Variations in Case Fatality and Dependency From Stroke in Western and Central Europe

BACKGROUND AND PURPOSE: There are significant variations in mortality rates from stroke in Europe. A European Union BIOMED Concerted Action was established to assess and determine the reasons for the variations in case fatality and disability after stroke. METHODS: Hospital-based stroke registers were established in 12 centers in 7 western and central European countries to collect demographic, clinical, and resource use details at the time of first-ever stroke during 1993-1994. At 3 months, details of survival, activity of daily living score, and use of health services were recorded. Multinomial logistic regression was used to estimate the relationship between centers and outcome (dead, functionally independent, functionally dependent), with adjustment for case mix and resource use variables, and to predict outcomes for the full cohort. This should minimize the bias due to loss to follow-up. RESULTS: A total of 4534 stroke events were registered. The mean age was 71.9 years (SD, 12.53). There were significant differences between centers for all case mix and resource use variables (P<0. 001). Multinomial logistic regression modeling of outcome indicated that for those patients initially unconscious (588), center was not significantly related to outcome (P=0.427). For those initially conscious, there were wide variations in death and dependency between centers after adjustment for case mix, type of bed, and use of CT scan. The predicted proportion dead at 3 months ranged from 42% (95% CI, 35% to 49%) in one UK center to 19% (95% CI, 14% to 24%) in France. CONCLUSIONS: Areas with high mortality rates within western and central Europe have been identified for stroke outcome, and there appears to be opportunity for considerable health gain in certain centers. Adjustment for case mix and health service resource use does not explain these differences in outcome. Although there are true differences in outcome, the aspects of care that need to be altered to improve outcome remain unclear despite detailed data collection. Comparisons of outcome of the same design used in the present study do not allow rational policy decisions to be made.