Mortality rates following a stroke or heart attack allow us to better understand the quality of acute care services provided for these two common conditions. We look at 30-day mortality rates after admission to hospital for ischaemic stroke, hemorrhagic stroke and acute myocardial infarction (AMI).
In the UK, ischaemic heart disease is the top cause of premature death and cerebrovascular disease is the third most common cause (Institute for Health Metrics and Evaluation, 2016). 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 can be 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. In the UK, 30-day mortality after admission to hospital for ischaemic stroke (based on linked data) decreased rapidly from 17.1 per 100 patients in 2008 to 10.8 per 100 patients in 2013, but rates subsequently plateaued and still remain higher than most of the comparator countries. In 2015, Sweden's 30-day mortality rate for ischaemic stroke was the lowest at 7.7 per 100 patients and New Zealand's mortality rate was the highest at 12.2 per 100 patients.
In the UK, the rate of 30-day mortality after admission to hospital for haemorrhagic stroke (based on linked data) decreased from 35.6 per 100 patients in 2008 to 28.5 per 100 patients in 2013, afterwhich rates plateaued at a level that was relatively high compared to other OECD countries. In 2015, the UK's mortality rate for haemorrhagic stroke was lower than that of Denmark (33.3 per 100 patients) and New Zealand (31.6 per 100 patients) but higher than that of Canada (27.3 per 100 patients), Spain (26.2 per 100 patients), and Finland (19.7 per 100 patients).
Though the decline in the mortality rate shown in the graphs is positive it is 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, 2013). 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.
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 2015, 30-day mortality after admission to hospital for AMI (based on linked data) in the UK decreased from 12.1 per 100 patients to 8.8 per 100 patients.
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.
About this data
Definitions and comparability for the indicators are taken directly from the OECD report Health at a Glance 2017: OECD indicators. Detailed information about the definitions and the source and methods for each country can be found here.
The case-fatality rate measures the percentage of people aged 45 and over who die within 30 days following admission to hospital for a specific acute condition. Rates based on unlinked data refer to a situation where the death occurred in the same hospital as the initial admission. Rates based on linked data refer to a situation where the death occurred in the same hospital, a different hospital, or out of hospital. While the linked data based method is considered more robust, it requires a unique patient identifier to link the data across the relevant datasets which is not available in all countries.
Rates are age-sex standardised to the 2010 OECD population aged 45+ admitted to hospital for a specific acute condition such as AMI and ischaemic stroke.