Stroke incidence trends and the role of chronic disease management in a universal health coverage system: a retrospective observational study in Macao, 2019-2024.
Tam K, Chou H, et al. • Family medicine and community health • 2026
Age-standardised stroke incidence declined in Macao from 2019 to 2022 but rebounded in 2023-2024, and while over 88% of high-risk patients had documented healthcare follow-up, persistent stroke burden suggests that 'achieving high coverage alone is not sufficient—ongoing quality improvement in chronic disease management is essential to translate engagement into better outcomes.'
Key Findings
Results
Age-standardised stroke incidence in Macao declined from 2019 to 2022 before rebounding in 2023-2024.
Age-standardised stroke incidence fell from 250.03 per 100,000 in 2019 to 219.95 per 100,000 in 2022.
A rebound in incidence was observed in 2023-2024, which the authors note 'may partly reflect pandemic-related data entry delays.'
The study covered Macao residents aged ≥15 years with confirmed ischaemic or haemorrhagic stroke recorded between 1 January 2019 and 31 December 2024.
Total study population comprised n=8,265 stroke cases.
Results
Over 88% of stroke patients with pre-existing hypertension or type 2 diabetes mellitus had documented healthcare follow-up in the year preceding their stroke.
Healthcare engagement was measured as documented follow-up in the Macao Health Bureau primary care system within the year before stroke onset.
The system provides free, publicly funded community health services to all residents under universal health coverage (UHC).
High healthcare engagement was associated with improved risk monitoring among these high-risk patients.
Pre-existing conditions examined were hypertension (HTN) and type 2 diabetes mellitus (T2DM).
Results
Stroke incidence among high-risk patients (those with pre-existing HTN or T2DM) declined over the study period, and the interval from diagnosis to stroke onset lengthened significantly.
The lengthening of the interval from chronic disease diagnosis to stroke onset was described as statistically significant.
Despite these improvements, 'a substantial stroke burden persisted' among this high-risk group.
The study was a retrospective observational study using routinely collected electronic health records from the Macao Health Bureau's primary care system.
The findings suggest that healthcare engagement was associated with delayed but not prevented stroke onset in this population.
Discussion
High healthcare coverage alone was not sufficient to eliminate stroke burden, indicating a need for quality improvement in chronic disease management.
Despite high engagement rates (>88% follow-up), a substantial stroke burden persisted in the high-risk population.
The authors conclude that 'ongoing quality improvement in chronic disease management is essential to translate engagement into better outcomes.'
The study evaluated stroke trends in the context of a universal health coverage system providing free public primary care.
The findings distinguish between healthcare access/engagement and the quality of care delivered within that system.
Results
The observed rebound in stroke incidence in 2023-2024 may partly reflect pandemic-related data entry delays rather than a true epidemiological increase.
The rebound followed a declining trend from 2019 (250.03 per 100,000) to 2022 (219.95 per 100,000).
Authors explicitly note this rebound 'may partly reflect pandemic-related data entry delays.'
The study design was retrospective and observational, relying on routinely collected electronic health records, which may be subject to administrative lags.
This represents a methodological limitation in interpreting the 2023-2024 data points.
What This Means
This research examined stroke rates in Macao, a city with a universal healthcare system that provides free medical services to all residents, between 2019 and 2024. Looking at over 8,000 stroke cases, the researchers found that stroke rates initially fell from 2019 to 2022 but then appeared to rise again in 2023-2024, though this uptick may partly be explained by delays in recording patient data during the COVID-19 pandemic rather than a true increase in strokes. Importantly, more than 88% of stroke patients who already had high blood pressure or diabetes had been seen by a doctor in the year before their stroke, and among these patients, it took longer for a stroke to occur after their original diagnosis—suggesting that routine medical care was helping to delay strokes even if not preventing them entirely.
However, a key finding is that even with very high rates of patients attending healthcare appointments, a significant number of strokes still occurred. This suggests that simply having access to healthcare and showing up for appointments is not enough on its own to prevent strokes in people with chronic conditions like high blood pressure and diabetes. The quality of the care provided—meaning how well blood pressure and blood sugar are actually controlled and managed—appears to matter just as much as whether people are seen regularly.
This research suggests that universal health coverage systems, while valuable for ensuring everyone can access care, need to focus not just on getting people through the door but on improving the effectiveness of chronic disease treatment once patients are engaged. For communities and health systems thinking about stroke prevention, these findings highlight that measuring healthcare attendance is only one part of the picture, and that deeper attention to treatment quality and outcomes is needed to meaningfully reduce stroke rates in people with known risk factors.
Tam K, Chou H, Kwong W, Lei S, Zeng W, Wong I. (2026). Stroke incidence trends and the role of chronic disease management in a universal health coverage system: a retrospective observational study in Macao, 2019-2024.. Family medicine and community health. https://doi.org/10.1136/fmch-2026-004068