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Translational Research: From Observational Studies to Health Policy

2011; Lippincott Williams & Wilkins; Volume: 42; Issue: 12 Linguagem: Inglês

10.1161/strokeaha.111.636563

1524-4628

Gustavo Saposnik, Conrado J. Estol,

Meta-analysis and systematic reviews

HomeStrokeVol. 42, No. 12Translational Research: From Observational Studies to Health Policy Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBTranslational Research: From Observational Studies to Health PolicyHow a Cohort Study Can Help Improve Outcomes After Stroke Gustavo Saposnik, MD, MSc, FAHA and Conrado J. Estol, MD, PhD, FAAN Gustavo SaposnikGustavo Saposnik From the Stroke Outcomes Research Unit (G.S.), Stroke Outcomes Research Canada (SORCan), Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; the Institute for Clinical Evaluative Sciences & Li Ka Shing Knowledge Institute (G.S.), Toronto, Ontario, Canada; the Departments of Medicine and Health Policy, Management and Evaluation (G.S.), University of Toronto, Toronto, Ontario, Canada; and the Neurological Center and Vascular Prevention Unit (C.J.E.), Buenos Aires, Argentina. and Conrado J. EstolConrado J. Estol From the Stroke Outcomes Research Unit (G.S.), Stroke Outcomes Research Canada (SORCan), Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; the Institute for Clinical Evaluative Sciences & Li Ka Shing Knowledge Institute (G.S.), Toronto, Ontario, Canada; the Departments of Medicine and Health Policy, Management and Evaluation (G.S.), University of Toronto, Toronto, Ontario, Canada; and the Neurological Center and Vascular Prevention Unit (C.J.E.), Buenos Aires, Argentina. Originally published3 Nov 2011https://doi.org/10.1161/STROKEAHA.111.636563Stroke. 2011;42:3336–3337Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 See related articles, pages 3338, 3341, 3651, and 3655."When it is obvious that the goals cannot be reached, don't adjust the goals, adjust the action steps."—Confucius (551–479 BC), Chinese philosopher and reformerAccess to specialized care and primary prevention are associated with better outcomes in cardiovascular diseases.1,2 The burden of stroke, and vascular disease in general, is higher in lower-income countries where 82% of all cardiovascular deaths (14 million) occurs annually.3,4 For example, in emerging/low-middle income countries (ELMICs; those with low gross domestic product and health expenditures), stroke affects individuals 1 to 2 decades earlier (50% 3, was 32.6%. More surprising, and likely related, 42.9% of the patients had a previous stroke. A vascular episode (stroke in this case) is the most significant risk factor for a recurrent event and thus the study reveals the opportunity missed by not focusing an aggressive prevention strategy on previously affected patients. Of note, when compared with other studies, there was a high prevalence of diabetes (49%) and hypertension (88%) among patients with ischemic stroke. Because the study included consecutive patients with stroke (limiting the selection bias), these findings suggest an inadequate access to cardiovascular prevention.Second, the authors reported on process measures associated with access to care (eg, stroke unit admission) and stroke prevention before discharge (eg, antithrombotics, statins, antihypertensive agents). This is a major strength of the article considering the limited information on process measures of stroke care from Central and South America and other ELMICs.8 Of interest is the low use of statins (52%) and high prevalence of pneumonia (19%) among patients with an ischemic stroke when compared with other studies.2,8–10Finally, only 7.2% of patients received a basic cerebrovascular investigation including electrocardiography, echocardiography, and carotid Doppler. There was a significant underuse of studies as shown by only 3.5% of patients who underwent MRI, 27% carotid ultrasound, 32% echocardiograms, and 2.9% digital angiography (only one third of patients with subarachnoid hemorrhage had angiograms). These limited evaluations probably explain why most patients did not receive adequate stroke treatment. Studies performed were also delayed as reflected by a prolonged 15 days length of stay on average. Only 12% of patients were admitted to a stroke unit, and only 1.1% of the patients with ischemic stroke received thrombolysis (similar to other reports from Argentina).8,11 Interestingly, although in general patients did not have complete vascular evaluations, those admitted to what the authors defined as "stroke units" had suboptimal but significantly greater rates of laboratory testing compared with those evaluated in the general wards. This underscores the value of dedicated vascular units even when overall management is not adequate. Together, these findings suggest not only a limited access to stroke prevention, but also to interventions and investigations in the acute phase of stroke, thus affecting early identification of the stroke mechanism to further guide therapeutic and preventive strategies.Lessons Learned From This StudyPublic reporting has been associated with better outcomes.12 For example, in a large study using propensity score matching (to attenuate differences in baseline characteristics), public reporting of hospital outcomes was associated with reductions in mortality for acute myocardial infarction, congestive heart failure, pneumonia, sepsis as well as for both ischemic and hemorrhagic stroke.12 The basis for effective public reporting is the transparency of data. Therefore, the authors should be commended for revealing the modest results found in their analysis. These findings should lead to modifications in process measures aiming at a specific risk benchmark and may positively influence other local or similar type of health facilities in the region. This could be accomplished by optimizing access to stroke care, facilitating required investigations, increasing the use of dedicated vascular units, and consulting with stroke specialists by telemedicine or by transferring patients to tertiary stroke centers. Unfortunately, some of these ideas may not be feasible in the short term for ELMICs and this will translate in too many lives lost. However, recent data from carotid and coronary artery disease studies have shown that medical treatment results in at least similar outcomes compared with invasive revascularization.13,14 This provides a unique opportunity because pharmacological treatments are easier to access than the more complex and expensive surgical and endovascular therapeutic strategies. Widespread use of the polypill may further facilitate the possibility to accomplish effective vascular prevention.15 Despite a wealth of impressive results from stroke prevention and treatment studies, the worldwide gap between what is known and what is done becomes an abyss in ELMICs. The authors clearly reflect this with their study in a city representative of the 500 million population in Latin America. Brasil (in the "BRIC" group together with Russia, India, and China) is considered 1 of the rising stars in the emerging economies, yet major disparities in the population that are characteristic of emerging regions explain the paradox of suboptimal health management in the midst of economic prosperity. A rapidly aging population and the occidentalization (eg, growing rates of smoking, obesity, and sedentary lifestyles) of ELMICs will exponentially increase during the next decade the already grim problem posed presently by cardiovascular disease. Perhaps the most relevant lesson from this article is related to the potential it provides to increase awareness among policymakers and health administrators about the importance of early and effective access to acute stroke care and secondary prevention before discharge. The successful implementation of strategies toward these goals will result in fewer and less disabling strokes. As such, the present article has the potential to influence policymakers to impact on the lives of stroke patients not only in Fortaleza, Brazil, but globally.DisclosuresNone.FootnotesThe opinions in this editorial are not necessarily those of the editors or of the American Heart Association.Correspondence to Gustavo Saposnik, MD, MSc, FAHA, 55 Queen Street East, Suite 931, St Michael's Hospital, University of Toronto, Toronto, M5C 1R6, Canada. E-mail [email protected]caReferences1. Cruz-Flores S, Rabinstein A, Biller J, Elkind MS, Griffith P, Gorelick PB, et al. Racial–ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:2091–2116.LinkGoogle Scholar2. Fonarow GC, Reeves MJ, Smith EE, Saver JL, Zhao X, Olson DW, et al. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in Get With The Guidelines–Stroke. Circ Cardiovasc Qual Outcomes. 2011; 3:291–302.LinkGoogle Scholar3. World Health Organization. Cardiovascular diseases. Facts Sheet #317. January2011. Available at: www.who.int/mediacentre/factsheets/fs317/en/index.html. Accessed August 24, 2011.Google Scholar4. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet. 2007; 370:1929–1938.CrossrefMedlineGoogle Scholar5. Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 2009; 8:355–369.CrossrefMedlineGoogle Scholar6. Sposato L, Saposnik G. Gross domestic product and health expenditure associated with incidence, 30-day fatality and age at stroke onset: a systematic review. Stroke. 2011; 42:Epub ahead of print, October 27, 2011.MedlineGoogle Scholar7. de Carvalho JJF, Alves MB, Viana GAA, Machado CB, dos Santos BFC, Kanamura AH, et al. Stroke epidemiology, patterns of management, and outcomes in Fortaleza, Brazil: a hospital-based multicenter prospective study. Stroke. 2011; 42:3341–3346.LinkGoogle Scholar8. Sposato LA, Esnaola MM, Zamora R, Zurru MC, Fustinoni O, Saposnik G. Quality of ischemic stroke care in emerging countries: the Argentinian national stroke registry (Renacer). Stroke. 2008; 39:3036–3041.LinkGoogle Scholar9. Heuschmann PU, Kolominsky-Rabas PL, Roether J, Misselwitz B, Lowitzsch K, Heidrich J, et al. Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy. JAMA. 2004; 292:1831–1838.CrossrefMedlineGoogle Scholar10. Saposnik G, Black SE, Hakim A, Fang J, Tu JV, Kapral MK. Age disparities in stroke quality of care and delivery of health services. Stroke. 2009; 40:3328–3335.LinkGoogle Scholar11. Estol CJ, Esnaola y Rojas MM. Stroke in Argentina. Int J Stroke. 2010; 5:35–39.CrossrefMedlineGoogle Scholar12. Hollenbeak CS, Gorton CP, Tabak YP, Jones JL, Milstein A, Johannes RS. Reductions in mortality associated with intensive public reporting of hospital outcomes. Am J Med Qual. 2008; 23:279–286.CrossrefMedlineGoogle Scholar13. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007; 356:1503–1516.CrossrefMedlineGoogle Scholar14. Spence JD, Coates V, Li H, Tamayo A, Munoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010; 67:180–186.CrossrefMedlineGoogle Scholar15. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003; 326:1419.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lazaridou A, Philbrook P and Tzika A (2013) Yoga and Mindfulness as Therapeutic Interventions for Stroke Rehabilitation: A Systematic Review, Evidence-Based Complementary and Alternative Medicine, 10.1155/2013/357108, 2013, (1-9), . Silva G and Schwamm L (2013) Review of Stroke Center Effectiveness and Other Get with the Guidelines Data, Current Atherosclerosis Reports, 10.1007/s11883-013-0350-8, 15:9, Online publication date: 1-Sep-2013. Tirschwell D, Ton T, Ly K, Van Ngo Q, Vo T, Pham C, Longstreth W and Fitzpatrick A (2012) A prospective cohort study of stroke characteristics, care, and mortality in a hospital stroke registry in Vietnam, BMC Neurology, 10.1186/1471-2377-12-150, 12:1, Online publication date: 1-Dec-2012. December 2011Vol 42, Issue 12 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.636563PMID: 22052519 Manuscript receivedSeptember 7, 2011Manuscript acceptedSeptember 7, 2011Originally publishedNovember 3, 2011 Keywordsprocess measuresoutcomes researchorganized stroke careoutcomespublic policyhealth indicatorsstroke managementperformancehealth policyPDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac CareComputerized Tomography (CT)Ethics and PolicyIschemic StrokeTreatment