Peter LanghorneMartin J. O'DonnellSiu Lim ChinHongye ZhangDenis XavierAlvaro AvezumNandini MathurMelanie TurnerMary Joan MacLeodPatricio Lopez-JaramilloAlbertino DamascenoGraeme J. HankeyAntonio L. DansAhmed ElsayedCharles MondoMohammad WasayAnna CzlonkowskaChristian WeimarAfzal Hussein YusufaliFawaz Al HussainLiu LishengHans Christoph DienerDanuta RyglewiczNana PogosovaRomana IqbalRafael DiazKhalid YusoffAytekin OguzXingyu WangErnesto PenaherreraFernando LanasOkechukwu S. OgahAdesola OgunniyiHelle K. IversenGerman MalagaZvonko RumboldtDaliwonga MagaziYongchai NilanontAnnika RosengrenShahram OveisgharanSalim YusufM. O'DonnellS. RangarajanP. Rao-MelaciniX. Michelle ZhangS. IslamC. KabaliA. CasanovaJ. DeJesusM. DehghanS. AgapayM. McQueenK. HallJ. KeysA. DevanathR. GuptaD. PrabhakaranP. SchygielM. GarroteM. A. RodriguezA. CaccavoR. G. DuranL. SposatoJ. MolinosP. ValdezC. M. CedrollaP. G. NofalM. F. HuertaP. M. DesmeryM. C. ZurruB. Della VedovaJ. VarigosG. HankeyT. KraemerP. GatesC. BladinG. HerkesM. P. PereiraL. MinuzzoL. OliveiraM. TeixeiraH. ReisA. CarvalhoS. Ouriques MartinsJ. J. CarvalhoO. GebaraC. MinelliD. C. OliveiraA. C. Sobral SousaA. C. Ferraz de AlmeidaM. E. HernandezM. FriedrichD. M. MotaL. E. RittD. Correa Vila NovaP. TealD. GladstoneA. ShuaibF. SilverD. DowlatshahiDubai Medical CollegeUniversidad de SantanderFederal State Institution National Research Center for Preventive MedicineUCSI UniversityPopulation Health Research Institute, OntarioUniversidade Eduardo MondlaneInstitute of Psychiatry and Neurology, WarszawaHospital Luis VernazaMulago HospitalUniversity of the Philippines ManilaUniversidad Peruana Cayetano HerediaThe Aga Khan University HospitalUniversity of Western AustraliaSahlgrenska UniversitetssjukhusetKøbenhavns UniversitetInstituto Dante Pazzanese de CardiologiaUniversity College Hospital, IbadanUniversity of LimpopoUniversity of AberdeenKing Saud UniversityUniversidad de la FronteraFaculty of Medicine, Siriraj Hospital, Mahidol UniversityNational University of Ireland GalwayUniversitäts Klinikum Essen und Medizinische FakultätSveučilište u SplituSt. John's Medical CollegeUniversity of GlasgowNational Center for Cardiovascular Diseasesİstanbul Medeniyet ÜniversitesiRush Alzheimer’s Disease CenterEstudios Clínicos LatinoaméricaAlzaeim Alazhari UniversityBeijing Hypertension League Institute2019-08-282019-08-282018-01-01The Lancet. Vol.391, No.10134 (2018), 2019-20271474547X014067362-s2.0-85047139566https://repository.li.mahidol.ac.th/handle/20.500.14594/47257© 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.Mahidol UniversityMedicineArticleSCOPUS10.1016/S0140-6736(18)30802-X