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.