International Stroke Conference
Danny R. Rose, Jr., MD
Improving stroke systems of care around the globe is a complex challenge that truly captures the “international” aspect of the International Stroke Conference. Each country faces its own unique set of challenges and opportunities based on available resources, geography, government and many other factors. The four talks were split evenly between discussing challenges for high income and low/middle income countries, with representation from Canada, Germany, India and Brazil.
The first talk was by Dr. Gordon Gubitz, MD, from Dalhousie University in Nova Scotia, Canada, discussing the implementation of stroke systems of care in Canada’s national single-payer healthcare system. Dr. Gubitz stressed that the foundation of the success of the Canadian model was developing nurturing relationships between physicians, researchers and advocacy groups, informed by best practice. The Canadian healthcare system is Medicare, a publically funded program that has been in place since 1971. The federal government provides funds that are distributed and utilized at the provincial level, according to the needs of each individual province or territory. This was largely due to the recognition that there is a wide disparity in geography, population density, infrastructure and other things between very rural areas like the Northwest Territories and a populous province like Ontario.
Dr. Gubitz discussed the evolution of the stroke systems in Canada, from the 1952 founding of the Heart (later, Heart and Stroke) Foundation of Canada to the Canadian Stroke Network, which was in place from 1999–2014. This included a national registry that is unfortunately now defunct, as well as discussing the Canadian Best Practice Recommendations for Stroke Care, a consistently revised series of recommendations that independently reviews and assigns grades for aspects of stroke care with systemic implications in mind. He also touched on the fact that Canada has designated Stroke Prevention Clinics around the country to supplement primary care with the specific task of increasing accessibility to resources to help manage stroke risk factors.
Dr. Werner Hacke, MD, PhD, from the University of Heidelberg in Germany discussed his country’s implementation of nationwide access to thrombectomy in the endovascular era. He discussed an analysis based on DRG Statistics from the Federal Statistical Office of Germany to review the proportion of acute stroke patients receiving mechanical thrombectomy (MT), as well as the proportion of acute stroke cases receiving IV thrombolysis, analyzed according to the patients’ place of residence and location of treating facility. Although this method did not include quality outcomes or the quality of the procedures, it did provide 100% coverage of all hospitalized patients.
The study looked at these rates from 2012, 2014 and 2016. The most striking statistic from this study was the rapid increase in mechanical thrombectomy rates between 2014 and 2016, coinciding with several published studies showing the efficacy of such procedures. The rate of MT increased from 2.3% in 2014 to 4.5% in 2016, nearly a twofold increase. Intravenous thrombolysis rates modestly increased around 20% during the same timespan from 11.6% to 13.4%. Impressively, all but one of the 413 districts in Germany had patients that were treated with MT during this time period, suggesting sufficient access to care across the country. Dr. Hacke credits this to the national organization of >300 certified Stroke Units.
Dr. Jeyaraj Pandian, MBBS, MD, from Christian Medical College in Ludhiana, India, reviewed the state of stroke systems of care in India and other low-middle income countries (LMICs). He referred to several problems that are hindrances to establishing stroke systems of care that are available in high income countries, including traffic and lack of an emergency telephone “911” system. He discussed India’s implementation of a “108” model, which included collaboration between the private and public sector and is now implemented in 29 states. Stroke units, which are recognized by the AHA as best practice for the treatment of acute ischemic stroke, are difficult to implement in LMICs due to lack of specialty physicians and resources. Dr. Pandian advocated for the implementation of physician-based stroke systems of care based around stroke units and showed data showing similar improvement in outcomes when stroke units were implemented in India as compared to other countries where this practice is widespread.
A unique approach undertaken in India is the training of Accredited Social Health Activists (ASHAs), who function as community health liaisons in rural villages. He cited a study that involved the training of 220 ASHAs who were able to make a positive impact on stroke risk factor screening, as well as acute stroke recognition. Dr. Pandian’s closing comments spoke to the challenge of training and recruiting interventionalists to increase the availability of thrombectomy to more areas in India.
Dr. Ayrton Massaro, MD, of Hospital Sirio Libanes in São Paulo, Brazil, spoke primarily about healthcare disparities in LMICs. He noted the epidemiological transition in LMICs, where economic and social development increases the proportion of disease burden from chronic and noncommunicable diseases like stroke. He presented data from the World Stroke Organization showing that low income level increases risk of cardiovascular events independent of geography, employment and health insurance coverage. He also noted a proportionally increased risk of hemorrhagic stroke in patients treated in public hospitals, showing subsequent increased cost burden associated with this, coupled with the relative underfunding of these hospitals. With respect to ischemic stroke, one of the biggest hurdles in Brazil was the fact that rtPA was only finally approved in 2012.
There were clear disparities between the patient populations of private versus public hospitals in Brazil, with public hospital patients having more severe strokes, less well controlled risk factors and worse functional outcomes. Thrombolysis rates differed significantly between the two as well. The reasons for this were multifactorial and widespread, from transportation to hospitals themselves, to lack of public education and lack of access to preventative care.
From the perspective of someone who has trained in the U.S. medical system, I believe there are valuable lessons to be learned from all of these speakers. The stories from Canada and Germany speak to how efficient and effective the implementation of broad systems of care can be under a nationalized healthcare system without concern for profit margins and competition. The speakers from India and Brazil represent a valuable insight into the unique challenges in LMICs and the importance of understanding that standards of care developed with only high income countries in mind can make implementation difficult on a global scale. Cultivating a truly global understanding of the state of stroke care and encouraging collaboration and dialogue between all countries can only help, and I believe this forum was a great representation of that concept.