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Title: Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study
Authors: Peter Langhorne
Martin J. O'Donnell
Siu Lim Chin
Hongye Zhang
Denis Xavier
Alvaro Avezum
Nandini Mathur
Melanie Turner
Mary Joan MacLeod
Patricio Lopez-Jaramillo
Albertino Damasceno
Graeme J. Hankey
Antonio L. Dans
Ahmed Elsayed
Charles Mondo
Mohammad Wasay
Anna Czlonkowska
Christian Weimar
Afzal Hussein Yusufali
Fawaz Al Hussain
Liu Lisheng
Hans Christoph Diener
Danuta Ryglewicz
Nana Pogosova
Romana Iqbal
Rafael Diaz
Khalid Yusoff
Aytekin Oguz
Xingyu Wang
Ernesto Penaherrera
Fernando Lanas
Okechukwu S. Ogah
Adesola Ogunniyi
Helle K. Iversen
German Malaga
Zvonko Rumboldt
Daliwonga Magazi
Yongchai Nilanont
Annika Rosengren
Shahram Oveisgharan
Salim Yusuf
M. O'Donnell
S. Rangarajan
P. Rao-Melacini
X. Michelle Zhang
S. Islam
C. Kabali
A. Casanova
J. DeJesus
M. Dehghan
S. Agapay
M. McQueen
K. Hall
J. Keys
A. Devanath
R. Gupta
D. Prabhakaran
P. Schygiel
M. Garrote
M. A. Rodriguez
A. Caccavo
R. G. Duran
L. Sposato
J. Molinos
P. Valdez
C. M. Cedrolla
P. G. Nofal
M. F. Huerta
P. M. Desmery
M. C. Zurru
B. Della Vedova
J. Varigos
G. Hankey
T. Kraemer
P. Gates
C. Bladin
G. Herkes
M. P. Pereira
L. Minuzzo
L. Oliveira
M. Teixeira
H. Reis
A. Carvalho
S. Ouriques Martins
J. J. Carvalho
O. Gebara
C. Minelli
D. C. Oliveira
A. C. Sobral Sousa
A. C. Ferraz de Almeida
M. E. Hernandez
M. Friedrich
D. M. Mota
L. E. Ritt
D. Correa Vila Nova
P. Teal
D. Gladstone
A. Shuaib
F. Silver
D. Dowlatshahi
Dubai Medical College
Universidad de Santander
Federal State Institution National Research Center for Preventive Medicine
UCSI University
Population Health Research Institute, Ontario
Universidade Eduardo Mondlane
Institute of Psychiatry and Neurology, Warszawa
Hospital Luis Vernaza
Mulago Hospital
University of the Philippines Manila
Universidad Peruana Cayetano Heredia
The Aga Khan University Hospital
University of Western Australia
Sahlgrenska Universitetssjukhuset
Københavns Universitet
Instituto Dante Pazzanese de Cardiologia
University College Hospital, Ibadan
University of Limpopo
University of Aberdeen
King Saud University
Universidad de la Frontera
Faculty of Medicine, Siriraj Hospital, Mahidol University
National University of Ireland Galway
Universitäts Klinikum Essen und Medizinische Fakultät
Sveučilište u Splitu
St. John's Medical College
University of Glasgow
National Center for Cardiovascular Diseases
İstanbul Medeniyet Üniversitesi
Rush Alzheimer’s Disease Center
Estudios Clínicos Latinoamérica
Alzaeim Alazhari University
Beijing Hypertension League Institute
Keywords: Medicine
Issue Date: 1-Jan-2018
Citation: The Lancet. Vol.391, No.10134 (2018), 2019-2027
Abstract: © 2018 Elsevier Ltd 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.
ISSN: 1474547X
Appears in Collections:Scopus 2018

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