title: Trends in stroke rates, risk, and outcomes in the United States, 1988 to 2008.
abstract: BACKGROUND
  Stroke is a major cause of morbidity and mortality. We describe trends in the incidence, outcomes, and risk factors for stroke in the US Medicare population from 1988 to 2008.
  
  
  METHODS
  We analyzed data from a 20% sample of hospitalized Medicare beneficiaries with a principal discharge diagnosis of ischemic (n = 918,124) or hemorrhagic stroke (n = 133,218). Stroke risk factors were determined from the National Health and Nutrition Examination Survey (years 1988-1994, 2001-2008) and medication uptake from the Medicare Current Beneficiary Survey (years 1992-2008). Primary outcomes were stroke incidence and 30-day mortality after stroke hospitalization.
  
  
  RESULTS
  Ischemic stroke incidence decreased from 927 per 100,000 in 1988 to 545 per 100,000 in 2008, and hemorrhagic stroke decreased from 112 per 100,000 to 94 per 100,000. Risk-adjusted 30-day mortality decreased from 15.9% in 1988 to 12.7% in 2008 for ischemic stroke and from 44.7% to 39.3% for hemorrhagic stroke. Although observed stroke rates decreased, the Framingham stroke model actually predicted increased stroke risk (mean stroke score 8.3% in 1988-1994, 8.8% in 2005-2008). Statin use in the general population increased (4.0% in 1992, 41.4% in 2008), as did antihypertensive use (53.0% in 1992, 73.5% in 2008).
  
  
  CONCLUSIONS
  Incident strokes in the Medicare population aged ≥65 years decreased by approximately 40% over the last 2 decades, a decline greater than expected on the basis of the population's stroke risk factors. Case fatality from stroke also declined. Although causality cannot be proven, declining stroke rates paralleled increased use of statins and antihypertensive medications.
authors.affiliation: Division of Hospital Medicine, University of California, San Francisco. Electronic address: mfang@medicine.ucsf.edu.
authors.forename: Margaret C
authors.initials: MC
authors.lastname: Fang
authors.affiliation: Department of Health Studies, University of Chicago, Ill.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Coca Perraillon
authors.affiliation: National Bureau of Economic Research, Cambridge, Mass.
authors.forename: Kaushik
authors.initials: K
authors.lastname: Ghosh
authors.affiliation: Department of Economics, Harvard University, Cambridge, Mass; National Bureau of Economic Research, Cambridge, Mass.
authors.forename: David M
authors.initials: DM
authors.lastname: Cutler
authors.affiliation: Department of Quantitative Health Sciences and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester; National Bureau of Economic Research, Cambridge, Mass.
authors.forename: Allison B
authors.initials: AB
authors.lastname: Rosen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology* / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: Antihypertensive medications; Hemorrhagic stroke; Ischemic stroke; Mortality; Outcomes; Risk; Statins; Stroke; Trends