Background

Comprehensive administrative data on TIA và stroke cases and treatment modalities are fundamental for improving structural conditions and adjusting future strategies of stroke care.

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Methods

The nationwide administrative database (German federal statistical office) was used khổng lồ extract all adult inpatient TIA and stroke cases và corresponding procedural codes for the period 2011–2017. Numbers were specified according lớn age, sex, stroke unit (SU) & critical care treatment (ICU), early transfer, và in-hospital mortality.

Findings

Inpatient adult TIA/stroke cases increased from annually 102,406 / 250,199 (2011) khổng lồ 106,245 / 264,208 (2017). 84% of strokes were ischemic (AIS) also having the highest relative increase most likely due to more accurate coding within the time period, 68.2% of AIS were treated on SUs. 78% of hemorrhagic strokes were intracerebral hematomas (ICH; rather than subarachnoid hemorrhages ). Hemorrhagic strokes were increasingly treated on SUs (32.6% <2011>, 37.8% <2017>). 68.8% of SAH were treated on ICUs (ICH:36.3%, AIS:10.3%). Early transfer in AIS increased (2.0 to 3.1%). Hemorrhagic strokes were associated with higher in-hospital mortality (SAH:19.6%, ICH:28.2%, AIS:7.3%).

Interpretation

The absolute increase of strokes presumably reflects the aging society và more awareness for cerebrovascular disease. The relative increase of AIS may be attributable to lớn an increased neurological expertise. The increasing amount of early transfers in AIS reflects new specialized treatment options. Our findings reflect the need for structural adjustments in inpatient stroke care.


Key messages


1.

The numbers of treated adult TIA and strokes cases in German hospitals has further increased in the observed time period 2011–2017. The proportion of hemorrhagic lớn ischemic stroke has not changed.

2.

The rate of treatment on specialized wards like strokes units (SU) & intensive care units (ICU) has further increased for both ischemic and hemorrhagic stroke.

3.

Hemorrhagic strokes are more frequently treated on ICUs, whereas cerebral infarctions and TIAs are more often treated on SUs. Hemorrhagic strokes are associated with higher in-hospital mortality.

4.

For AIS, early transfer, e.g., to specialized neuro-vascular centers providing mechanical thrombectomy has increased in the time period.

5.

The analysis of timely evolution of administrative data is important for future adjustments of infrastructure for inpatient stroke care.


Introduction


The Global Burden of Disease Study recently provided data on global, regional & country-specific epidemiological data of stroke <1,2,3,4>. Lượt thích in many other epidemiological analyses, insight in stroke epidemiology mostly relies on population-based, regionally limited, observational cohort or hospital-based registries, all of which bare specific constraints <5,6,7>. Due lớn the necessity to code both diagnoses and treatment procedures for reimbursement, the German DRG registry provides accurate và comprehensive data not only on all inpatient ischemic stroke / TIA cases & treatment modalities in German hospitals <8>. Analysis of all hospitalized stroke cases can provide new insights into evolving trends of both ischemic and hemorrhagic stroke subtypes in everyday practice. Therefore, data from the German federal statistical office of all adult stroke patients hospitalized from 2011 to 2017 were used lớn identify frequencies of all inpatient stroke subtypes as well as treatment modalities on specialized wards. In addition, age- and sex-related differences, early transfer rates & in-hospital mortality rates were evaluated.


Methods


Analyses were based upon the latest German Diagnosis-Related Groups (G-DRG) data provided by the German federal statistical office (DRG-statistic, www.destatis.de) for the years 2011 to lớn 2017. All in-patient stroke cases are encoded according khổng lồ ICD-10-GMFootnote 1 & relevant operating and procedure keys (OPS-301 codes) issued by the German Institute of Medical Documentation và Information (DIMDI). Here, the following ICD main diagnosis codes were considered: G45.0-G45.99 (transient ischemic attack, TIA); I60.0-I60.9 (subarachnoid hemorrhage, SAH); I61.0-I61.9 (intracerebral hemorrhage, ICH); I63.0-I63.9 (cerebral infarction, AIS); I64 (stroke, not specified as hemorrhage or infarction). All case numbers were aggregated at the level of the 3-digit ICD codes. The age-standardized rates were calculated using the standard population of Germany based on the census of 2011 (Federal Statistical Office: Statistics on Natural Population Movement) <9>. In addition, the following OPS codes in combination with each considered main diagnosis were analyzed for all stroke subtypesFootnote 2: 8–980 (basic intensive-care treatment); 8-98f (complex intensive-care treatment; from 2013 onwards); 8–981.0 (stroke unit treatment for more than 24 h và less than 72 h); 8–981.1 (stroke unit treatment for more than 72 h); 8-98b.*0/*1 (other acute stroke treatment without / with tele-consultation). For some analyses, OPS 8–980 và 8-98f were combined, as were the 3 subtypes of Stroke Unit care. Both first-ever và recurrent stroke cases were included, because the coding system cannot differentiate between them. Likewise, recurrent cerebrovascular events during hospital stay could not be analysed because these events are not coded consistently as a separate secondary diagnosis. Patients being transferred between hospitals during one treatment episode, (discharge key 06; transfer to another hospital), were censored accordingly in order to lớn avoid any possible double/multiple coding. In addition, we assessed the number of acute stroke patients being transferred from one hospital khổng lồ the other in the hyperacute phase for specific therapies such as mechanical thrombectomy, neurosurgical operations or intensive care treatment (so-called “hourly cases”). In-hospital mortality was assessed using discharge key 07 (death during hospital stay). For TIA và stroke subtypes, mean age with standard deviation, sex, and in-hospital mortality rate are provided. Only adult patients were considered.Footnote 3 The maps of the regional frequency of ICH và AIS in Germany are based on the 413 administrative districts & independent cities in 2017. The age standardized rates are calculated for each district / city.

The pre-specified primary hypotheses were as follows:

1.

The number of TIA and stroke cases (SAH, ICH, AIS, và non-specified stroke) treated in German hospitals has increased from 2011 lớn 2017.

2.

The proportion of AIS vs. Hemorrhagic strokes (SAH, ICH) has remained constant in the observed time period.

3.

Hemorrhagic strokes are more frequently treated on intensive care units (ICU), whereas cerebral infarctions and TIAs are more often treated on strokes units (SU).

4.

Hemorrhagic strokes are associated with higher in-hospital mortality.

5.

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For AIS, early transfer khổng lồ specialized neuro-vascular centers providing mechanical thrombectomy has increased.

For descriptive analyses, results are reported as absolute numbers & percentages. Age bracketing of results (20–44, 45–59, 60–69, 70–79, 80–89, ≥90 years of age) was determined before analysis. Statistical comparison of groups was performed with Chi-square-test and Yates´ correction. Taking into account multiple testing & the very high number of cases, only p-values of
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