Original Contribution

Declining Rate and Severity of Hospitalized

Stroke From 2004 to 2013
The National Acute Stroke Israeli Registry
Silvia Koton, PhD; Diklah Geva, PhD; Jonathan Y. Streifler, MD; Sagi Harnof, MD;
Yoav Pougach, MD; Olga Azrilin, MD; Shoshana Hadar, MD; Natan M. Bornstein, MD;
David Tanne, MD

Background and Purpose—Stroke is a leading cause of morbidity and disability. We assessed trends in rates of hospitalized
stroke and stroke severity on admission in a prospective national registry of stroke from 2004 to 2013.
Methods—All 6693 acute ischemic strokes and intracerebral hemorrhage in the National Acute Stroke Israeli participants
≥20 years old were included. Data were prospectively collected in 2004 (February–March), 2007 (March–April), 2010
(April–May), and 2013 (March–April). Rates of hospitalized stroke from 2004 to 2013 were studied using generalized
linear models assuming a quasi-Poisson error distribution with a log link. Stroke severity on admission was determined
Downloaded from http://stroke.ahajournals.org/ by guest on May 3, 2018

using the National Institutes of Health Stroke Scale score and trends were studied. Analysis was performed for stroke
overall and by sex and age-group as well as by stroke type.
Results—Estimated average annual rates of hospitalized stroke decreased from 24.9/10 000 in 2004 to 19.5/10 000 in 2013.
The age and sex-adjusted rates ratio (95% confidence interval) for hospitalized stroke overall was 0.82 (0.76–0.89) for
2007, 0.71 (0.65–0.77) for 2010, and 0.72 (0.66–0.78) for 2013 compared with 2004. Severity on admission decreased
over time: rates (95% confidence interval) of severe stroke (National Institutes of Health Stroke Scale score of ≥11)
decreased from 27% (25%–29%) in 2004 to 19% (17%–21%) in 2013, whereas rates (95% confidence interval) of
minor stroke (National Institutes of Health Stroke Scale score of ≤5) increased from 46% (44%–49%) in 2004 to 60%
(57%–62%) in 2013 (P<0.0001). Findings were consistent by sex, age-group, and stroke type.
Conclusions—Based on our national data, rates of hospitalized stroke and severity of stroke on admission have decreased
from 2004 to 2013 overall and by stroke type, in men and women. Despite the observed declines in rates and severity,
stroke continues to place a considerable burden to the Israeli health system.   (Stroke. 2018;49:00-00. DOI: 10.1161/
STROKEAHA.117.019822.)
Key Words: cause of death ◼ incidence ◼ linear models ◼ registries ◼ severity ◼ stroke ◼ trends

R ates of stroke hospitalizations and stroke severity are

important factors associated with the burden of stroke
on health systems. Stroke incidence has been decreasing in
the last decades,1–5 however, reports on trends in stroke inci-
dence rates are mainly based on specific communities or sub-
populations. In the United States, a 40% decrease in incident
strokes was reported from 1988 to 2008 among ≥65 years old
Medicare beneficiaries.6 Rates of hospitalization for ischemic
stroke in fee-for-service Medicare patients ≥65 years of age,
adjusted for age, sex and race, declined by 33.6%, from 1999
to 2011.7 Decreasing age-adjusted stroke hospitalization rates
have been shown in subjects ≥25 years old in Denmark during
1997 to 2009,8 however, reports on trends in stroke based on
national data are scarce.
Reports on trends in stroke severity are not consistent: an
analysis of data in the Framingham Study original and off-
spring cohorts did not show decreases in severity in the last 50
years.9 Data from the Swedish Stroke Register from 1995 to
2008 show that stroke severity remained stable in women but
declined in men.10 Although a significant decrease in stroke
severity in the last decade has been reported based on findings
from the Austrian Stroke Unit Registry11 as well as in Japan.12
The global burden of stroke as a leading cause of death and
physical and cognitive long-term disability in adult populations

Received October 20, 2017; final revision received March 19, 2018; accepted March 30, 2018.
From the Stanley Steyer School of Health Professions (S.K.) and Sackler Faculty of Medicine (S.K., J.Y.S., N.M.B., D.T.), Tel Aviv University, Israel;
Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel (D.G., D.T.); Neurology Unit (J.Y.S.) and Department of Neurosurgery (S. Harnof), Rabin
Medical Center, Petah Tikva, Israel; Tel Aviv Sourasky Medical Center, Israel (Y.P.); Nahariya Medical Center, Israel (O.A.); Laniado Medical Center,
Netanya, Israel (S. Hadar); and Shaare Zedek Medical Center, Jerusalem, Israel (N.M.B).
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.
117.019822/-/DC1.
Correspondence to Silvia Koton, PhD, Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978,
Israel. E-mail koton@tauex.tau.ac.il
© 2018 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.117.019822

1
 2  Stroke  June 2018
is significant.13 National stroke registries play an increasingly
important role in the assessment of stroke care.14 The study
of temporal trends in stroke based on unbiased data collected
in national registries, with comprehensive information on
patient-level sociodemographic and clinical data, is essential
for designing preventive strategies and reducing stroke-related
costs. We hypothesized that both rates and severity of hospi-
talized acute stroke have decreased in Israel in the last decade
and studied temporal trends in rates of hospitalized stroke and
stroke severity from 2004 to 2013 in a prospective national
registry of acute stroke patients to test our hypothesis.
Materials and Methods
The data that support the findings of this study are available from the
corresponding author on reasonable request.
Study Setting
The National Acute Stroke Israeli (NASIS) registry is a prospective
hospital-based nationwide project including all patients ≥18 years
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old hospitalized with acute ischemic stroke, intracerebral hemorrhage
(ICH), and transient ischemic attack, in all hospitals admitting acute
stroke patients in Israel. Starting in 2004, data have been collected
triennially during 2-month periods.15,16 The present analysis on hos-
pitalized stroke trends over time includes all 6693 patients aged ≥20
years with acute stroke in 4 periods of NASIS during 2004 (February–
March), 2007 (March–April), 2010 (April–May), and 2013 (March–
April). Trends of stroke severity were studied in 6678 (99.8%) patients
with available data on stroke severity. The study was approved by the
institutional ethical committees of participating hospitals.
Data Collection
At each hospital, a coordinating physician was in charge of collect-
ing data in all wards and on each patient admitted with a cerebro-
vascular event. Coordinating investigators underwent a workshop
before each period of data collection. A central adjudication commit-
tee was available for the coordinator to consult if there were doubts
about diagnoses or classification of events. A questionnaire specially
designed for the NASIS registry was used for data collection. Strokes
that occurred in the hospital were included. Data were checked for
completeness and consistency at a central coordinating center, based
on the discharge medical reports and through computerized data que-
ries. Ischemic stroke and ICH were differentiated by brain imaging
(computed tomography or magnetic resonance imaging), and unde-
termined stroke was reported in 107 cases (1.6%) with no available
data on brain imaging. In cases in which there was doubt about the
diagnosis, the decision was made by a central adjudication commit-
tee. Stroke severity was determined using the National Institutes of
Health Stroke Scale (NIHSS) score,17 and the modified Rankin Scale
was used for evaluation of prestroke functional status.18 Hypertension
was defined by history or use of antihypertensive agents or systolic
blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg
before stroke occurrence; diabetes mellitus by history or use of oral
hypoglycemic agents, insulin or fasting blood glucose >126 mg/dL,
and dyslipidemia by history or use of antihyperlipidemic agents or
a serum cholesterol level >200 mg/dL or LDL-C (low-density lipo-
protein cholesterol) >130 mg/dL or HDL-C (high-density lipoprotein
cholesterol) <40 mg/dL or triglycerides >200 mg/dL. Atrial fibrilla-
tion was either diagnosed during hospitalization or by the history of
chronic or paroxysmal atrial fibrillation. Prior heart disease included
chronic heart failure, prior myocardial infarction, angina pectoris, or
valve disease.
Outcome Variables
We studied temporal trends from 2004 to 2013 in rates of hospitalized
stroke and in stroke severity by the NIHSS score. The NIHSS has
high inter-rater reliability in both hospital and community settings.19
We categorized severity as NIHSS score of ≤5, NIHSS score of 6 to
10, NIHSS score of 11 to 15, NIHSS score of 16 to 20, and NIHSS
score of >20. Severe stroke was defined as NIHSS score of ≥11.
Trends were studied for all hospitalized stroke and by stroke type,
age, and sex.
Statistical Analysis
Characteristics of the participants were presented by NASIS period.
ANOVA was used for comparison of age between periods. Trends in
the distribution of sex, risk factors, comorbidities, stroke type, and
severity were studied using the Mantel–Haenszel χ2 test and P for
trend was presented.
Rates of hospitalized strokes per 10 000 population by NASIS
period overall and by stroke type are shown. For the estimated aver-
age annual rates, the numerators were computed multiplying by 6
the number of hospitalizations in each 2-month NASIS period, and
the denominators were the age- and sex-specific Israeli population as
listed by the Central Bureau of Statistics (Israel). We used generalized
linear models assuming a quasi-Poisson error distribution with a log
link to obtain the rates curves over age along with 95% confidence
intervals (CIs). Rate ratio (95% CI) for hospitalization in NASIS
2007, 2010, and 2013 compared with 2004 controlling for sex and
age were presented.
Trends in stroke severity from 2004 to 2013 were studied by stroke
type, sex, and age-group. Distribution of stroke severity categories
by NASIS period was compared with the χ2 test. Logistic regression
models for severe stroke for NASIS 2007, 2010, and 2013 compared
with 2004 were produced adjusting for potential risk factors. Three
models were produced: model 1 including NASIS period, age, and
sex; model 2 including variables in model 1 as well as stroke type
and vascular risk factors (hypertension, atrial fibrillation, diabetes
mellitus, dyslipidemia, and current smoking), and model 3 adding
preexisting cardiovascular disease (heart disease, prior stroke, and
peripheral arterial disease). All tests were 2-sided and P<0.05 was
considered significant. Analyses were performed with SAS 9.4 (SAS
Institute Inc, Cary, NC) and R (R Core Team 2015, R: A language and
environment for statistical computing. R Foundation for Statistical
Computing, Vienna, Austria. https://www.R-project.org/).
Results
Baseline Characteristics of Patients
In total, 6693 hospitalized strokes were included, 55% men.
The mean (SD) age of participants was 70.9 (13.1) years.
Ischemic stroke was diagnosed in 5956 (89.0%) cases,
whereas ICH was reported for 631 (9.4%) and undetermined
stroke type was reported for 106 (1.6%).
Distribution of characteristics by registry period is presented
in Table 1. Mean age decreased from 71.5 years in 2004 to
70.4 years in 2007 and afterward increased to 70.6 in 2010 and
71.3 in 2013. No significant trend over time was observed in
the distribution of sex. Rates of reported hypertension, diabe-
tes mellitus, dyslipidemia, and atrial fibrillation on admission
increased while the prevalence of heart disease decreased over
time. Prestroke statin use increased from 28% in 2004 to 52%
in 2013. Anticoagulant treatment among patients with atrial
fibrillation increased, but there was no clear trend in rates over
time. The distribution of stroke type was similar throughout
the NASIS periods, although rates of undetermined stroke
decreased. Rates of total anterior circulation ischemic stroke
decreased from 11% in 2004 to 7% in 2013.
Trends in Hospitalized Stroke Rates
Number of hospitalized stroke during NASIS periods was
1791 in 2004, 1670 in 2007, 1559 in 2010, and 1678 in 2013
 Koton et al   Declining Rate and Severity of Hospitalized Stroke   3

Table 1.  Baseline Characteristics of Patients With Acute Stroke in the NASIS Registry, by Time Period, n=6693
NASIS Registry Period
2004 2007 2010 2013
n=1790 n=1669 n=1557 n=1677 P for Trend
Demographic characteristics
 Age, mean (SD), y 71.46 (12.42) 70.38 (13.05) 70.55 (13.92) 71.26 (13.08) 0.041
 Men 972 (54.30) 939 (56.26) 823 (52.86) 956 (57.01) 0.36
Risk factors and comorbidity
 Hypertension 1350 (76.40) 1309 (78.43) 1251 (80.35) 1349 (81.12) 0.0003
 Dyslipidemia 701 (39.16) 968 (58.00) 1013 (65.06) 1062 (63.33) <0.0001
 Statin use on admission 483 (28.00) 707 (44.27) 756 (49.03) 841 (51.98) <0.0001
 Current smoking 310 (17.93) 335 (20.40) 344 (22.16) 333 (20.26) 0.045
 Peripheral artery disease 146 (8.53) 101 (6.15) 82 (5.28) 99 (5.94) 0.013
 Prior stroke 514 (29.37) 513 (30.76) 424 (27.28) 452 (27.56) 0.077
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 Prior disability (mRS≥2) 617 (35.38) 543 (33.64) 423 (27.59) 522 (32.10) 0.002
 Diabetes mellitus 719 (41.16) 673 (40.37) 637 (40.99) 757 (45.36) 0.014
 Atrial fibrillation 315 (18.38) 342 (20.54) 305 (19.60) 366 (21.94) 0.024
 Anticoagulant treatment among patients 108 (36.12) 144 (43.90) 109 (36.21) 139 (38.61) 0.95
with atrial fibrillation
 Prior heart disease 592 (33.75) 537 (32.19) 525 (33.74) 466 (27.87) 0.0013
 Prestroke dementia 159 (9.32) 158 (10.08) 150 (9.75) 193 (11.87) 0.027
 Type of stroke 0.069
  
Ischemic stroke 1555 (86.87) 1486 (89.04) 1399 (89.85) 1516 (90.40)
  
Intracerebral hemorrhage 158 (8.83) 172 (10.31) 151 (9.70) 150 (8.94)
  
Undetermined 77 (4.30) 11 (0.66) 7 (0.45) 11 (0.66)
Total anterior circulation ischemic stroke 163 (10.62) 112 (7.54) 84 (6.02) 111 (7.40) 0.0003
Figures represent a number of patients and percentage unless otherwise specified. Hypertension by history or use of antihypertensive agents or systolic blood
pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg; diabetes mellitus by history or use of oral hypoglycemic agents, insulin or fasting blood glucose >126
mg/dL, and dyslipidemia by history or use of antihyperlipidemic agents or a serum cholesterol level >200 mg/dL or LDL-C >130 mg/dL, or HDL-C <40 mg/dL, or
triglycerides >200 mg/dL. Prior heart disease included chronic heart failure, prior myocardial infarction, angina pectoris or valve disease, and atrial fibrillation was either
diagnosed during hospitalization or by the history of chronic or paroxysmal atrial fibrillation. HDL-C indicates high-density lipoprotein cholesterol; LDL-C, low-density
lipoprotein cholesterol; mRS, modified Rankin Scale; and NASIS, National Acute Stroke Israeli.

with average 2-month rates decreasing from 4.2/10 000 in
2004 to 3.3/10 000 in 2013. Estimated average annual rates
were 24.9/10 000 in 2004, 22.0/10 000 in 2007, 19.1/10 000
in 2010, and 19.5/10 000 in 2013. Temporal trends in rates
are shown in Figure 1. Trends in sex-specific rates over time
are presented on Figures I and II in the online-only Data
Supplement. The age- and sex-adjusted rate ratio (95% CI)
for hospitalized stroke associated with one calendar year
was 0.96 (0.95–0.97), P<0.0001, for all strokes; 0.97 (0.96–
0.98), P<0.0001 for ischemic stroke; and 0.95 (0.93–0.97),
P<0.0001 for ICH (Figure 2). The decrease in rates over
time is steeper in older age-groups compared with younger
ages (Figure 1; Figures I and II in the online-only Data
Supplement).
Trends in Stroke Severity on Admission
Overall, rates (95% CI) of severe stroke (NIHSS score of ≥11)
decreased from 27% (25% to 29%) in 2004 to 19% (17%
to 21%) in 2013, whereas rates (95% CI) of minor stroke
(NIHSS score of ≤5) increased from 46% (44% to 49%) in
2004 to 60% (57% to 62%) in 2013 (P<0.0001; Figure 3A).
Increasing rates of minor stroke over time was found both
in men and women (Figure III in the online-only Data
Supplement) and in the various age-groups (Figures IV in the
online-only Data Supplement). In general, increasing propor-
tions of minor stroke over time were reported for ischemic
stroke and ICH, although the temporal trend was not signifi-
cant for ICH (Figure 3B and 3C).
Compared with NASIS 2004, adjusted risk estimates for
severe stroke were significantly decreased in 2010 (odds
ratio, 0.77; 95% CI, 0.64–0.92) and 2013 (odds ratio, 0.63;
95% CI, 0.52–0.75). Findings were similar for ischemic
stroke; however, for ICH, the association between severe
stroke and time period was not significant after controlling
for personal characteristics, comorbidities, and risk factors
(Table 2). Potential interactions between stroke severity and
time period, and between age and time period were assessed
and found not significant.
 4  Stroke  June 2018
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Figure 1.  Estimated annual rates of hospitalized stroke per
10 000 population, by age-group and stroke type, National Acute
Stroke Israeli (NASIS) 2004 to 2013.
Discussion
Our national data show decreases from 2004 to 2013
not only in rates of hospitalized stroke but also in stroke
Figure 2.  Rate ratios (RR, 95% confidence interval [CI]) for
hospitalized stroke associated with National Acute Stroke Israeli
(NASIS) period, sex and age, overall and by stroke type.
severity in Israel. Overall, we observed decreasing rates
of severe stroke along with a parallel increase in rates of
minor stroke.
Few studies have previously looked at temporal trends in
stroke severity. One large study on hospitalized ischemic stroke
patients in Japan showed a decrease in severity from 2001 to
201212; however, other studies on stroke severity trends either
used indirect markers or measures that do not allow for quan-
titative comprehensive evaluation of neurological deficits,10
included only selected patients11 or did not report findings for
recent years.10 Although data from the Framingham Study9
and the Minnesota Stroke Survey20 have been published in the
United States, findings were not based on quantitative mea-
sures and did not present trends in severity in the last decade.
Other studies, like the ARIC Study (Atherosclerosis Risk in
Communities), have reported changes in physician-adjudi-
cated stroke rates in the last decades,3 but lack information on
stroke severity. Our study based on nationwide data on physi-
cian-adjudicated stroke events and severity from chart review
 Koton et al   Declining Rate and Severity of Hospitalized Stroke   5
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Figure 3.  Stroke severity on admission by National Acute Stroke
Israeli (NASIS) period, 2004 to 2013. A, All stroke. B, Ischemic
stroke. C, Intracerebral hemorrhage. NIHSS indicates National
Institutes of Health Stroke Scale.
on all hospitalized patients with acute stroke in a national
healthcare system with no barriers for hospital admission and
with comprehensive personal and clinical information con-
tributes unique information on temporal trends in the severity
of hospitalized stroke.
The overall burden of stroke has increased from 1990 to
2013 worldwide,21 however, in the United States and other
developed countries, stroke rates are decreasing.3,13,22,23 We
observed a sharper decrease in hospitalized stroke during the
first periods of NASIS in comparison to later periods, similar
to data on ischemic stroke hospitalizations in the United States,
showing decreasing rates from 2000 to 2005 followed by a
plateau from 2006 to 2010.24 In line with reports in the United
States,3,6,24,25 our results show steeper decreases over time
in older groups compared with younger ages. Although our
findings support previous reports, they contribute important
information as they are based on analysis of nationwide data
prospectively collected.
Differences between men and women in stroke rates over
time have been reported in some cohort studies,26 but not in
others.3 Discrepancies in findings might be at least partially
related to differences in study design. Future studies are
needed to further evaluate sex and age differences in changes
in stroke incidence over time,27 and national data are crucial
for such studies. However, accurate assessment of temporal
trends in age-sex-specific rates requires a larger number of
cases than currently available in our registry.
Changes in the distribution of factors associated with stroke
severity might explain at least partially the observed trends.
Prevalence of hypertension, dyslipidemia, diabetes melli-
tus, and atrial fibrillation among stroke patients increased
between 2004 and 2013 in Israel. Previous studies in other
countries have also reported increasing rates of hypertension
and other important risk factors,1,28,29 yet, these increases are
likely related to improvement in diagnosis or in prevention
therapy and not to actual changes in prevalence of risk fac-
tors. In NASIS, the increase in rates of hyperlipidemia over
time has been related to increased clinicians awareness of the
importance of lipid-level control,30 reflected also in the sharp
increase in rates of statin use. Levels of admission blood
pressure have significantly decreased in stroke patients, and
the use of multiagent combination therapy for hypertension
has increased in NASIS patients over time.31 Thanks to the
national health insurance policy, medical treatment is available
to the entire Israeli population, therefore increased awareness
has resulted in more appropriate treatment and control of car-
diovascular risk factors. Better control of cardiovascular risk
factors might have contributed to decreases in incidence and
severity of stroke. Another potential reason for the observed
trends could be changed in the case mix. The development
of newer technology allows for more accurate case ascertain-
ment. Increasing use of precise imaging could have resulted
in the reclassification of some transient ischemic attack events
as strokes, therefore contributing to a shift toward less severe
events. However, we have analyzed trends in a transient isch-
emic attack in NASIS and found no significant change in rates
over time (Koton et al, unpublished data, 2018). As men-
tioned, in Israel the entire population has health insurance by
law. Patients with an acute cerebrovascular event are regularly
admitted for in-hospital evaluation and management, therefore,
any shift in the case mix of cerebrovascular events in Israel
would be detected. In addition, there has been no change in
admission policy of cerebrovascular events during the study
period. In fact, nationwide efforts have been made to increase
the population awareness and knowledge of stroke, and media
campaigns aimed at encouraging persons with stroke warning
signs and symptoms to get to the hospital immediately were
conducted; consequently, we do not suspect any increase in the
number of stroke events treated out of hospitals, which could
explain the decreases in rates of hospitalized stroke.
The present study has many strengths resulting from the
rigorous methodology applied to nationwide data. Also, in
NASIS, stroke severity is assessed on admission, therefore,
the reported findings could not be influenced by changes over
time in rates of reperfusion therapy or varying strategies for
 6  Stroke  June 2018

Table 2.  Adjusted OR (95% CI) for Severe Stroke, NASIS 2004, present study. The study of changes in prevalence and con-
2007, 2010, and 2013 trol of cardiovascular risk factors, known to influence both
Severe Stroke (NIHSS score of ≥11), OR (95% CI)
incidence and severity of the stroke, is an important topic for
future research.
All stroke Model 1, n=6678 Model 2, n=6501 Model 3, n=6440
 NASIS 2004 1 (Ref.) 1 (Ref.) 1 (Ref.) Summary
 NASIS 2007 0.97 (0.83–1.13) 0.97 (0.82–1.14) 0.98 (0.83–1.16) Rates of hospitalized stroke in Israel have decreased from
 NASIS 2010 0.73 (0.62–0.86) 0.77 (0.64–0.92) 0.78 (0.66–0.94)
2004 to 2013, overall and by stroke type, in men and women.
During the same period, the severity of stroke on admission
 NASIS 2013 0.63 (0.53–0.74) 0.63 (0.52–0.75) 0.65 (0.54–0.78) decreased for all stroke and for ischemic stroke. The decrease
 ROC 0.643 0.721 0.724 in stroke severity was evident in men and women as well as
Ischemic stroke Model 1, n=5944 Model 2, n=5797 Model 3, n=5741 in all age-groups. Despite the observed declines in rates and
severity, stroke continues to place a considerable burden to the
 NASIS 2004 1 (Ref.) 1 (Ref.) 1 (Ref.)
health system.
 NASIS 2007 0.91 (0.77–1.08) 0.94 (0.78–1.12) 0.95 (0.79–1.15)
 NASIS 2010 0.68 (0.57–0.82) 0.74 (0.61–0.90) 0.76 (0.63–0.92) Acknowledgments
 NASIS 2013 0.58 (0.48–0.69) 0.58 (0.48–0.71) 0.61 (0.50–0.75) We are grateful to the National Acute Stroke Israeli (NASIS) par-
ticipants and to all the medical centers, physicians, and nurses that
 ROC 0.665 0.698 0.702 collaborated in NASIS.
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Intracerebral Model 1, n=629 Model 2, n=609 Model 3, n=607

hemorrhage Disclosures
 NASIS 2004 1 (Ref.) 1 (Ref.) 1 (Ref.) None.

 NASIS 2007 1.13 (0.73–1.74) 1.22 (0.77–1.93) 1.21 (0.76–1.92)

 NASIS 2010 0.89 (0.57–1.40) 0.99 (0.61–1.58) 0.95 (0.59–1.53)
 NASIS 2013 0.85 (0.54–1.34) 0.84 (0.52–1.36) 0.81 (0.50–1.32)
 ROC 0.556 0.605 0.612
Data on stroke severity were available for 6678/6693 patients. Model 1:
NASIS period, age, and sex. Model 2: NASIS period, age, sex, stroke type,
hypertension, atrial fibrillation, diabetes mellitus, dyslipidemia, and current
smoking. Model 3: NASIS period, age, sex, stroke type, hypertension, atrial
fibrillation, diabetes mellitus, dyslipidemia, current smoking, prior stroke, prior
heart disease (chronic heart failure, prior myocardial infarction, angina pectoris
or valve disease), and peripheral artery disease. CI indicates confidence interval;
NASIS, National Acute Stroke Israeli; NIHSS, National Institutes of Health Stroke
Scale; OR, odds ratio; and ROC, receiver operating characteristic.
the management of acute stroke. Yet, it has some limitations.
NASIS includes all hospitalized stroke cases in Israel and,
although the policy is to admit any acute stroke patient, the
applicability of our findings to nonadmitted cases is question-
able. Improvements in diagnosis over time could have resulted
in more accurate diagnoses in later years, thus affecting rates.
Referrals to the adjudication committee in case of doubts
helped to increase the accuracy of NASIS reports, neverthe-
less, a potential effect of improved diagnoses over time is a
limitation in NASIS as in any other stroke registry. In addition,
the number of hospitalizations in the young age-groups did
not allow for analysis of trends over time in age-sex-specific
rates. Future accumulation of data in this ongoing project will
help to overcome power concerns relating subgroup analysis.
An additional limitation is related to the fact that NASIS data
are not collected continuously. As a result, detection of sea-
sonal patterns in stroke is not possible. Attempts to reduce
potential effects of this limitation are done by collecting data
in 2-months during the same season, avoiding months char-
acterized by high or low temperatures. Last, identification
of the specific factors associated with the observed trends in
incidence and severity of stroke was above the scope of the
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 Declining Rate and Severity of Hospitalized Stroke From 2004 to 2013: The National
Acute Stroke Israeli Registry
Silvia Koton, Diklah Geva, Jonathan Y. Streifler, Sagi Harnof, Yoav Pougach, Olga Azrilin,
Shoshana Hadar, Natan M. Bornstein and David Tanne
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 SUPPLEMENTAL MATERIAL
Declining Rate and Severity of Hospitalized Stroke from 2004 to 2013- The National Acute Stroke Israeli (NASIS) Registry
Figure I: Estimated annual rates of hospitalized stroke, Figure II: Estimated annual rates of hospitalized stroke,
per 10,000 MEN, by age group, NASIS 2004-2013 per 10,000 WOMEN, by age group, NASIS 2004-2013
Figure III: Stroke severity on admission by NASIS period, 2004-2013, all strokes by sex, n=6678

Men p<0.0001 Women p<0.0001

100% 100%
90% 90%
80% 35.77 80%
44.3 41.95 46.46
50.88 50
70% 70% 57.3 56.99

60% 60%
50% 50%
40% 40%
30% 64.23 30%
55.7 58.05 53.54
49.12 50
20% 20% 42.7 43.01

10% 10%
0% 0%
2004 2007 2010 2013 2004 2007 2010 2013
NIHSS 0-5 NIHSS >5 NIHSS 0-5 NIHSS >5
Figure IV: Stroke severity on admission by NASIS period, 2004-2013, all strokes by age-group, n=6678

Age ≤55 p=0.005 Age 56-65 p=0.0001

100% 100%
90% 25.51 90%
31.49 27.15
80% 38.21 35.02 80% 40.63 37.65 34.95
70% 70%
60% 60%
50% 50%
40% 74.49 40%
68.51 72.85
30% 61.79 64.98 30% 62.35 65.05
59.37
20% 20%
10% 10%
0% 0%
2004 2007 2010 2013 2004 2007 2010 2013

Age 66-75 p=0.001 Age >75 p<0.0001

100% 100%
90% 90%
80% 46.19 42.78 42.01 80%
52.34 50.35
70% 70% 64.53 63.54 58.07
60% 60%
50% 50%
40% 40%
30% 53.81 57.22 57.99 30%
47.66 49.65
20% 20% 35.47 36.46 41.93
10% 10%
0% 0%
2004 2007 2010 2013 2004 2007 2010 2013