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

Langhorne P 1 , O'Donnell MJ 2 , Chin SL 3 , Zhang H 4 , Xavier D 5 , Avezum A 6 Show all authors , Mathur N 5 , Turner M 7 , MacLeod MJ 7 , Lopez-Jaramillo P 8 , Damasceno A 9 , Hankey GJ 10 , Dans AL 11 , Elsayed A 12 , Mondo C 13 , Wasay M 14 , Czlonkowska A 15 , Weimar C 16 , Yusufali AH 17 , Hussain FA 18 , Lisheng L 19 , Diener HC 16 , Ryglewicz D 15 , Pogosova N 20 , Iqbal R 14 , Diaz R 21 , Yusoff K 22 , Oguz A 23 , Wang X 4 , Penaherrera E 24 , Lanas F 25 , Ogah OS 26 , Ogunniyi A 27 , Iversen HK 28 , Malaga G 29 , Rumboldt Z 30 , Magazi D 31 , Nilanont Y 32 , Rosengren A 33 , Oveisgharan S 34 , Yusuf S 3 , INTERSTROKE collaborators

Affiliations 

  • 1 Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK. Electronic address: peter.langhorne@glasgow.ac.uk
  • 2 Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
  • 3 Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
  • 4 Beijing Hypertension League Institute, Beijing, China
  • 5 St John's Medical College and Research Institute, Bangalore, India
  • 6 Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
  • 7 Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
  • 8 Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
  • 9 Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
  • 10 Medical School, The University of Western Australia, Perth, WA, Australia
  • 11 College of Medicine, University of Philippines, Manila, Philippines
  • 12 Alzaeim Alazhari University, Khartoum North, Sudan
  • 13 Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
  • 14 Department of Medicine, Aga Khan University, Karachi, Pakistan
  • 15 Institute of Psychiatry and Neurology, Warsaw, Poland
  • 16 Department of Neurology, University Hospital, Essen, Germany
  • 17 Dubai Health Authority, Dubai Medical College, Dubai, United Arab Emirates
  • 18 King Saud University, Riyadh, Saudi Arabia
  • 19 National Center of Cardiovascular Disease, Beijing, China
  • 20 National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
  • 21 Estudios Clinicos Latinoamerica, Rosario, Argentina
  • 22 UCSI University, Cheras, Kuala Lumpur, Malaysia
  • 23 Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
  • 24 Department of Cardiology, Hospital Luis Vernaza, Guayaquil, Ecuador
  • 25 Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
  • 26 Division of Cardiovascular Medicine, University College Hospital, Ibadan, Nigeria
  • 27 Department of Medicine, University College Hospital, Ibadan, Nigeria
  • 28 Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
  • 29 Universidad Peruana Cayetano Heredia, Lima, Peru
  • 30 University of Split, Split, Croatia
  • 31 University of Limpopo, Pretoria, South Africa
  • 32 Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
  • 33 Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
  • 34 Rush Alzheimer Disease Research Center in Chicago, Chicago, IL, USA
Lancet, 2018 05 19;391(10134):2019-2027.
PMID: 29864018 DOI: 10.1016/S0140-6736(18)30802-X

Abstract

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.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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