Elsevier

The Lancet

Volume 391, Issue 10134, 19–25 May 2018, Pages 2019-2027
The Lancet

Articles
Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study

https://doi.org/10.1016/S0140-6736(18)30802-XGet rights and content

Summary

Background

Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels.

Methods

We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month.

Findings

We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14–1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12–1·72) irrespective of other patient and service characteristics.

Interpretation

Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes.

Funding

Chest, Heart and Stroke Scotland.

Introduction

Stroke is the second most common cause of death worldwide and one of the leading causes of disability.1, 2, 3 Although prevention strategies can reduce this burden of disease,4, 5 effective and affordable treatments are essential for reducing mortality and morbidity in those who have already had a stroke. Aspirin,4, 5 intravenous thrombolysis,4, 5 and mechanical thrombectomy6 for acute ischaemic stroke, plus stroke unit care and early rehabilitation services for all stroke patients4, 5 can reduce mortality and morbidity.

Results of the 2014 PURE study7 showed that clinical outcomes after stroke were substantially poorer in low-income and middle-income countries than in high-income countries. Whether this finding reflects differences in the patient population, services available, or treatments received is uncertain. In many high-income countries, clinical practice guidelines and national strategies now recommend the establishment of stroke units in all hospitals that care for patients with acute stroke.8, 9, 10, 11, 12, 13 This practice has been linked to an increased provision of evidence-based care14, 15, 16, 17, 18, 19 and improved patient outcomes.17, 18, 19, 20 However the greatest adoption of these practices has been in high-income countries, where most clinical trials of stroke units have been done. The number of stroke units in low-income and middle-income countries is unknown, along with whether these are associated with improved outcomes.4, 5, 8 Such information could inform the establishment of stroke units in low-income and middle-income countries.

Research in context

Evidence before this study

We searched MEDLINE, Embase, and PubMed from Jan 1, 2000, to May 24, 2017, for large stroke register studies using Medical Subject Headings including the following search terms: “stroke OR cerebral hemorrhage OR cerebral infarction AND quality indicator OR performance indicator OR quality improvement OR quality of care OR quality of health care OR registry OR register OR audit AND outcome OR mortality OR case fatality OR survival OR disability OR function OR recovery OR discharge OR discharge destination OR return home OR complications”. We identified 20 studies but none had been done in low or middle-income country settings.

Added value of this study

This is the first large study to use standardised, prospective data collection across a range of World Bank country income categories levels in more than 12 000 carefully characterised acute stroke patients from 108 hospitals in 28 countries. We have found that evidence-based treatments, diagnostics, and availability of stroke units were less common in low-income and middle-income countries. Access to stroke units and appropriate antiplatelet treatment were consistently associated with improved recovery.

Implications of all the available evidence

This analysis supports the widespread provision of appropriate early antiplatelet treatment and stroke unit care within hospitals in low-income and middle-income country settings. A certain basic standard of care and supporting resources are likely to be needed to fully achieve these benefits. Further research needs to develop and test methods of effectively implementing lower-cost, regionally appropriate models of stroke unit care.

INTERSTROKE was an international observational stroke study done in 32 countries at different economic levels.21 Individuals who had had a stroke were selected using standardised criteria and were characterised in detail. In this study we use INTERSTOKE data to compare patterns of care available and their association with patient outcomes, across a much broader range of health-care settings than has previously been possible.

Section snippets

Study design and participants

INTERSTROKE was an international case-control study of risk factors for first stroke,21 which enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. For this analysis of practice patterns, our hypotheses were that, across all countries studied, there would be variations in access to stroke treatments and services and that, after adjusting for variations in patient casemix, patient outcomes would be affected by the treatments and services

Results

Between Jan 11, 2007, and Aug 8, 2015, the INTERSTROKE study21 enrolled 13 447 acute stroke patients from 142 centres; 34 centres (1105 participants) did not provide information about the service survey. We therefore had complete individual patient data and service information from 12 342 participants from 108 hospitals in 28 countries covering western Europe, east and central Europe, the Middle East, Africa, South Asia, China, southeast Asia, Latin America, North America, and Australia.

Table 1

Discussion

We had anticipated that INTERSTROKE patients enrolled from hospitals in low-income and middle-income countries would have poorer access to investigations, treatments, and services than those enrolled from hospitals in high-income countries. However, these patients also had poorer clinical outcomes (survival 88% vs 98% in high-income countries; survival without severe disability 78% vs 90%), which could only be partly explained by the inclusion of more severe stroke patients. Across all

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