Disability-adjusted life years analysis: implications for stroke research

Trends of Sex Differences and Associated Factors in Stroke Outcomes Among Patients With Acute Ischemic Stroke: 2007 to 2018

BACKGROUND AND OBJECTIVES

Female patients have been shown to experience worse clinical outcomes after acute ischemic stroke (AIS) compared with male patients. We aimed to estimate the temporal trends in the sex differences in stroke outcomes and identify risk factors contributing to the sex differences spanning 10 years in China.

METHODS

This cohort study was conducted based on data from the China National Stroke Registries (CNSRs, comprising 3 phases, I-III, from 2007 to 2018). Patients with ischemic stroke within 7 days of symptom onset were included. The primary outcome was a 12-month poor functional outcome. Other outcomes included mortality and disability-adjusted life-year (DALY) lost. The sex differences in outcomes and associated factors were estimated using multivariable logistic regression. The sex differences between CNSRs were tested by the interaction of sex and time.

RESULTS

Among 42,564 patients included, 35.4% were female. The age-adjusted event rate of 12-month poor functional outcome and mortality decreased both in male and female patients after stroke onset (CNSRs I, II, and III, all p varies over time <0.001). There was a decrease in DALY lost for both sexes over the decade (male patients: from 10.1 to 9.3 DALYs; female patients: from 10.9 to 9.6 DALYs). Female patients showed worse 12-month poor functional outcome in CNSRs I and II (odds ratio [OR] with 95% CI: 1.24 [1.10-1.39] and 1.12 [1.01-1.25], respectively) compared with male patients, but the sex difference attenuated in CNSR III (OR with 95% CI: 1.02 [0.89-1.16]), with the temporal trend (p varies over time = 0.004). The sex difference and the temporal trend of the sex difference in mortality from 2007 to 2018 were not found (p varies over time = 0.45). The most important factors attenuating the sex difference in poor functional outcome in CNSRs I and III were education level, socioeconomic deprivation, baseline stroke severity, and current smoking.

DISCUSSION

This study demonstrated that the sex disparity in poor functional outcome at 12 months was substantially narrowed covering 10 years and completely attenuated in 2015-2018. The findings suggested that female patients have experienced larger improvements in stroke outcomes than male patients over the past decade.

First application of dynamic oxygen-17 magnetic resonance imaging at 7 Tesla in a patient with early subacute stroke

Dynamic oxygen-17 (¹⁷O) magnetic resonance imaging (MRI) is an imaging method that enables a direct and non-invasive assessment of cerebral oxygen metabolism and thus potentially the distinction between viable and non-viable tissue employing a three-phase inhalation experiment. The purpose of this investigation was the first application of dynamic ¹⁷O MRI at 7 Tesla (T) in a patient with stroke. In this proof-of-concept experiment, dynamic ¹⁷O MRI was applied during ¹⁷O inhalation in a patient with early subacute stroke. The analysis of the relative ¹⁷O water (H₂¹⁷O) signal for the affected stroke region compared to the healthy contralateral side revealed no significant difference. However, the technical feasibility of ¹⁷O MRI has been demonstrated paving the way for future investigations in neurovascular diseases.

Association of Parental Cardiovascular Health With Disability-Adjusted Life Years in the Offspring: Results From the Framingham Heart Study

BACKGROUND

Disability-adjusted life years (DALYs) are used to evaluate the relative burden of diseases in populations to help set prevention or treatment priorities. The impact of parental cardiovascular health (CVH) on healthy life years lost from cardiovascular disease (CVD) in adult offspring is unknown. We compared parent-offspring CVD DALYs trends over the life course and examined the association of parental CVH with offspring CVD DALYs.

METHODS

Using data from the Framingham Heart Study, 4814 offspring-mother-father trios were matched for age at selected baseline exams. CVH score was computed from the number of CVH metrics attained at recommended levels: poor (0-2), intermediate (3-4), and ideal (5-7). CVD DALYs were defined as the sum of years of life lost and years lived with CVD. Age-sex-standardized life expectancy and disability weights were derived from the actuarial life tables and Global Burden of Disease study, respectively. Multivariable-adjusted linear regression was used to investigate the association of parental CVH with offspring CVD DALYs.

RESULTS

Over an equal 47-year follow-up, parents lost nearly twice the number of CVD DALYs compared to their offspring (23 234 versus 12 217). However, age-adjusted CVD DALYs were higher at younger ages and similar along the life course for parents and offspring. One-unit increase in parental CVH was associated with 5 healthy life months saved in offspring. Offspring of mothers with ideal versus poor CVH had 3 healthy life years saved (β=-3.0 DALYs [95% CI, -5.6 to -0.3]). No statistically significant association was found between paternal CVH categories and offspring CVD DALYs.

CONCLUSIONS

Higher maternal and paternal CVH were associated with increased healthy life years in offspring; however, the association was strongest between mothers and offspring. Investment in CVH promotion along the life course has the potential to reduce the burden of CVD in the current and future generation of adults.

Effects of Message Framing and Time Discounting on Health Communication for Optimum Cardiovascular Disease and Stroke Prevention (EMT-OCSP): a protocol for a pragmatic, multicentre, observer-blinded, 12-month randomised controlled study

INTRODUCTION

Primary prevention of cardiovascular disease (CVD) and stroke often fails due to poor adherence among patients to evidence-based prevention recommendations. The proper formatting of messages portraying CVD and stroke risks and interventional benefits may promote individuals' perception and motivation, adherence to healthy plans and eventual success in achieving risk control. The main objective of this study is to determine whether risk and intervention communication strategies (gain-framed vs loss-framed and long-term vs short-term contexts) and potential interaction thereof have different effects on the optimisation of adherence to clinical preventive management for the endpoint of CVD risk reduction among subjects with at least one CVD risk factor.

METHODS AND ANALYSIS

This trial is designed as a 2×2 factorial, observer-blinded multicentre randomised controlled study with four parallel groups. Trial participants are aged 45-80 years and have at least one CVD risk factor. Based on sample size calculations for primary outcome, we plan to enrol 15 000 participants. Data collection will occur at baseline, 6 months and 1 year after randomisation. The primary outcomes are changes in the estimated 10-year CVD risk, estimated lifetime CVD risk and estimated CVD-free life expectancy from baseline to the 1-year follow-up.

ETHICS AND DISSEMINATION

This study received approval from the Ethical Committee of West China Hospital, Sichuan University and will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04450888.

Beyond Words: Understanding Grit in Survivors of Stroke and Caregivers

Grit is defined as perseverance and long-term focus on goals. Grit may be helpful in surviving stroke for both survivors and caregivers. The purpose of this study was to investigate the level of grit among survivors of stroke and caregivers using health humanities to gain a deeper understanding of the lived experience of stroke survivors. A sample of convenience was used. Phase I (n = 22) utilized the Grit Scale survey. Phase II (n = 6) utilized phenomenological interviews. The Grit Scale survey data were analyzed with SPSS 25. Qualitative data were analyzed with the whole-parts-whole method of Giorgi, Dahlberg, Drew, and Nyström. Grit scores were high for both survivors of stroke (3.77 ± 0.50) and caregivers (3.89 ± 0.51). Themes emerging from the phenomenological interviews included: (a) gritty toughness, (b) challenges, (3) accomplishments, and (4) advice for health-care providers. Survivors of stroke and caregivers embodied high grit levels. Participants articulated the importance of long-term goals despite challenges. Understanding grit among survivors and caregivers may help clinicians develop best practices to better support these individuals.

Sex Differences in Outcome After Endovascular Stroke Therapy for Acute Ischemic Stroke

Background and Purpose- We determined the effect of sex on outcome after endovascular stroke thrombectomy in acute ischemic stroke, including lifelong disability outcomes. Methods- We analyzed patients treated with the Solitaire stent retriever in the combined SWIFT (Solitaire FR With the Intention for Thrombectomy), STAR (Solitaire FR Thrombectomy for Acute Revascularization), and SWIFT PRIME (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment) cohorts. Ordinal and logistic regression were used to examine known factors influencing outcome after endovascular stroke thrombectomy and study the effect of sex on the association between these factors and outcomes, including age and time to reperfusion. Years of optimal life after thrombectomy were defined as disability-adjusted life years and calculated by projecting disability through adjusted poststroke life expectancy by sex. Results- Among 389 patients treated with endovascular stroke thrombectomy, 55% were females, and median National Institutes of Health Stroke Scale was 17 (interquartile range, 8-28). There were no differences between females versus males in presenting deficit severity (National Institutes of Health Stroke Scale score, 17 versus 17, P=0.21), occlusion location (69% versus 64% M1, P=0.62), presenting infarct extent (Alberta Stroke Program Early CT Score 8 versus 8, P=0.24), rate of substantial reperfusion (Thrombolysis in Cerebral Infarction 2b/3, 87% versus 83%, P=0.37), onset to reperfusion time (294 versus 302 minutes, P=0.46). Despite older ages (69 versus 64, P<0.001) and higher rate of atrial fibrillation (45% versus 30%, P=0.002) for females compared with males, adjusted rates of functional independence at 90 days were similar (odds ratio, 1.0; 95% CI, 0.6-1.6). After adjusting for age at presentation and stroke severity, females had more years of optimal life (disability-adjusted life year) after endovascular stroke thrombectomy, 10.6 versus 8.5 years (P<0.001). Conclusions- Despite greater age and higher rate of atrial fibrillation, females experienced comparable functional outcomes and greater years of optimal life after intervention compared with males.

[Estimating disability-adjusted life-years for subtypes of acute ischemic stroke]

Objective To test the hypothesis that DALYs, estimated individually for each patient with acute ischemic stroke upon hospital discharge, without reperfusion therapy, are not different between the different subtypes of ischemic stroke. Patients and Methods In the Hospital Universitario de la Samaritana in Bogotá, the health records of patients diagnosed with their first acute ischemic stroke event from admission and monitoring to discharge were selected. The subtype of acute ischemic stroke was classified according to the criteria established by the Trial of Org 10172 in Acute Stroke Treatment (TOAST). DALYs were estimated for each patient with acute ischemic stroke at hospital discharge. To establish differences of DALYs among the five acute ischemic stroke subtypes (TOAST), the Kruskal Wallis test was used. Results Of the 39 cases of acute ischemic stroke, 17 (43.6 %) were classified as artherosclerosis, 10 (25.6 %) as lacunar events, 6 (15.4 %) as cardioembolic attacks, and another 6 (15.4 %) cases with unclear etiology. At hospital discharge, the estimated total DALYs provided by patients with acute ischemic stroke was 316.9 years, without statistically significant differences between the subtypes of ischemic stroke. At hospital discharge, the average of optimal years free of disability lost by a patient surviving an acute ischemic stroke was 8.12. Conclusion Non conclusive results are attributed to the concurrence of dissimilar acute clinical care processes and to the risk factors distributions, comorbidities and patient complications.

Burden of informal caregivers of stroke survivors: Validation of the Zarit burden interview in an African population

Background:

Informal care giving can be burdensome particularly where the option of institutionalized informal care scarcely exist.

Objective:

To look at the burden of informal caregivers of stroke survivors using the Zarit burden interview (ZBI).

Method:

64 stroke survivors were assessed for demographics of age, gender, duration of follow-up since discharged from in-patient care, modified Rankin score at the time of discharge and at the time of evaluation for this study and the most important informal care giver at home was also assessed for whether care giving was telling on their health or life in any negative way. All the caregivers were subsequently assessed with the ZBI.

Results:

Mean age of most important informal care givers was 40.67 ± 14.27 years and the sex distribution was 33(51.6%) female and 29(45.4%) males. 21(32.8%) reported that caregiving was a health burden. Mean ZBI scores were significantly higher (30.19 ± 14.81 vs 20.30 ± 12.96, P < 0.01) in those that reported that caregiving was telling on their health. ZBI overall rating of burden of caregiving was also significantly associated with whether caregiving was telling on the health of caregiver (P = 0.01) and also symmetrically agreed with whether the burden of caregiving was telling on health (k = 0.33, P < 0.01). The sensitivity and specificity of ZBI were 70% and 68.4% respectively on ROC statistics (AUC = 0.67, P = 0.017).

Conclusion:

Reported burden of informal caregiving of about 33% is in our opinion huge. The moderate sensitivity and specificity of the ZBI means it could be safely used in the population studied.

Quantifying Burden of Disease to Measure Population Health in Korea

Quantitative assessments of the health status of a population are essential to make decisions and set priorities in the field of public health. Changing epidemiologic patterns increase the demand for comprehensive estimates of population health across the full health spectrum, including non-communicable diseases and injuries. Burden of disease (BoD) analysis has helped meet this need. With the success of the Global Burden of Disease (GBD) Study, the BoD technique has become predominantly associated with the GBD approach and its methodology using disability-adjusted life year (DALY) has been rapidly disseminated and generally accepted over the last several years. The first Korean BoD study using the DALY metric was presented in 2002. Various BoD studies have since been conducted, but the DALY concept has remained primarily academic and has not yet been actively utilized in the health policy arena. Here, we review the DALY metric and population-based Korean BoD studies using national health data, with the intent of increasing the understanding of their value and their potential role in strengthening future assessments of the Korean population's health status.

Epidemiology of stroke and transient ischemic attacks: Current knowledge and perspectives

Because of the growing size and aging of the world's population, the global burden of stroke is increasing dramatically. Current epidemiological data indicate that 16.9 million people suffer a stroke each year, which represents a global incidence of 258/100,000/year, with marked differences between high- and low-income countries, and an age-adjusted incidence 1.5 times higher in men than in women. Although primary prevention has contributed to a decrease in stroke incidence in high-income countries, the so-called 'epidemiological transition' has led to an increase in incidence in middle-to-low-income countries as well. In addition, the incidence of ischemic stroke in young adults is on the rise, suggesting a need for specific preventative interventions in that age group. The number of stroke survivors almost doubled between 1990 and 2010, and has now reached 33 million people. According to epidemiological projections, this number will rise to 77 million by 2030. In France, the number of hospitalizations for an acute cerebrovascular event was about 138,000 in 2009, accounting for 3% of the total national health expenditure. Outcomes after stroke are frequently impaired by complications, including motor handicaps, dementia, depression, fatigue, and a high risk of early rehospitalization and institutionalization, with adverse consequences in terms of socioeconomic costs. In addition, there are 5.9 million stroke-related deaths worldwide every year. Finally, although many analytical epidemiological studies have considerably increased our knowledge of risk factors for stroke, the recent INTERSTROKE study provided evidence that 10 risk factors alone accounted for 88% of all strokes. Many of these risk factors are modifiable, which suggests that efforts should be made to promote interventions that aim to reduce the risk of stroke. A new 'mass approach' aiming to reduce the level of stroke risk factors in all people in a region, regardless of any given individual's level of risk, is currently still being developed. This interesting and innovative way to spread stroke awareness is based on the use of an internationally validated mobile-phone application that can calculate the risk of stroke for any given individual, and also contains a section to educate people on stroke warning symptoms and signs.