in 1950 to 11.8/100,000 in 1983 and 77.2/ 100,000 in 2005 [7,8]. Stroke became the most common cause of death in Thailand in 2005 [8,9]. In Thailand, several studies have addressed stroke prevalence, risk factors, management, and outcomes [10–12]. The mean age of stroke patients in Thailand is approximately 65 years and there ⇑ Corresponding author. Tel.: +66 43 363 664; fax: +66 43 348 399. E-mail address: [email protected] (K. Sawanyawisuth). http://dx.doi.org/10.1016/j.jocn.2014.08.031 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
is a slight male predominance (57%). Hypertension was the most common risk factor, seen in 57% of patients, followed by smoking (29%) and diabetes (24%). Eighteen percent of acute ischemic stroke patients also had an abnormal ankle brachial index suggestive of comorbid peripheral artery disease [10]. Information regarding predictors for in-hospital mortality and the impact of serious medical and neurological complications, however, is limited [13]. A study in the USA that was conducted based on hospital databases all over the country showed that factors associated with mortality were the patient’s age, being female, not having Medicare insurance, and having a comorbid disease [13]. There are limited data from the entire country Thailand and no national database on the incidence of stroke, stroke impact, stroke outcomes, in-hospital deaths, and predictors for mortality from stroke. The in-hospital deaths after stroke probably reflect the optimized overall premorbid health status, acute stroke treatment, and acute general medical care in hospitals and the health system levels. This study aimed to identify these limited data by using the three national databases that cover 1172 hospitals in Thailand.
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The stroke patients’ baseline characteristics are shown in Table 2. The ratio of males to females in CI patients was 1.16. Stroke rates tended to be higher in older age groups in all three types of stroke. The two most common complications were pneumonia and urinary tract infection. Just over half of the TIA patients were male (54%) and the average age of the TIA patients was 63 years. The frequently found comorbid diseases in TIA patients were similar to CI patients. The average age of ICH patients was the lowest at 62 years. Patients with ICH had a higher percentage of hypertension than CI or TIA patients. Reimbursement of hospital charges is shown in Table 3. Around three-quarters of patients were in the UC system, followed by CSMBS (19%) and SS (8%). Primary, secondary and tertiary level hospitals admitted a similar proportion of patients with TIA. About 80% of ICH and CI patients were admitted to secondary and tertiary level hospitals. ICH patients had the highest mortality rate (27%) while CI had a rate of only 7%. The average hospital charges and length of stay are presented in Table 4. CI patients receiving thrombolytic agents paid the highest average hospital charge. The length of stay for patients with ICH was longer than patients with TIA. In 2010, 550 CI patients all over Thailand received thrombolytic treatment (1.05%) as shown in Table 5. The most common complication of thrombolytic treatment was ICH. Thrombolytic treatment was mostly provided in the tertiary hospitals and had a mortality rate of 6% overall. Factors associated with death of CI in-patients were calculated by univariate (Table 6) and multivariable logistic regressions (Table 7). Significant factors associated with mortality included sex, insurance scheme, hospital level, risk factors, and complications of stroke.
2. Materials and methods Data were obtained from the national database system covering 95.5% of the Thai population who were under health security schemes [14]. The first system (7.1% of the population) is the civil servant medical benefit system (CSMBS) that covers government employees and their dependents including parents, spouses and up to two children aged <20 years. The second system (13.2%) is the social security (SS) that covers private sector employees, excluding their dependents. The third system (75.2%) is the universal coverage (UC) that covers the rest of population who are not covered by SS and CSMBS. These database systems were studied because they represent almost all of the people in Thailand except those who are self-insured. This study included patients over the age of 18 years who were admitted to a hospital in Thailand due to stroke from 1 October 2009 to 30 September 2010. Clinical data were retrieved from reimbursement forms. The diagnosis of stroke was based on the International Classification of Diseases (ICD) 10th revision using the codes G45 (transient cerebral ischemic attacks [TIA] and related syndromes), I61 (intracerebral hemorrhage [ICH]), and I63 (cerebral infarction [CI]). The types of stroke were identified by CT scans of the brain. The length of hospital stay for each patient, their age, sex, comorbid diseases, complications, mortality rate, and hospital charges per admission were recorded. There are four categories of hospitals in Thailand, being primary or community, secondary, tertiary, and private hospitals. Primary or community hospitals serve people in the districts or at community levels, and usually have 10 to 30 beds. Secondary hospitals provide healthcare in the provincial areas, while tertiary hospitals receive patients via the referral system. Private hospitals are located all over the country at the provincial level, and serve 4% of the entire population. Thrombolytic prescription frequency was based on the ICD-9 code 99.10 (injection or infusion of thrombolytic agents in patients diagnosed as having CI). The percentage of stroke complications, length of hospital stay, and hospital charges were also studied in patients receiving thrombolytic therapy. Analysis of factors associated with mortality in patients with CI who received treatment at a hospital was conducted using multivariable logistic regression, with a p value <0.05 considered statistically significant.
4. Discussion This study is a compilation of national data regarding in-hospital stroke patients, outcomes and predictors associated with mortality in Thailand. The average stroke prevalence in Thailand was 122 per 100,000 of population. The prevalence was highest in the central part of the country and Bangkok where the economic status is also the highest in the country. Similarly, the diagnosis of metabolic syndrome in Thailand was commonly found in urban areas or the central part of Thailand in a national survey in 2012 [15]. A report from the Bureau of Epidemiology showed that the prevalence of metabolic syndrome was 50.56 people per 100,000 of population [15]. These data were collected from the yearly report of all hospitals all over Thailand. The prevalence seen in other countries is varied and differs from Thailand; South Asia has a prevalence of 45 to 471 per 100,000 of the adult (>18 years old) population [16], and 260 to 719 per 100,000 for all ages in China [17]. Similar to results from the USA and Canada [4,18] and Asian results from India, China, Singapore, and Indonesia [9,16,17], CI was the most common stroke subtype. In Thailand, the mean age of CI patients was 66 years and males were slightly predominant (54%). The prevalence of CI increased with age and the highest
3. Results During the 2010 fiscal year (1 October 2009 to 30 September 2010), 82,061 stroke patients were admitted to 1172 hospitals all over Thailand. This included 747 primary hospitals, 134 secondary hospitals, 120 tertiary hospitals, and 171 private hospitals. Patients were divided into 52,437 cases (63.9%) of CI, 23,366 cases (28.5%) of ICH, and 6258 cases (7.6%) of TIA. Prevalence of stroke among patients over 18 years of age was divided into regions as shown in Table 1. The central region had the highest prevalence of stroke during this period. Table 1 Prevalence of cerebrovascular diseases per 100,000 of population in Thailand Regions
Northern North-east Central Southern Total
Population
8,871,705 15,964,936 11,896,555 6,287,474 47,171,244
TIA
ICH
CI
Number
Prevalence/100,000
Number
Prevalence/100,000
Number
Prevalence/100,000
1,282 1,672 2,361 919 6,234
14 10 20 15 14
5,480 5,725 9,337 2,596 23,138
62 36 78 41 54
10,389 14,786 20,426 6,672 52,273
117 93 172 106 122
CI = cerebral infarction, ICH = intracerebral hemorrhage, TIA = transient ischemic attack.
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K. Kongbunkiat et al. / Journal of Clinical Neuroscience 22 (2015) 493–497 Table 2 Baseline characteristics of patients with cerebrovascular disease (International Classification of Diseases 10th Revision codes G45, I61, I63) Demographic factors
TIA
ICH
CI
p value
Males Age, years, mean (SD)
3,409 (54) 63 (15)
14,002 (60) 62 (15)
28,165 (54) 66 (14)
<0.001
Age group, years <35 35–44 45–54 55–64 65–74 75–84 85+
235 (3.8) 483 (7.7) 1,082 (17.3) 1,467 (23.4) 1,569 (25.1) 1,157 (18.5) 265 (4.2)
809 (3.5) 2,023 (8.7) 5,036 (21.6) 5,487 (23.5) 4,961 (21.2) 3,932 (16.8) 1,118 (4.8)
945 (1.8) 2,641 (5.0) 7,297 (13.9) 11.385 (21.7) 14.459 (27.57) 12.348 (23.6) 3,362 (6.4)
<0.001
Comorbid diseases Hypertensive diseases Disorders of lipoprotein metabolism and other lipidemias Diabetes mellitus Chronic kidney disease Atrial fibrillation and flutter Congestive heart failure Myocardial infarction HIV
2,746 (43.9) 1,896 (30.3) 1,276 (20.4) 216 (3.5) 318 (5.1) 67 (1.1) 38 (0.6) 22 (0.4)
12,459 (53.3) 2,229 (9.5) 2,801 (12.0) 809 (3.5) 397 (1.7) 185 (1.0) 120 (0.5) 88 (0.3)
23,685 (45.1) 16,424 (31.3) 12,024 (22.9) 2,404 (4.6) 4,289 (8.2) 1,136 (2.2) 523 (1.0) 216 (0.4)
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.662
Complications Pneumonia Urinary tract infection Decubitus ulcer Phlebitis and thrombophlebitis of other deep vessels Pulmonary embolism Epilepsy Status epilepticus Other septicemias Total
8 (0.1) 82 (1.3) 3 (0.05) 3 (0.05) 1 (0.01) 38 (0.6) 0 (0) 11 (0.2) 6,258
1,647 (7.1) 1,302 (5.6) 308 (1.3) 38 (0.2) 3 (0.01) 278 (1.2) 62 (0.3) 994 (4.3) 23,364
2,702 (5.2) 2,702 (5.2) 578 (1.1) 108 (0.2) 23 (0.04) 737 (1.4) 151 (0.3) 1,841 (3.5) 52,437
<0.001 <0.001 <0.001 0.083 0.097 <0.001 <0.001 <0.001
Data are presented as number (%) unless otherwise specified. CI = cerebral infarction, HIV = human immunodeficiency virus, ICH = intracerebral hemorrhage, SD = standard deviation, TIA = transient ischemic attack.
Table 3 Insurance scheme, hospital level, discharge status and brain CT scan data TIA
ICH
CI
p value
Insurance scheme CSMBS SS UC
1181 (19) 519 (8) 4,558 (73)
3,611 (15) 1,293 (6) 18,462 (80)
10,515 (20) 2,159 (4) 39,763 (76)
<0.001
Hospital level Primary Secondary Tertiary Private
2,102 (34) 1,531 (24) 2,126 (34) 499 (8)
2,315 (10) 7,142 (31) 12,292 (52) 1,617 (7)
7,284 (14) 18,402 (36) 23,913 (46) 2,838 (54)
<0.001
Discharge status Recovered and improved Not improved Dead
6,045 (97) 207 (3) 6 (0.001)
13,398 (57) 3,735 (16) 6,231 (27)
45,206 (86) 3,428 (7) 3,803 (7)
<0.001
Imaging CT scan of the brain Total
2,217 (35.4) 6,258
12,518 (53.6) 23,364
32,459 (61.9) 52,437
<0.001
CI = cerebral infarction, CSMBS = civil servant medical benefit system, ICH = intracerebral hemorrhage, SS = social security, TIA = transient ischemic attack, UC = universal coverage. Discharge status defined by the attending physician at discharge.
prevalence was found in the age group of 65–74 years. The mean age was 8 years lower than other countries where the mean age of CI was 74 years [4] and females had a slightly higher prevalence [4,19]. Some risk factors were similar to the Western countries including common comorbid diseases and stroke complications. The average length of hospital stay for ICH, CI, and TIA patients was 10.7, 6.3, and 2.7 days, respectively. The length of stay for CI patients in the USA, Canada and Germany was 4.1 days [4], 8 days [18] and 10.6 days [20], respectively. The length of stay in this analysis is comparable with previous international studies [4,18,20]. The length of stay depends on stroke subtype, with ICH
having the longest hospital stay. The highest hospital costs per admission were seen in ICH patients ($USD1717) and CI patients who received thrombolytic therapy ($USD1840). The mortality rate in the CI group was 7%. In the USA it was 9.8% in 1997–1998 and 8.8% in 2005–2006 [4]. Thailand has a slightly lower overall in-hospital stroke mortality rate of 6%. This finding may be explained by the Thai culture. Very sick patients will be taken home to die by their relatives even against medical advice. The in-hospital mortality rate may therefore be an underestimate of the true early mortality. However, the number of patients included in this ‘‘against medical advice’’ category was not high
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Table 4 Hospital costs and length of stay per admission Hospital charge per admission, THB (USD)
Length of stay per admission day
TIA
7,080 ($236)
2.7
ICH
51,618 ($1717)
10.7
CI
20,740 ($691)
6.3
CI with thrombolytic treatment
55,405 ($1840)
6.5
CI = cerebral infarction, ICH = intracerebral hemorrhage, TBH = Thai baht, TIA = transient ischemic attack, USD = United States dollars.
Table 5 Thrombolytic therapy in cerebral infarction Ischemic stroke (N = 52,437)
N (%)
Injection or infusion of thrombolytic agent
550 (1.05)
Complications Subarachnoid hemorrhage Intracerebral hemorrhage Gastrointestinal hemorrhage, unspecified Gastrointestinal bleeding + transfusion of blood and blood components
2 (0.4) 11 (2.0) 7 (1.3) 3 (0.5)
Hospital level Primary Secondary Tertiary Private
7 (1.2) 17 (3.1) 513 (93.3) 13 (2.4)
Discharge type With physician approval Transfer to other hospital Against medical advice, death
487 (89) 30 (5) 8 + 25 (6)
Table 6 Univariate analysis of factors associated with hospital mortality of cerebral infarction patients Factors
Alive
Dead
Total
p value
Male Diabetes mellitus Hypertensive diseases Dyslipidemia Chronic kidney disease Atrial fibrillation Heart failure Myocardial infarction HIV infection Pneumonia Decubitus ulcer Urinary tract infection Phlebitis and deep vein thrombosis Pulmonary embolism Epilepsy Status epilepticus Other septicemia
26,383 11,144 22,094 15,841 2,120 3,645 854 378 193 1,861 430 2,225 94 17 662 101 883
1,782 880 1,591 583 284 644 282 145 23 841 148 477 14 6 75 50 958
28,165 12,024 23,685 16,424 2,404 4,289 1,136 523 216 2,702 578 2,702 108 23 737 151 1,841
<0.001 0.765 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.072 <0.001 <0.001 <0.001 0.035 0.002 0.003 <0.001 <0.001
HIV = human immunodeficiency virus.
(Table 5). The mortality rate increases to 14% if those patients who left the hospital with a ‘‘not improved’’ condition were included. A previous study from Germany observed a mortality rate ranging from 3% to 35% depending on the population studied [20]. The mortality rate in ICH is 27% (if ‘‘not improved’’ patients were included, it would increase to 35%) similar to the USA (30.7% in 1997–1998 and 28.2% in 2005–2006) [4]. The rate of thrombolytic prescription use was much lower than in other countries. In 2010, the overall thrombolytic therapy in stroke patients in Thailand was only 1.05%. Of those, 93% of CI patients received thrombolytic therapy in tertiary care hospitals. Low thrombolytic therapy uptake in Thailand may be explained
Table 7 Multivariate logistic regression model of factors associated with hospital mortality in cerebral infarction patients Factors
Adjusted odds ratio
95% confidence interval
Demographic data Male versus Female
0.8
0.7–0.9
Insurance scheme Social security fund Universal coverage
0.7 1.3
0.5–0.9 1.2–1.4
Hospital level Secondary Tertiary Private
2.7 2.6 2.4
2.3–3.2 2.2–3.0 1.9–3.0
Risk factors Dyslipidemia Chronic kidney disease Atrial fibrillation and flutter Congestive heart failure Myocardial infarction HIV infection
0.4 1.5 1.7 2.7 3.5 1.8
0.4–0.5 1.3–1.7 1.5–1.9 2.3–3.3 2.7–4.5 1.2–2.9
1.9 4.2 1.5 4.3 2.8 11.6
1.4–2.5 3.7–4.7 1.4–1.8 1.2–14.6 1.7–4.7 10.3–13.0
Complications Decubitus ulcer Pneumonia Urinary tract infection Pulmonary embolism Status epilepticus Other septicemia HIV = human immunodeficiency virus.
by a lack of stroke knowledge in the general population, healthcare access issues, and availability of CT scans and thrombolytic drugs, particularly in primary or secondary hospitals. Thrombolytic therapy use was also low at the beginning of the era and then dramatically increased over time. About 1–2% of stroke patients in the developed world are treated with intravenous thrombolytic therapy [11], but higher treatment rates have been reported in some areas [11]. In Sweden, prescriptions of thrombolytic agents was 0.9% in 2003 and then grew to 6.6% in 2008 [21]. Similarly, a study from Israel showed that the rate of thrombolytic therapy rose from 0.4% to 5.9% within a period of 6 years [22]. It is therefore believed that there will be an increasing use of thrombolytic therapy in Thailand in the near future. Factors associated with death in CI patients were particular comorbid diseases and complications after the stroke. Having cardiovascular risks such as heart failure, myocardial infarction, or atrial fibrillation significantly increased the risk of mortality. Similar to studies from China and Germany, stroke complications and particularly infection were associated with a higher risk of death [22–24]. In this study, septicemia had the highest adjusted odds ratio for death in CI patients, followed by pneumonia and pulmonary embolism. This study was strengthened by its nationwide scope that represented 95.5% [14] of the in-patient settings of the Thai population (the other 4.5% [14] were patients without public health insurance, and those who were unregistered or waiting to establish eligibility). Data were retrieved from the reimbursement section of the Ministry of Public Health to access all three databases. The
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diagnosis and type of stroke were well established by attending physicians, and not from patient self-reporting. Some issues in terms of coding related to diagnosis may have had an impact; however, there were several steps in checking this possibility before making the reimbursement. Therefore it is believed that the diagnosis and coding data should be valid. There were some limitations in this study. The data were lacking information regarding illness severity including both neurological symptoms and medical symptoms. The data resources lacked documented information on the rate of non-hospital stroke, and therefore these results may not be applicable for the outpatient setting and the many stroke-related deaths that occur out of the hospital. 5. Conclusions The incidence rate, outcome and in-hospital mortality rate of stroke in Thailand were comparable with other countries. Significant factors associated with mortality included sex, insurance scheme, hospital level, risk factors, and complications of stroke. Physicians in Thailand should be aware of these predictors for stroke mortality. Acute stroke treatment is important all over the country because it is the beginning of the thrombolytic therapy era in Thailand. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. Acknowledgements We would like to thank Prof. James A Will (University of Wisconsin) for reviewing and proof reading this manuscript. This study was supported by TRF grants from Senior Research Scholar Grant, Thailand Research Fund grant number RTA5580004 and the Higher Education Research Promotion and National Research University Project of Thailand, Office of the Higher Education Commission, Thailand through the Health Cluster (SHeP-GMS), Khon Kaen University. References [1] Bonita R, Mendis S, Truelsen T, et al. The global stroke initiative. Lancet Neurol 2004;3:391–3.
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