Study On The Burden Of Disease Of Rural Stroke Patients In Hanzhong City

Stroke severely threatens human being's health for its constant high incidence rate, mortality rate and handicap-causing rate. Enormous studies showed that the prognosis was improved little no matter how perfect the treatment had been for the stroke patients. As stroke was an important factor of death and handicap for the aged, the burden of disease of stroke would become greater for human beings with the acceleration of aging tendency in both China and the world. Therefore, it has great practical significance to understand the burden of stroke comprehensively, especially for China where rural population predominates. Based on the stroke monitor base of rural population in Hanzhong city, an study was carried out for the burden of disease of stroke for rural population. Thus it provided the basis for the development for study stroke burden and a rational allocation of future health resources.1. Study on the burden of disease of rural stroke patients (1) The distribution of incidence and mortality rate of stroke from 1983 to 2000 in Hanzhong rural areaAccording to WHO MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) project, thestroke monitor base was established in Hanzhong city in 1983. The monitored dynamic cohort consisted those local residents with 25 years old and above. The baseline of Hanzhong population was 32 064 in 1983, all of them were rural population. After the baseline investigation, a monitor site was set up in each village, charged by one standard trained monitor assisstant director. The monitor data (mainly the morbidity and mortality of stroke) were reported once a month and checked at the monitor site by special doctor at the end of each month. Cross-over checks were made by the person who in charge of each group at the end of each year. At the same time records were made for dropout person, and all the stroke dead cases were checked with the household registration section of local police station. The monitor period was from Jan. 1st, 1983 to Dec.31st, 2000, with the total of 18 years and the overall monitor population was 931185 person-year.The results showed: the average incidence and mortality rates of stroke per year were 152.9/100,000 and 115.9/100,000, respectively. The highest incidence rate was 214.9/100,000 in 1988, the lowest was 112.5/100,000 in 2000. The trend of incidence rate was declined significantly from 1983 to 2000 (PO.01) . The highest mortality rate was 157.0/100,000 in 1984, the lowest was 92.3 /100,000 in 2000. The trend of mortality rate did not decline significantly from 1983 to 2000 ( P>0.05 ) .The incidence and mortality rates of male were significantly higher than those of female (P<0.01) . The highest incidence and mortality rates of stroke were the group aged 75 years old and above. It was significantly higher than other groups. The incidence and mortality proportions were 72.5% and 75.4% respectively among stroke cases aged 65 years old and above.The results suggested that the decrease of incidence of stroke was possibly linked with the spread of prevention knowledge and people's gradually deeper realization of stroke, and there was no apparent decrease of mortality rate may be the result of backward of medical conditions in rural area. The results also indicated: the key population of stroke prevention should be people aged 65 years old and above.(2) The burden of stroke in 2003Cluster sampling was adopted in this study, 53 natural villages with the total of 75 000 monitored population were selected from the stroke monitor base of rural population in Hanzhong. The objects were all the prevalence patients of stroke from Jan. 1^st, 2003 to Dec.31^st, 2003. Together with the person in charge of monitor base, monitor director and monitor assistant director, interview plan was made. Then household interviews were carried out with self-designed questionnaire. Altogether 164 stroke cases were investigated.The questionnaire mainly included general items and disability assessment. The disability assessment included 10 items: feeding, dressing, hygienes (washing, teeth-brushing, hair-combing, shaving) , transfer, walking, threshold-stepping or stair-climbing, bathing, toliet, urinate and defecation. In the first 8 items, "fully independence" accounts for "0" , "assistance required" accounts for "0.5", "fully dependence" accounts for "0.9". In the last 2 items, "continent" accounts for "0" , "occasional accidents" accounts for "0.5", "incontinent" accounts for "0.9". Sum up the values of 10 items and divided by 10 to get the disability weighting of each case. The range of disability weighting was from 0 to 0.9.In calculating all the indexes, method of GBDCGlobal Burden of Disease) was adopted in the calculation of PYLL (Potential Yearsof Life Lost) and derived indexes, DALY (Disability-adjusted Life Years) and HeaLY (Healthy Life Years). Life expectancy was 70, the average lifetime of Shaanxi population in the calculation of PYLL. Fixed value was in accordance with the value of GBD. A new method was adopted for disability value in this study. Modified Barthel's ADL was used in this assessment of stroke patients. Disability assessment for each patient was carried out by using the value defined above.The results showed: The incidence, prevelance, mortality and fatality rates of stroke were 97.3/100 000, 218.7/100 000, 48.0/100 000 and 22.0%, respectively. The total PYLL were 220.0, among which male were 130.0 and female were 90.0 in 2003. It was the largest in 55⁵9 group.The AYLL (Average Years of Life Lost) were 6.1, among which male were 6.5 and female were 5.6. The total WPYLL (Work Years of Potential Life Lost) were 140, among which male were 82.5 and female were 57.5. It was the largest in 45⁴9 group.The average of WPYLL were 3.89 per case, among which male were 4.13 and female were 3.59. The VPYLL (Valued Years of Potential Life Lost) were —471, among which male were -278 and female were -193. It was the most in 40⁴4 group.The total PEYLL (Period Expected Years of Life Lost) were 651.92, among which male were 358.49 and female were 293.43. It was the largesr in 55⁵9 group. The total DALY were 598.88, among which YLL (years of 1ife lost) were 471.05 and YLD (years lived with disability) were 127.83, the proportion were 78.7% and 21.3%. The average DALY of stroke was 3.65 per case, and the average DALY of rural population in Hanzhong city were 8.0 per 1000 person. The HeaLY were 301.73, the proportionof death and disability were 73.5% and 26.5%.In applying DALY, the latest index of burden of disease, Barthel's ADL was first adopted. It provided a new thought for DALY's calculation method of stroke by household interview to the patients and evaluation of patients disability in the field, as well as the first adoption of DALY calculation by direct evaluation of disability.It suggested: in the burden of disease caused by stroke, males were greater than females. Male patients with 45⁴9 age group brought largest loss of life to the society. Stroke mainly threatened the lives of the aged. The burden of stroke was higher in China than in developed countries. One factor may be that the incidence and mortality rates of stroke were relatively high in our country. Another factor may be the shortcomings of formula of DALY, which caused the over-estimation of disease burden in China. The burden caused by death were higher than that caused by disability according to the reports both home and abroad. It also suggested: DALY could not totally replace traditional indexes, though as a new index, it may reflect the disease burden more comprehensive than the tarditional one. 2. The economic burden of rural stroke patients in 2003To evaluate the economic burden of stroke of the Hanzhong rural population, all 164 stroke patients were selected among 75000 natural village population in this study. After a comprehensive consideration of literature, suggestions of both doctors and patients, a local-approprated questionnaire for the direct economic burden of stroke patient was designed. It includes the cost of hospitalization, board of hospitalization, outpatient, board of outpatient, household treatment, long-term medication, employment for nursing and funeral, etc. Board of hospitalization and outpatient included all the costs such as traffic fees and board cost for the patients and caregivers.Employment cost referred to the cost spent for caregiver employment.The data were collected by household interview. The data had a skew distribution, so was described by quartile. Rank sum test was adopted in statistics test.The results showed: The direct economic burden of rural stroke was $3100 per patient in Hanzhong city. The direct economic burden of first stroke was $5500, and that of stroke was $1700. The proportion of direct economic burden below $1000 was 29.2%, and $1001^$5000 was 36.0%. The direct economic burden was 2.9 times than average income among Hanzhong rural population. The cost of hospitalization, board of hospitalization and household treatment for middle age patients were significantly higher than that of old age patients (P<0.05) .The human capital method combining with DALYs was adopted in this study. The indirect economic burden of stroke for rural population was first analyzed in China. The formula was: indirect economic burden = GNP per capita X DALYs X productivity weight. The data of DALYs mentioned above was adopted.; GNP was $ 9 036.16 in China in 2003, which showed on the website of National Bureau of Statistics. Productivity weight were difined as: 0¹4 years old valued 0.15, 15⁴4 valued 0.75, 45⁵9 valued 0.80, 60 years old and above values 0.10.The results showed: The total indirect economic burden of rural stroke was $1 993 977.8, the average of indirect economic burden of stroke was $12 158.4 per case.It suggested: The direct economic burden of stroke was huge in Hanzhong rural population. Measures should be addopted to decrease the direct economic burden of stroke in Hanzhong rural population.