Projected burden of stroke in China through 2050 : Chinese Medical Journal

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Original Article

Projected burden of stroke in China through 2050

Yao, Minghong1,2,3; Ren, Yan1,2,3; Jia, Yulong1,2,3; Xu, Jiayue1,2,3; Wang, Yuning1,2,3; Zou, Kang1,2,3; Sun, Xin1,2,3

Editor(s): Wang, Ningning

Author Information
Chinese Medical Journal ():10.1097/CM9.0000000000002060, December 30, 2022. | DOI: 10.1097/CM9.0000000000002060

Abstract

Introduction

Stroke, a major chronic non-communicable disease, seriously endangers human health worldwide.[1] Stroke has been the leading cause of death in China since 2005, and annual stroke deaths in China account for roughly one-third of total worldwide stroke mortality.[2] The overall lifetime risk of stroke in the Chinese population is 39.3%, which is 1.6 times the average risk elsewhere in the world and ranks first among all 195 countries.[3] According to the Global Burden of Disease (GBD) 2019 report, compared with those in 1990, the crude rates in incidence, prevalence, deaths, and disability-adjusted life years (DALYs) because of stroke had increased by 86.02%, 105.99%, 32.29%, and 13.73% in China in 2019, and the corresponding number increases were 123.53%, 147.53%, 58.97%, and 36.67%, respectively.[1]

These marked increases in recent decades raise important questions about trends in the future burden of stroke in China. Diabetes, hypertension, dyslipidemia, overweight or obesity, and smoking are well established as important risk factors for stroke, and the large number of patients with the above risk factors has led to a dramatic increase in the number of people at high risk for stroke in China; moreover, the age of the population at high risk for stroke (defined as having one or more risk factors) is younger than in recent years. For example, the proportion of people aged 40 to 64 years among the newly screened high-risk population in 2018 was 73.88%.[4] Furthermore, although substantial improvements in stroke prevention, care, and management have been made, the rapid aging of the Chinese population in the coming decades may not decrease the stroke burden, in which case the absolute burden from stroke would increase rather than decrease.

Therefore, it is of utmost importance to accurately predict the trends in stroke burden to guide medium- and long-term stroke research funding allocations, health care planning, and health policy development.

Several studies have projected future trends in the stroke burden, but existing research has been primarily focused internationally,[5,6] on a specific region,[7-9] or in various developed countries.[10-12] Few studies have explored these trends in developing countries, and the need may be greatest for China, which has the highest disease burden of stroke in the world. In addition, most previous studies have given more attention to projecting stroke in terms of incidence and deaths; however, the critical need for data on prevalence and DALYs cannot be ignored.[7,9] Therefore, the study aimed to project trends associated with stroke burden in China through 2050, not only in terms of incidence and mortality but also for prevalence and DALYs. These estimated projections will provide a scientific reference for policymakers to formulate guidelines for stroke-associated health care services and preventive measures in China.

Methods

Projection models

Separate age- and sex-specific projection models, in 5-year bands (0–4, 5–9, 10–14 years, through 90–94 years, with subjects aged ≥95 years in a single group), were developed to estimate the trends in four stroke measures: incidence, prevalence, deaths, and DALYs. Each measure was modeled as a rate (per 100,000 population) using historical data for the period 1990 to 2019. Based on limited data available from recently published studies,[7,13,14] three models were employed for projections: the log-linear model,[7] the Lee-Carter model,[15] and the functional time series model.[16]

The equations for the log-linear model, the Lee-Carter model, and the functional time series model were expressed as the following Equations (1), (2), and (3), respectively:

(1)lnRa,k,i,t=Ca,k,i+β1lnYt+β2lnt
(2)lnRa,k,i,t=αa,k,i+βa,k,ikt,k,i
(3)lnRa,k,i,t=μa,k,i+m=1Mβa,k,i,t,mϕa,k,i,m

For the log-linear model, Ra,k,i,t is the rate for age group a, sex k, measure i, and year t; Ca,k,i is a constant term; Yt denotes gross domestic product (GDP) per capita in year t, and t stands for time in years. For the Lee-Carter model, αa,k,i is a static age function capturing the general shape for age group a, sex k, and measure i; kt,k,i is a time-varying index which denotes the temporal trend for sex k and measure i. For the functional time series model, μa,k,i is a measure of location of lnRa,k,i,t, ϕa,k,i,m is a set of orthonormal basis functions that are estimated by functional principal component analysis, and the m was chosen as six.[16]

The projected absolute numbers for each measure were calculated by multiplying the projected rates from 2020 to 2050 by the corresponding age-, sex-, and year-specific population projections. We also calculated the age-standardized rates in incidence, prevalence, deaths, and DALYs using the direct method of standardization and the most recent sixth China population census (2010) as a reference. We calculated the age-, sex-, and measure-specific average annual percentage changes (AAPC) in the crude rates from 2020 to 2050.

Data availability

Age-, sex-, and year-specific data for incidence, prevalence, deaths, and DALYs for stroke in China can be directly obtained from the GBD Network at http://ghdx.healthdata.org/gbd-results-tool. Historical and future GDP per-capita data were obtained from the World Bank and the Organization for Economic Co-operation and Development online toolkits.[17,18] Predicted future population data were accessed from the United Nations Department of Economic and Social Affairs/Population Division.[19] Consistent with a previous study,[7] we chose the medium-variant population assumptions in our analyses, which assumes that a decline in fertility will still be observed for most families and that mortality will continue to decline throughout the age range.

Model forecast assessment and selection

To compare the forecast accuracies of the three models, we fitted the models using only data from 1990 to 2009 to forecast outcomes for the period 2010 to 2019. We compared the projected results for 2010 to 2019 with the actual observed data for the same period. Forecast accuracy was assessed by considering the mean absolute percentage error (MAPE) and the root mean squared error (RMSE).

The results of MAPE and RMSE for each model are shown in [Supplementary Figures 1 and 2, https://links.lww.com/CM9/A985], respectively. Compared with the other models, the Lee-Carter model had lower MAPE and RMSE values for the four measures over the test period, indicating superior performance. Accordingly, the Lee-Carter model was chosen to project the trend in burden of stroke in China.

Sensitivity analysis

We conducted a sensitivity analysis that included three different scenarios for changes in age-specific rates of stroke incidence, prevalence, deaths, and DALYs (1) rates would remain stable with reference to 2019 observed rates[7]; (2) the average annual rate of change over the period 1990 to 2019 would continue over the predicted period[20]; (3) the most recent annual rate of change would continue over the predicted period. We used the joinpoint regression to model changes in rates over time, with as many as three joinpoints in the period 1990 to 2019, and the most recent annual rate change was identified from the last joinpoint to 2019.[21] Age-, sex-, and measure-specific AAPCs in the crude rates from 1990 to 2019 are shown in [Supplementary Table 1, https://links.lww.com/CM9/A985]. For the second and third scenarios, the projection formula was:(4)Ra,k,it0+t=Ra,k,it0Ca,k,i+1twhere t0 is the baseline year 2019; t is the length of the projection period, with 2020 = 1 and 2050 = 31; C is the annual rate of change observed over the period 1990 to 2019 or the most recent annual rate change from the last joinpoint to 2019; and Ra,k,it0 is the rate at time t0 for age group a, sex k, and measure i.

All analyses were conducted using R statistical software version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria).

Results

Table 1 presents the projected relative changes in incidence, prevalence, deaths, and DALYs because of stroke in China between 2019 and 2050. Although the population size is expected to remain relatively stable, the proportion of the aged population will gradually increase. In 2019, there were 3.94 million incident cases, a prevalence of 28.76 million cases, 2.19 million deaths, and 45.95 million DALYs. By 2050, the crude rates for these four measures are predicted to increase [Table 1 and Supplementary Figure 3, https://links.lww.com/CM9/A985]: 62.75% for incidence, 122.28% for prevalence, 74.62% for mortality, and 21.75% for DALYs, resulting in an additional 2.19 million incident stroke cases (55.58% increase), 34.27 million prevalent cases (119.16% increase), 1.58 million deaths (72.15% increase), and 9.21 million DALY (20.04% increase). Although the age-standardized rates substantially declined for incidence (8.94%), deaths (40.37%), and DALYs (43.47%), the age-standardized prevalence rate is predicted to increase by 10.82% [Supplementary Figure 4, https://links.lww.com/CM9/A985]. Supplementary Tables 2 and 3, https://links.lww.com/CM9/A985 show the projected changes in the four measures for females and males, respectively, in China between 2019 and 2050. The projected relative change in incidence and prevalence for females between 2019 and 2050 is greater than that for males, and the projected changes in deaths and DALYs for males are greater than those for females.

Table 1 - Changes in projected incidence, prevalence, deaths, DALYs due to stroke in China between 2019 and 2050.
Absolute values Relative change (vs. 2019)


Category 2019 2030 2050 2030 2050
Population count
 Overall 1422.35 1464.34 1402.41 1.03 0.99
 ≥ 60 years (%) 256.90 (18.06) 363.55 (24.83) 458.49 (32.69) 1.42 (1.37) 1.78 (1.81)
Incidence
 Count 3.94 4.94 (4.73, 5.17) 6.13 (5.78, 6.95) 1.25 (1.20, 1.31) 1.56 (1.47, 1.76)
 Crude rate 276.67 337.42 (322.83, 353.18) 450.28 (411.92, 495.53) 1.22 (1.17, 1.28) 1.63 (1.49, 1.79)
 Age standardized rate 217.71 208.05 (198.19, 218.67) 198.24 (184.05, 214.16) 0.96 (0.91, 1.00) 0.91 (0.85, 0.98)
Prevalence
 Count 28.76 38.12 (36.89, 39.40) 63.03 (58.69, 67.61) 1.33 (1.28, 1.37) 2.19 (2.04, 2.35)
 Crude rate 2022.02 2603.54 (2519.25, 2690.74) 4494.61 (4185.11, 4820.72) 1.29 (1.25, 1.33) 2.22 (2.07, 2.38)
 Age standardized rate 1619.78 1632.28 (1581.72, 1684.49) 1795.12 (1699.69, 1895.22) 1.01 (0.98, 1.04) 1.11 (1.05, 1.17)
Deaths
 Count 2.19 2.56 (2.33, 2.80) 3.77 (3.32, 4.28) 1.17 (1.06, 1.28) 1.72 (1.52, 1.95)
 Crude rate 153.91 174.52 (158.94, 191.20) 268.76 (236.45, 305.47) 1.13 (1.03, 1.24) 1.75 (1.54, 1.98)
 Age standardized rate 118.17 99.29 (90.31, 108.91) 70.47 (60.69, 81.72) 0.84 (0.76, 0.92) 0.60 (0.51, 0.69)
DALYs
 Count 45.95 49.61 (45.64, 53.87) 55.16 (48.45, 62.52) 1.08 (0.99, 1.17) 1.20 (1.05, 1.36)
 Crude rate 3230.51 3387.61 (3116.75, 3678.62) 3933.22 (3455.03, 4457.93) 1.05 (0.96, 1.14) 1.22 (1.07, 1.38)
 Age standardized rate 2553.18 2095.20 (1925.95, 2277.60) 1443.29 (1250.43, 1657.63) 0.82 (0.75, 0.89) 0.57 (0.49, 0.65)
Data are shown as n or n (95% cofidence interval). Count data are in millions. Rate data are in per 100,000. Age standardized rates are estimated with reference to the most recent sixth China population census (2010). DALYs indicates disability-adjusted life years.

Figure 1 illustrates the projected percentage changes in the counts of the population and stroke incidence, prevalence, deaths, and DALYs by age group in China between 2019 and 2050. The projected increase in incident and prevalent cases will be observed exclusively in those aged ≥60 years, and deaths and DALYs will be increased only among those aged ≥75 years. These four epidemio-logical measures are expected to decline among the younger age groups. Figure 2 shows the projected trends in the percentages of stroke incidence, prevalence, deaths, and DALYs by age groups in China from 1990 through 2050. As the proportion of the aged population continues to increase [Supplementary Figure 5, https://links.lww.com/CM9/A985], the percentages of all measures are expected to increase in older adults. From 2019 to 2050, the percentages of incidence, prevalence, deaths, and DALYs in the population ≥65 years are projected to increase from 59.45% to 75.98%, 56.25% to 81.76%, 81.40% to 94.41%, and 63.70% to 84.45%, respectively, with the corresponding numbers increasing from 2.34 million to 4.79 million, 16.18 million to 51.53 million, 1.78 million to 3.56 million, and 29.27 million to 46.52 million, respectively.

F1
Figure 1:
Projected changes in population, incidence, prevalence, deaths, and DALYs count by age groups in China (2050 vs. 2019). DALYs: Disability-adjusted life years. Stable: rates would remain stable with reference to 2019 observed rates; observed: the average annual rate of change over the period 1990 to 2019 would continue over the predicted period; latest: the most recent annual rate of change would continue over the predicted period.
F2
Figure 2:
Historical and projected trends in the proportions of stroke incidence, prevalence, deaths, and DALYs by age group in China from 1990 to 2050. DALYs: Disability-adjusted life years.

Table 2 presents the estimated AAPCs in the crude rates of incidence, prevalence, deaths, and DALYs in China during the period 2020 to 2050. The crude incidence, prevalence, mortality, and DALYs rates are projected to decrease in all age groups, with the exceptions that the incidence and prevalence are expected to increase in the women aged 60 to 79 years and in both sexes aged ≥60 years, respectively. For all age groups considered together, the crude incidence, prevalence, deaths, and DALYs rates are expected to increase in both sexes.

Table 2 - Projected average annual percent change in the crude rates of incidence, prevalence, deaths, and DALYs in China during 2020 to 2050.
Incidence change (%) Prevalence change (%) Deaths change (%) DALYs change (%)




Ages (year) Female Male Female Male Female Male Female Male
0–4 –0.61 –0.41 –3.35 NA –10.65 –10.25 –9.69 –9.68
5–9 –0.40 –0.30 –1.02 –1.94 –5.46 –4.46 –3.75 –3.78
10–14 –0.32 –0.20 –0.46 –1.40 –4.02 –3.09 –2.11 –2.16
15–19 –0.59 –0.27 –0.48 –1.20 –2.82 –2.77 –1.79 –2.42
20–24 –1.14 –0.37 –0.36 –0.69 –2.98 –1.33 –2.03 –1.15
25–29 –1.51 –0.30 –0.50 –0.43 –4.29 –0.62 –2.88 –0.59
30–34 –1.73 –0.33 –0.70 –0.36 –4.28 –0.40 –3.23 –0.40
35–39 –1.89 –0.40 –0.95 –0.34 –3.99 –0.88 –3.23 –0.86
40–44 –1.76 –0.47 –1.01 –0.39 –4.11 –1.33 –3.51 –1.27
45–49 –1.60 –0.47 –1.01 –0.31 –4.51 –1.36 –3.99 –1.26
50–54 –0.74 –0.31 –0.85 –0.23 –4.28 –2.24 –3.87 –2.15
55–59 –0.09 –0.17 –0.43 –0.05 –3.73 –2.37 –3.26 –2.27
60–64 0.19 –0.14 0.10 0.17 –3.16 –1.95 –2.76 –1.87
65–69 0.28 –0.14 0.43 0.43 –2.86 –1.91 –2.49 –1.85
70–74 0.18 –0.14 0.71 0.83 –2.63 –1.82 –2.38 –1.85
75–79 0.02 –0.14 1.06 1.39 –2.17 –1.52 –1.95 –1.56
80–84 –0.78 –0.51 1.32 1.88 –1.75 –1.25 –1.61 –1.34
85–89 –1.99 –1.04 1.48 2.14 –1.98 –0.52 –2.02 –0.53
90–94 –2.96 –1.39 1.46 1.85 –2.00 –0.54 –2.20 –0.60
95+ –3.74 –1.60 0.98 1.09 –1.71 –1.28 –2.00 –1.52
All age 1.84 1.83 2.98 2.84 1.68 2.47 0.60 1.09
DALYs indicates disability-adjusted life years, all results are statistically significant. NA: Not available.

Figure 3 shows the predicted trajectories of stroke in terms of incidence, prevalence, deaths, and DALYs under different scenarios in China from 2020 to 2050. Under the baseline scenario, the total incidence, prevalence, deaths, and DALYs in 2050 are projected to be 7.05, 48.99, 5.88, and 91.20 million, respectively. If the crude rate trends from 1990 to 2019 were to continue for the 31 years until 2050, the projected total incidence, prevalence, deaths, and DALYs would be 6.49, 65.17, 3.80, and 57.86 million, respectively. If the observed recent trends continue over the forecast period, the projected total numbers in incidence, prevalence, deaths, and DALYs would be 6.63, 66.96, 2.92, and 49.25 million, respectively.

F3
Figure 3:
Projected future trends in stroke incidence, prevalence, deaths, and DALYs under different scenarios in China from 2020 to 2050. Note: “stable,”“observed,” and “latest” refer to scenarios 1, 2, and 3, respectively; detailed information can be found in the Methods section. DALYs indicates disability-adjusted life years.

Discussion

In the present study, based on international and standardized datasets, we applied the Lee-Carter model to create comprehensive projections of future trends in stroke burden through 2050 in China. We predicted that between 2019 and 2050, the absolute numbers of incident cases, deaths, and DALYs in China will increase by 55.58% (from 3.94 million to 6.13 million), 72.15% (from 2.19 million to 3.77 million), and 20.04% (from 45.95 million to 55.16 million), respectively; however, the corresponding age-standardized rates will decline. The prevalence of stroke is expected to increase by 119.16% (from 28.76 million to 63.03 million) and 10.82% (from 1619.78 to 1795.12 per 100,000 persons) in terms of absolute numbers and age-standardized rates, respectively.

Our results show that the incidence of stroke will increase substantially. In other projections of stroke in terms of incidence, several studies conducted in developed countries and regions have also predicted increases.[11,12,22] For example, Wafa et al [7] anticipated that 40,000 additional incident strokes would occur in the European Union in 2047 compared with the number of strokes in 2017. Current research predicts a 55.58% increase in stroke events in China in 2050 compared with the number of stroke events in 2019, with a corresponding number of 2.19 million. This projected increase is attributable in part to the increases in incidence rate for some age groups (e.g., women aged 60–79 years). Another important contributor is the aging of the population; although incidence rates are projected to decline in nearly all age groups, those improvements are not sufficient to completely reverse the increase in new stroke cases. For example, the proportion of the population aged >65 years is projected to increase from 12.54% in 2019 to 26.07% in 2050, and the corresponding proportion of new stroke patients is projected to increase from 59.45% to 75.98%. Furthermore, we observed that in 2050, the number of new stroke cases among people aged ≥60 years is projected to be greater than the number in 2019, with fewer new stroke cases for people aged <60 years than in 2019. The same phenomenon has been observed over the past 3 decades; from 1990 to 2019, the proportion of people aged >65 years increased from 5.42% to 12.54%, and the proportion of new stroke patients aged >65 years increased from 48.53% to 59.44%.[23]

The number of stroke survivors will also increase substantially. In addition, unlike mortality, crude prevalence rates are expected to increase in the age group ≥60 years. By 2050, 4.07% of the population in China is projected to have had a stroke, an increase of 101.49% compared with the percentage in 2019 (2.02%). The rapid increase in the number of stroke survivors may be explained as follows: First, the increasing number of new strokes in the aging population has increased the number of stroke patients to some extent. For example, we projected that the number of new stroke incidents in persons aged ≥65 years will rise from 2.34 million in 2019 to 4.79 million in 2050, whereas the number of new strokes in persons aged <65 years will decline from 1.60 million to 1.34 million. Second, as more and more advanced technologies are used in the treatment, management, and secondary prevention of stroke, the probability of surviving a stroke will be further increased. Over recent decades, along with the growing economy, China has increased its investment in health care and carried out in-depth reform of the health care system, which has improved the diagnosis and treatment of stroke and access to stroke care.[24] For example, by the end of 2018, a total of 437 stroke centers had been established in China, covering 29 provinces, 196 prefecture-level cities, and 352 counties.[4] In addition, improving the quality of stroke care has become a national priority,[25] and secondary prevention programs have made noticeable progress since the coordinated action in this field began in 2000.[26-32] However, we must observe that the large increase in the number of stroke survivors, especially those aged >65 years, will lead to a correspondingly large increase in the demand for stroke-related rehabilitation and long-term care, leading in turn to an increase in workload and financial burden for the working population aged 15 to 64 years.[7]

Regarding stroke deaths, our findings are not uniformly consistent with the results of existing studies. Several studies carried out in developed countries have predicted that the number of deaths from stroke will decline.[7,33] For China, one international study predicted that the number of stroke deaths will fall from 1.79 million in 2016 to 1.64 million in 2040[6]; differences in prediction methods likely explain such disparities. Although the projection methods used in this study have been rigorously evaluated, given the scarcity of data, we did not consider major stroke risk factors such as hypertension and smoking[6,13,14]; all predictions were based on observed stroke mortality data, and more complex models are needed to further explore the performance of the prediction. According to our results, stroke mortality should decrease in all age groups, which is consistent with the results observed from 1990 to 2019, but the total deaths will nonetheless increase by 72.15%. The main reason for this predicted increase in stroke deaths is the increase in the proportion of the population that is aged or elderly. Our study projects the proportion of stroke deaths in persons aged >65 years to increase from 81.40% in 2019 to 94.42% in 2050, with the corresponding increase in number from 1.78 million in 2019 to 3.56 million in 2050, whereas deaths from stroke in those aged <65 years are projected to decline from 0.41 million to 0.21 million.

More effective ways to reduce the burden of stroke should be considered, especially for older adults. During recent decades, the crude and age-standardized rates of stroke in incidence, mortality, and DALYs have fallen in almost all age groups in China, suggesting that substantial improvements in stroke prevention, management, and health care have been made.[29,34] However, the burden of stroke has increased significantly in China, suggesting that these improvements have not yet fully reversed the increased burden of stroke due to the aging population.[1] Goal 3.4 of the United Nations Sustainable Development Goals aims for premature mortality from non-communicable diseases to be reduced by one-third by 2030 compared with that in 2015[35]; in addition, the Healthy China 2030 plan states that premature mortality from major chronic diseases will be reduced by 30% in 2030 compared with that in 2015.[36] As an important chronic non-communicable disease, reducing the burden of stroke will play an pivotal role in achieving both the Sustainable Development Goals and Healthy China 2030 plan objectives. In the current study, if we assumed that the declines in rates observed in the past were to continue over the next three decades, the predicted burden of stroke would increase substantially, and the percentage of the burden in older adults would increase significantly. In addition, even if the most recent declines in rates were to continue over the prediction period, the burden of stroke would also be predicted to increase substantially. Furthermore, although China changed its one-child policy in 2016 and introduced a three-child policy in 2021, the aging trend is unlikely to be reversed in the near future. All of these factors suggest that better stroke prevention strategies must be developed, and continued effort is needed to address the anticipated surge in the burden of stroke, specifically in older adults.

Our study has some limitations. First, the prediction model was constructed without considering risk factors related to stroke (such as hypertension, diabetes, hyperlipidemia, and smoking) because of the scarcity of related data. These risk factors can be expected to significantly affect the incidence, treatment, and prognosis of stroke. Future studies should use more comprehensive projection models that account for the impact of these factors. Second, given the inconsistent availability of data, this study did not consider the differences in the disease burden of stroke in different provinces. More research is needed to explore trends in the burden of stroke in different provinces, so as to develop targeted prevention and control measures at the provincial level. Third, because China has recently implemented a three-child policy, the future proportion of the population that is aged may be lower than that upon which the results of this study were derived; therefore, our projections related to this proportion may be overestimated.

Although substantial improvements in stroke prevention, treatment, management, and health care practices have been made in recent decades, as the aging of the Chinese population continues to accelerate, China will face increasing challenges in stroke care and prevention. The absolute burden of stroke is expected to continue to increase over the next 30 years in China, particularly among older adults. More effective stroke prevention and treatment strategies are thus needed to anticipate and if possible to lessen this burden.

Funding

This study was supported by National Key R&D Program of China (Nos. 2019YFC1709804 and 2017YFC1700406), National Natural Science Foundation of China (Grant No. 72004149), China Medical Board (Grant No. CMB19–324), Sichuan Youth Science and Technology Innovation Research Team (No. 2020JDTD0015), and 1·3·5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (No. ZYYC08003).

Conflicts of interest

None.

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Keywords:

Projections; Incidence; Prevalence; Mortality; Disability-adjusted life years; Stroke

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