Trends in stroke outcomes at hospital discharge in first-ever stroke patients: Observations from the Malaysia National Stroke Registry (2009–2017)

Published:April 10, 2019DOI:


      • There is a significant change in stroke outcomes in Malaysia.
      • The stroke deaths were declining between year 2009 and 2017.
      • The proportion of patients achieving functional independence state was increasing.
      • The trend in stroke outcomes were significant by stratum of sex.



      Stroke outcomes could be a quality indicator across the continuum of care and inform stroke management policymaking. However, this topic has rarely to date been studied directly.


      We sought to investigate recent trends in stroke outcomes at hospital discharge among first-ever stroke patients.


      This was an analysis of data from the Malaysia National Stroke Registry. Patients aged 18 years or older documented as having a first episode of stroke in the registry were recruited. Subsequently, the comparison of proportions for overall and sex-specific stroke outcomes between years (from 2009 to 2017) was conducted. The primary outcome was modified Rankin Scale score, which was assessed at hospital discharge, and each patient was categorized as follows: 1) functional independence, 2) functional dependence, or 3) death for analysis.


      This study included 9361 first-ever stroke patients. Approximately 36.2% (3369) were discharged in an independence state, 53.1% (4945) experienced functional dependence, and 10.8% (1006) patients died at the time of hospital discharge. The percentage of patients who were discharged independently increased from 23.3% in 2009 to 46.5% in 2017, while that of patients discharged in a disabled state fell from 56.0% in 2009 to 45.6% in 2017. The percentage of death at discharge was reduced from 20.7% in 2009 to 7.8% in 2017. These findings suggest that the proportions of stroke outcomes at hospital discharge have changed significantly over time (p < 0.001), and there was a significant sex-related difference in stroke outcomes at hospital discharge following first stroke episode (p < 0.001).


      Our data indicate there has been a significant change in stroke outcomes over the past nine years in Malaysia. This information ought to be considered in ongoing efforts of tertiary stroke prevention.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ministry of Health Malaysia
        Health Indicators 2017.
        Ministry of Health, Malaysia2017
        • World Health Organization
        World Health Rankings (Malaysia: Stroke).
        ([cited 2018 30 July]. Available from:)
        • Institute for Public Health
        Malaysia Burden of Disease and Injury Study 2009–2014. Kuala Lumpur.
        Institute for Public Health, Ministry of Health, 2017
        • Aziz Z.A.
        • Lee Y.Y.
        • Ngah B.A.
        • Sidek N.N.
        • Looi I.
        • Hanip M.R.
        • et al.
        Acute stroke registry Malaysia, 2010-2014: results from the National Neurology Registry.
        J. Stroke Cerebrovasc. Dis. 2015; 24: 2701-2709
        • de Campos L.M.
        • Martins B.M.
        • Cabral N.L.
        • Franco S.C.
        • Pontes-Neto O.M.
        • Mazin S.C.
        • et al.
        How many patients become functionally dependent after a stroke? A 3-year population-based study in Joinville, Brazil.
        PLoS ONE. 2017; 12e0170204
        • Feigin V.L.
        • Forouzanfar M.H.
        • Krishnamurthi R.
        • Mensah G.A.
        • Connor M.
        • Bennett D.A.
        • et al.
        Global and regional burden of stroke during 1990–2010: findings from the global burden of disease study 2010.
        Lancet. 2014; 383: 245-255
        • Nazifah S.N.
        • Azmi I.K.
        • Hamidon B.B.
        • Looi I.
        • Zariah A.A.
        • Hanip M.R.
        National Stroke Registry (NSR): Terengganu and Seberang Jaya experience.
        Med J Malaysia. 2012; 67: 302-304
        • Hwong W.Y.
        • Abdul Aziz Z.
        • Sidek N.N.
        • Bots M.L.
        • Selvarajah S.
        • Kappelle L.J.
        • et al.
        Prescription of secondary preventive drugs after ischemic stroke: results from the Malaysian National Stroke Registry.
        BMC Neurol. 2017; 17: 203
        • Aziz Z.A.
        • Sidek N.N.
        • Ngah B.A.
        • Looi I.
        • Hanip M.R.
        • Basri H.B.
        Clinical characteristics of atrial fibrillation in first-ever ischemic stroke patients; results from Malaysia National Neurology Registry.
        Internet J. Cardiovasc. Res. 2016; 5
        • Aziz Z.A.
        • Lee Y.Y.
        • Sidek N.N.
        • Ngah B.A.
        • Looi I.
        • Hanip M.R.
        • et al.
        Gender disparities and thrombolysis use among patient with first-ever ischemic stroke in Malaysia.
        Neurol. Res. 2016; 38: 406-413
        • Hwong W.Y.
        • Bots M.L.
        • Selvarajah S.
        • Aziz Z.A.
        • Sidek N.N.
        • Spiering W.
        • et al.
        Use of antihypertensive drugs and ischemic stroke severity–is there a role for angiotensin-II?.
        PLoS ONE. 2016; 11e0166524
        • Hwong W.Y.
        • Bots M.L.
        • Selvarajah S.
        • Kappelle L.J.
        • Aziz Z.A.
        • Sidek N.N.
        • et al.
        Use of a diagnostic score to prioritize computed tomographic (CT) imaging for patients suspected of ischemic stroke who may benefit from thrombolytic therapy.
        PLoS ONE. 2016; 11e0165330
        • Jaya F.
        • Win M.N.
        • Abdullah M.R.
        • Abdullah J.M.
        Stroke patterns in Northeast Malaysia: a hospital-based prospective study.
        Neuroepidemiology. 2002; 21: 28-35
        • Rameezan B.
        • Zaliha O.
        Functional status of acute stroke patients in University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia.
        Med. J. Malays. 2005; 60: 548
        • Wan-Arfah N.
        • Wan Muhamad Amir W.A.
        • Muzaimi M.
        • Mustafa M.
        • Naing N.N.
        Determinants of mortality in first-ever stroke patients in the suburban Malaysia: a retrospective hospital-based study, 2005–2011.
        Iran. J. Public Health. 2015; 44: 1291-1293
        • Institute for Public Health (IPH)
        National Health and Morbidity Survey 2015 (NHMS 2015). Volume II: Non-communicable Diseases, Risk Factors & Other Health Problems. Kuala Lumpur.
        • Ministry of Health Malaysia
        Clinical Practice Guidelines Management of Ischemic Stroke. Putrajaya.
      1. Overview of the National Neurology Registry Kuala Lumpur.
        (Available from)
        • World Health Organization
        International Statistical Classifcation of Diseases and Related Health Problems - 10th Revision. Switzerland.
        • van Swieten J.C.
        • Koudstaal P.J.
        • Visser M.C.
        • Schouten H.J.
        • van Gijn J.
        Interobserver agreement for the assessment of handicap in stroke patients.
        Stroke. 1988; 19: 604-607
        • Rodríguez-Castro E.
        • López-Dequit I.
        • Santamaría-Cadavid M.
        • Arias-Rivas S.
        • Rodríguez-Yáñez M.
        • Pumar J.M.
        • et al.
        Trends in stroke outcomes in the last ten years in a European tertiary hospital.
        BMC Neurol. 2018; 18: 164
        • RStudio Team
        RStudio: Integrated Development Environment for R.
        RStudio, Inc, Boston, MA2015
        • R Core Team
        R: A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2018
        • du Prel J.-B.
        • Hommel G.
        • Röhrig B.
        • Blettner M.
        Confidence interval or p-value?: part 4 of a series on evaluation of scientific publications.
        Dtsch. Arztebl. Int. 2009; 106: 335
        • Franke T.M.
        • Ho T.
        • Christie C.A.
        The chi-square test: often used and more often misinterpreted.
        Am. J. Eval. 2012; 33: 448-458
        • Mozaffarian D.
        • Benjamin E.J.
        • Go A.S.
        • Arnett D.K.
        • Blaha M.J.
        • Cushman M.
        • et al.
        Heart disease and stroke statistics-2016 update: a report from the American Heart Association.
        Circulation. 2016; 133: e38-360
        • Ministry of Health Malaysia
        National Strategic Plan for Non-communicable Disease.
        • Hanger H.C.
        • Fogarty B.
        • Wilkinson T.J.
        • Sainsbury R.
        Stroke patients' views on stroke outcomes: death versus disability.
        Clin. Rehabil. 2000; 14: 417-424
        • Akhavan Hejazi S.M.
        • Mazlan M.
        • Abdullah S.J.
        • Engkasan J.P.
        Cost of post-stroke outpatient care in Malaysia.
        Singap. Med. J. 2015; 56: 116-119
        • Yan L.L.
        • Li C.
        • Chen J.
        • Miranda J.J.
        • Luo R.
        • Bettger J.
        • et al.
        Prevention, management, and rehabilitation of stroke in low- and middle-income countries.
        eNeurologicalSci. 2016; 2: 21-30
        • Aziz A.F.A.
        • Nordin N.A.M.
        • Aziz N.A.
        • Abdullah S.
        • Sulong S.
        • Aljunid S.M.
        Care for post-stroke patients at Malaysian public health centres: self-reported practices of family medicine specialists.
        BMC Fam. Pract. 2014; 15: 40
        • Hiraga A.
        Gender differences and stroke outcomes.
        Neuroepidemiology. 2017; 48: 61-62
        • Petrea R.E.
        • Beiser A.S.
        • Seshadri S.
        • Kelly-Hayes M.
        • Kase C.S.
        • Wolf P.A.
        Gender differences in stroke incidence and poststroke disability in the Framingham heart study.
        Stroke. 2009; 40: 1032-1037
        • Ullberg T.
        • Zia E.
        • Petersson J.
        • Norrving B.
        Changes in functional outcome over the first year after stroke: an observational study from the Swedish stroke register.
        Stroke. 2015; 46: 389-394
        • Feigin V.L.
        • Abajobir A.A.
        • Abate K.H.
        • Abd-Allah F.
        • Abdulle A.M.
        • Abera S.F.
        • et al.
        Global, regional, and national burden of neurological disorders during 1990-2015.
        Lancet Neurol. 2017; 11: 877-897
        • Merican M.I.
        • Rohaizat Y.
        • Haniza S.
        Developing the Malaysian health system to meet the challenges of the future.
        Med. J. Malays. 2004; 59: 84-93
        • Raffiq A.
        • Abdullah J.M.
        • Haspani S.
        • Adnan J.S.
        History of neurosurgery in Malaysia.
        Malays. J. Med. Sci. 2015; 22 (Spec Issue): 5-8
        • Owolabi M.
        • Miranda J.J.
        • Yaria J.
        • Ovbiagele B.
        Controlling cardiovascular diseases in low and middle income countries by placing proof in pragmatism.
        BMJ Global Health. 2016; 1
        • Gliklich R.E.
        • Dreyer N.A.
        • Leavy M.B.
        Registries for Evaluating Patient Outcomes: A User's Guide.
        (Internet)3rd ed. Government Printing Office, 2014 (2014 Apr. 13)
        • Krumholz H.M.
        Registries and selection bias: the need for accountability.
        Circulation. 2009; 2: 517-518
        • Fang M.C.
        • Coca Perraillon M.
        • Ghosh K.
        • Cutler D.M.
        • Rosen A.B.
        Trends in stroke rates, risk, and outcomes in the United States, 1988 to 2008.
        Am. J. Med. 2014; 127: 608-615
        • Banks J.L.
        • Marotta C.A.
        Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials.
        Lit. Rev. Synth. 2007; 38: 1091-1096