A total of 1462 patients (58.7% males) experienced first-ever strokes between January 1, 1992, and December 31, 2018. In these patients, the mean age of onset was 66.85 years, and53.2% of patients were ≥65 years old. A larger percentage of patients were aged 45-64 years during the 2009-2018 (47.7%) period than during the earlier period (35.9%; P < 0.001). ISs accounted for 77.6% of the overall stroke events, with a significant increase in the proportion of IS events between the later (81.2%) and earlier (73.4%, P < 0.001) periods ( Table 1 ).

Table 2 shows that there were increases in the proportions of patients diagnosed using neuroimaging and who were hospitalized during the 2009-2018 period than during the earlier period, for all strokes ( P < 0.001), with similar trends observed for both men and women. The rate of neuroimaging-based diagnoses, however, remained relatively constant for patients with hemorrhagic strokes (P > 0.05).

Moreover, among patients <45 years old, the hospitalization rates were higher for men and the total patient population for all strokes during the 2009-2018 period than during the 1992-2008; women did not show a similar trend. For patients ≥45 years old, the hospitalization rate during the 2009-2018 period was higher than during the 1992-2008 period, regardless of sex or stroke type. The percentage of patients (≥45 years old) diagnosed with ISs (and total strokes), using neuroimaging, was significantly higher during the 1992-2008 period than during the later period ( Table 3 ).

For all patients, the one-year case fatality rate for first-ever strokes in 2009-2018 decreased by 27.8%, overall, compared with 1992-2008 (P = 0.002). This included a 23.4% decrease among men (P = 0.043) and a 34.2% decrease among women ( P = 0.012). However, the recurrence rate among men was 1.3-fold higher during the 2009-2018 period, compared with the 1992-2008 period (P = 0.006). There were no significant changes in the one-year outcomes, across stroke types, between the study periods ( Table 4 ).

Table 5 indicates the absence of significant changes in case fatality or recurrence rates, between the two periods, for patients aged <65 years, regardless of stroke type. However, the overall one-year case fatality rate for all stroke patients aged ≥65 years during the 2009-2018 period was lower than that during the 1992-2008 period (25.5% vs 33.7%; P = 0.013); the case fatality rate for women ≥65 years old decreased by 30.0% (23.3% vs 33.3%; P  = 0.043). Between the two study periods, the overall stroke recurrence rate increased 1.9-fold (P = 0.001), and the recurrence rate among male patients aged ≥65 years increased 2.5-fold (P = 0.010). For hemorrhagic stroke patients aged ≥65 years, the overall case fatality rate decreased by 44.5% (P  = 0.042), including by 30.0% among men (P = 0.043), between both study periods; the recurrence rate increased significantly among men (P  = 0.036). Meanwhile, there were no significant changes in the one-year outcomes in undetermined strokes between both study periods (all P > 0.05).

Since 2009, more than 95% of the residents in the study population were covered by universal medical insurance. However, only 52% of the stroke patients used their medical insurance; the remaining 48% did not as they could not afford the threshold fee. During the 2009-2018 period, the overall one-year case fatality rate for first-ever strokes was higher among male patients who did not use medical insurance (22.6%) than among those who did (15.2%; P = 0.043). A similar trend was observed among patients aged ≥65 years; the case fatality rate was 20.7% for the insured patients and 32.8% for the un-insured patients (P = 0.050). However, there were no significant differences in the recurrence rates, regardless of age ( Table 6 ).

The interrupted time-series analysis showed that before the implementation of the policy (1992-2008), the case fatality rate decreased, and the slope was -0.012 (95% CI = -0.022, -0.003; P  = 0.015). After the implementation of the policy (2009-2018), the slope of the case fatality rate was -0.008 (95% CI = -0.031, -0.015; P  = 0.443). In 1992-2008, the recurrence rate increased, with a slope of 0.004 (95% CI = 0.002, 0.006; P < 0.001), while in 2009-2018, the recurrence rate decreased, with a slope of-0.005 (95% CI = -0.011, 0.000; P  = 0.061). In addition, for hospitalization, the corresponding slopes for both periods were 0.011 (95% CI = 0.007, 0.015; P < 0.001) and 0.044 (95% CI = 0.010, 0.077; P = 0.017), and for diagnosis using neuroimaging, the corresponding slopes for both periods were 0.031 (95% CI = 0.018, 0.045; P < 0.001) and 0.017 (95% CI = 0.002, 0.031; P = 0.027). After 2009, a significant decline in the recurrence rate (P = 0.001) and a significant increase in the hospitalization rate (P = 0.004) occurred. However, no significant differences were observed for trends incase fatality (P = 0.702) and diagnosis using neuroimaging (P = 0.285; Figure 1 ).

Figure 1.  The interrupted time-series analysis of management and prognosis among stroke patients. Figure 1 showed that a significant decline in the recurrence rate (P = 0.001) and a significant increase in the hospitalization rate (P = 0.004) occurred after 2009. However, no significant differences were observed for trends incase fatality (P  = 0.702) and diagnosis using neuroimaging (P  = 0.285).

This is the first report describing the association of stroke outcomes with the utilization of medical insurance in a low-income population in rural China following the 2009 national health care reform. The preponderant stroke type was IS, the proportion of which increased significantly from the pre-reform (1992-2008) to the post-reform (2009-2018) period. The proportions of strokes diagnosed using neuroimaging and patients who were hospitalization also significantly increased between the later and earlier periods, especially among patients aged ≥45 years. The increase in hospitalization rate was significantly higher in 2009-2018 than in 1992-2008. For all first-ever stroke patients, the one-year case fatality rate during the 2009-2018 period was lower for both males and females than it was during the earlier period. The trend of overall recurrence rate decreased after 2009, although the recurrence rate in men was1.3-fold higher in 1992-2008 than in2009-2018. Moreover, the overall one-year case fatality rate for patients aged ≥65 years was lower during the later period than during the earlier one; the recurrence rates for all strokes, ISs, and hemorrhagic strokes were higher among men. During the 2009-2018 period, the overall (and male) case fatality rate was higher among non-insured patients than among insured patients; among patients aged ≥65 years, there were 58.5% more case fatalities among the non-insured patients than among the insured patients.

A population-based survey of 480 687 adults, in China, indicated that the stroke incidence has declined in urban areas and risen in rural areas over the past 30 years [18]. Our previous study demonstrated that, in rural China, the IS incidence increased sharply, particularly among middle aged adults, between 1992 and 2012 [19]. However, prior to 2008, the percentage of rural stroke patients undergoing computed tomography examinations was low [20], reflecting the low level of medical spending in rural areas before 2009. However, according to 2019 data from the National Bureau of Statistics of China [21], bed utilization rates in township health centers have increased from 55.8% (2008) to 59.6% (2018) and the personally financed proportion of medical expenses has increased from 7.8% to 10.2%. A study from Gansu, China indicated that both total and out-of-pocket costs have fallen, while actual compensation rates have risen since the implementation of the new rural health insurance payment system [22 ]. Before 2008, 79% of rural residents and 45% of urban residents did not have health insurance; in 2018, health care insurance covered >95% of China’s citizens [3]. Between 2008 and 2017, outpatient visits increased by 12.1% at tertiary hospitals, by 3.4% at secondary level hospitals, and by 4.4% at primary health care facilities, annually; per outpatient visit charges increased at 6.7%-7.1%, annually [ 2]. In this study, the proportions of patients diagnosed using neuroimaging and who were hospitalized, were significantly higher during the 2009-2018 period than during the 1992-2008 period, especially among patients ≥45 years old. These findings demonstrated that the health care system has improved the ability of rural residents to pay for medical care; this is especially apparent among middle-aged and elderly patients. Although China's health care reform began only 13 years ago, its achievements are obvious.

The one-year case fatality rate for first-ever stroke patients during the 2009-2018 period was significantly lower than during the 1992-2008 period, especially among female patients aged ≥65 years. In China, health care for women, especially elderly women, was neglected due to their low socioeconomic status. Thus, elderly women were often treated at home or by the local village doctor. The results of this study demonstrate, to a certain extent, that the universal medical insurance, implemented in 2009, has benefited rural residents and decreased the stroke burden.

For most post-stroke patients, secondary prevention medications are now prescribed, beginning during hospitalization; however, poor post-discharge adherence continues to be a problem, especially in rural China [18,19]. A previous study reported that among post-stroke patients, only 10.6%, 10.1%, 7.6%, 2.3%, 18.2%, and 1.4% were regularly taking antiplatelet drugs, β-blockers, angiotensin-converting enzyme inhibitors, diuretics, calcium-channel blockers, and statins, respectively [19 ]. In one study [18], the use of anti-platelet agents (18.6%) and any of the blood pressure (BP)-lowering drugs (38.2%) by patients with histories of either ischemic heart disease or stroke, in China, were much lower than for patients in similar North American [20] (anti-platelet drugs, 52.2%; BP-lowering medication, 69.2%) and Middle Eastern (anti-platelet drugs, 49.7%; BP-lowering medication, 64.3%) studies. In addition, there were significantly different levels of secondary prevention provided to patients with high socioeconomic status than to those with low socioeconomic status, in China [18]. Part of the reason for the alarmingly low use of secondary prevention medications is the inadequate ability of low-income people to pay for these medications [18,21]. In the present study, although the one-year stroke case fatality rate was remarkably lower during the 2009-2018 period than during the 1992-2008 period, the stroke recurrence rate during the later period was more than twice that during the earlier period, indicating that the secondary prevention of cerebrovascular disease is far from ideal in rural China. Both the poor awareness of the benefits of secondary prevention methods and the inability to pay for medicines, among rural residents, are major causes of the high recurrence rate [22]. However, the downward trend in the recurrence rate of stroke showed that the universal medical insurance in China plays a positive role in stroke recurrence.

Although the Chinese government has implemented a universal medical insurance policy [2], there are still some low-income groups who are unable to pay even the threshold fee. Moreover, stroke recurrence aggravates poverty, forming a vicious circle in low-income populations. As a result, China will continue to experience an enormous health burden due to strokes as >41.48% of the total population lives in rural areas [3 ].

Many of the health inequities in low- and middle-income countries are related to insurance status. Thus, the inevitable consequence is that serious and costly diseases, like strokes, very often have disastrous financial consequences for the patients and their families, especially for low-income patients in rural areas. Out-of-pocket payments, as a portion of total health care spending, are very high in both China and India [23,24]. According to a 2003 national census, 45% of residents in urban areas and 80% of those in rural areas of China were not covered by public insurance [25]. In April 2009, China unveiled a huge and complex health reform plan designed to provide all citizens with equal access to basic health care by 2020 [1]. However, the coverage provided through this program is very small, in terms of both the service benefit package and financial protection provided [26]. In many parts of China, outpatient services are under-insured or not covered. Inpatient services, if covered, still require patients to bear a number of costs (co-payments, deductibles, or additional fees). For instance, the rural cooperative medical scheme only reimburses about 30% of hospitalization expenses [27]. In many cases, medical assistance programs for poor people simply help them participate in the rural scheme rather than paying more of the treatment costs. As a result, the access that poor people actually have to primary care has not really improved, and financial protection against high medical costs remains very limited [16]. In the present study, the mortality rate was significantly higher among male patients not using medical insurance than among those using it. This was especially true among patients aged ≥65 years who had a mortality rate that was 58.5% higher than for those with medical insurance. Therefore, to effectively reduce the stroke burden, the government will need to formulate health insurance policies that are more in-line with the ability of low-income people to pay for their medical services.

This study has several limitations. First, the study population was from one township in northern China, which is not representative of the overall rural population of China. However, the consistency of the national medical insurance policy allows these results to represent the overall situation in rural China. Second, the number of stroke cases was limited. However, the observation time was 391 748 person-years, which meets the criterion for epidemiological studies in stroke patient populations. Third, early in this study, the low rate of neuroimaging-based diagnoses may have affected the determination of stroke types. Fourth, the study population was characterized as being low-income and poorly educated, with access to poor medical services. Thus, some patients with acute attacks may not have been diagnosed in a timely manner, leading to an underestimation of the recurrence rate.

Compared to the 1992-2008 period, the percentages of stroke patients diagnosed using neuroimaging and who were hospitalized were significantly higher during the 2009-2018 period. Further, the stroke case fatality rate was remarkably higher among patients not using medical insurance than among those who used medical insurance; the stroke recurrence rate also showed a downward trend after 2009. Moreover, men without adequate medical insurance benefits, due to their low incomes, demonstrated high mortality rates. These findings suggest that the universal medical insurance for urban and rural residents, in China, has played a major role in improving the management and prognoses of first-ever stroke patients residing in rural, low-income areas of China, especially for patients aged ≥65 years. However, there is a crucial need for the government to restructure its medical insurance policy to facilitate access to medical care by low-income, rural residents to reduce the stroke burden in China, especially for those poverty residents.