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Age and Ageing Advance Access originally published online on October 25, 2007
Age and Ageing 2008 37(1):90-95; doi:10.1093/ageing/afm134
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Older patients with acute stroke in Denmark: quality of care and short-term mortality. A nationwide follow-up study

Kaare Dyre Palnum1,, Palle Petersen2, Henrik Toft Sørensen1, Anette Ingeman3, Jan Mainz3, Paul Bartels3 and Søren Paaske Johnsen1

1 Department of Clinical Epidemiology, Aarhus University Hospital, Ole Worms Allé 1150, 8000 Aarhus C, Denmark
2 Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
3 The Coordinating Secretariat (NIP), County of Aarhus, Lyseng Allé 1, 8270 Hojbjerg, Denmark

Address correspondence to: Kaare Dyre Palnum. Tel: +45 8942 4808; Fax: +45 8942 4801. Email: kdp{at}dce.au.dk


   Abstract
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 Abstract
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Background and purpose: age may predict level of care and subsequent outcome among patients with stroke. We examined fulfilment of quality-of-care criteria according to age and the possible impact of any age-related differences on short-term mortality in a population-based nationwide follow-up study in Denmark.

Methods: we identified 29,549 patients admitted with stroke between January 2003 and October 2005 in the Danish National Indicator Project (DNIP). Data on 30- and 90-day mortality were obtained from the Civil Registration System. We compared proportions of patients receiving adequate care across age groups, as measured by admission to a specialised stroke unit, administration of antiplatelet or anticoagulant therapy, examination with CT/MR scan, assessment by a physiotherapist and an occupational therapist, or assessment of nutritional risk. Further, we estimated 30- and 90-day mortality rate ratios (MRRs) across age groups, adjusted for fulfilment of quality-of-care criteria and patient characteristics.

Results: the proportion of eligible patients who received adequate care declined with age for all the examined processes. The relative risk (RR) of receiving specific components of care ranged from 0.66 (95% confidence interval (CI): 0.60–0.73) to 0.97 (95% CI: 0.95–0.99) when comparing patients >80 years of age with patients ≤65 years of age. Although mortality increased with age, adjusting for the age-related differences in care did not alter the magnitude of the increase.

Conclusions: elderly stroke patients in Denmark receive a lower quality of care than do younger stroke patients, however, the age-related differences are modest for most examined quality-of-care criteria and do not appear to explain the higher mortality among older patients.

Keywords: quality of care, prognosis, elderly, stroke


   Introduction
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Advanced age is associated not only with primary stroke but also with increased mortality and a reduced functional status after the stroke [1–3]. There have been few attempts to clarify the association between the age, quality of care and outcomes of stroke, but studies have reported age-related differences in care. Older patients, typically starting from age 65 years, seem to receive fewer relevant evidence-based diagnostic examinations and less care [4, 5] than do younger patients. Uncertainty remains, however, about the magnitude and implications for the outcomes of stroke of these possible age-related differences. The existing studies were based on selected patient populations, lacked detailed data on diagnosis and care (in particular, the timing of specific interventions), and had incomplete follow-up. Furthermore, these studies have not examined to which extent the possible differences in the quality of care could explain the higher mortality among older patients with stroke.

We aimed to explore whether age-related differences in care occur, and, if so, to assess whether they affect short-term mortality. We, therefore, examined the quality of care and mortality according to age in a nationwide population-based follow-up study of Danish patients with stroke.


   Methods
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The Danish National Indicator Project (DNIP)
The Danish National Health Service provides tax-supported health care to the country's 5 million residents, all of whom have free access to hospital care. The Danish National Indicator Project (DNIP) is a nationwide initiative to monitor and improve the quality of care for specific diseases, including stroke [6]. The project does this by focusing on the development and implementation of evidence-based indicators related to the structure, process and outcome of health care and, subsequently, by monitoring the fulfilment of these indicators. Participation in the project is mandatory for all hospital departments treating patients with stroke.

Study population
We identified all admissions with acute stroke registered in DNIP from 13 January 2003 to 1 November 2005 (n = 31,157). All patients (≥18 years of age) admitted to Danish hospitals with acute stroke according to the WHO criteria (i.e. rapidly developed clinical signs of focal or global disturbance of cerebral function, lasting more than 24 h or until death, with no apparent non-vascular cause [7]) are eligible for inclusion in DNIP. Patients with subdural hematoma, epidural or subarachnoidal hemorrhage, retinal infarct, and infarct caused by trauma, infection, surgery or an intracerebral malign process are not included. For this study, we only included the first stroke event registered during the study period. Furthermore, only patients with a valid civil registry number (a unique personal identification number allowing unambiguous linkage between various public registers) residing in Denmark, and therefore, eligible for follow-up were included. A total of 29,549 patients (94.8% of the original patient population) were included.

Quality-of-care criteria
A national expert panel including physicians, nurses, physiotherapists and occupational therapists identified seven quality-of-care criteria covering the acute phase of stroke based on systematic search of the scientific literature [6]: admission to a specialised stroke unit, antiplatelet therapy initiated among patients with ischemic stroke without atrial fibrillation, oral anticoagulant therapy initiated among patients with ischemic stroke and atrial fibrillation, examination with CT/MRI scan, assessment by a physiotherapist, assessment by an occupational therapist and assessment of nutritional risk. A time frame was defined for each criterion to capture the timeliness of the interventions. The time frame was the second day of hospitalisation for all criteria, except initiation of oral anticoagulant therapy where the time frame was the 14th day of hospitalisation.

Assessment by a physiotherapist and occupational therapist was defined as a formal bedside assessment of the patient's need for rehabilitation, whereas assessment of nutritional risk was defined as an assessment following the recommendations of the European Society for Parenteral and Enteral Nutrition, i.e. calculation of a score which both accounts for the nutritional status and for the stress induced by the stroke [8].

Upon hospital admission, data on care, and prognostic factors for short-term mortality were collected for each patient using a standardised form. After hospital discharge the data were entered into a central database. Patients were classified as eligible or non-eligible for the specific processes of care depending on whether the stroke team or physician treating the patient identified contraindications, e.g. severe dementia in a patient with ischemic stroke and atrial fibrillation precluding oral anticoagulant therapy, or rapid spontaneous recovery of motor symptoms making early assessment by a physiotherapist and occupational therapist irrelevant.

Thus, it was left to the staff to decide whether or not contraindications to the specific criteria were present.

Prognostic factors for short-term mortality
Data on prognostic factors included age, sex, marital status (living with partner, family or friend, living alone), housing (own home, nursing home or other form of institution), Scandinavian Stroke Scale score, history of stroke or myocardial infarction, previous and/or current atrial fibrillation, hypertension, diabetes mellitus or intermittant claudication, smoking habits (smoker, ex-smoker, never), and alcohol intake (≤14/21, >14/21 drinks per week for women and men, respectively).

Statistical analysis
First we calculated, in each age group, proportions of patients receiving adequate care, as defined by fulfilment of the quality-of-care criteria. The age groups were defined to allow for comparison with the existing studies. The proportions were compared using patients aged ≤65 years of age as reference, and relative risks (RRs) were computed for each age group. Secondly, we computed 30- and 90-day mortality rates according to age. We used Cox's proportional hazards regression to obtain mortality rate ratios (MRRs) for time to death within 30 or 90 days after stroke, according to age, while adjusting for potential confounders of the association between age and mortality i.e. fulfilment of quality-of-care criteria and prognostic factors. Follow-up time started on the date of hospital admission for stroke and ended on date of death, emigration, or after 30 (or 90) days, whichever came first. We first computed the MRRs according to age, while adjusting for fulfilment of each of the quality-of-care criteria and prognostic factors. In order to include all of the quality-of-care criteria in the same analysis, we then restricted the analysis to patients without contraindications to any of the quality-of-care criteria. As the criteria on antiplatelet and oral anticoagulant therapy were mutually exclusive, we combined these two indicators into a combined criterion (antiplatelet or anticoagulant therapy) in the latter analysis.

We analysed data using STATA version 9.0 (StataCorp, College Station, Texas, USA).


   Results
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Table 1 shows characteristics of the 29,549 patients according to age groups. Increasing age was associated with a more adverse prognostic profile, including atrial fibrillation, previous myocardial infarction and stroke; likewise, the proportion of patients with severe stroke increased with age.


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  		Table 1. Descriptive characteristics of 29,549 patients with acute stroke registered in the Danish National Indicator Project, 2003–2005

 
Fulfilment of quality-of-care criteria
Table 2 displays, according to age, the proportions of patients which fulfilled the quality-of-care criteria. The varying number of patients included in the analysis of the specific criteria reflect that a varying proportion of the patients was eligible for the individual criteria, e.g. in 6,141 out of 8,580 patients aged 65 years or younger platelet inhibitor therapy was considered to be indicated as the patients had an ischemic or unspecified stroke and no contraindications for platelet inhibitory therapy, and of these, 4,719 received the treatment within 2 days after hospitalisation. The proportion of eligible patients who fulfilled the quality-of-care criteria declined with age for all the examined processes. The oldest patients (>80 years) were in all analyses least likely to fulfil the quality-of-care criteria. In this age group, the RR for receiving specific components of care ranged from 0.66 (95% CI: 0.60–0.73) to 0.97 (95% CI: 0.95–0.99) when compared with patients aged ≤65 years of age. However, the RR remained above 0.90 for all quality-of-care criteria except for treatment with oral anticoagulants (0.66 (95% CI: 0.60–0.73)) and early assessment of nutritional risk (0.78 (95% CI: 0.76–0.82)), respectively.


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  		Table 2. Fulfilment of quality-of-care criteria according to age

 
A total of 12,744 patients were found eligible for all quality-of-care criteria, e.g. the patients had no contraindications to any of the processes of care. Age-related differences in care were also found in this subgroup, i.e. 23.7, 21.4 and 16.5% of patients aged ≤65, >65–80 and >80 years of age, respectively, fulfilled all the quality-of-care criteria.

30 and 90-day cumulative mortality
Mortality increased with age: the cumulative 30-day mortality was 5.3, 9.7 and 19.4% among patients aged ≤65, >65–80 and >80 years of age, respectively. As expected, we found a reduction of the MRRs after adjustment for a wide range of prognostic factors, including socio-demographic and clinical characteristics (Table 3). However, further adjustment for age-related differences in fulfilment of the examined quality-of-care criteria had no or only a minor effect on the age-related differences in mortality. Conducting these analyses for the outcome of 90-day mortality produced the same pattern (data not shown).


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  		Table 3. Mortality rate ratios (MRR) during 30 days, according to age. Adjusted for fulfilment of quality-of-care criteria and prognostic factors

 
Among the 12,744 patients who were eligible for all quality-of-care criteria, the age-related differences in both 30- and 90-day mortality were also present and likewise remained unaltered by accounting for the age-related differences in fulfilment of the quality-of-care criteria: the MMRs for 30 days changed from 1.70 (1.26–2.31) to 1.70 (1.25–2.31) and 2.89 (2.10–3.97) to 2.82 (2.06–3.88) for patients aged >65–80 and >80 years of age, respectively.


   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
Key points
 Conflicts of interest...
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In this large nationwide follow-up study, we found an inverse association between age and quality of care. However, the age-related differences in quality of care were substantial only for two quality-of-care criteria—oral anticoagulant therapy and early evaluation of nutritional status—and they did not appear to explain age-related differences in mortality.

The main strength of our study is its prospective population-based design, complete long-term follow-up, negligible selection bias and low risk of information bias. Further, our analyses were based on a large cohort, with detailed data on a range of specific processes of care; only patients without contraindications for the specific processes of care were included in the analyses. Furthermore, while examining mortality, we reduced confounding by adjusting for a wide range of prognostic factors.

Use of data collected in a non-standardised setting during routine clinical work is a limitation of this study, potentially affecting accuracy of collected data. At the same time, participation in DNIP is mandatory for all departments treating patients with acute stroke in Denmark, and extensive efforts are made to ensure the validity of DNIP [6]. In particular, a regular structured audit is conducted nationally, regionally and locally, and includes validation of the completeness of patient registration against county hospital discharge registries. Furthermore, any misclassification of data on care in DNIP is unlikely to depend on age and thus, if present, would lessen our ability to detect age-related differences in quality of care and result in conservative RR estimates.

Although we adjusted for a wide range of prognostic factors, we cannot entirely exclude the possibility that our results may still be influenced by residual confounding due to the use of crude variables (e.g. data on levels of hypertension were not available) or unaccounted confounding from factors not included in the analyses (e.g. mental function). The prevalence of patients with missing data on the prognostic factors ranged between 5 and 30% for the variables considered. Although missing data should always be a reason for concern, we have no reason to believe that this had any substantial influence on our findings, which remained virtually unchanged whether or not patients with missing data were included in the analyses.

We used mortality as the clinical end-point. Despite its obvious importance, mortality is certainly not the only end-point relevant for patients with stroke. Examination of the possible effect of age-related differences in quality of care on other end-points, e.g. functional level after discharge would of course also be highly relevant. Unfortunately, such data were not available in our study.

Our findings are in accordance with those from other studies [4, 5, 9]. In a joint European study, Bhalla et al. found a less intensive effort for diagnosis, care and rehabilitation of patients aged ≥75 years compared with patients aged <75 years, as manifested by lower proportions of them examined with CT scan (87 versus 79%) or echocardiography (34 versus 17%), a lesser physio- and ergotherapeutical effort, and lower rates of transfer to rehabilitation ward upon discharge [4]. In another prospective joint European study on 4,499 patients with stroke from 12 specialised centres, Di Carlo et al. found that brain imaging and other diagnostic tools were less frequently utilised in the older patients, whereby merely 66.9% of older patients received brain imaging compared with 87.7% of younger patients. Recently, Fairhead and Rothwell reported a lower use of carotid imaging and carotid endarterectomy in routine clinical practice in patients aged ≥ 80 years of age with transient ischaemic attack or ischaemic stroke [9].

The 30-day mortality found in our study is consistent with the findings of Di Carlo et al., who found a 28-day mortality of 10.0% among patients <80 years of age compared with 20.8% among patients ≥80 years of age. However, to our knowledge, no existing study has investigated whether this difference in mortality could be explained by the age-related differences in quality of care. Taking these differences into account had very little impact on the MMRs in our study, indicating that the differences in the examined processes of care are not major contributors to the higher mortality among the elderly.

Age-related differences in the quality of care have also been reported within other medical specialities [10–15]. The phenomenon is commonly referred to as ‘ageism’. A central aspect in the struggle against ageism is to get a clearer picture of the scope and consequences of age-related differential treatment. In this context, it is important to be aware that in some situations there are good ethical and clinical reasons for treating elderly patients different, e.g. severe comorbidity or inability to comply with the recommended treatment. It is essential that studies of age-related differences take these aspects into account, in order to avoid overestimating or misinterpreting the observed differences thus hindering the effort of effective elimination of true ageism.

In conclusion, we found that elderly stroke patients in Denmark, in particular those older than 80 years of age, receive a poorer quality of care than do younger patients. The largest age-related differences were found for early anticoagulant therapy and early assessment of nutritional risk. However, the differences in the quality of care were not substantial for most of the examined processes. The rather small age-related differences found in the examined processes of care did not appear to explain the higher mortality among the elderly. Continuous efforts are warranted in order to ensure patients with stroke optimal care irrespective of age.


   Key points
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
Conflicts of interest...
 Funding
 References
 

  • Elderly patients with stroke in Denmark, in particular, those over the age of 80 years of age, receive a lower quality of care than do younger patients.
  • The age-related differences were minor for most examined processes of care except for early anticoagulant therapy and early assessment of nutritional risk.
  • Age-related differences of the examined processes of care did not appear to explain the higher mortality among elderly stroke patients.


   Conflicts of interest disclosures
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 Methods
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 Conflicts of interest...
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None


   Funding
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 Abstract
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 Methods
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 Discussion
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 Conflicts of interest...
 Funding
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Supported by grants from the Foundation for Research in Neurology and The Aarhus University Research Foundation.


   References
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  1. Warlow C. Stroke a Practical Guide to Management (2001) 2nd edition. Oxford: Blackwell Science.
  2. Stevens A. Health Care needs Assessment the Epidemiologically Based Needs Assessment Reviews (2004) 2nd edition. Oxford: Radcliffe.
  3. Kwakkel G, Wagenaar RC, Kollen BJ, et al. Predicting disability in stroke–a critical review of the literature. Age Ageing (1996) 25:479–89.[Abstract/Free Full Text]
  4. Bhalla A, Grieve R, Tilling K, et al. Older stroke patients in Europe: stroke care and determinants of outcome. Age Ageing (2004) 33:618–24.[Abstract/Free Full Text]
  5. Di CA, Lamassa M, Pracucci G, et al. Stroke in the very old: clinical presentation and determinants of 3-month functional outcome: A European perspective. European BIOMED Study of Stroke Care Group. Stroke (1999) 30:2313–9.[Abstract/Free Full Text]
  6. Mainz J, Krog BR, Bjornshave B, et al. Nationwide continuous quality improvement using clinical indicators: The Danish National Indicator Project. Int J Qual Health Care (2004) 16(Suppl. 1):i45–50.[Abstract]
  7. The World Health Organization. MONICA project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol (1988) 41:105–14.[CrossRef][Web of Science][Medline]
  8. Kondrup J, Allison SP, Elia M, et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr (2003) 22:415–21.[CrossRef][Web of Science][Medline]
  9. Fairhead JF, Rothwell PM. Underinvestigation and undertreatment of carotid disease in elderly patients with transient ischaemic attack and stroke: comparative population based study. BMJ (2006) 333:525–7.[Abstract/Free Full Text]
  10. Peake MD, Thompson S, Lowe D, et al. Ageism in the management of lung cancer. Age Ageing (2003) 32:171–7.[Abstract/Free Full Text]
  11. Regueiro CR, Gill N, Hart A, et al. Primary angioplasty in acute myocardial infarction: does age or race matter? J Thromb Thrombolysis (2003) 15:119–23.[CrossRef][Web of Science][Medline]
  12. Bond M, Bowling A, McKee D, et al. Does ageism affect the management of ischaemic heart disease? J Health Serv Res Policy (2003) 8:40–7.[CrossRef][Medline]
  13. Woodard S, Nadella PC, Kotur L, et al. Older women with breast carcinoma are less likely to receive adjuvant chemotherapy: evidence of possible age bias? Cancer (2003) 98:1141–9.[CrossRef][Web of Science][Medline]
  14. Jerant AF, Franks P, Jackson JE, et al. Age-related disparities in cancer screening: analysis of 2001 behavioral risk factor surveillance system data. Ann Fam Med (2004) 2:481–7.[Abstract/Free Full Text]
  15. O'Connell JB, Maggard MA, Ko CY. Cancer-directed surgery for localized disease: decreased use in the elderly. Ann Surg Oncol (2004) 11:962–9.[CrossRef][Web of Science][Medline]
Received 30 November 2006; accepted in revised form 26 July 2007.


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