A systematic comparison of key features of ischemic stroke prevention guidelines in low- and middle-income vs. high-income countries

Abstract

Background and purpose Implementation of contextually appropriate, evidence-based, expert-recommended stroke prevention guideline is particularly important in Low-Income Countries (LMICs), which bear disproportional larger burden of stroke while possessing fewer resources. However, key quality characteristics of guidelines issued in LMICs compared with those in High-Income Countries (HICs) have not been systematically studied. We aimed to compare important features of stroke prevention guidelines issued in these groups. Methods We systematically searched PubMed, AJOL, SciELO, and LILACS databases for stroke prevention guidelines published between January 2005 and December 2015 by country. Primary search items included: “Stroke” and “Guidelines”. We critically appraised the articles for evidence level, issuance frequency, translatability to clinical practice, and ethical considerations. We followed the PRISMA guidelines for the elaboration process. Results Among 36 stroke prevention guidelines published, 22 (61%) met eligibility criteria: 8 from LMICs (36%) and 14 from HICs (64%). LMIC-issued guidelines were less likely to have articulation of recommendations (62% vs. 100%, p = 0.03), involve high quality systematic reviews (21% vs. 79%, p = 0.006), have a good dissemination channels (12% vs 71%, p = 0.02) and have an external reviewer (12% vs 57%, p = 0.07). The patient views and preferences were the most significant stakeholder considerations in HIC (57%, p = 0.01) compared with LMICs. The most frequent evidence grading system was American Heart Association (AHA) used in 22% of the guidelines. The Class I/III and Level (A) recommendations were homogenous among LMICs. Conclusions The quality and quantity of stroke prevention guidelines in LMICs are less than those of HICs and need to be significantly improved upon.

Quality of care for ischemic stroke in China vs India

“…Furthermore, these comparative data are relevant to recent studies showing opportunities for improvement of stroke prevention guidelines in low-and middle-income countries such as China and India. 13 While both groups developed stroke at younger ages compared to Western populations, 14 Indian patients were significantly younger than Chinese patients. Stroke was male preponderant in both countries, likely due to a higher incidence and possible cultural biases resulting in men being evaluated and admitted more often than women.…”

Assessing the Quality of Clinical Practice Guidelines in the Middle East and North Africa (MENA) Region: A Systematic Review

“…reviews have been conducted to compare and identify the gaps in several guidelines in low-income and middleincome countries compared with high-income countries. [94][95][96] Since some of the MENA countries are classified as low-income and middle-income, as described in the data of the World Bank, the results of such research can be taken into consideration. 28 Results from those reviews found several factors in the CPGs of low-and middle-income countries that had an impact on their quality and resulted in less clear and applicable guidelines.…”

“…28 Results from those reviews found several factors in the CPGs of low-and middle-income countries that had an impact on their quality and resulted in less clear and applicable guidelines. 28,95 These factors can be broadly classified into evidencerelated and contextual-related. 97,98 Regarding evidencerelated factors, the ability to search and critique clinical evidence is limited in developing countries.…”

Strategic, Successful, and Sustained Synergy: The Global Alliance for Chronic Diseases Hypertension Program

“…The COUNCIL (Control UNique to Cardiovascular diseases In LMIC) initiative started with the aim of reviewing the relevance of current cardiovascular disease guidelines for LMIC settings and developing an implementation pipeline for pragmatic solutions to the cardiovascular disease burden in LMICs [4]. The COUNCIL initiative has now also included other chronic NCDs including diabetes [5], stroke [6], obesity, chronic obstructive pulmonary disorder, and depression. The data consensus group aimed to develop consensus measures for data collection [7] and ensured an improvement in the commonality of data points collected across the projects, as well as improved consistent definitions across projects.…”