Stroke care in Africa: A systematic review of the literature.

Background Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited. Aim To describe the status of stroke care in Africa. Summary of review We undertook a systematic search of the published literature to identify recent (1 January 2006-20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa. Conclusions This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda.

BACKGROUND: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. METHODS: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. RESULTS: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. CONCLUSION: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis.

PURPOSE: Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. METHOD: We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. FINDINGS: We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit. DISCUSSION: Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. CONCLUSION: Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.