PAPER

¹ Institute of Neuroscience, University of Nottingham, Nottingham, UK
² Leo Pharma A/S, Ballerup, Denmark
³ Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
⁴ Department of Neurology, University of Antwerp, Antwerp, Belgium
⁵ Vest-Agder Sentralsykehus, Kristiansand, Norway
⁶ Clinique Neurologique, CHRU de Lille, Lille, France
⁷ Department of Neurology, Turku University Central Hospital, Turku, Finland
⁸ Institute for Neurology, Universitetssjukhuset, Linköping, Sweden
⁹ Department of Age Related Health Care, Adelaide and Meath Hospital, Dublin, Ireland
¹⁰ Neurology Clinic, Universität Münster, Münster, Germany
¹¹ Slotervaartziekenhuis, Amsterdam, Netherlands
¹² Hamilton General Hospital, Hamilton, Canada

Correspondence to:
Professor Philip Bath
Division of Stroke Medicine, University of Nottingham, D Floor, South Block, Queen’s Medical Centre, Nottingham NG7 2UH, UK; philip.bath{at}nottingham.ac.uk

Background: The medical care of patients with acute stroke varies considerably between countries. This could lead to measurable differences in mortality and functional outcome.

Objective: To compare case mix, clinical management, and functional outcome in stroke between 11 countries.

Methods: All 1484 patients from 11 countries who were enrolled into the tinzaparin in acute ischaemic stroke trial (TAIST) were included in this substudy. Information collected prospectively on demographics, risk factors, clinical features, measures of service quality (for example, admission to a stroke unit), and outcome were assessed. Outcomes were adjusted for treatment assignment, case mix, and service relative to the British Isles.

Results: Differences in case mix (mostly minor) and clinical service (many of prognostic relevance) were present between the countries. Significant differences in outcome were present between the countries. When assessed by geographical region, death or dependency were lower in North America (odds ratio (OR) adjusted for treatment group only = 0.52 (95% confidence interval, 0.39 to 0.71) and north west Europe (OR = 0.54 (0.37 to 0.78)) relative to the British Isles; similar reductions were found when adjustments were made for 11 case mix variables and five service quality measures. Similarly, case fatality rates were lower in North America (OR = 0.44 (0.30 to 0.66)) and Scandinavia (OR = 0.50 (0.33 to 0.74)) relative to the British Isles, whether crude or adjusted for case mix and service quality.

Conclusions: Both functional outcome and case fatality vary considerably between countries, even when adjusted for prognostic case mix variables and measures of good stroke care. Differing health care systems and the management of patients with acute stroke may contribute to these findings.

Keywords: case mix; country; outcome; service quality; stroke

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