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  • 1. Appelros, Peter
    et al.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asberg, Signild
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asberg, Kerstin Hulter
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terent, Andreas
    Trends in Stroke Treatment and Outcome between 1995 and 2010: Observations from Riks-Stroke, the Swedish Stroke Register2014In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 37, no 1, p. 22-29Article in journal (Refereed)
    Abstract [en]

    Background: Continuous changes in stroke treatment and care, as well as changes in stroke characteristics, may alter stroke outcome over time. The aim of this paper is to describe time trends for treatment and outcome data, and to discuss if any such changes could be attributed to quality changes in stroke care.

    Methods: Data from Riks-Stroke, the Swedish stroke register, were analyzed for the time period of 1995 through 2010. The total number of patients included was 320,181. The following parameters were included: use of computed tomography (CT), stroke unit care, thrombolysis, medication before and after the stroke, length of stay in hospital, and discharge destination. Three months after stroke, data regarding walking, toileting and dressing ability, as well social situation, were gathered. Survival status after 7, 27 and 90 days was registered. Results: In 1995, 53.9% of stroke patients were treated in stroke units. In 2010 this proportion had increased to 87.5%. Fewer patients were discharged to geriatric or rehabilitation departments in later years (23.6% in 2001 compared with 13.4% in 2010), but more were discharged directly home (44.2 vs. 52.4%) or home with home rehabilitation (0 vs. 10.7%). The need for home help service increased from 18.2% in 1995 to 22.1% in 2010. Regarding prevention, more patients were on warfarin, antihypertensives and statins both before and after the stroke. The functional outcome measures after 3 months did improve from 2001 to 2010. In 2001, 83.8% of patients were walking independently, while 85.6% were independent in 2010. For toileting, independence increased from 81.2 to 84.1%, and for dressing from 78.0 to 80.4%. Case fatality (CF) rates after 3 months increased from 18.7% (2001) to 20.0% (2010). This trend is driven by patients with severe strokes.

    Conclusions: Stroke outcomes may change over a relatively short time period. In some ways, the quality of care has improved. More stroke patients have CT, more patients are treated in stroke units and more have secondary prevention. Patients with milder strokes may have benefited more from these measures than patients with severe strokes. Increased CF rates for patients with severe stroke may be caused by shorter hospital stays, shorter in-hospital rehabilitation periods and lack of suitable care after discharge from hospital. (C) 2013 S. Karger AG, Basel

  • 2. Appelros, Peter
    et al.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asberg, Kerstin Hulter
    Norrving, Bo
    Stegmayr, Birgitta
    Epidemiologic Center, National Board of Health and Welfare, Stockholm.
    Terént, Andreas
    Trends in baseline patient characteristics during the years 1995-2008: observations from Riks-Stroke, the Swedish Stroke Register2010In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 30, no 2, p. 114-119Article in journal (Refereed)
    Abstract [en]

    Many baseline parameters in Riks-Stroke have changed over the years. This has consequences for the interpretation of outcome data. Some changes may be due to inclusion bias, others due to alterations in general health, evolution of vascular risk factors or demographics.

  • 3.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Department of Statistics.
    Effects of Extending the Time Window of Thrombolysis to 4.5 Hours: Observations in the Swedish Stroke Register (Riks-Stroke)2011In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 42, no 9, p. 2492-2497Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: The European Cooperative Acute Stroke Study (ECASS) III trial and Safe Implementation of Thrombolysis in Stroke–International Stroke Thrombolysis Register (SITS-ISTR) data were published in 2008. Riks-Stroke, the Swedish Stroke Register, was used to explore how thrombolysis in the 3- to 4.5-hour window has been spread in different hospitals and patient groups and what effects this has had on treatment within 3 hours.

    Methods: All 76 hospitals in Sweden admitting patients with acute stroke participate in Riks-Stroke. During the study period, January 2003 to June 2010, 92 150 18- to 80-year-old patients were hospitalized for acute ischemic stroke.

    Results: After the publication of the ECASS III results in the third quarter of 2008, thrombolysis in the 3- to 4.5-hour window increased from 0.5% before publication to 2.1% in 2010. Thrombolysis in the 3- to 4.5-hour window spread somewhat faster in men than women (P=0.04) but at a similar rate in different age groups. The use of thrombolysis within 3 hours after onset of symptoms increased successively from 0.9% in 2003 to 6.6% in late 2008 and then it stabilized at 6%. The median time from arrival to the hospital to start of treatment remained unchanged at 66 to 69 minutes before and after 2008 (P=0.06).

    Conclusions: Since the end of 2008, there has been a rapid nationwide dissemination of thrombolysis in the 3- to 4.5-hour window, whereas rates in the <3-hour window have leveled off. The extended time window has not affected door-to-needle time.

  • 4.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Norrving, B.
    Department of Neurology, Skane University Hospital, Lund.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Implementation in routine clinical practice of thrombolysis in extended time window 3-4.5 h: A nationwide swedish study2011In: Special Issue: Abstracts of the 15th Congress of the EFNS, Budapest, Hungary, 2011, Oxford: Rapid Communications , 2011, Vol. 18, p. 52-52Conference paper (Refereed)
  • 5.
    Bråndal, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Department of Clinical Sciences, Karolinska Institute, Danderyd hospital, Stockholm, Sweden.
    Effect of early supported discharge after stroke on patient reported outcome based on the Swedish Riksstroke registry2019In: BMC Neurology, ISSN 1471-2377, E-ISSN 1471-2377, Vol. 19, article id 40Article in journal (Refereed)
    Abstract [en]

    Background: The efficacy of early supported discharge (ESD) has not been tested in current stroke care setting, which provide relatively short hospital stays, access to hyper-acute therapies and early carotid stenosis interventions. This study aimed to compare patient-reported outcome measures (PROM) among patients with stroke that received modern stroke unit care with or without ESD.

    Methods: Observational study of 30,232 patients with first-ever stroke registered in the Riksstroke registry in Sweden, between 1 January 2010 and 31 December 2013. Patient characteristics were collected from the Riksstroke and Statistics Sweden databases. The primary outcome was satisfaction with the rehabilitation at 3 months after discharge. Secondary outcome were information about stroke provided, tiredness/fatigue, pain, dysthymia/ depression, general health status and dependence in activities of daily living (mobility, toileting and dressing) at 3 months after the stroke. We used separate multivariable logistic regression models for each PROM variable to analyze associations between PROMs and ESD/no ESD.

    Results: The ESD group comprised 1495 participants: the control group comprised 28,737 participants. Multivariable logistic regression models of PROMs showed that, compared to controls, the ESD group was more satisfied with rehabilitation after discharge (OR: 1.78, 95% CI: 1.17–2.49), experienced less dysthymia/depression (OR: 0.68, 95% 0.55–0.84) and showed more independence in mobility (OR: 1.50, 95% CI: 1.17–1.92), toileting (OR: 1.30, 95%CI: 1.05–1.61), and dressing (OR: 1.23, 95%CI: 1.02–1.48).

    Conclusion: In the setting of modern stroke unit care, ESD appeared to have positive effects on stroke rehabilitation, in the subacute phase.

  • 6.
    Bråndal, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lundin-Olsson, Lillemor
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Does a cardiorespiratory interval training program at home improve post-stroke fatigue? Study protocol of a randomized controlled trialManuscript (preprint) (Other academic)
  • 7.
    Darehed, David
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Blom, M.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Niklasson, Johan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Norrving, B.
    Eriksson, M.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Acute stroke patients are subject to seasonal variation in quality of care and survival: a Swedish nationwide registry-based study2018In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 13, p. 177-177Article in journal (Other academic)
  • 8.
    Darehed, David
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Blom, Mathias
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Niklasson, Johan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Norrving, Bo
    Bray, Benjamin D.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Diurnal variations in the quality of stroke care in Sweden2019In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 140, no 2, p. 123-130Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: A recent study of acute stroke patients in England and Wales revealed several patterns of temporal variation in quality of care. We hypothesized that similar patterns would be present in Sweden and aimed to describe these patterns. Additionally, we aimed to investigate whether hospital type conferred resilience against temporal variation.

    MATERIALS & METHODS: We conducted this nationwide registry-based study using data from the Swedish Stroke Register (Riksstroke) including all adult patients registered with acute stroke between 2011 and 2015. Outcomes included process measures and survival. We modeled time of presentation as on/off hours, shifts, day of week, 4h and 12 h time blocks. We studied hospital resilience by comparing outcomes across hospital types.

    RESULTS: 113862 stroke events in 72 hospitals were included. The process indicators and survival all showed significant temporal variation. Door-to-needle (DTN) time within 30 minutes was less likely during nighttime than daytime (OR 0.50; 95% CI 0.41-0.60). Patients admitted during off-hours had lower odds of direct stroke unit (SU) admission (OR 0.72; 95% CI 0.70-0.75). 30-day survival was lower in nighttime versus daytime presentations (OR 0.90, 95% CI 0.84-0.96). The effects of temporal variation differed significantly between hospital types for DTN time within 30 minutes and direct SU admission where university hospitals were more resilient than specialized non-university hospitals.

    CONCLUSIONS: Our study shows that variation in quality of care and survival is present throughout the whole week. We also found that university hospitals were more resilient to temporal variation than specialized non-university hospitals.

  • 9.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Norrving, B.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Post-stroke suicide attempts and completed suicides: A socioeconomic and nationwide perspective2015In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 10, p. 33-33Article in journal (Other academic)
  • 10.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Kvalitetsregistret Riksstroke visar på ojämlik strokevård: omedveten diskriminering kanske förklarar en del av skillnaderna2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, article id DR7HArticle in journal (Refereed)
    Abstract [en]

    In this article, results from a series of studies on the relationships between socioeconomic factors and stroke processes (stroke unit care, acute reperfusion treatment, secondary prevention with oral anticoagulants and statins) and outcomes (long-term survival, return to work and risk of suicide and suicide attempts) are summarized. The overall pattern is that acute and secondary prevention interventions and prognosis are better in patients with a high compared with a low level of education, better in people with high than low income, better in people who are cohabitant than single. As to country of birth, a more complex pattern has emerged. Unmeasured confounding may possibly explain part of the difference, but the socioeconomic gradients remain after adjustment for multiple potential confounders, leaving the possibility that there is an element of unconscious discrimination in stroke care.

  • 11.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Poststroke suicide attempts and completed suicides: a socioeconomic and nationwide perspective2015In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 84, no 17, p. 1732-1738Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: We examined attempted and completed suicides after stroke to determine whether they were associated with socioeconomic status, other patient characteristics, or time after stroke.

    METHODS: This nationwide cohort study included stroke patients from Riksstroke (the Swedish Stroke Register) from 2001 to 2012. We used personal identification numbers to link the Riksstroke data with other national registers. Suicide attempts were identified by a record of hospital admission for intentional self-harm (ICD-10: X60-X84), and completed suicides were identified in the national Cause of Death Register. We used multiple Cox regression to analyze time from stroke onset to first suicide attempt.

    RESULTS: We observed 220,336 stroke patients with a total follow-up time of 860,713 person-years. During follow-up, there were 1,217 suicide attempts, of which 260 were fatal. This was approximately double the rate of the general Swedish population. Patients with lower education or income (hazard ratio [HR] 1.37, 95% confidence interval [CI] 1.11-1.68) for primary vs university and patients living alone (HR 1.73, 95% CI 1.52-1.97) had an increased risk of attempted suicide, and patients born outside of Europe had a lower risk compared to patients of European origin. Male sex, young age, severe stroke, and poststroke depression were other factors associated with an increased risk of attempted suicide after stroke. The risk was highest during the first 2 years after stroke.

    CONCLUSIONS: Both clinical and socioeconomic factors increase the risk of poststroke suicide attempts. This suggests a need for psychosocial support and suicide preventive interventions in high-risk groups of stroke patients.

  • 12.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden2017In: Brain and Behavior, ISSN 2162-3279, E-ISSN 2162-3279, Vol. 7, no 4, article id e00654Article in journal (Refereed)
    Abstract [en]

    Objectives: Ambulance services and stroke alerts reduce the time from stroke onset to acute stroke diagnosis. We describe the use of stroke alerts and ambulance services in different hospitals and patient groups and their relationship with reperfusion therapy. Methods: This nationwide study included 49,907 patients admitted with acute stroke who were registered in The Swedish Stroke Register (Riksstroke) in 2011-2012. Results: The proportions of patients admitted as stroke alerts out of all acute stroke admissions varied from 12.2% to 45.7% in university hospitals (n=9), 0.5% to 38.7% in specialized nonuniversity hospitals (n=22), and 4.2% to 40.3% in community hospitals (n=41). Younger age, atrial fibrillation (AF), living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were factors associated with a higher probability of stroke alerts. Living alone, primary school education, non-European origin, previous stroke, diabetes, smoking, and dependency in activities of daily living (ADL) were associated with a lower probability of stroke alert. The proportion of patients arriving at the hospital by ambulance varied from 60.3% to 94.5%. Older age, living alone, primary school education, being born in a European country, previous stroke, AF, dependency in ADL, living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were associated with ambulance services. Hospital stroke alert frequencies correlated strongly with reperfusion rates (r=.75). Conclusion: Acute stroke alerts have a significant potential to improve stroke reperfusion rates. Prehospital stroke management varies conspicuously between hospitals and patient groups, and the elderly and patients living alone have a markedly reduced likelihood of stroke alerts.

  • 13.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Norrving, Bo
    the Department of Neurology, Lund University Hospital, Lund, Sweden.
    Terént, Andreas
    the Department of Medical Sciences, Uppsala University Hospital, Uppsala.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sex differences in stroke care and outcome in the Swedish national quality register for stroke care2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 3, p. 909-914Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Previous reports concerning sex-related differences in stroke management and outcome are inconsistent and are sometimes difficult to interpret. We used data from a national stroke register to further explore possible differences between men and women in baseline characteristics, stroke treatment, and outcome.

    Methods: This study included 24633 stroke events registered in Riks-Stroke, the Swedish national quality register for stroke care, during 2006. Information on background variables and treatment was collected during the hospital stay. After 3 months, the patients' living situation and outcome were assessed.

    Results: Women were older than men when they had their stroke (mean age, 78.4 versus 73.6 years; P<0.001). On admission to the hospital, women were more often unconscious. Among conscious patients, there was no sex-related difference in the use of stroke unit care. Men and women had equal probability to receive thrombolysis and oral anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men were more likely to develop pneumonia during their hospital stay. Women had a lower 3-month survival, a difference that was associated with higher age and impaired level of consciousness on admission. Women were less often living at home at the 3-month follow-up. However, the difference in residency was not present in patients <85 years who were living at home without community support before the stroke.

    Conclusions: Reported sex differences in stroke care and outcome were mainly explained by the women's higher age and lower level of consciousness on admission.

  • 14.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stecksén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Appelros, Peter
    Hulter Åsberg, Kerstin
    Stegmayr, Birgitta
    The National Board of Health and Welfare, Stockholm, Sweden.
    Terént, Andreas
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Discarding heparins as treatment for progressive stroke in Sweden 2001 to 20082010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 11, p. 2552-2558Article in journal (Refereed)
    Abstract [en]

    There is no immediate, stepwise effect of new scientific information and national guidelines on clinical practice. Rather, the phasing out of heparin has followed a linear course over several years, with less variation between hospitals. We speculate that open comparisons between hospitals in a national stroke register may have helped to reduce the variations in clinical practice.

  • 15.
    Ghatnekar, Ola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mapping health outcome measures from a stroke registry to EQ-5D weights2013In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 11, no 34Article in journal (Refereed)
    Abstract [en]

    Purpose: To map health outcome related variables from a national register, not part of any validated instrument, with EQ-5D weights among stroke patients.

    Methods: We used two cross-sectional data sets including patient characteristics, outcome variables and EQ-5D weights from the national Swedish stroke register. Three regression techniques were used on the estimation set (n = 272): ordinary least squares (OLS), Tobit, and censored least absolute deviation (CLAD). The regression coefficients for “dressing“, “toileting“, “mobility”, “mood”, “general health” and “proxy-responders” were applied to the validation set (n = 272), and the performance was analysed with mean absolute error (MAE) and mean square error (MSE).

    Results: The number of statistically significant coefficients varied by model, but all models generated consistent coefficients in terms of sign. Mean utility was underestimated in all models (least in OLS) and with lower variation (least in OLS) compared to the observed. The maximum attainable EQ-5D weight ranged from 0.90 (OLS) to 1.00 (Tobit and CLAD). Health states with utility weights <0.5 had greater errors than those with weights ≥0.5 (P < 0.01).

    Conclusion: This study indicates that it is possible to map non-validated health outcome measures from a stroke register into preference-based utilities to study the development of stroke care over time, and to compare with other conditions in terms of utility.

  • 16.
    Ghatnekar, Ola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The effect of atrial fibrillation on stroke-related inpatient costs in Sweden: a 3-year analysis of registry incidence data from 20012008In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 11, no 5, p. 862-868Article in journal (Refereed)
    Abstract [en]

    Objective: Atrial fibrillation (AF) is an important risk factor for stroke. It is prevalent in approximately one-fourth of stroke patients, and predictive of worse outcomes. This study aimed to analyze the effect of AF on stroke-related inpatient costs among first-ever stroke patients in Sweden.

    Methods: Hospitalizations and death records were monitored for 3 years in 6611 first-ever stroke patients. For stroke as primary diagnosis, inpatient costs were calculated on the basis of length of stay at different wards. For stroke as secondary diagnosis, costs were based on diagnosis-related groups.

    Results: Patients with AF (24% of all patients) were older (80 years vs. 73 years), had a higher prevalence of hypertension (49% vs. 41%) and/or diabetes (22% vs. 19%), higher risk of experiencing a restroke, and higher case fatality rate (43% vs. 25%) than patients without AF. The average cost per patient over 3 years was euro9004, with no statistically significant difference between AF and non-AF patients. However, a multiple regression analysis showed that the presence of AF resulted in higher costs after considering a number of background factors. Among patients surviving the index event, AF patients had on average euro818 higher inpatient costs over 3 years than non-AF patients (euro10,192 vs. euro9374, P < 0.01). The difference in costs was highest for patients aged <65 years, with a difference of euro4412 (P < 0.01).

    Conclusion: AF-related strokes are associated with higher 3-year inpatient costs than non-AF strokes when controlling for factors such as case fatality rates, other risk factors for stroke, and age.

  • 17.
    Ghatnekar, Ola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Persson, U
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The societal cost of stroke in Sweden 2009 and developments since 19972013In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 35, no Suppl. 3, p. 475-475Article in journal (Other academic)
  • 18.
    Ghatnekar, Ola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Persson, Ulf
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Costs for stroke in Sweden 2009 and developments since 19972014In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 30, no 2, p. 203-209Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of this study was to estimate direct and indirect excess costs attributable to stroke in Sweden in 2009 and to compare these with similar estimates from 1997. Methods: Data on first-ever stoke admissions in the first half of 2009 from the Swedish national stroke register (RS) were used for cost calculations and compared with results from 1997 also using RS data. A societal perspective was taken including the acute and follow-up phase, rehabilitation, stroke re-admissions, drugs, home-and residential care services for activities of daily life (ADL) support, and indirect costs for premature death and productivity losses (2009 prices). Survival was extrapolated to estimate the lifetime present value cost of stroke. Results: The societal lifetime present value cost for stroke in 2009 was (sic)68,800 per patient (ADL support: 59 percent; productivity losses: 21 percent). Women had higher costs than men in all age groups as a result from greater need for ADL support. Patients treated at a stroke unit indicated low incremental cost per life-year gained compared with those who had not. The total lifetime cost increased between 1997 and 2009. Hospitalization costs per patient were stable, while long-term costs for home-and residential care services increased. Conclusions: Changes in patient characteristics, longer expected survival, and possibly in the Swedish stroke care, have led to higher annual and lifetime costs per patient in 2009 compared with 1997. A comprehensive national stroke care performance register like RS may be suitable for health economic assessments.

  • 19.
    Ghatnekar, Ola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Persson, Ulf
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Cost of stroke in Sweden: an incidence estimate2004In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 20, no 3, p. 375-380Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To estimate the excess cost of stroke in Sweden and the potential costs that could be avoided by preventing first-ever strokes.

    METHODS: We adopted the incidence approach for estimating the present value of both direct and indirect costs. Data on mortality, stroke recurrence, and inpatient care were estimated from a national register of patient data with a four-year follow-up period. To estimate costs for social services, we used survey data on living conditions before stroke onset and at three and at twenty-four months. Costs for outpatient visits, rehabilitation, drugs, and production losses due to premature death and early retirement were estimated on the basis of both published and nonpublished sources. Lifetime costs were based on life tables adjusted for excess mortality of stroke, and costs in year 4 were extrapolated to subsequent years.

    RESULTS: The present value direct cost for an average stroke patient is SEK 513,800 (USdollars 56,024 or Euro 60,825). The corresponding indirect cost is SEK 125,110 (USdollars 13,640 or Euro 14,810). Almost 45 percent of the direct costs were attributable to social services. Women had higher costs than men, and costs for survivors increased with age due to social services.

    CONCLUSIONS: With an incidence of 213 first-ever strokes per 100,000 individuals, the total excess direct and indirect cost of stroke would be SEK 12.3 billion (approximately US$ 1.3 billion or Euro 1.5 billion). Hence, there are large potential cost offsets both in the health-care sector and in the social service sector if the incidence of first-ever stroke could be reduced.

  • 20.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stroke care in Sweden: Hospital care and patient follow-up based on Riks-Stroke, the National Quality Register for Stroke Care2003Doctoral thesis, comprehensive summary (Other academic)
  • 21.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Edlund, Hilda
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Sukhova, M
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, B
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    More equal stroke unit care over time. A 15-year follow up of socioeconomic disparities in stroke unit care in Sweden2013In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 35, no Suppl. 3, p. 702-702Article in journal (Other academic)
  • 22.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Edlund, Hilda
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Sukhova, Maria
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Department of Clinical Sciences, Section of Neurology, Lund University, Sweden.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Reduced inequality in access to stroke unit care over time: a 15-year follow-up of socioeconomic disparities in Sweden2013In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 36, no 5-6, p. 407-411Article in journal (Refereed)
    Abstract [en]

    Background: Despite the compelling scientific evidence on the superiority of stroke unit care, far from all acute stroke patients have access to stroke unit care. In congruence with what has been observed when other new methods are introduced in health care, we hypothesized that there has been an inequality in the buildup phase of stroke units but that the gradients between patient groups have decreased as the total capacity of stroke unit care has increased. The purpose of this study was to explore if patients in a national sample who were socioeconomically disadvantaged (low education or low income) had reduced access to stroke unit care and if differences varied over time.

    Methods: All patients 18-74 years of age registered between 1995 and 2009 in Riks-Stroke, the Swedish stroke register, were included. The Stroke Unit Trialists' definition of a stroke unit has been adopted by Riks-Stroke and hospitals participating in the registry. Basic patient characteristics, stroke risk factors, process and outcome variables are recorded in Riks-Stroke. Socioeconomic data were accessed from Statistics Sweden. Multiple logistic regression analyses were used to calculate odds ratios (ORs) for stroke unit care between prespecified patient subgroups.

    Results: A total of 319,240 stroke patients were included in Riks-Stroke during the years 1995-2009, and 124,173 were aged between 18 and 74 years; they were included in the final analyses. After adjustment for confounders in a multiple regression model, women were treated in stroke units slightly less often [OR 0.97, 95% confidence interval (CI) 0.95-0.99]. There were no statistically significant associations between stroke unit care and age or between stroke unit care and cohabiting or living alone. The highest level of education predicted access to stroke unit care (secondary vs. primary school: OR 1.04, 95% CI 1.01-1.07; university vs. primary school: OR 1.06, 95% CI 1.02-1.10). Differences according to level of education diminished over time (p = 0.001). Income was not independently associated with stroke unit care, and over time the proportion of patients treated in stroke units increased at a similar rate in all income groups (p = 0.12).

    Conclusions: Even in a country with modest socioeconomic differences in the general population and public financing of all acute hospital care, socioeconomic inequalities in access to stroke unit care were evident during the early years, but they diminished as the total capacity for stroke unit care increased.

    © 2013 S. Karger AG, Basel.

  • 23.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Jonsson, B.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Socioeconomic status predicts return to work after first stroke in younger adults2015In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 10, p. 174-174Article in journal (Other academic)
  • 24.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jonsson, B.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Norrving, B.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Socioeconomic factors' effect on return to work after first stroke2017In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 135, no 6, p. 608-613Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The objective of this nationwide study was to analyze how functional status and socioeconomic status affect return to work (RTW) among younger patients with first-time stroke in a Sweden.

    MATERIAL AND METHODS: This register-based cohort study included employed patients aged 25-55 with first-time stroke between 2008 and 2011 and primary outcome was RTW within 1 year after stroke. Data regarding functional status and employment status were retrieved from the Swedish Stroke Register, Riksstroke, and socioeconomic data (income, education, and country of birth) from Statistics Sweden.

    RESULTS: We included 2539 patients who had answered the question on RTW, and 1880 (74.0%) had RTW within 12 months. Patients with low income (69.9% in lowest income group vs 79.9% in highest group, P<.001), patients born in countries outside the Nordic countries (Sweden 75.5%, Nordic countries 74.3%, European countries 61.7%, other countries 57.3%, P<.001), and the youngest patients (25-34, 63.1%; 35-44, 75.9%; 45-55, 74.3%; P=.008) were less likely to RTW. Pain, low mood, and answering the questionnaire with help were more common in low socioeconomic groups, and when adjusting for these variables, together with age and sex, income and country of birth were no longer independent predictors for RTW.

    CONCLUSION: Patients with low socioeconomic status less often RTW 1 year after stroke.Impaired functional status after stroke is more common in patients with lower socioeconomic status and mediates socioeconomic differences in RTW. Improvement of functional status should be targeted to facilitate RTW among stroke patients with low socioeconomic status.

  • 25.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sjölander, Maria
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lundberg, Michael
    Persistent use of secondary preventive drugs declines rapidly during the first 2 years after stroke.2010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 2, p. 397-401Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: To prevent new cardiovascular events after stroke, prescribed preventive drugs should be used continuously. This study measures persistent use of preventive drugs after stroke and identifies factors associated with persistence.

    METHODS: A 1-year cohort (21,077 survivors) from Riks-Stroke, the Swedish Stroke Register, was linked to the Swedish Prescribed Drug Register.

    RESULTS: The proportion of patients who were persistent users of drugs prescribed at discharge from hospital declined progressively over the first 2 years to reach 74.2% for antihypertensive drugs, 56.1% for statins, 63.7% for antiplatelet drugs, and 45.0% for warfarin. For most drugs, advanced age, comorbidity, good self-perceived health, absence of low mood, acute treatment in a stroke unit, and institutional living at follow-up were independently associated with persistent medication use.

    CONCLUSIONS: Persistent secondary prevention treatment declines rapidly during the first 2 years after stroke, particularly for statins and warfarin. Effective interventions to improve persistent secondary prevention after stroke need to be developed.

  • 26.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Poststroke Fatigue: A 2-Year Follow-Up Study of Stroke Patients in Sweden2002In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 33, p. 1327-1333Article in journal (Refereed)
    Abstract [en]

    Background and Purpose Fatigue is common among stroke patients. This study determined the prevalence of fatigue among long-term survivors after stroke and what impact fatigue had on various aspects of daily life and on survival.

    Methods— This study was based on Riks-Stroke, a hospital-based national register for quality assessment of acute stroke events in Sweden. During the first 6 months of 1997, 8194 patients were registered in Riks-Stroke, and 5189 were still alive 2 years after the stroke. They were followed up by a mail questionnaire, to which 4023 (79%) responded. Patients who reported that they always felt depressed were excluded.

    Results— To the question, “Do you feel tired?” 366 (10.0%) of the patients answered that they always felt tired, and an additional 1070 (29.2%) were often tired. Patients who always felt tired were on average older than the rest of the study population (74.5 versus 71.5 years, P<0.001); therefore, all subsequent analyses were age adjusted. Fatigue was an independent predictor for having to move into an institutional setting after stroke. Fatigue was also an independent predictor for being dependent in primary activities of daily living functions. Three years after stroke, patients with fatigue also had a higher case fatality rate.

    Conclusions— Fatigue is frequent and often severe, even late after stroke. It is associated with profound deterioration of several aspects of everyday life and with higher case fatality, but it usually receives little attention by healthcare professionals. Intervention studies are needed.

  • 27.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Lennart
    National Board of Health and Welfare, Stockholm, Sweden.
    Hulter-Åsberg, Kerstin
    Department of Medicine, Enköping Hospital, Enköping, Sweden.
    Wester, P.-O.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Differences in Long-Term Outcome Between Patients Treated in Stroke Units and in General Wards: A 2-Year Follow-Up of Stroke Patients in Sweden2001In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 32, p. 2124-2130Article in journal (Refereed)
    Abstract [en]

    Background and Purpose— The long-term beneficial effects of stroke unit care have been proved in several randomized trials. However, there is a question of large-scale applicability in routine clinical practice of interventions used by dedicated investigators in small randomized trials. The objective of this study was to compare, 21/2 years after stroke, patients who had been treated in stroke units and those treated in general wards in routine clinical practice.

    Methods— This is a prospective cohort study based on 8194 patients who were included, during the first 6 months in 1997, in Riks-Stroke, the Swedish National Register for quality assessment of acute stroke. Two years after the event, 5189 patients were still alive and 5104 were followed up with a postal questionnaire to which 4038 responded.

    Results— Among the group of patients who were independent in activities of daily living (ADL) functions before the stroke, patients who were treated in stroke units were less often dependent in ADL functions, after adjustment for case mix (OR, 0.79; CI, 0.66 to 0.94). If they also lived at home before the stroke, then they had a lower case-fatality rate 2 years after the stroke (OR, 0.81; CI, 0.72 to 0.92).

    Conclusions— Long-term beneficial effects of treatment in stroke units were shown for patients who were independent in ADL functions before the stroke. No benefits were shown for patients who were dependent on help for primary ADL before the stroke. Further studies on this group of patients with more detailed outcome measures are needed.

  • 28.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terent, Andreas
    Department of Clinical Neuroscience, Lund University, Lund, Sweden.
    Hulter-Åsberg, Kerstin
    Department of Medical Science, Uppsala University, Uppsala, Sweden.
    Wester, P.-O.
    Department of Medicine, Enköping Hospital, Enköping, Sweden.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Large variations in the use of oral anticoagulants in stroke patients with atrial fibrillation: A Swedish national perspective2004In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 255, no 1, p. 22-32Article in journal (Refereed)
    Abstract [en]

    Objectives. To explore nation-wide use of anticoagulation in stroke patients with atrial fibrillation, in routine clinical practice in Sweden.

    Design.  Cross-sectional cohort study.

    Setting. Patients included in Riks-Stroke, the Swedish national quality register for stroke care, during 2001.

    Subjects. Hospitals with incomplete coverage were excluded, leaving 4538 stroke patients with atrial fibrillation amongst 18 276 stroke patients from 75 hospitals in six health care regions.

    Main outcome measure.  Treatment with oral anticoagulants.

    Results. At stroke onset, the proportion of patients with atrial fibrillation and first-ever stroke, receiving oral anticoagulants as primary prevention was 11.0% (range 8.4–13.5% between regions and 2.5–24.4% between hospitals). Younger age, male sex and diabetes at stroke onset independently predicted primary prevention with oral anticoagulants. The proportion of stroke patients with atrial fibrillation receiving oral anticoagulants as secondary prevention at discharge was 33.5% (range 29.9–40.6% between regions and 16.4–61.9% between hospitals). Independent predictors for secondary prevention were younger age, male sex and independent activities of daily life (ADL) function before the stroke, being discharged to home, being fully conscious on admission and health care region.

    Conclusion.  There were variations between hospitals and regions that differences in age, sex, functional impairments and comorbidities could not fully explain. This indicates that evidence-based primary and secondary prevention of embolic stroke is insufficiently practised. Local factors seem to determine whether patients with atrial fibrillation gain access to optimal prevention of stroke or not.

  • 29. Lindgren, Peter
    et al.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jönsson, Bengt
    Utility loss and indirect costs after stroke in Sweden2008In: European Journal of Cardiovascular Prevention & Rehabilitation, ISSN 1741-8267, E-ISSN 1741-8275, Vol. 15, no 2, p. 230-233Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Currently little data exist on the development of quality of life over time in patients suffering from stroke, in particular using instruments that can be adapted in economic studies. The purpose of the study was to assess the utility loss and indirect costs following a stroke in Sweden.

    DESIGN: A cross-sectional mail survey. METHODS: In collaboration with the National Stroke registry (RIKS-STROKE), a questionnaire consisting of the EuroQol-5D and questions regarding the present working status and the status prior to the stroke was mailed to patients below 76 years of age at six participating centres. The questionnaire was mailed to 393 patients in total, divided into groups with 3, 6, 9 or 12 months having passed since the stroke. The EuroQol-5D scores were converted to utility scores using the UK social tariff. Indirect costs were valued according to the average salary+employer contributions.

    RESULTS: A total of 275 questionnaires (70%) were returned. Utility scores were similar over time: 0.65, 0.75, 0.63, and 0.67 at 3, 6, 9 and 12 months, respectively. Regression analyses revealed a tendency for lower utility scores among women, but no significant differences overall. Among patients in the working ages, a stroke caused 18.5 work weeks lost, corresponding to an indirect cost of 120,000 Swedish Kronor (SEK) (13,200euro, 95% confidence interval 82,541-160,050 SEK, 9080-17 605euro).

    CONCLUSIONS: Stroke causes a significant reduction in utility and causes high indirect costs. A substantial improvement was not noted over time, which is important to consider in economic models.

  • 30.
    Lindmark, Anita
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, B
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Socioeconomic disparities in stroke case fatality: observations from Riks-Stroke, the Swedish stroke register2013In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 35, no Suppl. 3, p. 225-225Article in journal (Other academic)
  • 31.
    Lindmark, Anita
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Socioeconomic disparities in stroke case fatality: observations from Riks-Stroke, the Swedish stroke register2014In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 9, no 4, p. 429-436Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Low socioeconomic status (low education and income level) has been found to be associated with increased stroke mortality. However, findings from previous studies on the association between socioeconomic status and case fatality (survival) after stroke have been inconsistent.

    AIMS: The study aims to explore the association between socio-economic status and survival after stroke using Riks-Stroke, the Swedish Stroke Register, with emphasis on changes in survival (in)equality with time after stroke.

    METHODS: All 76 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. Riks-Stroke data on 18- to 74-year-old patients with onset of first stroke during the years 2001-2009 were combined with data from other official Swedish registers. Case fatality was analyzed by socioeconomic status (education, income, country of birth, and cohabitation) and other patient characteristics.

    RESULTS: Of the 62 497 patients in the study, a total of 6094 (9·8%) died within the first year after stroke. Low income, primary school education, and living alone were independently associated with higher case fatality after the acute phase. Differences related to income and cohabitation were present already early, at 8-28 days after stroke, with the gaps expanding thereafter. The association between education and case fatality was not present until 29 days to one-year after stroke. Dissimilarities in secondary preventative medications prescribed on discharge from hospital had only a minor impact on these differences.

    CONCLUSIONS: Socioeconomic status had only a limited effect on acute phase case fatality, indicating minor disparities in acute stroke treatment. The survival inequality, present already in the subacute phase, increased markedly over time since the stroke event. The socioeconomic differences could not be explained by differences in secondary prevention at discharge from hospital. Large socioeconomic differences in long-term survival after stroke may exist also in a country with limited income inequity.

  • 32.
    Lindmark, Anita
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    van Rompaye, Bart
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics. Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium.
    Goetghebeur, Els
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    The Importance of Integrating Clinical Relevance and Statistical Significance in the Assessment of Quality of Care - Illustrated Using the Swedish Stroke Register2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 4, article id e0153082Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: When profiling hospital performance, quality inicators are commonly evaluated through hospital-specific adjusted means with confidence intervals. When identifying deviations from a norm, large hospitals can have statistically significant results even for clinically irrelevant deviations while important deviations in small hospitals can remain undiscovered. We have used data from the Swedish Stroke Register (Riksstroke) to illustrate the properties of a benchmarking method that integrates considerations of both clinical relevance and level of statistical significance.

    METHODS: The performance measure used was case-mix adjusted risk of death or dependency in activities of daily living within 3 months after stroke. A hospital was labeled as having outlying performance if its case-mix adjusted risk exceeded a benchmark value with a specified statistical confidence level. The benchmark was expressed relative to the population risk and should reflect the clinically relevant deviation that is to be detected. A simulation study based on Riksstroke patient data from 2008-2009 was performed to investigate the effect of the choice of the statistical confidence level and benchmark value on the diagnostic properties of the method.

    RESULTS: Simulations were based on 18,309 patients in 76 hospitals. The widely used setting, comparing 95% confidence intervals to the national average, resulted in low sensitivity (0.252) and high specificity (0.991). There were large variations in sensitivity and specificity for different requirements of statistical confidence. Lowering statistical confidence improved sensitivity with a relatively smaller loss of specificity. Variations due to different benchmark values were smaller, especially for sensitivity. This allows the choice of a clinically relevant benchmark to be driven by clinical factors without major concerns about sufficiently reliable evidence.

    CONCLUSIONS: The study emphasizes the importance of combining clinical relevance and level of statistical confidence when profiling hospital performance. To guide the decision process a web-based tool that gives ROC-curves for different scenarios is provided.

  • 33.
    Pennlert, Johanna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Socioeconomic Status and the Risk of Stroke Recurrence: Persisting Gaps Observed in a Nationwide Swedish Study 2001 to 2012.2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 6, p. 1518-1523Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: This nationwide observational study aimed to investigate how socioeconomic status is associated with risk of stroke recurrence and how possible associations change over time.

    METHODS: This study included 168 295 patients, previously independent in activities of daily living, with a first-ever stroke in the Swedish Stroke Register (Riksstroke) 2001 to 2012. Riksstroke was linked with Statistics Sweden as to add individual information on education and income. Subdistribution hazard regression was used to analyze time from 28 days after first stroke to stroke recurrence, accounting for the competing risk of other causes of death.

    RESULTS: Median time of follow-up was 3.0 years. During follow-up, 23 560 patients had a first recurrent stroke, and 53 867 died from other causes. The estimated cumulative incidence of stroke recurrence was 5.3% at 1 year, and 14.3% at 5 years. Corresponding incidence for other deaths were 10.3% and 30.2%. Higher education and income were associated with a reduced risk of stroke recurrence. After adjusting for confounding variables, university versus primary school education returned a hazard ratio of 0.902; 95% confidence interval, 0.864 to 0.942, and the highest versus the lowest income tertile a hazard ratio of 0.955; 95% confidence interval, 0.922 to 0.989. The risk of stroke recurrence decreased during the study period, but the inverse effect of socioeconomic status on risk of recurrence did not change significantly.

    CONCLUSIONS: Despite a declining risk of stroke recurrence over time, the differences in recurrence risk between different socioeconomic groups remained at a similar level in Sweden during 2001 to 2012.

  • 34.
    Röding, Jenny
    et al.
    Department of Health Sciences, Luleå University of Technology, Luleå, Sweden.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Malm, Jan
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurology.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindström, Britta
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Perceived impaired physical and cognitive functions after stroke in men and women between 18 and 55 years of age: a national survey2009In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 31, no 13, p. 1092-9Article in journal (Refereed)
    Abstract [en]

    PURPOSE: We describe self-reported consequences for physical and cognitive functions, detect possible gender differences, and find factors that were associated with deteriorated physical function in younger stroke patients, independent in their personal activities of daily life. METHODS: This study involved all first ever stroke patients, aged 18-55 years, registered in the Swedish national quality register for stroke. A questionnaire was answered by 1068 patients 8-36 months after the stroke. Changes were sought in physical and cognitive functions as compared with the pre-stroke condition. RESULTS: Eight hundred and sixty-seven patients (83%) were independent in personal activities of daily life. Significant differences between men and women were found: deteriorated physical ability was reported by 56-71% of the men and 65-79% of the women; deteriorated cognitive function was reported by 48-57% of the men and 57-68% of the women. Many patients (70% men, 77% women) reported that they had received insufficient information about physical exertion. Significant associations were found between deteriorated physical function and deteriorated cognitive function as well as fear of physical exertion. CONCLUSIONS: Deterioration was found in physical and cognitive functions greater in women then in men. Insecurity regarding physical exertion existed indicating that younger stroke patients might need information directly aimed at physical functioning and more gender specific than today. This study has raised the awareness that there also might be gender differences in other fields, which needs further studies.

  • 35.
    Röding, Jenny
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Malm, Jan
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurology.
    Lindström, Britta
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Life satisfaction in younger individuals after stroke: different predisposing factors among men and women2010In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 42, no 2, p. 155-161Article in journal (Refereed)
    Abstract [en]

    There were different factors for being satisfied with life as a whole between men and women, indicating a need for a more gender-specific rehabilitation than is currently used. The impact that deteriorated ability to concentrate has on life satisfaction is an important finding that needs to be considered in the rehabilitation process of younger patients after stroke.

  • 36.
    Sjölander, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Socioeconomic Inequalities in the Prescription of Oral Anticoagulants in Stroke Patients With Atrial Fibrillation2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 8, p. 2220-2225Article in journal (Refereed)
    Abstract [en]

    Background and Purpose—Oral anticoagulants (OACs) are effective against ischemic stroke in patients with atrial fibrillation. Our aim was to investigate differences in the prescribing of OACs after ischemic stroke in patients with atrial fibrillation based on age, sex, country of birth, and socioeconomic status.

    Methods—Patients with first-ever ischemic stroke and atrial fibrillation without OAC treatment were included from the Swedish stroke register from 2009 to 2012. The outcome was OAC prescribed at discharge. Income, education, country of birth, and risk factors were obtained from official registers. Risk factors and health status were controlled for in multivariable logistic regression.

    Results—Of 12 088 stroke patients, 36.3% were prescribed an OAC. Prescribing was less common with older age and, in patients born in other Nordic countries (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.68–0.98) or countries outside of Europe (OR, 0.65; 95% CI, 0.42–0.99) compared with those born in Sweden. University education (OR, 1.20; 95% CI, 1.05–1.36) and highest income (OR, 1.19; 95% CI, 1.06–1.33) were associated with higher levels of OAC prescribing compared with those with primary school education or lowest income level.

    Conclusion—Differences by age, income, education, and country of birth were found in the prescribing of OACs after stroke. Differences were not explained by common risk factors. This indicates socioeconomic inequalities in the prescribing of preventive treatment after stroke.

  • 37.
    Sjölander, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Few sex differences in the use of drugs for secondary prevention after stroke: a nationwide observational study2012In: Pharmacoepidemiology and Drug Safety, ISSN 1053-8569, E-ISSN 1099-1557, Vol. 21, no 9, p. 911-919Article in journal (Refereed)
    Abstract [en]

    PURPOSE: This observational study describes the sex differences in the use of secondary preventive drugs after ischemic stroke in terms of prescribing and persistence. Also, sex differences in patient- and treatment-related factors associated with drug use were investigated.

    METHODS: In this nationwide register-based study, the Swedish Stroke Register was linked to the Swedish Prescribed Drug Register for information on drugs prescribed for, and bought by, stroke patients. Background factors were included from the Swedish Stroke Register.

    RESULTS: Included in the database were 9331 men and 9018 women. Men were more often prescribed statins, 48.8% versus 38.1% [age-adjusted prevalence ratio (PR) = 0.86, 95%CI = 0.82-0.91], and warfarin, 38.4% versus 26.4% after stroke (age-adjusted PR = 0.88, 95%CI = 0.79-0.97). There were no differences in prescribing of antihypertensive or antiplatelet drugs. No sex differences were seen regarding not continuing drug treatment after discharge (primary non-adherence). Women had slightly higher persistence to antihypertensive treatment 2 years after discharge, 76.3% versus 71.9% for men (age-adjusted PR = 1.05, 95%CI = 1.00-1.09), but there were no differences in persistence to antiplatelet, warfarin or statin treatments. Similar factors were related to statin and warfarin prescribing for both men and women. Only antihypertensive treatment before stroke was associated to persistence to antihypertensive treatment, and this increased persistence for both men and women.

    CONCLUSIONS: This study showed few differences between men and women after stroke. Patients' use of secondary preventive drugs needs to be improved, and from a public health perspective, poor persistence is probably a greater problem than differences between the sexes. Copyright © 2011 John Wiley & Sons, Ltd.

  • 38.
    Sjölander, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Few sex differences in use of drugs for secondary prevention after stroke: a nationwide observational study2011In: Abstracts 27th International Conference on Pharmacoepidemiology & Therapeutic Risk Management Hyatt Regency Chicago: Chicago, Illinois, USA August 14–17, 2011, Wiley , 2011, Vol. 20, p. S110-S110Conference paper (Refereed)
    Abstract [en]

    Background: Secondary preventive drug treatment after stroke is important to prevent further development of disease. Although recommendations for secondary prevention are the same for men and women, reality is not always in accordance with recommendations.

    Objectives: This observational study intended to describe the differences between men and women in the use of secondary preventive drugs after ischemic stroke in terms of prescribing and continuous use. The purpose was also to investigate differences in patient and treatment related factors associated with drug use.

    Methods: In this nationwide register - based study, the Swedish Stroke Register was linked to the Swedish Prescribed Drug Register for information on drugs prescribed for, and bought by, stroke patients. Background factors were included from the Stroke Register.

    Results: Men were more often prescribed statins after stroke, 45.2% versus 33.8% (p<0.001). There were no differences in prescribing of antihypertensive or antithrombotic drugs. No differences were seen between the sexes regarding not continuing drug treatment after discharge (primary non - adherence). Women had a slightly higher persistence rate to antihypertensive treatment 2 years after discharge from hospital, 76.3% versus 71.9% for men (p<0.001), but there were no differences in persistence to antithrombotic or lipid - lowering treatments. The same factors were related to statin prescribing for both men and women. Factors associated to persistence to antihypertensive treatment were the same for both sexes except for a follow - up visit to hospital which was associated with increased persistence for men; age was associated with increased persistence and dissatisfaction with care was associated with decreased persistence for women.

    Conclusions: This study showed small or no differences between men and women after stroke. Patients' use of secondary preventive drugs needs to be improved. Men and women do not have to be treated differently.

  • 39.
    Sjölander, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Inequalities in medication adherence to statin treatment after stroke: A nationwide observational study2016In: European Stroke Journal, ISSN 2396-9873, Vol. 1, no 2, p. 101-107Article in journal (Refereed)
    Abstract [en]

    Introduction: The objective was to investigate differences in adherence to statins after stroke based on age, sex, socioeconomic status and country of birth.

    Patients and methods: Patients with ischemic stroke in 2009–2010 were included from the Swedish stroke register. Adherence to statin treatment was measured over two years as proportion of days covered with 80% as cut-off for adherence. Income, education, and country of birth were obtained from official registers. Factors associated with adherence were controlled for in multivariable logistic regression.

    Results: Of 15,192 included patients, 73.9% had an adherence rate 80%. The oldest (85þ years) and youngest (18–54 years) had the lowest adherence, and a smaller proportion of women were adherent (odds ratio (OR) 0.84; 95% confidence interval (CI) 0.77–0.92). Adherence was less common in patients born in Nordic countries (OR 0.82; 95% CI (0.68–0.97), Europe (OR 0.78; 95% CI 0.65–0.93), and in non-European countries (OR 0.65; 95% CI 0.50–0.84) compared to Sweden-born. Patients with university education were to a lower extent adherent compared to patients with primary school education (OR 0.81; 95% CI 0.72–0.91). There was no association between adherence and income.

    Discussion: The study was based on individual level real-life data with national coverage. Adherence was estimated from data on filled prescriptions, but filled prescription does not mean that drugs are used as intended.

    Conclusion: Adherence to statin treatment over two years was suboptimal, and adherence was less common among women, patients born outside of Sweden and patients with university education.

  • 40.
    Sjölander, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE).
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Social stratification in the dissemination of statins after stroke in Sweden2013In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 69, no 5, p. 1173-1180Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Since 2005, statins have been recommended to patients with ischaemic stroke. The objective of this study was to analyse how statin treatment has been disseminated in different patient groups (age, sex, socioeconomic status and country of birth) in Sweden between 2004 and 2009.

    METHODS: The Swedish Stroke Register (Riks-Stroke) has been linked to the Longitudinal Integration Database for Health Insurance and Labour Market Studies. Approximately 85 % of stroke patients in Sweden are included in Riks-Stroke. Odds ratios for statin prescribing were calculated using a multivariable logistic regression model including age, sex, socioeconomic status and risk factors.

    RESULTS: During the study period, 108,950 ischaemic stroke patients were discharged alive from hospital. The proportion with statins at discharge increased from 32.9 % in 2004 to 60.1 % in 2009. Patients with secondary school or university education had slightly higher odds [odds ratio (OR) 1.07, 95 % confidence interval (CI) 1.04-1.11 and OR 1.05, 95 % CI 1.01-1.10 respectively] than patients with primary school education. Patients on a high income were prescribed more statins than those on a low income (OR 1.24, 95 % CI 1.19-1.28). Compared with patients born in Sweden, patients born in other countries were prescribed more statins (Nordic countries excepting Sweden: OR 1.07, 95 % CI 1.01-1.14; Europe: OR 1.31, 95 % CI 1.22-1.40; Outside Europe: OR 1.20, 95 % CI 1.08-1.34).

    CONCLUSIONS: Statin prescribing after ischaemic stroke has increased from 2004 to 2009. Our results also show a social stratification in the dissemination of statins, with patients having a higher income and patients with higher education receiving statins more often than those with a lower income and education, and patients born in Sweden receiving statins less often than those born outside of Sweden.

  • 41.
    Sjölander, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The association between patients' beliefs about medicines and adherence to drug treatment after stroke: a cross-sectional questionnaire survey2013In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 9, article id e003551Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Adherence to preventive drug treatment is a clinical problem and we hypothesised that patients' beliefs about medicines and stroke are associated with adherence. The objective was to examine associations between beliefs of patients with stroke about stroke and drug treatment and their adherence to drug treatment.

    DESIGN: Cross-sectional questionnaire survey.

    SETTING: Patients with stroke from 25 Swedish hospitals were included.

    MEASUREMENTS: Questionnaires were sent to 989 patients to assess their perceptions about stroke (Brief Illness Perception Questionnaire, Brief IPQ), beliefs about medicines (Beliefs about Medicines Questionnaires, BMQ) and adherence to treatment (Medication Adherence Report Scale, MARS) 3 months after stroke onset. Only patients living at home were included in the analysis. The primary outcome was self-reported adherence as measured on MARS. MARS scores were dichotomised into adherent/non-adherent. Background and clinical data from the Swedish Stroke register were included.

    RESULTS: 811 patients were still living at home and 595 answered the questionnaire. Complete MARS data were available for 578 patients and 72 (12.5%) of these were classified as non-adherent. Non-adherent patients scored lower on positive beliefs as measured on BMQ-necessity (OR = 0.90, 95% CI 0.83 to 0.98) and BMQ-benefit (OR=0.77, 95% CI 0.68 to 0.87), and higher on negative beliefs as measured on BMQ-concern (OR=1.12, 95% CI 1.05 to 1.21), BMQ-overuse (OR=1.29, 95% CI 1.14 to 1.45), and BMQ-harm (OR=1.12, 95% CI 1.01 to 1.24). The Brief IPQ showed that non-adherent patients believed their current treatment to be less useful (p=0.001).

    CONCLUSIONS: This study showed associations between beliefs of Swedish patients with stroke about medicines and adherence. Positive beliefs were less common and negative more common among non-adherent. To improve adherence, patients' beliefs about medicines should be considered.

  • 42.
    Stecksén, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Appelros, Peter
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Thrombolytic therapy rates and stroke severity: an analysis of data from the Swedish Stroke Register (Riks-Stroke) 2007-20102012In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 43, no 2, p. 536-538Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: We tested the hypothesis that higher proportions of patients with minor stroke being treated with thrombolysis contribute to increasing overall rates of thrombolysis.

    Methods: We included 1743 ischemic stroke patients (age 18–80 years) treated with thrombolysis, recorded in the Swedish stroke register Riks-Stroke between 2007 and 2010. Minor stroke was defined as National Institutes of Health Stroke Scale score ≤5.

    Results: The proportion with minor stroke among patients treated with thrombolysis increased from 22.1% in 2007 to 28.7% in 2010 (P=0.021). The rate of increase did not differ significantly between men and women, age groups, or hospital types (university hospitals, other large hospitals, or community hospitals). Hospitals with high proportions of thrombolysis patients with minor stroke were more likely to have high thrombolysis frequencies (R=0.55; P<0.001).

    Conclusions: In recent years, an increase in the proportion of patients with minor stroke treated with thrombolysis has contributed to rising overall thrombolysis rates in Sweden. At the hospital level, high rates of thrombolysis are associated with a high proportion of minor stroke being treated.

  • 43.
    Stecksén, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Klinisk medicin, Lund Univ, Lund, Sweden.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Socioeconomic inequalities in access to stroke thrombolysis: observations in the Swedish stroke register (Riks-Stroke)2013In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 35, no Suppl. 3, p. 671-671Article in journal (Other academic)
  • 44.
    Stecksén, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Education level and inequalities in stroke reperfusion therapy: observations in the Swedish stroke register2014In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 9, p. 2762-2768Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Previous studies have revealed inequalities in stroke treatment based on demographics, hospital type, and region. We used the Swedish Stroke Register (Riksstroke) to test whether patient education level is associated with reperfusion (either or both of thrombolysis and thrombectomy) treatment.

    METHODS: We included 85 885 patients with ischemic stroke aged 18 to 80 years registered in Riksstroke between 2003 and 2009. Education level was retrieved from Statistics Sweden, and thrombolysis, thrombectomy, patient, and hospital data were obtained from Riksstroke. We used multivariable logistic regression to analyze the association between reperfusion therapy and patient education.

    RESULTS: A total of 3649 (4.2%) of the patients received reperfusion therapy. University-educated patients were more likely to be treated (5.5%) than patients with secondary (4.6%) or primary education (3.6%; P<0.001). The inequality associated with education was still present after adjustment for patient characteristics; university education odds ratio, 1.14; 95% confidence interval, 1.03 to 1.26 and secondary education odds ratio, 1.08; 95% confidence interval, 1.00 to 1.17 compared with primary education. Higher hospital specialization level was also associated with higher reperfusion levels (P<0.001). In stratified multivariable analyses by hospital type, significant treatment differences by education level existed only among large nonuniversity hospitals (university education odds ratio, 1.20; 95% confidence interval, 1.04-1.40; secondary education odds ratio, 1.14; 95% confidence interval, 1.01-1.29).

    CONCLUSIONS: We demonstrated a social stratification in reperfusion, partly explained by patient characteristics and the local hospital specialization level. Further studies should address treatment delays, stroke knowledge, and means to improve reperfusion implementation in less specialized hospitals.

  • 45.
    Stecksén, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Implementing thrombolytic guidelines in stroke care: perceived facilitators and barriers2014In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 24, no 3, p. 412-419Article in journal (Refereed)
    Abstract [en]

    We performed a qualitative study to identify facilitators of and barriers to the implementation of national guidelines on thrombolytic therapy for acute ischemic stroke. We interviewed physicians and nurses at nine Swedish hospitals using 16 explorative, semistructured interviews, and selected hospitals based on their implementation rate of new stroke care methods according to data from the Swedish Stroke Register, Riks-Stroke. Through content analysis, we identified facilitators and barriers to implementation, which we classified into three categories: (a) individuals, (b) social interactions and context, and (c) organizational and resource issues. Insights obtained from this study can be used to identify target areas for improving the implementation of thrombolytic therapy and other new methods in stroke care.

  • 46.
    Söderholm, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Validation of Hospital Performance Measures of Acute Stroke Care Quality. Riksstroke, the Swedish Stroke Register2016In: Neuroepidemiology, ISSN 0251-5350, E-ISSN 1423-0208, Vol. 46, no 4, p. 229-234Article in journal (Refereed)
    Abstract [en]

    Background: Registers are increasingly used to monitor stroke care performance. Fair benchmarking requires sufficient data quality. We have validated acute care data in Riksstroke, the Swedish Stroke Register.

    Methods: Completeness was assessed by comparisons with diagnoses at hospital discharge recorded in the compulsory National Patient Register and content validity by comparisons with (a) key variables identified by European stroke experts, and (b) items recorded in other European stroke care performance registers. Five test cases recorded by 67 hospitals were used to estimate inter-hospital reliability.

    Results: All 72 Swedish hospitals admitting acute stroke patients participated in Riksstroke. The register was estimated to cover at least 90% of acute stroke patients. It includes 18 of 22 quality indicators identified by international stroke experts and 14 of 15 indicators used by at least 2 stroke performance registers in other European countries. Inter-hospital reliability was high (85%) in 77 of 81 Riksstroke items.

    Conclusions: A nationwide stroke care register can be maintained with sufficient data quality to permit between-hospital performance benchmarking. Our experiences may serve as a model for other stroke registers while evaluating data quality.

  • 47. Ullberg, Teresa
    et al.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Zia, Elisabet
    Petersson, Jesper
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Norrving, Bo
    Associations between Ischemic Stroke Follow-Up, Socioeconomic Status, and Adherence to Secondary Preventive Drugs in Southern Sweden: Observations from the Swedish Stroke Register (Riksstroke)2017In: Neuroepidemiology, ISSN 0251-5350, E-ISSN 1423-0208, Vol. 48, no 1/2, p. 32-38Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Currently, the knowledge that one has on adequate stroke follow-up practices is limited. We report associations between 90-day stroke follow-up, socio-economy and adherence to secondary prevention in southern Sweden.

    METHODS: Data on 5,602 patients with ischemic stroke January 1, 2008-December 31, 2010, were obtained from Riksstroke and linked to official registers for information on education, birth country, doctor's follow-ups, and secondary prevention. Primary adherence at 4 months and persistence at 14 months post-stroke were calculated for warfarin, statins, antihypertensive, and antiplatelet drugs.

    RESULTS: The 90-day follow-up rate was 75%. Patients not receiving a 90-day follow-up had lower age-adjusted OR of persistent drug use at 14 months for antihypertensive agents (OR = 0.74, 95% CI 0.60-0.91) and for antiplatelet drugs (OR = 0.72, 95% CI 0.60-0.87). Drug adherence rates 14 months post-stroke were 85% for antiplatelet drugs, 69% for warfarin, 88% for antihypertensive agents, and 76% for statins. One in three patients discontinued using one or more drug class within 14 months, and nonadherence was associated with activities of daily living dependency at 3 months (age-adjusted OR 0.63, 95% CI 0.57-0.69), but not with age, gender, or educational status.

    CONCLUSIONS: The use of secondary preventive drugs decreases over the first year after stroke and remains suboptimal. Specific reasons for nonadherence warrant further study.

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