Journal of Clinical Neuroscience 22 (2015) 493–497

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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

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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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K. Kongbunkiat et al. / Journal of Clinical Neuroscience 22 (2015) 493–497

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

National data on stroke outcomes in Thailand.

Stroke is a major public health problem worldwide. There are limited data on national stroke prevalence and outcomes after the beginning of the thromb...
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