Stroke management and quality of care in low and middle-income countries: an
integrative literature review
Manejo do AVC e qualidade da assistência em países de baixa e média renda:
uma revisão integrativa da literatura
DOI:10.34117/bjdv6n3-354
Recebimento dos originais: 14/02/2020 Aceitação para publicação: 24/03/2020
Bruno Bastos Godoi
Acadêmico do curso de Medicina da UFVJM
Instituição: Universidade Federal dos Vales do Jequitinhonha e Mucuri, Faculdade de Medicina, Grupo de Pesquisa em Neurologia e Neurocirurgia, Diamantina MG, Brasil.
Endereço: Campus JK - Rodovia MGT 367 - KM 583, N° 5000. Bairro Alto da Jacuba. Diamantina/MG. CEP 39.100-000.
Email: bastosgodoi@gmail.com
Bárbara Fernandes Diniz Vianna
Médica Neurologista pelo Hospital Universitário Antônio Pedro
Instituição: Universidade Federal dos Vales do Jequitinhonha e Mucuri, Faculdade de Medicina, Docente de Neurologia, Diamantina MG, Brasil.
Endereço: Campus JK - Rodovia MGT 367 - KM 583, N° 5000. Bairro Alto da Jacuba. Diamantina/MG. CEP 39.100-000.
Email: barbara.f.diniz@gmail.com
Delba Fonseca Santos
Doutora em Saúde Coletiva pela Universidade Estadual de Campinas
Instituição: Universidade Federal dos Vales do Jequitinhonha e Mucuri, Faculdade de Medicina, Grupo de Pesquisa em Neurologia e Neurocirurgia, Diamantina MG, Brasil
Endereço: Campus JK - Rodovia MGT 367 - KM 583, N° 5000. Bairro Alto da Jacuba. Diamantina/MG. CEP 39.100-000.
Email: delbafonseca@yahoo.com.br
ABSTRACT
Stroke is the principal world mortality cause and is associated with specific risk factor in Latin America. Brazil is the country that have higher rates of incidence, mortality and morbidity of stroke of Latin America. Rates of stroke varies in accordance with socioeconomic area status. This can be exampled by higher rates in lower socioeconomic Brazilian regions, like north and northeast. The main objective of this integrative literature review is to carry out a summary of acute stroke, how to manage this issue at emergency department and the diversity of risk factors involved on the developing acute stroke. Were evaluated 28 articles in accordance with 6 groups of keywords used at the research on the data bases. These six groups were divided into 4 categories: 1. Global Burden of Stroke (groups 1, 2 and 4); 2. Risk factors and Prevention (Group 6); 3. Quality of care in acute stroke (Group 3) and 4. Economic burden of stroke (group 5). For effective and sustainable control of stroke, specific control measures should be developed in conjunction with other integrated
inter-sectoral public policies, improvements in social conditions, improved access to health care services and health education.
Keywords: Stroke;Brazil; Risk Factors; Quality of Health Care; Outcome assessment (Health Care).
RESUMO
O Acidente Vascular Cerebral (AVC) é a principal causa de mortalidade mundial e está associado a um fator de risco específico na América Latina. O Brasil é o país que apresenta maiores taxas de incidência, mortalidade e morbidade porAVC na América Latina. Taxas de AVC variam de acordo com o status socioeconômico da área em estudo. Isso pode ser comprovado por taxas mais altas em regiões brasileiras de baixo nível socioeconômico, como norte e nordeste. O principal objetivo desta revisão integrativa de literatura é realizar um resumo do AVC agudo, como gerenciar esse problema no departamento de emergência e a diversidade de fatores de risco envolvidos no desencadeamento do AVC. Foram avaliados 28 artigos de acordo com 6 grupos de palavras-chave utilizadas na pesquisa nas bases de dados. Esses seis grupos foram divididos em 4 categorias: 1. Carga Global do AVC (grupos 1, 2 e 4); 2. Fatores de Risco e Prevenção (Grupo 6); 3. Qualidade dos cuidados no AVC agudo (Grupo 3) e 4. Carga econômica do AVC (grupo 5). Para o controle efetivo e sustentável do AVC, medidas específicas de controle devem ser desenvolvidas em conjunto com outras políticas públicas intersetoriais integradas, melhorias nas condições sociais, melhor acesso aos serviços de saúde e educação em saúde.
Palavras-chave: Acidente Vascular Cerebral; Brasil; Fatores de Risco; Qualidade da Assistência à Saúde; Avaliação de Resultados (Cuidados de Saúde).
1 INTRODUCTION
The most recent assessment of global, regional and country-specific burden of stroke refers to 1990, 2005 and 2013. Over the past years was possible to identify growing rates of stroke, higher rates of mortality and disability.Data about stroke outcomes permitted to evaluate health problems linked to cerebrovascular diseases and the allocation of appropriate resources to improve the care of these patients 1.
The American Heart Association/American Stroke Association (AHA/ASA) released updated guidelines for the early management of all strokes at the 2018 International Stroke Conference 2. Previous guidelines published in 2013, within more than 400 studies, shows up reviews and recommendations about stroke management 2.The frequency of risk factors is much higher (78%) in ischemic stroke than in hemorrhagic stroke (22%) 3.
Stroke is associated with specific risk factors in Latin America, and is the main cause of mortality globally/worldwide. Among Latin American countries, Brazil has the greatest stroke incidence, mortality rate, and morbidity rate from stroke. Rates of stroke vary in accordance with socioeconomic status and, by geographical region. For example, Brazilian north and northeastern regions, two of this country’s poorest socioeconomic areas, have the highest incidence of stroke
Brazilian public hospitals. They have found a medium value of each hospitalization about US$1,902 for ischemic stroke and US$4,101 for hemorrhagic stroke 6.
According to a study published by the Brazilian Ministry of Health in 2012 (Brazilian Policy for Stroke), thrombolytic therapy became available (at that year) for the first time in Brazilian public hospitals. The National Stroke Project was created by a group of medical associations concerned with stroke research and therapy. The aim of this new association is to: (a) promote educational campaigns about how to prevent stroke and the risk factors involved in this issue; (b) develop technical knowledge at medical emergency services; (c) develop stroke centers inside secondary and tertiary hospitals across the country; and (d) implement new programs for early rehabilitation and family support 7.
The main objective of this integrative literature review is to carry out a summary of the current status of acute stroke care and research in Brazil, how to manage this issue in emergency departments, and the many risk factors associated with how a stroke progresses in its first stages.
2 METHODS
It is an integrative review, which, according to Whitemore and Knalf (2005)8, the
"integrative term originates in the integration of opinions, concepts or ideas from the researches used in the method", a point that "shows the potential for if science is built. " In addition, it should be keep in mind that integrative review is a subtype of a systematic literature review, which can be subdivided into: meta-analysis, systematic review, qualitative review or integrative review.
Thus, in agreement with Botelho, Cunha and Macedo (2011)9 and Redeker (2000)10, the present integrative review has the main objective to carry out a summary of acute stroke and the latest news of how to manage it at emergency department and the diversity of risk factors involved in this pathology in low and middle-countries.
This paper consisted on bibliographic research at the following data bases: BVS, Periodic Portal CAPES and PubMed trough 6 groups of keywords: Group 1: Stroke and epidemiology and incidence and prevalence and mortality and health surveys and brazil and/or WHO STEPS STROKE; Group 2: Incidence and prevalence and mortality and global stroke and burden and epidemiology and ischaemic stroke and haemorrhagic stroke and global burden (GBD) and Stroke and Atlas and Burden and GBD 2013; Group 3:Stroke and quality of care and quality improvement and hospital medicine and healthcare quality improvement and Best Practice Recommendations; Group 4: cross-sectional and prevalence and epidemiology and stroke and burden and population-based studies; Group 5: Etiology and stroke of undetermined mechanism and prognosis and sex differences and clinical profile and short-term outcome and young adult and registries and stroke
registries and transient ischemic attack; Group 6: stroke and diabetes mellitus and hyperlipidemias and hypertension and prevention and control and smoking.This 6 groups were assessed on the PICO’s principle of systematic review (table 1).
The inclusion criteria where: whole articles published between 2015 and 2018; peer-reviewed; been on English, Portuguese or Spanish; data related to stroke diagnosis, prevention, prognostic, and risk factors. Otherwise, the exclusion criteria where to those articles not related to the objective of this research; published in annals; editorials; duplicated articles and greyliterature. On this, were found 237 articles, which, after reading abstracts and title, have been excluded 171 articles. After that, the 66 remaining were read in full. Thereby, remained 27 articles which will be extremely important to show the art state of stroke and its management. The selection process is shown in Figure 1.
Table 1. Keywords used at the respective groups in order to PICO’s principle of systematic review
GROUP 1 Problem Stroke AND brazil
Intervention WHO STEPS STROKE
Comparison Epidemiology
Outcome Mortality AND Health surveys
AND incidence AND prevalence
GROUP 2 Problem Global stroke AND Hemorrhagic
stroke AND stroke AND burden AND global burden (GBD) AND atlas AND burden AND GBD 2013
Intervention -
Comparison Incidence AND Prevalence AND
epidemiology
Outcome Mortality
GROUP 3 Problem Stroke AND Quality of care
Intervention Quality improvement AND
healthcare quality improvement
Comparison Hospital medicine
Outcome Best Practice Recommendations
GROUP 4 Problem Stroke AND burden AND
population-based studies AND cross-sectional
Intervention -
Comparison Epidemiology
GROUP 5 Problem Economic Burden
Intervention Stroke care AND health economic
Comparison National stroke register
Outcome Health economic outcomes
GROUP 6 Problem Stroke AND diabetes mellitus
AND hyperlipidemias AND hypertension AND smoke
Intervention Prevention
Comparison -
Outcome Control
Figure 1. Flowchart of the selection process to eligible articles, including the databases: PUBMED, BVS and Portal
Periódico CAPES.
3 RESULTS
It was assessed 28 articles in accordance with those 6 groups of keywords used at the research on the data bases (table 2). They were divided into 4 categories: 1. Global Burden Stroke (groups 1, 2 and 4); 2. Risk factors and Prevention (Group 6); 3. Quality of care in acute stroke (Group 3) and 4. Economic burden of stroke (group5).
PUBMED (n=47) BVS (n=24) Portal Periódicos
CAPES (n=166)
Excluded articles due study protocol (n=171) Studies included (n=27) Fully eligible assessed articles (n=66) Assessed articles (n=237) Total numbers of articles (n=237) Id en ti fi ca ti o n Sc re e n in g El ig ib ili ty In cl u si o n Excluded articles after read in full
3.1 GLOBAL BURDEN STROKE (GBS)
The frequency of studies aims to talk about GBS was 29,6%.
Arnao et al., 201611, show in a systematicreview,thatincidenceandprevalenceofstroke in women in middleandlow-countries (Sub-SaharanAfrica, Rural areasof South Asiaand Rural areasof South America) are lowerthanmen. This proportion can be visualised according to mortality rates in Latin America: 22.5/100.00 for men and 19.4/100.000 for women. However, despite the same proportion of incidence and prevalence between men and women, stroke mortality in high-income countries (USA, Canada, Japan, Europe) is lower than those of middle and low-income countries.
Sanya et al., 201512, presents a descriptive cross sectional study on stroke epidemiology
among individuals from the age of 18 years and above in three semi-urban communities in a low-income country. As well as Arnao et al. (2016)11, they showed a gender difference in the incidence
of stroke (58.8% men and 41.2% women). The mean age of stroke was 58.2 years. The main risk factors were systemic arterial hypertension (82.4%), followed by transient ischemic attack (41.2%).Among 17.6% of the cases had multiple risk factors, such as cigarette smoking, excessive use of alcoholic beverages and oral contraceptive use.
Catalá-Lopéz et al., 201413, in a cross-sectionaldescriptivepopulation-based, shows
theburdenof cerebrovascular diseases in a high-income countrybasedonthedisability-adjustedlifeyears. The studied population it was observed that, as Arnao et al., 201611 said, the mortality in a high-income country is lower than in middle- and low-income countries. In addition, corroborating with Sanya et al., 201512, a higher incidence and mortality is shown in young men than in women of the same age (men / women incidence: 8.4% / 4%, men / women mortality: 3.3% / 1.3%). Moreover, it is shown that the age group most affected by stroke, independent of sex, is above 85 years, in consonance with the data presented by Arnao et al., 201611 and Sanya et al., 201512. And, lastly, similar to the data demonstrated by Viswanathan et al., 201514, shows a percentage of about 60% of disability-adjusted life years of patients post stroke.
Kamalakannan et al., 201715 as Arnao et al., 201611 and Sanya et al., 201512, show burden
stroke (incidence and prevalence) in a middle-income country. Thus, as expected, a higher incidence and prevalence of stroke was observed in patients older than 85 years. In rural the prevalence was 165 per 100.00 and in urban areas was 136 per 100.000 11–13.
Avezum et al., 20154 demonstrate the burden of stroke in Latin America and some
opportunities for prevention, as well as showed by Olaiya, et al., 201716andFeigin et al., 20161. To
compile the statistical comparisons, data were collected from three Latin American countries (Chile, Brazil and Mexico). Therefore, it has been observed, as well as other studies 11–15, that the incidence of stroke per 100,000 inhabitants is higher in patients over 85 years of age. In addition, it
was also possible to notice a superiority of women's death rates compared to women, reaching 140 deaths per 100,000 in men and 120 per 100,000 in women. Another important point to be mentioned about the middle- and low-income countries in Latin America (Brazil, Argentina, Chile, Costa Rica, Mexico, Nicaragua and Peru) is that only Brazil there are 122 hospitals with thrombolytic therapy. On the other hand, the country with the second highest rate totalize 4 hospitals with such therapy. It is important to point that only Brazil and Chile have a national stroke prevention program.
Adami et al., 20165 shows a different view of stroke rates in Brazil, which is a medium-income country, demonstrating mortality and incidence of hospital admissions for stroke among Brazilians aged 15 to 49 years. Unlike the data shown by Arnao et al., 201611, Sanya et al., 201512
and Catalá-Lopéz et al., 201413, women had a higher mortality rate than men (95% CI, men 2.25
and women 5.75). Among, of the 35.005 patients analyzed, there were no statistically significant differences between the incidence of stroke among men and women, which is in agreement with the other studies comparing incidence rates and prevalence between genders11–13.
De Campos et al., 201717, as Viswanathan et al., 201514, shows the number of patients that
become functionally dependent after a stroke. The research was made according to data from 727 patients. As well as the other studies 11–15, a superiority of the incidence of men over women was demonstrated, being higher in ages over 63 years. Moreover, in consonance with Arnao et al., 201611, Sanya et al., 201512 and Catalá-Lopéz et al., 201413, it is shown that patients with a lower socioeconomic level (C – E) obtained a rate of 73% incidence of stroke. Associated with this, and according to Viswanathan et al., 201514, more than 60% of the patients analyzed have at least two risk factors, as dyslipidemia and systemic arterial hypertension.
As Arnao et al., 201611, Sanya et al., 201512, Catalá-Lopéz et al., 201413 and De Campos et al., 201717, Phan et al., 201718, demonstrate a panorama of sex differences in long-term mortality after stroke. Analyzes were performed at 1 and 5 years after stroke comparing to gender and their respective probability of survival. In one year, it was observed that the probability of survival of the women was close to 0.9, whereas the men's approximation was 0.75, reaching values smaller than this after 300 days of the acute cerebrovascular event. After the 5-year analysis of stroke, it was observed that women had a probability of survival greater than 0.75. On the other hand, men reached rates lower than 0.5. Moreover, the mortality rate ratio with 95% confidence interval shows that, as Kamalakannan et al., 201715, Arnao et al., 201611 and Sanya et al., 201512, mortality rates
3.2 RISK FACTORS AND PREVENTION
The equency of studies aims to talk about Risk Factors was 25,9%.
Viswanathan et al., 201514, by means of longitudinal cohort, demonstrate the influence of vascular risk factors and Stroke on cognition in late life trough application of modified Framingham risk score (MFRS). It was evident, that individuals with previous history of stroke performed worse results at the MFRS. Showing that, through a value of p less than 0.001, a percentage of 67.8% of patients after stroke had some grain of cognitive dysfunction in accordance with the results obtained by MFRS. In addition, as well as raised by Sanya et al., 201512, there is influence of high values of systolic and diastolic blood pressures on stroke involvement and consequently cognitive loss in the future.
As well as raised by Catalá-Lopéz et al., 201413, De Melo et al., 201619 demonstrates that
stroke has several risk factors1,7,14,16,20, either before the acute event or as comorbid factors.
Therefore, through EMMA study data, it has been shown that major depression is a predictor of lower survival after an acute cerebrovascular event. In this study 25.1% of the patients with major depression (MD) after stroke were evidenced. Therefore, according to the modified mRS, a worse prognosis was observed in patients with MD, having approximately 85% survival after 350 days versus more than 95% survival in those who did not have MD after stroke.
Olaiya, et al., 201716 demonstrate that, as well as raised by Catalá-Lopéz et al., 201413, De Melo et al., 201619 and other researches 1,7,14,16,20, there are many risk factors for acute stroke and therefore there are many ways of prevention, primary, secondary, tertiary or even quaternary.In this study, 84.8% of smokers, 80% with systemic arterial hypertension and 70% with BMI above 25 kg/m2 were observed. Given this, stroke prevention measures were developed, and risk factor rates decreased by at least 3% in relation to one of these factors. In agreement with such data, Feigin et al., 20161 demonstrated the importance of preventing stroke and its main strategies according to the Global burden of Disease 2013 Study. In addition, according to Kamalakannan et al., 201715, Arnao
et al., 201611 and Sanya et al., 201512, it was observed that there was a 50% increase in deaths from
1990 to 2013, with medium- and low-income countries accounting for 75% of deaths.
Lopes et al., 201621 shows that, as in other studies1,7,14,16,20, hypertension and diabetes are the
main risk factors for stroke. As a result, rates of hospitalization for ischemic stroke in the year 1998 to 2001 were around 35.6 per 100 thousand, a reduction of 73.64% between 2002 and 2005 was evident, totaling a rate of hospitalization of 10.33 per 100 thousand. In addition, through the implementation of the Hiperdia program in the year 2002, there was a marked decrease in mortality due to ischemic stroke in Brazilian hospitals. In line with these mortality data, Passos et al., 201622 also demonstrates trends in reducing stroke mortality in Brazil. And in 1996 men had a mortality
rate per 100,000 of 13.6 and in 2011 this figure decreased to 60.9. Women in 1996 had a rate of 84.4, which dropped to 42.3 in 2011. And, like the other studies7,8,13,14,21,mainly according to George et al., 201723, hypertension and diabetes are the most important risk factors and the great control of this two diseases culminates in reduction of stroke incidence rates, prevalence and mortality.
3.3 QUALITY OF CARE IN ACUTE STROKE
The frequency of studies aims to talk about Quality of Care in Acute Stroke was 29,7%. Sunol et al., 201524, shows, in a multilevel cross-sectional study, that the association of
departmental quality strategies is positive with clinical practices. They analyzed a total of 9021 clinical records in 7 high-income countries. It was demonstrated, as in the other articles11–15,17, that
there was a superiority of stroke incidence in men than in women. In addition, older patients (>65 years) were shown higher rates. However, an interesting fact was that they divided the quality management measures into four department levels (figure 2): specialized expertise & responsibility, evidence-based organization of pathways, patient’s safety strategies and clinical review. From this, these levels were stratified into scores ranging from 0 to 10, obtaining, respectively, the following scores: 6.6; 7.5; 6.3 and 4.8
Figure 2. Directed acyclic graph (DAG) guiding the analysis and showing hypothesized relationships between predictors, outcome, and covariates in this study (Sunol et al., 201524).
Hsieh et al., 201625, differently from Sunol et al., 201524, show a perspective of quality improvement in acute ischemic stroke care in a low-income country. A comparison of the quality of acute stroke care before and after the implementation of what has been termed the Breakthrough Series (BTS) consisting of a model for achieving breakthrough improvements in quality while reducing costs. Comparing rates of some good practice criteria is advocated by the American Stroke Association (ASA), such as the time elapsed between the arrival of the patient with acute stroke and the performance of a computed tomography (CT) of the skull in less than 25 minutes (obtaining a rate of 33.9% before and 76.1% after the BTS). In addition, another important data is to be cited is the performance of the antithrombotic therapy in less than 60 minutes after the patient arrival at the stroke unit (being a bill of 7.1% before the BTS and 50.8% after its implementation).
Langhorne et al., 201826, by means of an international observational study
(INTERSTROKE), realized a comparison of practices patterns and outcomes after stroke across low, middle and high-income countries. In this respect, a p value of less than 0.001 was demonstrated, that in high-income countries, 92% of patients with a stroke had a stroke center available for care. however, those countries with medium and low income had rates of respectively 23% and 61%. In addition, for units that had all the best practices possible (the stroke unit characteristics included discrete ward, staff who specialize in stroke, regular multidisciplinary team meetings, protocols for care in place, programs of education and training for staff), they were limited to 71% in high-income countries, 19% in middle-income countries and 20% in low-income countries.
As Hsieh et al., 201625, Baatiema et al., 201727 demonstrate a panorama of best practices in acute stroke care in a low-income country. It was demonstrated that only 9.1% of the evaluated hospitals had a local protocol for a rapid screening of suspected cases of acute stroke and a unit dedicated solely to stroke care. In addition, 63.3% of the hospitals evaluated had functioning computed tomography. It was also evidenced the absence of policies for the development of care for patients with acute stroke.
Fraser, Baeza and Boaz, 201728 demonstrate, by means of semi-structured interviews, the
role evidence of reconfiguration of stroke service in a high-income country. They demonstrate that, to reach best practices in acute stroke, must be sought better patients’ outcomes and professional support and clinical credibility alongside a tightly managed consultation process. No statistical data were collected that could be compared with the other articles collected. Likewise Fraser, Baeza and Boaz, 201728, Fulop et al., 201629 demonstrate qualitative outcomes in major system after
implementing centralised acute stroke services in two large metropolitan regions in a high-income country.
Scholten et al., 201530 shows the quality of patient care with acute stroke according to advances in antithrombotic therapy in a high income country. It was demonstrated that, following the progression of antithrombotic therapy, a factor advocated by the ASA, there was an increase in treatment with this tool from 4.8% in 2006 to 11% in the year 2010. In addition, there was evidence variation from 0% to 35.7% in the use of thrombolytic treatment in acute stroke.
3.4 ECONOMIC BURDEN OF STROKE
The frequency of studies aims to talk about economic burden of stroke was 14,8%.
Jennum et al., 201531 estimate the direct and indirect costs of stroke in patients and their
partners. They bring a panorama of the costs with patients before and after the diagnosis of the stroke. Being divided in hemorrhagic (£141,389 before diagnosis and £89,043 after diagnosis), ischemic (£547,465 before diagnosis and £398,140 after diagnosis) and not otherwise specified (£628,432 before diagnosis and £566,620 after diagnosis).
Differently from Jennum et al., 201531 and Xu et al., 201832, Song et al., 201733 shows a correlation between the socioeconomic impact of patients and outcomes after acute ischemic stroke in high-income country. After this, the degree of dysfunction after stroke was measured using the mRS scale. 51.3% of those patients who had a value of 5 in mRS had a schooling shorter than 6 years and 32.6% received less than $160 a month. Since those with mRS 0 had more than 32% with schooling greater than 9 years and more than 40% received more than $160 a month.
Xu et al., 201832, as well as Jennum et al., 201531, shows an overview of the total cost of health (includes ambulance, MRI or CT scan, thrombolysis, acute stroke unit care, rehabilitation stroke unit care, general medical ward care, community rehabilitation) and social (care home, home help, meals on wheels and social service day centre visits) care of patients with acute stroke in high-income countries. Thus, a cost of £21,121 was observed one year after the ischemic stroke and £41,432after 5 years. being also observed a high cost after cerebral hemorrhage (after one year: £24,297 euros and after five years: £52,726).
Hunter et al., 201834 shows the economic implication of two different implementation
strategies for major system change in a high-income country. In this way, it is possible to visualize that with an additional cost of £770.027 per 1000 patients admitted with stroke, a 9 deaths per 1000 patients were obtained. However, unlike this, with an economy of £156.118 per 1,000 patients there was an increase of 2 deaths per 1000 patients.
AUTHORS/YEAR PAPER’S TITLE STUDY TYPE RESEARCH’S OBJECTIVES CONCLUSION Mello, De et al., 201619
Major Depression as a Predictor of Poor Long-Term Survival in a Brazilian Stroke Cohort (Study of Stroke Mortality and Morbidity in Adults) EMMA study. Prospective cohort Evaluate the influence of major depression disorder on long-term survival in the participants from The Study
of Stroke Mortality and Morbidity in Adults (EMMA Study) in São Paulo, Brazil.
High rate of major depression disorder after stroke, which was considered as a potential marker of poor prognosis, increasing the risk of death 4 times compared to those who did not develop this condition 1 year after stroke.
Olaiya et al., 201716 Survivors of stroke or transient ischemic
attack (TIA) are at great risk of having severe or fatal secondary vascular events Community-Based Intervention to Improve Cardiometabolic Targets in Patients With Stroke A Randomized Controlled Trial. Randomize controlled trial Investigate the effectiveness of a management program for attaining cardiometabolic targets in survivors of stroke/transient ischemic attack. The interventions applied improved attainment of targets for the control of lipids in survivors of stroke/TIA after a 12-month follow up but no detectable differences for other risk factors at 12 months or any factor at 24 months. Arnao et al., 201611 Stroke incidence, prevalence and
mortality in women worldwide.
Systematic review Determine the information available on stroke epidemiology in women worldwide and possible sex differences in stroke epidemiology, and, if so, Sex differences studies from previously performed studies indicating that sex influences treatment and outcome.
describe the nature of these differences and whether they are consistent across countries. Sanya et al., 201512 Prevalence of stroke in three semi-urban
communities in middle-belt region of Nigeria: a door to door survey.
Door-to-door Determine the stroke prevalence in a semi urban community in middle-belt region of Nigeria. Stroke is a condition that is prevalent in our environment, especially in older adults. Uncontrolled systematic hypertension and previous transient ischemic attacks were the commonest risk factors for stroke.
Viswanathan et al., 201514
The Influence of Vascular Risk Factors and Stroke on Cognition in Late Life: Analysis of the NACC Cohort.
Longitudinal cohort Investigate the contribution of vascular risk factors in late life to cognitive decline in a cohort of normal elderly individuals. Late-life vascular risk factor burden in normal older adults plays a less important role in cognitive decline compares with the effects of age. Previous history of stroke appears to have independent effects on cognition. Catalá-López et al., 201413
The national burden of cerebrovascular diseases in Spain: A population-based study using disability-adjusted life years. Cross-sectional, descriptive population-based Determine the national burden of cerebrovascular diseases in the adult population in Spain. Prevention and control programmes aimed at reducing the cerebrovascular disease burden merit further priority in Spain. Raising awareness and maintaining a
framework for cooperation and engagement between policy-makers, researchers, clinicians and patients with cerebrovascular diseases is warranted. Kamalakannan et al., 201715
Incidence & prevalence of stroke in India: A systematic review.
Systematic review Conduce a systematic review of epidemiologic studies on stroke conducted in India to document the magnitude of stroke. A paucity of good-quality epidemiological studies on stroke in India emphasizes the
need for a
coordinated effort at both the State and national level to study the burden of stroke in India. Feigin et al., 20161 Prevention of stroke: A strategic global
imperative.
Systematic review
Review the latest stroke epidemiology literature, with an emphasis on the published Global Burden of Disease 2013 study estimates, highlight the problems with current primary stroke and cardiovascular disease prevention strategies and outline new developments in
Stroke has been identified as one of the prioritized noncommunicable disease by World Health Organization, as a consequence, primary stroke prevention in entering a new era in
which these
organizations must together with government bodies, medical systems and non-governmental organizations.
primary stroke and
cardiovascular disease prevention. Avezum et al., 20154 Stroke in Latin America: Burden of
Disease and Opportunities for Prevention. Systematic review Describe the available scientific evidence associated with the burden of stroke in Latin America to better understand how to prevent and improve outcomes related to stroke in the region along with the need for future research that could be translated into better population wide cardiovascular health. Early recognition and appropriate treatment of stroke from patient and physician perspectives are crucial for reassuring health outcomes for patients, however, in parallel, strategies for primary prevention of stroke are fundamental to substantially reduce the burden of stroke in Latin America.
Lopes et al., 201621 Hospitalization for ischemic stroke in
Brazil: an ecological study on the possible impact of Hiperdia
Ecological study Evaluate the trend of hospitalization for ischemic stroke and its hospital
mortality in Brazil over the last 15 years as well as the impact of the Hiperdia
program in this
There was a sharp decline in the incidence of hospitalization for ischemic stroke (HIS) in Brazil for all ranges and gender, as well as there is no regionalization in the event of HIS, coinciding with the implementation of
scenario. Hiperdia from 2002 onward. However, it was not observed
decrease of
mortality in the same magnitude. Adami et al., 20165 Mortality and Incidence of Hospital
Admissions for Stroke among Brazilians Aged 15 to 49 Years between 2008 and 2012.
Cross-sectional Analyse rates of stroke-related mortality and incidence of hospital admissions in Brazilians aged 15 to 49 years according to region and age group between 2008 and 2012. Decrease in stroke-related mortality, particularly in individuals over 30 years old, and stability of the incidence of hospitalizations; and also variation in stroke-related hospital admission incidence and mortality among Brazilian young adults. Campos, de et al., 201717
How Many Patients Become Functionally Dependent after a Stroke? A 3-Year Population-Based Study in Joinville, Brazil. Population-based study Evaluate how many patients become functionally dependent over 3 years after an incident event in Joinville, Brazil. One-third of stroke survivors have functionally dependence (FD) during the first year after stroke in Brazil. Therefore, a city with half a million people might expect 120 new stroke patients with FD each year. Phan et al., 201718 Sex Differences in Long-Term Mortality
After Stroke in the INSTRUCT (INternationalSTRokeoUtComessTudy): A Meta-Analysis of Individual Participant Data.
Meta-analysis Identify factors that contribute to the differences of sex in mortality at 1 and 5 years after stroke. Greater mortality in women is mostly because of age but also severity, atrial fibrillation, and prestrike functional
limitations. Lower survival after stroke among the elderly is inevitable, but there
may be
opportunities for intervention, including better access to evidence-based care for cardiovascular and general health. Passos et al., 201622 Consistent declining trends in stroke
mortality in Brazil: mission accomplished?
Cross-sectional Study stroke mortality among the Brazilians adults in order to investigate if good trends in stroke mortality in Brazil have come to stay. Health authorities must maintain and improve the efforts in the way to continue the declining trend of stroke in Brazil.
George et al., 201723 CDC Grand Rounds: Public Health
Strategies to Prevent and Treat Strokes
Report Show a quick state of art of strategies to prevent and treat stroke worldwide. Prevention is the best to medicine, whether the intervention is the clinical or community level. Xu et al., 201832 The economic burden of stroke care in
England, Wales and Northern Ireland: Using a national stroke register to estimate and report patient-level health economic outcomes in stroke
Cross-sectional Extend the Sentinel Stroke National Audit Programme registry of England, Wales and Northern Ireland to derive and report patient-level estimates of the cost of stroke Integrate the measurement and reporting of health economic outcomes data into clinical registries could help
them become
increasingly useful resources for quality improvement and research.
care. Jennum et al.,
201531
Cost of stroke: A controlled national study evaluating societal effects on patients and their partners
Controlled national study Estimate the direct and indirect costs of stroke in patients and their partners. The consequences for partners are not negligible and
account for
approximately one-third of the total familiar costs. Costs are higher among younger adults due to loss of work and the resulting higher indirect costs. T. et al., 201733 Is there a correlation between
socioeconomic disparity and functional outcome after acute ischemic stroke?
Prospective study Investigate the impact of low socioeconomic status, indicated by low level of education, occupation and income, on 3 months functional outcome after ischemic stroke.
People who are relatively more
deprived in
socioeconomic status suffer poorer outcome after ischemic stroke. The influence of low-income level on 3-month outcome.
Bray et al., 201635 Weekly variation in health-care quality
by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care
Nationwide, registry-based and prospective cohort study Describe the pattern and magnitude of weekly variation in several domains of care quality for people admitted to hospital with acute stroke. Weekly variation should be further investigated in other health-care settings, and quality improvement should focus on reducing temporal variation in quality and not only the weekend effect. Sunol et al., 201524 Implementation of departmental quality
strategies is positively associated with clinical practice: Results of a multicenter study in 73 hospitals in 7
Cross-sectional To assess variations in clinical practice and explore
There are significant gaps between recommended standards of care
european countries associations with hospital and department level quality management systems.
and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Hsieh et al., 201625 Quality improvement in acute ischemic
stroke care in Taiwan: The breakthrough collaborative in stroke
Cross-sectional Demonstrate the improved quality of acute ischemic stroke management via a Breakthrough Series – BTS - (a model for achieving breakthrough improvements in quality while reducing costs) collaborative learning model in a nationwide, multi-center activity in Taiwan. BTS collaborative learning and campaign model can
improve the guideline adherence for management of acute ischemic stroke. Langhorne et al., 201826
Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study
Observational study Compare patterns of care available and their association with patient outcomes across countries at different economic levels. A certain basic standard of care and supporting resources are likely to be needed to fully realise these benefits. These include adequate staffing and the capacity to accept the majority of
stroke patients. Baatiema et al.,
201727
Towards best practice in acute stroke care in Ghana: A survey of hospital services Hospital-based survey Identify and evaluate available acute stroke in Ghana and the extent to which these services align with global best practice.
Limited and variable provision of evidence-based stroke services and the low priority for stroke care in resource poor settings.
Fraser, Baeza e Boaz, 201728
'Holding the line': A qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London
Systematic review
Problematise the concept of “holding the line” and explore
the power implications of such managerial approaches in the early phases of health service reconfiguration. Focusing on the use of evidence by senior managerial decision-makers involved in the reconfiguration of stroke services in London 2008-2012. It is important to consider the interplay between research evidence, power and policy in studies of health service
reconfiguration in order to get a deeper understanding of the roles played be different actors in setting agendas and
shaping new
systems.
Hunter et al., 201834 The potential role of cost-utility analysis
in the decision to implement major system change in acute stroke services in metropolitan areas in England
Decision analytic model Calculate difference-in-difference in costs and outcomes before and after the implementation of two major
The implementation of major system change in acute stroke care may result in a net health benefit to a region,
even one
system change strategies in stroke care in London and Greater Manchester. fixed budget. Scholten et al., 201530
Who does it first? The uptake of medical innovations in the performance of thrombolysis on ischemic stroke patients in Germany: A study based on hospital quality data
Study based on hospital quality data Analyse the factors at the organizational level that influence the implementation of thrombolysis in stroke patients. Organizational factors have an influence on the implementation of thrombolysis. Further research must be done in order to gain greater insight into the organizational climate, which influences
organizational responsiveness. Fulop et al., 201629 Explaining outcomes in major system
change: A qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England
Quality study Compare two major systems in acute stroke services, examining the relationships between implementation approaches employed and the implementation outcomes.
The model selection (simplicity and inclusivity) and implementation approach make significant contributions to implementation outcomes observed and it turn intervention outcomes. 4 DISCUSSION
Thisintegrative review data showed stroke is an important public-health problemand should be a significantpart of the public-health agenda, mainly in low and middle-countries36.The studyhas
monitoring deaths, risk factors, hospitalizations and, efforts needed to improve health services destined to take care of patients with acute stroke.
Stroke prevalence estimates may differ between studies because each study selects and recruits different samples of participants to represent the target study population (eg, state, region, or country)37.In the stroke mortality studies, is possible to understand the quality of provided acute care services.According to American Heart Association, approximately 795,000 strokes occur in the United States each year and approximately 60% of stroke deaths occurred outside of an acute care hospitals37. In 2010, there were an estimated incidence 11.6 million events of ischemic stroke and 5.3 million events of incident hemorrhagic stroke, 63% and 80%, respectively, in lower and middle-income countries38.The global burden of diseases in all countriesare due to noncommunicable
issues.Of all strokes, 87% are ischemic and 10% are intracranial hemorrhage (ICM) strokes, whereas 3% are subarachnoid hemorrhage (SAH) strokes37.
In the phase one of the INTERSTROKE study, investigators assessed multiple risk factors in 3000 individuals with stroke and 3000 age and sex-matched controls. The following risk factors accounted for approximately 90% of population-attributable risk for all stroke; i) hypertension, ii) current smoking, iii) abdominal obesity (waist-to-hip ratio >0.96 in men and >0.93 in women), iv) elevated dietary risk, v) physical inactivity, vi) diabetes mellitus, vii) elevated alcohol intake (>30 drinks/month or binge drinking), viii) psychosocial stress (permanent or several periods of stress in the workplace and/or home), ix) depression (feeling sad or depressed for ≥2 weeks over the past year), x) cardiac causes (atrial fibrillation), and xi) ratio of apolipoproteins B to A1. The first five of these risk factors accounted for 80% of global risk for all stroke (ischemic and intracerebral hemorrhagic), while the single, strongest risk factor for stroke was self-reported history of hypertension39.
80% of all strokes in adults may be preventable40, risk factors and/or lifestyles that can make more likely to have a stroke. In most cases, managing risk factors can help to prevent a stroke. The vast majority of the evidence on risk factors modification has shown that is possible to reduce mortality and morbidity in people with diagnosed or undiagnosed stroke.Part of this morbidity and mortality could be prevented through population-based strategies, by making cost-effective interventions accessible, both for people with stablished disease and for those at high risk of developing stroke. To address the rising burden of noncommunicable diseases, were adopted the Global Strategy for the Prevention and Control of Noncommunicable Diseases, Framework Convention on Tobacco Control and the Global Strategy for Diet, Physical Activity and Health41.
Knowing the risk factors for stroke is essential forprevent its occurrence. Data from the systematic review of prospective studies suggest that overweight and obesity are predictors of
major stroke subtypes in >2 million participants over ≥4 years. It was found an adjusted RR for ischemic stroke of 1.22 (95% CI, 1.05–1.41) in overweight individuals and an RR of 1.64 (95% CI, 1.36–1.99) for obese individuals relative to normal-weight individuals. RRs for hemorrhagic stroke were 1.01 (95% CI, 0.88–1.17) and 1.24 (95% CI, 0.99–1.54) for overweight and obese individuals, respectively. These risks were graded by increasing body mass index (BMI) and were independent of age, lifestyle, and other cardiovascular risk factors42. The Canadian Best Practice guidelines for the secondary prevention of stroke recommend the participation “in moderate dynamic exercise such as walking (ideally brisk walking), jogging, cycling, swimming or other dynamic exercise 4 to 7 days each week in addition to routine daily activities”43,44.
Persons within modifiable and non-modifiable risk group can be benefited with more attention in primary care. One in five women in the United States will have a stroke in her lifetime. Nearly 60% of stroke deaths are in women, and stroke kills twice as many women as breast cancer. Stroke is the third leading cause of death in women, yet most women do not know their risk of having a stroke37. With the increase in the aging population, prevalence of stroke survivors is projected to increase, especially among elderly women45. An analysis of data from the Framingham
Study (n=4897) determined that lifetime risk for first-ever stroke in individuals from age 55 to 75 is approximately 1 in 6 and is slightly higher in women than men (1 in 5 vs. 1 in 6), given longer female life expectancies46.
The association between diabetes mellitus (DM) and stroke risk differs between sexes. A systematic review of 64 cohort studies representing 775 385 individuals and 12 539 strokes revealed associated with DM was 2.28 (95% CI 1.93–2.69) in women and 1.83 (1.60–2.08) in men47.The group belonging to modifiable risks needs an incentive and support for lifestyle change.
Atrial fibrillation (AF) is one of the most common forms of abnormal heart rhythm (arrhythmia) and a major cause of stroke. Thus,patients with arrhythmia are five times more likely to have a stroke. Data from the Framingham Heart Study, suggest that the incidence and prevalence of AF are increasing over time. The studies indicated that AF was associated with an increased risk of cognitive impairment in patients after stroke (RR, 2.70; 95% CI, 1.82–4.00) and in patients without stroke history (RR 1.37; 95% CI, 1.08–1.73). The risk of dementia was similarly increased (RR, 1.38; 95% CI, 1.22–1.56)48.In the setting of AF, women have a significantly higher risk of stroke than men49.An important focus of management AF patients is the assessment of
thromboembolic risk, in particular stroke risk; however, the assessment and management of (CVD) risk are at least as important.People with heart failure are 2-3 times more likely to have a stroke and diabetic are twice as likely to have the disease37.
Fifferents etiologies stroke cause similar symptoms, because even in different ways each one affects directly brain blood flow. Rapidassessment and correct management of stroke in specialized care services reduces the risk of recurrent and improves stroke outcomes. Secondary prevention is crucial to reduce the burden and costs on the health care system, besides to improve patient outcomes 50, as shown byCatalá-Lopéz et al., 201413, De Melo et al., 201619andotherresearches1,7,14,16,20. The patient who arrives at an emergency care unit has as priority his hemodynamic stabilization, to be performed by the immediate assistance team. The fact of been recurrent or primary, the NIH Stroke Scale Grade (NIHSS), the time to achieve clinical stability and stroke associated complications predict the functional prognosis of each patient 1,4,13,23–27.
Many health services do not practice the best recommendation for stroke assessment and management 22–30. The reasons may be related to access to expert human resources, diagnostic
equipment and certain interventions51. For example, a recent report highlighted underuse of
appropriate cardiac rhythm monitoring in patients with stroke, with 31% receiving 24 hours of monitoring and less than 1% receiving prolonged monitoring52.
The clinical and research communities increasingly recognize the importance of post stroke cognitive decline, including mood, fatigue and quality of life14,16,17,19,29,33. A massive stroke ins’t
always fatal, leading to disability. Focusing on mortality alone underestimated that only 65% of who survived to a stroke may be functionally independent one year after the event 53,54.Secondary prevention should be regarded as an important part of post stroke care, as rehabilitation of functional skills like walking or swallowing. Recent studies have revealed that approximately 1 of every 3 stroke survivors develops post stroke depression. Depression is present in 33% (95% CI, 26%-39%) of patients one year after stroke, with a decline beyond 1 year: 25% (95% CI, 16%-33%) up to 5 years and 23% (95% CI, 14%-31%) after 5 years55. Poststroke depression is associated with higher mortality, a OR for at follow-up of 1.22 (95% CI, 1.02–1.47)56.Continuity of care and strong communication between healthcare professionals, the patient and their family are critical to smooth transitions between stroke care settings 22,24,25,28–30,57.
Tins et al (2013) reported the Brazilian challenges and experiences in the implementation of the National Stroke Project7. Cooperation between states and municipalities leads to development
of local acute stroke prevention plans, by promoting public health and social inclusion actions, consistent with the principles af the Brazilian Unified Health System 4,5,19,21,23,36.
This review has strengths and weaknesses. The former are in accordance with the methodological rigidity that was followed throughout the selection of the works here demonstrated and discussed. in addition, articles of renowned periodicals were collected in the area and as updated as possible. However, it is a subject that does not end and has different nuances according
to the population studied, the country and even the socioeconomic level. Thus, some good practices developed in some countries may not have been included in this review due to the fact that such practices have not been published, given the difficulty recently faced in relation to scientific publication.
5 CONCLUSIONS
For effective and sustainable stroke control, specific measures should be developed in conjunction with other integrated inter-sectoral public policies, like improvement in social conditions, better access to health care services and health education. Both financial and technical management will have to be more decentralized to state and municipal governments. It will make stroke surveillance, prevention and control more possible, in other to reduce its disabilities and deaths.
Timely and sustained lifestyle interventions associated to appropriate drug treatment will reduce stroke risk, and hence reduce premature morbidity, mortality and, disability. Many people are unaware of their risk status, so population screening by health care providers are a potentially useful guide for making clinical decisions and preventive interventions: dietary advice, suggestions for physical activity, and risk factors medication treatment. With the aim of always research and create new stroke initiatives, the goal of reducing the burden of stroke will be certainly possible to achieve.
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