International comparisons of stroke and AMI mortality

Mortality rates following a stroke or acute myocardial infarction (AMI) allow us to better understand the quality of acute care services provided for these two common conditions. We look at same-hospital mortality, as well as in- and out-of-hospital mortality, a more robust indicator which captures deaths more widely. 

How does the UK's ischaemic stroke mortality rate compare internationally over time?

In the UK, cardiovascular and circulatory diseases represent the second highest burden of disease (28.8% of total years of life lost) after cancer (Institute for Health Metrics and Evaluation, 2013). Ischaemic heart disease represents 15.9% of years of life lost and 6.8% is due to cerebrovascular diseases (of which 3% is due to haemorrhagic and other non-ischaemic stroke and 3.8% is due to ischaemic stroke) (Institute for Health Metrics and Evaluation, 2013). The majority of strokes in England are ischaemic – that is, where a clot blocks blood flow to part of the brain; haemorrhagic strokes happen when a blood vessel bursts and bleeds into the brain. (NHS Choices)

Mortality rates, which are used as a proxy for the quality of acute care, have been stable or declining over time in most of the countries included in the chart. For ischaemic stroke, patient-based 30-day in-hospital and out-of-hospital mortality rates have been declining rapidly in the UK (they fell from 17 per 100 patients in 2008 to 11 per 100 patients in 2013) but still remain above most of the comparator countries (New Zealand’s rate was also 11 per 100 patients in 2013). Korea has the lowest rate of all the OECD countries with 5 deaths per 100. According to the data for admission-based ischaemic stroke, 30-day in-hospital mortality has also been declining in the UK and there were 9.2 deaths per 100 hospital discharges in 2013. Japan has the lowest rate of all the OECD countries.

Updated January 2017.

How does the UK's haemorrhagic stroke mortality rate compare internationally over time?

The rate of 30-day mortality after admission to hospital for haemorrhagic stroke (based on patient data) in the UK declined between 2008 (35.2 per 1,000) and 2013 (28.3 per 1,000). In 2013 the rate in the UK was lower than that of New Zealand (32 per 1,000) but higher than Korea (17.4 per 1,000), Sweden (23.3 per 1,000) and Spain (25.9 per 1,000).

The 30-day mortality rate (based on admissions data) demonstrates a similar trend to the data discussed above, with the rate declining in the UK and other countries. In 2013 the rate in the UK (26.5 per 1,000) was relatively high compared to the other countries in the graph.

Though the decline in the mortality rate shown in the graphs is positive it is also important to note that inaccuracies in routine data and differences in stroke care around the world make international comparisons challenging.

In the UK, since the 1990s, the Royal College of Physicians has carried out work to improve quality of care for patients who have had a stroke. Most recently it has set up the Sentinel Stroke National Audit Programme (SSNAP), which aims to improve quality by auditing stroke services against evidence-based standards. Since December 2012, this audit has collected data on a quarterly basis for every stroke patient in England, Wales and Northern Ireland, looking across the entire care pathway – acute care, rehabilitation, six-month follow-up and outcomes. The most recent audit reports highlight that there have been significant improvements in the organisation and provision of stroke care services. However, large unacceptable variations remain and not all patients have access to the same high-quality care (Sentinel Stroke National Audit Programme (SSNAP)). Variations are mainly in staff mix and skills (nurses, care assistants and consultants), access to clinical psychology and social care, stroke specific early supported discharge, organisation of stroke units, CCG involvement in services development and strategic planning. A Cochrane review of evidence suggests that stroke patients who receive organised inpatient care in dedicated stroke units are more likely to be alive and lead an independent life one year after a stroke (Stroke Unit Trialists' Collaboration) .

In addition to these a review by the National Confidential Enquiry into Patient Outcome and Death (2013) on the quality of care received by patients with aneurysmal subarachnoid haemorrhage has provided a range of recommendations for improving the quality of care for haemorrhagic stroke. The report specifically highlights the importance of appropriate education for professionals about clinical presentation, establishing formal networks linking different levels of care, and introducing standard protocols of care at secondary and tertiary level.

Updated January 2017.

How does the UK's acute myocardial infarction mortality rate compare internationally over time?

Similar to strokes, acute myocardial infarctions (AMIs) – or heart attacks – require early diagnosis and fast specialist treatment, together with cardiac rehabilitation in order to reduce the probability of recurrent heart attacks or death, and improve quality of life (National Institute for Cardiovascular Outcomes Research, 2013, 2014).

The figures for 30-day AMI mortality show a declining trend and there is convergence across most of the countries. Between 2008 and 2013, 30-day mortality after admission to hospital for AMI (based on patient data) in the UK declined from 12 per 100 patients in 2008 to 9.1 per 100 in 2013. Thirty-day mortality (based on admission data) in the UK also declined, from 9.4 per 100 in 2008 to 7.6 per 100 in 2013.

While not directly comparable with these OECD AMI indicators, a report from the Myocardial Ischaemia National Audit Project (MINAP) showed there was a decline between 2003–04 and 2011–14 in same-hospital 30-day mortality rates (National Institute for Cardiovascular Outcomes Research, 2014). This finding suggests there have been significant improvements in the care provided to patients who have had a heart attack. However, the same report also expresses reservations about using unadjusted health outcome indicators to measure quality of care and conduct international comparisons of outcomes – due to differences in data collection, definitions and patient characteristics.

Updated January 2017.

About this data

Definitions and comparability for all the indicators discussed in this report are taken directly from the OECD report Health at a Glance 2013: OECD indicators. Detailed information about the definitions and the source and methods for each country can be found here.

Mortality following a stroke

The admission-based case-fatality rate is defined as the number of people aged 45 and over who died within 30 days of being admitted to hospital for ischemic stroke, where the death occurs in the same hospital as the initial stroke admission. The in- and out-of-hospital case-fatality rate is defined as the number of people who die within 30 days of being admitted to hospital with a stroke, where the death may occur in the same hospital, a different hospital or out of hospital. Rates were age-sex standardised to the 2010 OECD population aged 45+ admitted to hospital for stroke. The change in the population structure in this edition of Health at a Glance compared with previous editions (where rates were standardised using the 2005 OECD population of all ages) has led to a general increase in the standardised rates for all countries.

Mortality following acute myocardial infarction (AMI)

The admission-based case-fatality rate following AMI is defined as the number of people aged 45 and over who die within 30 days of being admitted to hospital with an AMI, where the death occurs in the same hospital as the initial AMI admission. The in- and out-of-hospital case-fatality rate is defined as the number of people who die within 30 days of being admitted to hospital with an AMI, where the death may occur in the same hospital, a different hospital, or out of hospital. Rates were age-sex standardised to the 2010 OECD population aged 45+ admitted to hospital for AMI. The change in the population structure in this edition of Health at a Glance compared with previous editions (where rates were standardised using the 2005 OECD population of all ages) has led to a general increase in the standardised rates for all countries.

Admission-based calculation

The unit of counting is a patient admission and does not require unique patient identification and the linking of related admissions. This means each admission is counted for the purposes of calculating indicator rates, regardless of whether a patient has multiple admissions within the specified period or not. Organisation for Economic Co-operation and Development, Definitions for Health Care Quality Indicators

Patient-based calculation

The unit of counting is a patient that can be individually tracked through several admissions and requires unique patient identification and the linking of related admissions within a specified period. Only one patient is counted for the purposes of calculating indicator rates; in the case of multiple admissions during the specified year, the first admission in the year is the one taken as index.Organisation for Economic Co-operation and Development, Definitions for Health Care Quality Indicators

Comments

Love these,but on my phone they could look a lot better if you remove the 20 to 60 range where non-contributory

Dr richard jones (not verified)
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