Quality of Ischemic Stroke Care in Emerging Countries

Abstract

on behalf of ReNACer Investigators and the Argentinian Neurological SocietyBackground and Purpose-Limited information is available on stroke management in developing countries. An accurate monitoring of quality of stroke care will become crucial, particularly with the emerging paradigm of pay-forperformance. Our aim was to explore the feasibility of measuring standardized indicators of quality of ischemic stroke care in acute care facilities in Argentina. Methods-ReNACer is a prospective, multicenter, countrywide, stroke registry comprising 74 academic and nonacademic institutions in Argentina. The registry includes patient-level information on demography, clinical characteristics, diagnostic procedures, treatment, and the selected key performance indicators of quality of ischemic stroke care (access to thrombolysis or aspirin use in the acute setting, admission to designated stroke units, length of stay, risk-adjusted in-hospital pneumonia, risk-adjusted in-hospital mortality, discharge on antithrombotics, and antihypertensive agents). Results-We included 1991 patients with ischemic stroke from 74 institutions in Argentina between November 2004 andOctober 2006. Seventy-nine per cent of the patients were prescribed antithrombotic therapy within 48 hours of admission, but only 1% received thrombolytics. No more than 5.7% were admitted to stroke units. In-hospital pneumonia was diagnosed in 14.3% of the patients and was higher in nonacademic facilities (16.4% versus 11.4%, PϽ0.02). The overall adjusted in-hospital mortality was 9.1%, also higher in nonacademic hospitals (10.6% versus 7.1%, PϽ0.008). At discharge, antithrombotics were prescribed in 90.2% and antihypertensive agents in 63.6% of the patients. Conclusions-In ReNACer, there was a limited access to stroke units and thrombolytics, and a relatively high incidence of in-hospital pneumonia. Differences in stroke care were observed between academic and nonacademic institutions.There is an urgent need to develop national stroke programs in Argentina. (Stroke. 2008;39:3036-3041.)

Registro de pacientes con accidente cerebro vascular en un hospital público del Perú, 2000-2009

“…Con relación a otros estudios internacionales (EE.UU. (9) y Argentina (10) ) nuestra mortalidad es mayor, pero, puede ser que la comparación no sea definitiva, pues en el estudio estadounidense se incluyó a pacientes con diagnóstico de CIT (casi el 25 % de la muestra) y en el estudio argentino solo evaluaron pacientes con ACV-i que, en general, tiene una menor mortalidad. La falta de una unidad especializada en ACV en el hospital o la falta de implementación de protocolos de administración de terapia trombolítica, pudieran explicar perfectamente estos resultados.…”

“…(0,89), Reino Unido (1,2-1,4) y Argentina (1,35) (9,10,18) . En base a este resultado nuestra población se comportaría de acuerdo con lo descrito por la AHA (11) , la cual afirma que la incidencia de ACV es mayor en varones; sin embargo, difiere de estudios nacionales, los que a su vez son discordantes, pues Deza et al (8) informaron una marcada diferencia de 2,21, mientras que Astorga et al (19) mostraron una razón de 0,45; esto probablemente se deba a una mayor atención al hombre o a la mujer en los hospitales donde se realizaron los estudios, o a que se trató de muestras no probabilísticas.…”

“…Este tiempo de hospitalización es mayor que el descrito en estudios norteamericanos (9) y sudamericanos, como el ReNACer de Argentina (10) . Estudios previamente realizados en nuestro país no han estudiado esta variable (8,19,21) .…”

Perception of stroke symptoms and utilization of emergency medical services

“…In Argentina, possibly less than 1% of patients with acute stroke receive IV thrombolysis, and this is mainly in private centers 18,19 . Emergency services not being focused on diagnosis, triage and rapid transportation of possible candidates for IV rtPA treatment can, at least in part, be responsible for this.…”

The Study of Anamnestic Factors and Their Role in Estimation of Short-Term (In-Hospital) Prognosis in Patients Underwent Brain Stroke or Transient Ischemic Attack, by the Data From Lis-2 Registry

“…Согласно представленным в этих работах дан-ным, госпитальная летальность составляла в среднем около 20-25%. Однако по данным регистров МИ, проведенных в других странах, показатели госпиталь-ной летальности были все-таки примерно в два-три раза ниже [14][15][16][17]. Ранее было продемонстрировано, что показатели ближайшего прогноза напрямую свя-заны с уровенем экономического развития страны: в странах с более высоким уровнем экономического развития эти показатели были лучше [18].…”