Elsevier

The Lancet Neurology

Volume 11, Issue 4, April 2012, Pages 341-348
The Lancet Neurology

Review
Applicability of stroke-unit care to low-income and middle-income countries

https://doi.org/10.1016/S1474-4422(12)70024-8Get rights and content

Summary

Stroke units have become established as the central component of modern stroke services. However, most stroke-unit trials and service developments have been done in high-income countries, which raises the question of whether such care is relevant and applicable to low-income and middle-income settings. To address this question, we first need to show that stroke units are likely to provide important health gains to populations. Second, we need to identify those components of stroke units that could be important for a low-technology unit, and to learn from examples of stroke units in low-income and middle-income countries. Finally, we need to understand how barriers to the establishment of stroke units could be overcome. Although substantial challenges are present to the development of stroke units more widely across the world, the potential gains from such developments are substantial.

Introduction

Stroke is a global health-care problem that causes a substantial burden of disease;1, 2 it is estimated to be the second most common cause of death worldwide and the seventh leading cause of disability (in disability-adjusted life years).1, 2 Because stroke incidence is increasing more rapidly in low-income than high-income countries,3 the burden of stroke is increasing more rapidly in poorer than in richer communities. By 2030, the worldwide burden of stroke in disability-adjusted life years is expected to be more than three times that of tuberculosis and more than four times that of malaria.4

In many high-income countries, stroke management has changed substantially in the past two decades. Although impressive developments have been made in thrombolysis5 and secondary prevention,6 we still lack a powerful, inexpensive, acute drug that can be easily given to most patients with stroke.7 Until such a treatment becomes available, much of the care after stroke will continue to rely on non-drug treatments and rehabilitation interventions.8 Fortunately, important, evidence-based improvements have been made in the delivery of stroke services.

In high-income health-care settings, stroke units are now seen as key components of effective stroke services. Findings from randomised trials and systematic reviews9 have shown that provision of care in a stroke unit can increase the number of patients who survive, return home, and regain independence in daily activities.10, 11 Stroke units seem to benefit a wide range of patients with stroke, including younger (aged <75 years) and older (aged ≥75 years) patients with various severities of stroke,11 and those who have had either ischaemic or haemorrhagic strokes.12 Findings from economic analyses13, 14 have indicated that stroke units offer a cost-effective system of care, at least within wealthy health-care economies. Observational studies15, 16, 17, 18 have provided evidence that stroke units can operate effectively in routine settings beyond a specialised research environment. Consequently, in most high-income, developed countries, clinical practice guidelines and national strategies recommend stroke units,19, 20, 21, 22, 23, 24 and, in many countries, concomitant improvement has been made in access to stroke-unit care.18, 25, 26, 27, 28 This improved access has been directly linked to improved patient outcomes;29, 30 however, most clinical trials of stroke-unit care have been done in high-income countries. Additionally, almost all major national strategic initiatives have been done in high-income, industrialised countries in which most of the health service is publicly funded. These issues bring into question whether stroke-unit care can have any relevance in less wealthy regions.

We review the evidence for different components of stroke-unit care31 and discuss some of the challenges (and potential solutions) to the implementation of care in low-resource settings. We use four important questions to address the applicability of stroke-unit care to low-income countries: (1) what is the potential worldwide effect of this care; (2) what evidence is available for the implementation of stroke units outside high-income health-care settings; (3) what components that could apply in low-income health-care settings are likely to be key for stroke-unit care; and (4) how might the barriers to implementation of stroke-unit care in such settings be overcome?

Section snippets

Worldwide effect of stroke-unit care on stroke outcome

We identified two previous analyses7, 32 that explored the potential population effect of different interventions for patients with stroke. These studies estimated the annual number of people in a population who are likely to have a stroke, be eligible to receive a particular intervention, and benefit from that intervention (in terms of additional survivors who are independent in daily activities). Findings from both studies suggest that a basic model of stroke-unit care could provide the most

Can stroke units be effective in low-income countries?

To identify the applicability of stroke-unit care to low-income settings, we focused on studies that compared care in a discrete stroke ward with conventional care in a general ward, in countries that did not qualify as high income according to World Bank definitions. We identified several studies from five continents38, 39, 40, 41, 42, 43, 44, 45, 46, 47 that had used various methodological approaches. All studies noted lower death rates in the stroke-unit group than in the control group (

Diagnostic facilities

Stroke-unit care is a complex intervention characterised by the interplay of several interrelated components.48 To compile advice for the design of stroke-unit care in low-income settings, we would ideally access direct evidence about the effectiveness of individual components. Although robust evidence of this kind is scarce, reasonable descriptions of such services are available.9, 10, 49 A key feature in stroke units is the presence of a multidisciplinary team (comprising medical, nursing,

Geographical base

Translation of the experience of stroke-unit trials from wealthy countries to less well-resourced settings makes several potential shortcomings apparent. Most patients with stroke do not need expensive high-dependency facilities; however, a geographically defined hospital area with dedicated beds and nursing staff is an essential minimum requirement for stroke-unit care. The specific care that patients need to prevent complications and to facilitate good functional outcomes seems to be

Planning, preparation, and proof

The key component in the implementation of a stroke unit is likely to be enthusiastic leadership from a clinician who is willing to act as a champion for development.6 An action plan to address the implementation of a stroke unit has been previously described.6 Many of the proposals outlined below are speculative, but are compiled from our experiences.42, 44, 77

Clinicians should establish the need for a stroke unit in their own hospitals and should establish the case for such development. This

Conclusions

Major challenges exist in the development of stroke-unit care widely across the world, but the potential gains from such developments are substantial. Research to clarify the drivers of service change in different settings is still needed and key care pathways that are appropriate for low-income health-care settings need to be more clearly defined and implemented than they are currently. This agenda could include defining and refining training resources (including sample pathways and video

Search strategy and selection criteria

We searched for the best available evidence to address each review question from 1966, until January, 2012, with no language restrictions. We identified articles estimating the global effect of stroke-unit care through searches of Medline with the terms “stroke unit” and “outcome”. We selected reports that provided an estimate of the population effect of stroke-unit care in relation to other recognised interventions. To identify evidence of stroke-unit implementation in low-income settings we

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