Estimating the Number of Hospital or Emergency Department Presentations for Stroke in Canada.

BACKGROUND: Although age-standardized stroke occurrence has been decreasing, the absolute number of stroke events globally, and in Canada, is increasing. Stroke surveillance is necessary for health services planning, informing research design, and public health messaging. We used administrative data to estimate the number of stroke events resulting in hospital or emergency department presentation across Canada in the 2017-18 fiscal year. METHODS: Hospitalization data were obtained from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database and the Ministry of Health and Social Services in Quebec. Emergency department data were obtained from the CIHI National Ambulatory Care Reporting System (Alberta and Ontario). Stroke events were identified using ICD-10 coding. Data were linked into episodes of care to account for readmissions and interfacility transfers. Projections for emergency department visits for provinces/territories outside of Alberta and Ontario were generated based upon age and sex-standardized estimates from Alberta and Ontario. RESULTS: In the 2017-18 fiscal year, there were 108,707 stroke events resulting in hospital or emergency department presentation across the country. This was made up of 54,357 events resulting in hospital admission and 54,350 events resulting in only emergency department presentation. The events resulting in only emergency department presentation consisted of 25,941 events observed in Alberta and Ontario and a projection of 28,409 events across the rest of the country. CONCLUSIONS: We estimate a stroke event resulting in hospital or emergency department presentation occurs every 5 minutes in Canada.

Sex Differences of Hospital and Emergency Department Presentations of Stroke in Canada.

We provide an updated estimate of adult stroke event rates by age group, sex, and stroke type using Canadian administrative data. In the 2017-2018 fiscal year, there were an estimated 81,781 hospital or emergency department visits for stroke events in Canada, excluding Quebec. Our findings show that overall, the event rate of stroke is similar between women and men. There were slight differences in stroke event rate at various ages by sex and stroke type and emerging patterns warrant attention in future studies. Our findings emphasize the importance of continuous surveillance to monitor the epidemiology of stroke in Canada.

The Impact of Stroke Public Awareness Campaigns Differs Between Sociodemographic Groups.

BACKGROUND: Prehospital delays are a major obstacle to timely reperfusion therapy in acute ischemic stroke. Stroke sign recognition, however, remains poor in the community. We present an analysis of repeated surveys to assess the impact of Face, Arm, Speech, Time (FAST) public awareness campaigns on stroke knowledge. METHODS: Four cross-sectional surveys were conducted between July 2016 and January 2019 in the province of Quebec, Canada (n = 2,451). Knowledge of FAST stroke signs (face drooping, arm weakness and speech difficulties) was assessed with open-ended questions. A bilingual English/French FAST public awareness campaign preceded survey waves 1-3 and two campaigns preceded wave 4. We used multivariable ordinal regression models weighted for age and sex to assess FAST stroke sign knowledge. RESULTS: We observed an overall significant improvement of 26% in FAST stroke sign knowledge between survey waves 1 and 4 (odds ratio [OR] = 1.26; 95% CI: 1.02, 1.55; p = 0.035). After the last campaign, however, 30.5% (95% CI: 27.5, 33.6) of people were still unable to name a single FAST sign. Factors associated with worse performance were male sex (OR = 0.68; 95% CI: 0.53, 0.86; p = 0.002) and retirement (OR = 0.54; 95% CI: 0.35, 0.83; p = 0.005). People with lower household income and education had a tendency towards worse stroke sign knowledge and were significantly less aware of the FAST campaigns. CONCLUSIONS: Knowledge of FAST stroke signs in the general population improved after multiple public awareness campaigns, although it remained low overall. Future FAST campaigns should especially target men, retired people and individuals with a lower socioeconomic status.

Stroke systems of care in high-income countries: what is optimal?

Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.

Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015.

BACKGROUND: Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province. METHODS: Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015. RESULTS: From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001). INTERPRETATION: At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.

Declining Admission and Mortality Rates for Subarachnoid Hemorrhage in Canada Between 2004 and 2015.

Background and Purpose- The purpose of this study was to assess recent trends in the admission and mortality rates for subarachnoid hemorrhage in Canada. Methods- This retrospective cross-sectional study was based on data retrieved from the Canadian Institute for Health Information for all patients diagnosed with subarachnoid hemorrhage in Canada between 2004 and 2015. Adjusted admission rate, in-hospital mortality rates, and discharge disposition were calculated. Results- A total of 19 765 patients were diagnosed with subarachnoid hemorrhage between 2004 and 2015. The mean age was 58.1 years, and 40.3% were men. The annual hospitalization rate was 6.34 per 100 000 person-years, declining by -0.67% annually. In-hospital mortality rate was 21.5%. Conclusions- The Canadian subarachnoid hemorrhage admission and mortality rates are lower than previously reported, with a declining trend.

An International Standard Set of Patient-Centered Outcome Measures After Stroke.

BACKGROUND AND PURPOSE: Value-based health care aims to bring together patients and health systems to maximize the ratio of quality over cost. To enable assessment of healthcare value in stroke management, an international standard set of patient-centered stroke outcome measures was defined for use in a variety of healthcare settings. METHODS: A modified Delphi process was implemented with an international expert panel representing patients, advocates, and clinical specialists in stroke outcomes, stroke registers, global health, epidemiology, and rehabilitation to reach consensus on the preferred outcome measures, included populations, and baseline risk adjustment variables. RESULTS: Patients presenting to a hospital with ischemic stroke or intracerebral hemorrhage were selected as the target population for these recommendations, with the inclusion of transient ischemic attacks optional. Outcome categories recommended for assessment were survival and disease control, acute complications, and patient-reported outcomes. Patient-reported outcomes proposed for assessment at 90 days were pain, mood, feeding, selfcare, mobility, communication, cognitive functioning, social participation, ability to return to usual activities, and health-related quality of life, with mobility, feeding, selfcare, and communication also collected at discharge. One instrument was able to collect most patient-reported subdomains (9/16, 56%). Minimum data collection for risk adjustment included patient demographics, premorbid functioning, stroke type and severity, vascular and systemic risk factors, and specific treatment/care-related factors. CONCLUSIONS: A consensus stroke measure Standard Set was developed as a simple, pragmatic method to increase the value of stroke care. The set should be validated in practice when used for monitoring and comparisons across different care settings.

A prototype worldwide survey of diagnostic and treatment modalities for stroke.

Stroke is a global health problem. However, very little is known about stroke care in low- to middle-income countries. Obtaining country-specific information could enable us to develop targeted programs to improve stroke care. We surveyed neurologists from 12 countries (Chile, Georgia, Nigeria, Qatar, India, Lithuania, Kazakhstan, Indonesia, Denmark, Brazil, Belgium, and Bangladesh) using a web-based survey tool. Data were analyzed both for individual countries and by income classification (low income, lower middle income, upper middle income, and high income). Six percent (n = 200) of 3123 targeted physicians completed the survey. There was a significant correlation between income classification and access and affordability of head computed tomography scan (ρ = .215, P = .002), transthoracic echocardiogram (ρ = .181, P = .012), extracranial carotid Doppler ultrasound (ρ = .312, P ≤ .000), cardiac telemetry (ρ = .353, P ≤ .000), and stroke treatments such as intravenous thrombolysis (ρ = .276, P ≤ .001), and carotid endarterectomy (ρ = .214, P ≤ .004); stroke quality measures such as venous thromboembolism prophylaxis during hospital stay (ρ = .163, P ≤ .022), discharge from hospital on antithrombotic therapy (ρ = .266, P ≤ .000), consideration for acute thrombolytic therapy (ρ = .358, P ≤ .000), and antithrombotic therapy prescribed by end of hospital day 2 (ρ = .334, P ≤ .000). However, there was no significant correlation between income classification and the access and affordability of antiplatelet agents, vitamin K antagonists and statins, anticoagulation for atrial fibrillation/flutter, statin medication, stroke education, and assessment for rehabilitation. Our study shows that it is possible to get an overview of stroke treatment measures in different countries by conducting an internet-based survey. The generalizability of the findings may be limited by the low survey response rate.

Criteria and Indicators for Centers of Clinical Excellence in Stroke Recovery and Rehabilitation: A Global Consensus Facilitated by ISRRA.

BACKGROUND: The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. OBJECTIVES: This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country's development or income status, to drive global improvement in stroke services. METHODS: Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. RESULTS: The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. CONCLUSIONS: We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

Benchmarks for acute stroke care delivery.

OBJECTIVE: Despite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators. DESIGN: Nine key acute stroke quality indicators were selected from the Canadian Stroke Best Practice Performance Measures Manual. PARTICIPANTS: A population-based retrospective sample of patients discharged from 142 hospitals in Ontario, Canada, between 1 April 2008 and 31 March 2009 (N = 3191) was used to calculate hospital rates of performance and benchmarks. INTERVENTION: The Achievable Benchmark of Care (ABC™) methodology was used to create benchmarks based on the performance of the upper 15% of patients in the top-performing hospitals. MAIN OUTCOME MEASURES: Benchmarks were calculated for rates of neuroimaging, carotid imaging, stroke unit admission, dysphasia screening and administration of stroke-related medications. RESULTS: The following benchmarks were derived: neuroimaging within 24 h, 98%; admission to a stroke unit, 77%; thrombolysis among patients arriving within 2.5 h, 59%; carotid imaging, 93%; dysphagia screening, 88%; antithrombotic therapy, 98%; anticoagulation for atrial fibrillation, 94%; antihypertensive therapy, 92% and lipid-lowering therapy, 77%. ABC™ acute stroke care benchmarks achieve or exceed the consensus-based targets required by Accreditation Canada, with the exception of dysphagia screening. CONCLUSIONS: Benchmarks for nine hospital-based acute stroke care quality indicators have been established. These can be used in the development of standards for quality improvement initiatives.

Recommendations on screening for high blood pressure in Canadian adults.

OBJECTIVE: To provide recommendations on screening for hypertension in adults aged 18 years and older without previously diagnosed hypertension. QUALITY OF EVIDENCE: Evidence was found through a systematic search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews (EBM Reviews), from January 1985 to September 2011. Study types were limited to randomized controlled trials, systematic reviews, and observational studies with control groups. MAIN MESSAGE: Three strong recommendations were made based on moderate-quality evidence. It is recommended that blood pressure measurement occur at all appropriate primary care visits, according to the current techniques described in the Canadian Hypertension Education Program recommendations for office and ambulatory blood pressure measurement. The Canadian Hypertension Education Program criteria for assessment and diagnosis of hypertension should be applied for people found to have elevated blood pressure. CONCLUSION: After review of the most recent evidence, the Canadian Task Force on Preventive Health Care continues to recommend blood pressure measurement during regular physician visits.

Cost avoidance associated with optimal stroke care in Canada.

BACKGROUND AND PURPOSE: Evidence-based stroke care has been shown to improve patient outcomes and may reduce health system costs. Cost savings, however, are poorly quantified. This study assesses 4 aspects of stroke management (rapid assessment and treatment services, thrombolytic therapy, organized stroke units, and early home-supported discharge) and estimates the potential for cost avoidance in Canada if these services were provided in a comprehensive fashion. METHODS: Several independent data sources, including the Canadian Institute of Health Information Discharge Abstract Database, the 2008-2009 National Stroke Audit, and the Acute Cerebrovascular Syndrome Registry in the province of British Columbia, were used to assess the current status of stroke care in Canada. Evidence from the literature was used to estimate the effect of providing optimal stroke care on rates of acute care hospitalization, length of stay in hospital, discharge disposition (including death), changes in quality of life, and costs avoided. RESULTS: Comprehensive and optimal stroke care in Canada would decrease the number of annual hospital episodes by 1062 (3.3%), the number of acute care days by 166 000 (25.9%), and the number of residential care days by 573 000 (12.8%). The number of deaths in the hospital would be reduced by 1061 (14.9%). Total avoidance of costs was estimated at $682 million annually ($307.4 million in direct costs, $374.3 million in indirect costs). CONCLUSIONS: The costs of stroke care in Canada can be substantially reduced, at the same time as improving patient outcomes, with the greater use of known effective treatment modalities.

World Stroke Organization (WSO): Global Stroke Fact Sheet 2022.

Stroke remains the second-leading cause of death and the third-leading cause of death and disability combined (as expressed by disability-adjusted life-years lost - DALYs) in the world. The estimated global cost of stroke is over US$721 billion (0.66% of the global GDP). From 1990 to 2019, the burden (in terms of the absolute number of cases) increased substantially (70.0% increase in incident strokes, 43.0% deaths from stroke, 102.0% prevalent strokes, and 143.0% DALYs), with the bulk of the global stroke burden (86.0% of deaths and 89.0% of DALYs) residing in lower-income and lower-middle-income countries (LMIC). This World Stroke Organisation (WSO) Global Stroke Fact Sheet 2022 provides the most updated information that can be used to inform communication with all internal and external stakeholders; all statistics have been reviewed and approved for use by the WSO Executive Committee as well as leaders from the Global Burden of Disease research group.

Exploring the poststroke experiences and unmet needs of South Asian communities in high-income countries: a scoping review protocol.

INTRODUCTION: South Asian groups experience a higher burden of stroke and poorer functional outcomes after stroke than their White counterparts. However, within the stroke literature, there has been little focus on the unique poststroke needs of the South Asian community and opportunities for community-based services to address these needs. RESEARCH QUESTION: What is the current knowledge base related to the experiences and needs, including unmet needs of people living with stroke and their caregivers from South Asian communities living in high-income countries? AIMS: This is a protocol for a review that intends to synthesise existing studies of the poststroke experiences and needs of individuals from South Asian communities to uncover opportunities for community-based resources to address these needs. METHODS AND ANALYSIS: This scoping review methodology will be guided by modified Arksey and O'Malley (2005) and Joanna Briggs Institute frameworks. A search on OVID Medline, OVID Embase, OVID PsycINFO, EBSCO CINAHL, the Cochrane Library, Scopus and Global Index Medicus will be conducted to synthesise existing peer-reviewed literature (all study designs). Grey literature will be searched through detailed hand searching. Literature focusing on the poststroke experiences and needs of South Asian groups impacted by stroke residing in high-income countries will be included. Study descriptors will be extracted (eg, study location, type, methodology). Data will be analysed descriptively and thematically. Team meetings will provide opportunities for peer debriefing, thereby enhancing analytic rigour. CONCLUSION AND IMPLICATIONS: Findings will enhance knowledge of the poststroke experiences and needs of South Asian communities living in high-income countries and identify actionable opportunities for community-based resources to address needs. ETHICS AND DISSEMINATION: Ethics approval was not required for this scoping review protocol. Community-based organisations will be consulted to provide insights into the analysis and assist with dissemination. Dissemination of findings will also occur through a publication and academic presentations.