Assessment of Trends in Guideline-Based Oral Anticoagulant Prescription for Patients With Ischemic Stroke and Atrial Fibrillation in China.

Importance: Adherence to oral anticoagulants (OACs) per guideline recommendations is crucial in reducing ischemic stroke and systemic thromboembolism in high-risk patients with ischemic stroke and atrial fibrillation. However, data on OAC use are underreported in China. Objective: To assess adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescription of OACs, the temporal improvement in adherence, and the risk factors associated with OAC prescriptions. Design, Setting, and Participants: This quality improvement study was conducted at 1430 participating hospitals in the Chinese Stroke Center Alliance (CSCA) among patients with ischemic stroke and atrial fibrillation enrolled in the CSCA between August 1, 2015, and July 31, 2019. Exposure: Calendar year. Main Outcomes and Measures: Adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescribing of OACs (warfarin and non-vitamin K OACs, including dabigatran, rivaroxaban, apixaban, and edoxaban) at discharge. Results: Among 35 767 patients (18 785 women [52.5%]; mean [SD] age, 75.5 [9.2] years) with previous atrial fibrillation at admission, the median CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score was 4.0 (interquartile range, 3.0-5.0); 6303 (17.6%) were taking OACs prior to hospitalization for stroke, a rate that increased from 14.3% (20 of 140) in the third quarter of 2015 to 21.1% (118 of 560) in the third quarter of 2019 (P < .001 for trend). Of 49 531 eligible patients (26 028 men [52.5%]; mean [SD] age, 73.4 [10.4] years), 20 390 (41.2%) had an OAC prescription at discharge, an increase from 23.2% (36 of 155) in the third quarter of 2015 to 47.1% (403 of 856) in the third quarter of 2019 (P < .001 for trend). Warfarin was the most commonly prescribed OAC (11 956 [24.2%]) and had the largest temporal increase (from 5.8% [9 of 155] to 20.7% [177 of 856]). Older age (adjusted odds ratio [aOR] per 5 year increase, 0.89;95% CI, 0.89-0.90), lower levels of education (aOR for below elementary school, 0.84; 95% CI, 0.74-0.95 ), lower income (aOR for ≤¥1000 [$154], 0.66; 95% CI, 0.59-0.73), having new rural cooperative medical scheme insurance (aOR, 0.92; 95% CI, 0.87-0.96), prior antiplatelet use (aOR, 0.70; 95% CI, 0.66-0.74), having several cardiovascular comorbid conditions (including stroke or transient ischemic attack [aOR, 0.78; 95% CI, 0.75-0.82], hypertension [aOR, 0.84; 95% CI, 0.80-0.89], diabetes [aOR, 0.91; 95% CI, 0.83-0.99], dyslipidemia [aOR, 0.87; 95% CI, 0.80-0.94], carotid stenosis [aOR, 0.83; 95% CI, 0.69-0.98], and peripheral vascular disease [aOR, 0.80; 95% CI, 0.71-0.90]), and admission to secondary hospitals (aOR, 0.71; 95% CI, 0.68-0.74) or hospitals located in the central region of China (aOR, 0.80; 95% CI, 0.75-0.84) were associated with not being prescribed an OAC at discharge. Conclusions and Relevance: This quality improvement study suggests that, despite significant improvement over time, OAC prescriptions remained low. Efforts to increase OAC prescriptions, especially non-vitamin K OACs, are needed for vulnerable subgroups by age, socioeconomic status, and presence of comorbid conditions.

China Stroke Statistics 2019: A Report From the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations.

China faces the greatest challenge from stroke in the world. The death rate for cerebrovascular diseases in China was 149.49 per 100 000, accounting for 1.57 million deaths in 2018. It ranked third among the leading causes of death behind malignant tumours and heart disease. The age-standardised prevalence and incidence of stroke in 2013 were 1114.8 per 100 000 population and 246.8 per 100 000 person-years, respectively. According to the Global Burden of Disease Study 2017, the years of life lost (YLLs) per 100 000 population for stroke increased by 14.6%; YLLs due to stroke rose from third highest among all causes in 1990 to the highest in 2017. The absolute numbers and rates per 100 000 population for all-age disability-adjusted life years (DALYs) for stroke increased substantially between 1990 and 2017, and stroke was the leading cause of all-age DALYs in 2017. The main contributors to cerebrovascular diseases include behavioural risk factors (smoking and alcohol use) and pre-existing conditions (hypertension, diabetes mellitus, dyslipidaemia and atrial fibrillation (AF)). The most prevalent risk factors among stroke survivors were hypertension (63.0%-84.2%) and smoking (31.7%-47.6%). The least prevalent was AF (2.7%-7.4%). The prevalences for major risk factors for stroke are high and most have increased over time. Based on the latest national epidemiological data, 26.6% of adults aged ≥15 years (307.6 million adults) smoked tobacco products. For those aged ≥18 years, age-adjusted prevalence of hypertension was 25.2%; adjusted prevalence of hypercholesterolaemia was 5.8%; and the standardised prevalence of diabetes was 10.9%. For those aged ≥40 years, the standardised prevalence of AF was 2.31%. Data from the Hospital Quality Monitoring System showed that 3 010 204 inpatients with stroke were admitted to 1853 tertiary care hospitals during 2018. Of those, 2 466 785 (81.9%) were ischaemic strokes (ISs); 447 609 (14.9%) were intracerebral haemorrhages (ICHs); and 95 810 (3.2%) were subarachnoid haemorrhages (SAHs). The average age of patients admitted was 66 years old, and nearly 60% were male. A total of 1555 (0.1%), 2774 (0.6%) and 1347 (1.4%) paediatric strokes (age <18 years) were identified among IS, ICH and SAH, respectively. Over one-third (1 063 892 (35.3%)) of the patients were covered by urban resident basic medical insurance, followed by urban employee basic medical insurance (699 513 (23.2%)) and new rural cooperative medical schema (489 361 (16.3%)). The leading risk factor was hypertension (67.4% for IS, 77.2% for ICH and 49.1% for SAH), and the leading comorbidity was pneumonia or pulmonary infection (10.1% for IS, 31.4% for ICH and 25.2% for SAH). In-hospital death/discharge against medical advice rate was 8.3% for stroke inpatients, ranging from 5.8% for IS to 19.5% for ICH. The median and IQR of length of stay was 10.0 (7.0-14.0) days, ranging from 10.0 (7.0-13.0) in IS to 14.0 (8.0-22.0) in SAH. Data from the Chinese Stroke Center Alliance demonstrated that the composite scores of guideline-recommended key performance indicators for patients with IS, ICH and SAH were 0.77±0.21, 0.72±0.28 and 0.59±0.32, respectively.

Disparities in outcomes associated with rural-urban insurance status in China among inpatient women with stroke: a registry-based cohort study.

BACKGROUND: Despite a few studies have demonstrated sex differences in stroke care and outcomes, limited research has explored insurance-related disparities in outcomes, particularly among women stroke patients. The aim was to determine whether rural-urban health insurance status affect the stroke treatment, process of care, and 1-year clinical outcomes for inpatient ischemic stroke in women. METHODS: Women patients with acute ischemic stroke (AIS) covered by New Rural Cooperative Medical Scheme (NRCMS) and urban resident/employee-based basic medical insurance scheme (URBMI/UEBMI) were abstracted from the China National Stroke Registry II (CNSR II). Shared frailty model in the Cox model or generalized estimating equation with consideration of the hospital's cluster effect were used to assess the associations between rural-urban insurance status and quality of care during hospitalization and 1-year stroke outcomes including all-cause death, 1-year recurrence, and 1-year disability. RESULTS: A total of 5,707 women patients enrolled from 219 hospitals in CNSR II were analyzed. Compared with 2,880 women patients covered by URBMI/UEBMI, 2,827 women patients covered by NRCMS were younger (65.7 versus 68.9 years), less likely to have vascular risk factors, awareness and treatment of hypertension and dyslipidemia prior to stroke. Women covered by NRCMS were more likely to receive early antithrombotics, discharge antithrombotics, lipid-lowering drugs, but less likely to receive antihypertensive medication than those covered by URBMI/UEBMI. One-year all-cause mortality and stroke recurrence were both significantly higher in women patients with NRCMS than those with URBMI/UEBMI [adjusted hazard ratio (95% confidence interval): 1.40 (1.06-1.84) and 1.38 (1.04-1.83), separately]. CONCLUSIONS: AIS women patients with rural-urban insurance status demonstrated remarkable differences in age, stroke risk factors, awareness and treatment, the process of care, and 1-year stroke recurrence and mortality. Healthcare policymakers need to focus their attention on these disparities and take proper steps to improve primary healthcare service in rural areas.

Insurance status and 1-year outcomes of stroke and transient ischaemic attack: a registry-based cohort study in China.

OBJECTIVE: Although more than 95% of the population is insured by urban or rural insurance programmes in China, little research has been done on insurance-related outcome disparities for patients with acute stroke and transient ischaemic attack (TIA). This study aimed to examine the relationship between insurance status and 1-year outcomes for patients with stroke and TIA. METHODS: We abstracted 24 941 patients with acute stroke and TIA from the China National Stroke Registry II. Insurance status was categorised as Urban Basic Medical Insurance Scheme (UBMIS), New Rural Cooperative Medical Scheme (NRCMS) and self-payment. The relationship between insurance status and 1-year outcomes, including all-cause death, stroke recurrence and disability, was analysed using the shared frailty model in the Cox model or generalised estimating equation with consideration of the hospital's cluster effect. RESULTS: About 50% of patients were covered by UBMIS, 41.2% by NRCMS and 8.9% by self-payment. Compared with patients covered by UBMIS, patients covered by NRCMS had a significantly higher risk of all-cause death (9.7% vs 8.6%, adjusted HR: 1.32 (95% CI 1.17 to 1.48), p<0.001), stroke recurrence (7.2% vs 6.5%, adjusted HR: 1.12 (95% CI 1.11 to 1.37), p<0.001) and disability (32.0% vs 26.3%, adjusted OR: 1.29 (95% CI 1.21 to 1.39), p<0.001). Compared with patients covered by UBMIS, self-payment patients had a similar risk of death and stroke recurrence but a higher risk of disability. CONCLUSIONS: Patients with stroke and TIA demonstrated differences in 1-year mortality, stroke recurrence and disability between urban and rural insurance groups in China.

Risk assessment of deep-vein thrombosis after acute stroke: a prospective study using clinical factors.

AIMS: Deep-vein thrombosis (DVT) represents a serious complication in acute stroke patients with pulmonary embolus (PE) as a potential outcome. Prediction of DVT may help with formulating a proper prevention strategy. To assess of the risk of deep venous thrombosis (DVT) in acute stroke patients, we developed and validated a clinical score in a cohort study. METHODS: Incidence of Deep Venous Thrombosis after Acute Stroke in China (INVENT-China) is a multicenter prospective cohort study. The potential predictive variables for DVT at baseline were collected, and the presence of DVT was evaluated using ultrasonography on the 14 ± 3 days. Data were randomly assigned to either a training data set or a test data set. Multivariate logistic regression analysis was used to develop risk scores to predict DVT in the training data set and the area under the receiver operating characteristic curve to validate the score in the test data set. RESULTS: From 2006-2007, 862 hospital-based acute stroke patients were enrolled in China. The overall incidence of DVT after acute stroke within two weeks was 12.4% (95%CI 10.3-14.7%). A seven-point score derived in the training data set (age [≥65 years = 1], sex [female gender = 1]), obesity [BMI ≥ 25 kg/m(2) = 1], active cancer [yes = 2], stroke subtype [cerebral hemorraghe = 1], muscle weakness [≥2 on Lower limb NIHSS score = 1] was highly predictive of 14-day risk of DVT(c statistic = 0.70, 95% CI, 0.64-0.76, P < 0.001), in the overall study population(c statistic = 0.65, 95% CI 0.59-0.70, P < 0.001). CONCLUSIONS: This clinical score may help identify acute stroke patients with high risk of DVT. In addition, it also serves as a platform to develop further models of DVT prediction in stroke patients based on clinical factors.

[Methodology research and preliminary assessment of Mycobacterium tuberculosis detection by immunomagnetic beads combined with functionalized fluorescent quantum dots].

OBJECTIVE: To establish a detection method for Mycobacterium tuberculosis (MTB) by immunomagnetic beads combined with functionalized fluorescent quantum dots technology, and to investigate the optimal test condition and the diagnostic value of this method. METHODS: MTB standard strain H37Rv was used as detection object. Nanobeads and quantum dots were prepared by using wet chemical method, and conjugated separately with MTB binding peptide H8 to obtain immunomagnetic beads and functionalized fluorescent quantum dots, which could react with H37Rv simultaneously and form a ternary complex structure. Based on measurement of the fluorescence value and observation under fluorescence microscopy to determine if MTB existed in the sample, a new detection method of MTB using nanotechnology was established. The optimal detection concentration and reaction time of immunomagnetic beads and quantum dots were investigated, and the detection limit and specificity of this detection method were evaluated by using bacterial suspension and simulation sputum samples. RESULTS: By fluorescence microscopy examination, it was found that conjugated immunomagnetic beads and functionalized fluorescent quantum dots both bound with H37Rv and formed the ternary complex structure. The fluorescent value ratio of the experimental group and the control group could be 4:1. The best detection concentration of immunomagnetic beads and functionalized fluorescent quantum dots was 100 mg/L and the optimal incubation time was 2 h. The detection limit of H37Rv bacterial suspension and simulation sputum sample were both 10(3) CFU/ml. The detection results for 3 non-mycobacteria were all negative, while for the 12 types of NTM, only Mycobacterium parafortuitum, Mycobacterium aurum, Mycobacterium smegmatis and Mycobacterium fortuitum were positive, and others were all negative. CONCLUSION: The detection method of immunomagnetic beads combined with fluorescence quantum dots can be a new detection method for MTB, but the clinical value needs to be evaluated further.

Epidemiology of subarachnoid hemorrhage, patterns of management, and outcomes in China: a hospital-based multicenter prospective study.

AIMS: To conduct a large-scale analysis on epidemiology, management, and outcomes of spontaneous subarachnoid hemorrhage (SAH), and to investigate the current situation of aneurysm obliteration in China. METHODS: A multicenter prospective cohort study involving 132 hospitals throughout China from September 2007 to August 2008 was conducted. A total of 651 patients with spontaneous SAH were evaluated. RESULTS: The most frequent type of SAH was aneurysmal SAH (77.4%), followed by uncommon causes (17.5%) and uncertain etiologies (5.1%). For aneurysmal SAH, the cumulative mortality at 28 days, 3 months, 6 months, and 12 months was 16.9%, 21.2%, 23.6%, and 24.6%, respectively. Obliteration of aneurysms, age, Hunt and Hess grade, and history of stroke affected the 12-month mortality. In multiple regression analysis, the region, type of hospital, patient's age, history of hypertension, and nonintraventricular hemorrhage impacted aneurysm obliteration. CONCLUSION: Aneurysmal rupture is the most common cause of spontaneous SAH in China. The percentage of aneurysm obliteration is still low in China that seems to contribute to long-term mortality. With continued training of specialists, proper allocation of healthcare resources, and establishment of stroke centers, the rate of securing aneurysms is expected to rise.

Antithrombotic management of ischaemic stroke and transient ischaemic attack in China: a consecutive cross-sectional survey.

1. Little is known about the prevention of secondary stroke in China. In the present study, we assessed the status of antithrombotic management of stroke patients in clinics across China. 2. A cross-sectional survey was conducted in 19 urban neurological clinics. All subjects diagnosed with ischaemic stroke (IS) or transient ischaemic attack (TIA) were enrolled consecutively in the study. Face-to-face interviews were conducted by research assistants using questionnaires on the day of enrollment. The data recorded included demographic and clinical characteristics, medication and reasons for not using medication. Independent predictors for the prescription of antiplatelet drugs were determined using multivariate logistic regression models. 3. Of the 2283 patients with IS or TIA enrolled in the study (34.7% women; mean ( +/- SD) age 65.8 +/- 11.6 years), 1719 (75.3%) had a prescription for antiplatelet therapy. Of the 108 patients with atrial fibrillation, only 14 (13.0%) were receiving warfarin therapy. The main independent factors significantly associated with being on antiplatelet therapy were having basic health insurance (odds ratio (OR) 1.47; 95% confidence interval (CI) 1.09-1.99), government insurance and labour insurance (OR 1.63; 95% CI 1.03-2.59) and a monthly income of > 500 yuan (US$66.70; OR 2.14; 95% CI 1.51-3.03). Being older (OR 0.70; 95% CI 0.50-0.99) and having a severe disability (OR 0.68; 95% CI 0.49-0.97) were associated with lower odds of receiving antiplatelet therapy. 4. Based on the survey results, adherence to guidelines for antithrombotic management in neurological clinics in China is poor. The main reasons contributing to the less than optimal management of stroke patients include negative attitudes among neurologists, a lack of medical insurance, a lower income and being elderly and/or severely disabled.

[A survey of neurological medical care resources in grade II suburban and urban hospitals in Beijing].

OBJECTIVE: To survey the current availability of expertise in diagnosis and treatment of neurological diseases in grade II hospitals (primary hospitals) in Beijing. METHODS: Observation, personal in-depth interview and structured questionnaire methods were conducted to survey the status of neurology health care system. RESULTS: From June to August 2005, 66 grade II suburban and urban hospitals in Beijing of China were investigated. There were 66 grade II hospitals in Beijing (suburban 34; urban 32). Cerebrovascular disease was the most common disease. Accounting for 84% of the hospitalized cases in inpatients neurology departments. In urban areas, the proportion of grade II and grade III hospitals (referral hospitals) was 58:60, but in suburban and rural areas, the proportion was 48:6. In suburban and rural areas. Only 64.7% of the hospitals could provide urokinase treatment, 26.5% could provide recombinant tissue plasminogen activator (rt-PA) treatment and 58.8% had standardized operation protocol. CONCLUSIONS: The grade II hospitals in suburban areas have heavy grave responsibility to deal with cerebrovascular disease, but these hospitals are in lack of specialists, diagnostic equipment and stroke treatment protocols and could not satisfy the medical demand. It is suggested that in the grade II hospitals in suburban areas of Beijing, strengthening personnel training, establishing primary stroke center and setting up telestroke emergency care systems are urgently needed.

Burden of stroke in China.

Stroke is second leading cause of death in China, however, there are very few data available in the English literature to reflect the burden. We summarize the current epidemiological trends and estimate of the burden of stroke in recent reports available in Chinese.