Health care reform and stroke prognosis in low-income Chinese populations from 1992 to 2018

BACKGROUND: To assess the impact of the health care reform on stroke prognoses among low-income Chinese residents. METHODS: Stroke events and all-cause deaths were registered during 1992-2018 in Tianjin, China. Trends in stroke management and prognoses were compared during the study periods1992-2008 and 2009-2018. RESULTS: A total of 1462 patients were diagnosed with first-ever stroke during the study periods. For patients aged ≥45 years, the rates of neuroimaging-based diagnoses and hospitalization were greater in 2009-2018 than in 1992-2008, regardless of patient sex or stroke type. Overall, the one-year case fatality rate was significantly lower in 2009-2018 than in the earlier period; the case fatality rate for women aged ≥65 years decreased by 30.0%. Between both periods, the stroke recurrence rate increased 1.9-fold, including a 2.5-fold increase in men (all P < 0.05). During the 2009-2018 period, the one-year case fatality rate was higher among elderly male patients not using medical insurance than among those using it (32.8% vs 20.7%; P = 0.050). After 2009, a significant decline in the recurrence rate (P = 0.001) and a significant increase in the hospitalization rate (P = 0.004) were observed in the interrupted time-series analysis. CONCLUSIONS: These findings suggest that the implementation of universal medical insurance for residents in urban and rural China played a major role in improving the prognoses of low-income, rural, first-ever stroke patients, especially for elderly (≥65 years old) residents. However, elderly male patients not using medical insurance benefits had a high case fatality rate. Thus, restructuring of the government medical insurance policy to facilitate its use by low-income, rural residents is crucial for reducing the stroke burden in China.