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. 2025 Feb;32(2):e70050.
doi: 10.1111/ene.70050.

Cross-Country Inequalities in Disease Burden and Quality of Care of Stroke, 1990-2021: A Systematic Analysis of the Global Burden of Disease Study 2021

Zeyu Luo  1 , Denan Jiang  2 , Shiyi Shan  1 , Jiali Zhou  1 , Weidi Sun  1 , Jing Wu  1 , Jiayao Ying  1 , Liying Zhou  1 , Yajie Zhu  3 , Peige Song  1 , Kazem Rahimi  4
Affiliations

Cross-Country Inequalities in Disease Burden and Quality of Care of Stroke, 1990-2021: A Systematic Analysis of the Global Burden of Disease Study 2021

Zeyu Luo et al. Eur J Neurol. 2025 Feb.

Abstract

Background and purpose: This study aims to assess the disease burden and care quality along with cross-country inequalities for stroke at global, regional, and national levels from 1990 to 2021.

Methods: Data on stroke were extracted from the Global Burden of Disease (GBD) study 2021 for the globe, five sociodemographic index (SDI) regions, 21 GBD regions, and 204 countries/territories. The disease burden was quantified using the age-standardized disability-adjusted life years rate (ASDR). Quality of care (QoC) was evaluated through the age-standardized QoC index (QCI). To assess cross-country disparities in both disease burden and age-standardized QCI, the slope index of inequality (SII) and the concentration index were utilized.

Results: From 1990 to 2021, the global ASDR of stroke decreased from 3078.95 (95% uncertainty interval [UI]: 2893.58, 3237.34) to 1886.20 (95% UI: 1738.99, 2017.90) per 100,000 population, while the age-standardized QCI improved from 50.79 to 64.61. However, the results of inequalities showed worsening inequalities in both ASDR and QCI, with lower SDI countries shouldering a disproportionate burden and higher SDI countries maintaining higher QoC. The SII and concentration index for ASDR indicated a worsening inequality among lower SDI countries, with SII increasing to -2616.44 and the concentration index increasing to -0.1119 in 2021. Meanwhile, the SII and concentration index for age-standardized QCI showed a worsening inequality among higher SDI countries, with SII of 27.48 and concentration index of 0.0922 in 2021.

Conclusions: Despite notable global advancements, significant disparities in stroke still exist, particularly in lower SDI regions facing high disease burdens and substandard care.

Keywords: disability‐adjusted life years; global burden of disease; inequality; quality of care; stroke.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Global maps of ASDR and QCI of stroke from 1990 to 2021. (A1) Global map of ASDR in 1990. (B1) Global map of ASDR in 2021. (C1) Global map of EAPC for ASDR from 1990 to 2021. (A2) Global map of QCI in 1990. (B2) Global map of QCI in 2021. (C2) Global map of EAPC for QCI from 1990 to 2021. Abbreviations: ASDR, age‐standardized DALYs rate; DALYs, disability‐adjusted life years; QCI, quality of care index; EAPC, estimated annual percentage change.
FIGURE 2
FIGURE 2
The relation between ASDR and QCI of stroke versus SDI for both sexes, by GBD region, 1990–2021. (A) The relation between ASDR of stroke versus SDI. (B) The relation between QCI of stroke versus SDI. Abbreviations: ASDR, age‐standardized DALYs rate; DALYs, disability‐adjusted life years; QCI, quality of care index; SDI, sociodemographic index; GBD, global burden of disease.
FIGURE 3
FIGURE 3
Absolute and relative cross‐country inequality in ASDR and QCI of stroke for both sexes, 1990–2021. (A) Health inequality regression curves for ASDR of stroke. (B) Concentration curves for ASDR of stroke. (C) Health inequality regression curves for QCI of stroke. (D) Concentration curves for QCI of stroke. Abbreviations: ASDR, age‐standardized DALYs rate; DALYs, disability‐adjusted life years; QCI, quality of care index; SDI, sociodemographic index.
FIGURE 4
FIGURE 4
Ranking graphs and changing patterns for SII and concentration index in ASDR and QCI of stroke among SDI regions for both sexes, 1990–2021. Abbreviations: ASDR, age‐standardized DALYs rate; DALYs, disability‐adjusted life years; QCI, quality of care index; SDI, sociodemographic index; SII, slope index of inequality; CI, concentration index; EAPC, estimated annual percentage change.
FIGURE 5
FIGURE 5
Ranking graphs and changing patterns for SII and concentration index in ASDR and QCI of stroke among GBD regions for both sexes, 1990–2021. Abbreviations: ASDR, age‐standardized DALYs rate; DALYs, disability‐adjusted life years; QCI, quality of care index; GBD, global burden of disease; SII, slope index of inequality; CI, concentration index; EAPC, estimated annual percentage change.
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