How does health care system performance differ for stroke among 17 industrialized countries?

The issue

The burden from stroke in developed countries is large, both in terms of disease burden and health system costs. Meanwhile, general health care expenditures continue to grow with little evidence demonstrating the best value for resources invested. There is considerable variation in treatment trends and health outcomes for the same disease in different countries. This report focused on stroke, with its high prevalence and high cost among older people. It analysed issues that affect health system performance, including economic incentives, policies, prevention and treatment efforts, costs and health outcomes.


The results showed variations across the whole continuum of care among 17 countries from the Organisation for Economic Co-operation and Development (OECD) that participated in the study. Variations in health care were apparent in the prevention of stroke, the hospitalization of stroke patients and the frequency of diagnostic tests. First, in the area of prevention, countries differed in their approaches, their areas of emphasis and their success in reducing the risk of stroke by addressing its major determinants, including smoking and high blood pressure. It is widely acknowledged that countries that succeed in reducing the numbers of smokers in their population are likely to see improvements in stroke outcomes fairly quickly, as the evidence shows that quitting has both an immediate and a long-term effect on health outcomes and costs. Effective control of high blood pressure is another important component of stroke prevention, with drug treatment a major focus of this aspect of care.

Second, there appeared to be a strong link between hospitalization for ischaemic stroke and its corresponding incidence rate. There is, however, more of a discretionary element, and variation among countries, around the decision to admit patients with a “temporary” stroke event (known as a transient ischaemic attack, or TIA) to hospital. Third, differences were also observed in health outcomes, with some countries having higher case fatality rates than others. Finally, some countries clearly had higher expenditures on stroke care.

These results have clear implications for how health care systems treat stroke, showing that some countries may be treating stroke more efficiently, especially given the fact some countries had higher expenditures but relatively poor outcomes.

The reasons for these variations are not straightforward. Moreover, conclusions about the links between variations in treatments, costs and outcomes cannot be made without more information about the relative severity of cases being treated. Nonetheless, the broad patterns found in this study reflect those found in other published studies.

Policy considerations

These results suggest there is room for improving the performance of health care systems in relation to stroke treatment. It identified two key implications. First, there is apparent benefit from a broad-based approach to managing stroke that includes prevention, acute care and rehabilitation. Second, the organization of treatment is a significant aspect of high-quality stroke care, and there appears to be specific benefit in using specialized stroke units – a benefit that may not be fully realized in most countries.

Type of evidence

Analysis of national (or proxy) information extracted from existing national databases (e.g. mortality, hospital records, health costs), using standardized questionnaires and data specification.

The views expressed in this summary are based on a publication of a HEN Network member agency and do not necessarily represent the decisions or stated policy of WHO/Europe.