Stroke in China: advances and challenges in epidemiology, prevention, and management.

With over 2 million new cases annually, stroke is associated with the highest disability-adjusted life-years lost of any disease in China. The burden is expected to increase further as a result of population ageing, an ongoing high prevalence of risk factors (eg, hypertension), and inadequate management. Despite improved access to overall health services, the availability of specialist stroke care is variable across the country, and especially uneven in rural areas. In-hospital outcomes have improved because of a greater availability of reperfusion therapies and supportive care, but adherence to secondary prevention strategies and long-term care are inadequate. Thrombolysis and stroke units are accepted as standards of care across the world, including in China, but bleeding-risk concerns and organisational challenges hamper widespread adoption of this care in China. Despite little supporting evidence, Chinese herbal products and neuroprotective drugs are widely used, and the increased availability of neuroimaging techniques also results in overdiagnosis and overtreatment of so-called silent stroke. Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.

Effects of introducing an integrated care pathway in an acute stroke unit.

BACKGROUND AND PURPOSE: integrated care pathways are often implemented to guide acute stroke therapy and improve organisation of care, but there is not sufficient evidence to support their routine use. We sought to evaluate the effects of introducing an integrated care pathway for acute stroke. METHODS: we performed a before-and-after study. The 'before' (control) group comprised 154 consecutive stroke patients admitted to the acute stroke unit over a 9-month period. The 'after' (intervention) group comprised 197 consecutive patients admitted to the same unit over a 9-month period in the year after the introduction of the integrated care pathway. Effectiveness was assessed with a variety of measures: quality of documentation; process of care; occurrence of complications; death and discharge destination. Results were adjusted for case mix using a validated model. RESULTS: the baseline characteristics of the two groups were similar, although there were more total anterior circulation strokes (29% versus 18%, P = 0.005) and fewer partial anterior circulation strokes (30% versus 42% P = 0.04) in the intervention group. In the intervention group, we found that urinary tract infections were significantly less frequent (OR 0.37, CI 0.15-10.91) and the quality of several aspects of care (e.g. CT scanning < 48 hours) and documentation were significantly better. However, there were no significant differences in deaths, discharge destination, or length of stay between the two groups. CONCLUSION: this before-and-after study has provided further evidence that introducing an integrated care pathway for acute stroke may improve the quality of documentation and process of care, and reduce the risk of certain post-stroke complications.