Robert W. Regenhardt, MD, PhD
Regenhardt RW, Biseko MR, Shayo AF, Mmbando TN, Grundy SJ, Xu A, et al. Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania. International Journal for Quality in Health Care. 2018
As the second leading cause of death in the world, stroke is a global problem. With the recent advances in treatment of acute stroke from large vessel occlusion, World Stroke Day reminds us that in many parts of the world, these therapies are unavailable. There are large disparities between high- and low-income countries and opportunities to dramatically influence outcomes by implementing system changes in resource-limited settings. As stroke care providers, there are different levels within stroke care systems where we can implement changes to improve care. These levels include prevention at the population level, access to acute therapies at the community infrastructure level, guideline adherence during the acute admission at the hospital system level, and rehabilitation and follow-up care thereafter. Each of these is critically important.
I recently had the opportunity to work on a project in urban Tanzania to describe the quality of stroke care and identify opportunities for improvement in this resource-limited setting. My time in Dar es Salaam was a truly life-changing experience. My first day rounding with the team at Muhimbili National Hospital (MNH), the largest academic referral center in Tanzania, made me better appreciate the resources we have in Boston. Many of the wards there are connected by dirt roads, and temperature control is unavailable. As I entered the Neurology Ward, I noticed the windows were open, allowing insects entry into the building; there were mosquito nets hanging over the patient; and 15-20 patients were placed in one common space. On a few occasions, there was a lack of running water on the wards, and jugs of water were obtained so we could wash our hands. Despite the relative lack of resources compared to hospitals in high-income settings, there were many similarities. It was clear the house staff had passion for their work and deeply cared for the patients. Many of the same services we offer patients in Boston were available at MNH, but in scaled-down versions. Everyone worked hard to make things work with the available resources.
We aimed to describe the quality of care at the hospital system level. Of those admitted to MNH with stroke, 85% had no insurance; 83% reported they had hypertension, but only 49% were on antihypertensives; 42% had imaging evidence of prior strokes; 74% were transferred from another hospital; median NIHSS was 19; 46% had ischemic strokes; 54% had hemorrhagic strokes; and median hospitalization time was 5.5 days. We recorded the implementation of stroke-focused treatments over the study: dysphagia screening (80%), DVT prophylaxis (0%), aspirin (83%), antihypertensives (89%), statins (95%), prolonged continuous heart monitoring (0%), carotid artery imaging (0%), acute thrombolysis (0%), and thrombectomy (0%). Outcomes were also assessed: Of ischemic stroke patients, 19% died and 56% had mRS 4-5 at discharge; 49% died by 90 days. Of hemorrhagic stroke patients, 33% died and 49% had mRS 4-5 at discharge; 50% died by 90 days.
To prioritize goals, we considered the number needed to treat (NNT) versus the resources required for potential interventions. The interventions with the lowest NNT, such as thrombolysis and thrombectomy, required the greatest resources and system changes. This helped us to establish long-term goals that would be impactful, though challenging. We also identified several short-term goals that were “low hanging fruit.” While less impactful, they were feasible and more easily implemented. This approach can be extrapolated to other hospital systems in low-income countries to identify and prioritize interventions to improve stroke care. Future work is aimed at both improving care after discharge from the acute hospitalization and at understanding the community infrastructure and network of care access points to identify the largest barriers to acute stroke treatment implementation.