Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era.

BACKGROUND AND PURPOSE: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, doctors and public authorities have demonstrated concern about the reduction in quality of care for other health conditions due to social restrictions and lack of resources. Using a population-based stroke registry, we investigated the impact of the onset of the COVID-19 pandemic in stroke admissions in Joinville, Brazil. METHODS: Patients admitted after the onset of COVID-19 restrictions in the city (defined as March 17, 2020) were compared with those admitted in 2019. We analyzed differences between stroke incidence, types, severity, reperfusion therapies, and time from stroke onset to admission. Statistical tests were also performed to compare the 30 days before and after COVID-19 to the same period in 2019. RESULTS: We observed a decrease in total stroke admissions from an average of 12.9/100 000 per month in 2019 to 8.3 after COVID-19 (P=0.0029). When compared with the same period in 2019, there was a 36.4% reduction in stroke admissions. There was no difference in admissions for severe stroke (National Institutes of Health Stroke Scale score >8), intraparenchymal hemorrhage, and subarachnoid hemorrhage. CONCLUSIONS: The onset of COVID-19 was correlated with a reduction in admissions for transient, mild, and moderate strokes. Given the need to prevent the worsening of symptoms and the occurrence of medical complications in these groups, a reorganization of the stroke-care networks is necessary to reduce collateral damage caused by COVID-19.

Ischemic stroke: Process perspective, clinical and profile characteristics, and external factors.

OBJECTIVE: To describe a method of analysis for understanding the health care process, enriched with information on the clinical and profile characteristics of the patients. To apply the proposed technique to analyze an ischemic stroke dataset. MATERIALS AND METHODS: We analyzed 4,830 electronic health records (EHRs) from patients with ischemic stroke (2010-2017), containing information about events realized during treatment and clinical and profile information of the patients. The proposed method combined process mining techniques with data analysis, grouping the data by primary care units (PCU - units responsible for the primary care of patients residing in a geographical area). RESULTS: A novel method, named process, data, and management (PDM) analysis method was used for ischemic stroke data and it provided the following outcomes: health care process for patients with ischemic stroke with time statistics; analysis of potential factors for slow hospital admission indicating an increase in the time to hospital admission of 3.4 h (mean value) for patients with an origin at the urgent care center (UCC) - 30% of patients; analysis of PCUs with distinct secondary stroke rates indicating that the social class of patients is the main difference between them; and the visualization of risk factors (before the stroke) by the PCU to inform the health manager about the potential of prevention. DISCUSSION: PDM analysis describes a step-by-step method for combining process analysis with data analysis considering a management focus. The results obtained on the stroke context can support the definition of more refined action plans by the health manager, improving the stroke health care process and preventing new events. CONCLUSION: When a patient is diagnosed with ischemic stroke, immediate treatment is needed. Moreover, it is possible to prevent new events to some degree by monitoring and treating risk factors. PDM analysis provides an overview of the health care process with time, combining elements that affect the treatment flow and factors, which can indicate a potential for preventing new events. We also can apply PDM analysis in different scenarios, when there is information about activities from treatment flow and other characteristics related to the treatment or the prevention of the analyzed disease. The management focus of the results aids in the formulation of service policies, action plans, and resource allocation.

Increase of Stroke Incidence in Young Adults in a Middle-Income Country: A 10-Year Population-Based Study.

BACKGROUND AND PURPOSE: The incidence of stroke is on the rise in young adults in high-income countries. However, there is a gap of knowledge about trends in stroke incidence in young adults from low- and middle-income countries. We aimed to measure trends in incidence of ischemic stroke (IS) and intracerebral hemorrhage (IH) in young people from 2005 to 2015 in Joinville, Brazil. METHODS: We retrospectively ascertained all first-ever IS subtypes and IH that occurred in Joinville in the periods of 2005 to 2006, 2010 to 2011, and 2014 to 2015. Poisson regression was used to calculate incidence rate ratios of all strokes, IS, and IH. We also compared the prevalence of risk factors and extension of diagnostic work-up across the 3 periods. RESULTS: For 10 years, we registered 2483 patients (7.5% aged <45 years). From 2005 to 2006 to 2014 to 2015, overall stroke incidence significantly increased by 62% (incidence rate ratios, 1.62; 95% confidence interval, 1.10-2.40) in subjects <45 years and by 29% in those <55 years (incidence rate ratios, 1.29; 95% confidence interval, 1.04-1.60). Incidence of IS increased by 66% (incidence rate ratios, 1.66; 95% confidence interval, 1.09-2.54), but there was no significant change in incidence of IH in subjects <45 years. Smoking rates decreased by 71% (odds ratio, 0.29; 95% confidence interval, 0.12-0.68). CONCLUSIONS: Stroke incidence is rising in young adults in Joinville, Brazil, because of increase in rates of ischemic but not hemorrhagic strokes. We urgently need better policies of cardiovascular prevention in the young.

Trends of Stroke Incidence from 1995 to 2013 in Joinville, Brazil.

BACKGROUND: Temporal trends on the incidence of stroke and its subtypes could help assess on-going public health policies and point to further targets for action among middle- and low-income countries, where the stroke burden is very high. This study aimed at evaluating longitudinal trends of stroke incidence in Joinville, Brazil. METHODS: We ascertained the incidence of all first-ever strokes occurred in 1995, 2005-2006 and 2012-2013, which were extracted from Joinville Stroke Registry, a prospective epidemiological data bank, launched in 1995. RESULTS: From 1995 to 2013, the age-adjusted incidence of all strokes decreased 37% (95% CI 32-42). From 2005 to 2013, the haemorrhagic stroke (HS) incidence decreased 60% (95% CI 13-86), ischemic stroke (IS) incidence decreased 15% (95% CI 1-28), and subarachnoid haemorrhage incidence remained stable. The proportion of IS and HS patients with regularly treated hypertension increased by 60% (p = 0.01) and 33% (p = 0.01), respectively. The proportion of IS and HS patients that quit smoking increased 8% (p = 0.03) and 17% (p = 0.03), respectively. CONCLUSIONS: Stroke incidence has been decreasing in Joinville over the last 18 years, more so for HS than IS. Better control of hypertension and tobacco use might explain these findings.

Three-year survival and recurrence after first-ever stroke: the Joinville stroke registry.

BACKGROUND: Data estimating the recurrence and risk of death are lacking in low and middle income countries, where two thirds of the stroke burden occurs. Previously we had shown that the incidence and mortality have been decreasing over the last 18 years in Joinville, Southern Brazil. In this study, we aim to determine the recurrence rates, survival rates and the cause of death in 3 years after their first-ever incident in a urban population-based setting. METHODS: From the Joinville Stroke Registry, we identified all the cases of first-ever stroke that occurred from October 2009 to September 2010. Multiple overlapping sources of information were used to ensure the completeness of case identification. Patients were followed up prospectively at regular intervals from 30-days to 3 years after the index event. Kaplan-Meir and Cox proportional hazards were used to assess the cumulative risk of death and recurrence. RESULTS: We registered 407 first-ever stroke patients. After 3 years, 136 (33%) had died. In the first year of stroke the risk of death was 28% (95% CI, 25 to 32). Beyond the first year, approximately 3 to 5% of survivors died each year. The cumulative risk of death in ischemic stroke (IS) subtypes was 3.6 higher for cardioembolic (CE) IS (hazard ratio 3.6, 95% CI, 2.1 to 6.4; p = 0.001) and 3.3 times higher for undetermined IS (HR 3.3, 95% CI 1.9 to 5.8; p = 0.001) compared to small artery occlusion IS. Over 3 years, the overall stroke recurrence risk was 9% (35/407). We found no difference in stroke recurrence risk between IS subtypes. Cardiovascular disease was the main cause of death all follow up time. CONCLUSIONS: Compared to other cohort studies conducted between 10 and 20 years ago in high-income countries, our recurrence rates and 3-year risk of death were similar. Among IS subtypes, we confirmed that CE has highest risk of death. The most common cause of death after a first-ever stroke is cardiovascular disease. This has implications for the uptake of current secondary preventive strategies and the development of new strategies.

'Quer N0 AVC' for Monitoring Stroke Patients' Healthcare Using a Mobile App.

Stroke is one of the leading causes of death and impairments worldwide. After hospital discharge, it is necessary to monitor these patients during their recovery. This research addresses the implementation of a mobile app, entitled 'Quer N0 AVC', to improve the quality of stroke patient care in Joinville, Brazil. The study method was divided into two parts. The adaptation phase included all the necessary information in the app for monitoring stroke patients. The implementation phase aimed to prepare a routine for the Quer mobile app installation. One of the questionnaires collected data from 42 patients and identified that before hospital admission 29% of them did not have medical appointments, 36% had one or two appointments, 11% had three appointments, and 24% had four or more appointments. This research portrayed adaptation feasibility and the implementation of a cell phone app for following up on stroke patients.

Stroke profile and care during the COVID-19 pandemic: What changed and what did not? A prospective cohort from Joinville, Brazil.

Introduction: The COVID-19 pandemic has wrought negative consequences concerning quality of care for stroke patients since its onset. Prospective population-based data about stroke care in the pandemic are limited. This study aims to investigate the impact of COVID-19 pandemic on stroke profile and care in Joinville, Brazil. Methods: A prospective population-based cohort enrolled the first-ever cerebrovascular events in Joinville, Brazil, and a comparative analyzes was conducted between the first 12 months following COVID-19 restrictions (starting March 2020) and the 12 months just before. Patients with transient ischemic attack (TIA) or stroke had their profiles, incidences, subtypes, severity, access to reperfusion therapy, in-hospital stay, complementary investigation, and mortality compared. Results: The profiles of TIA/stroke patients in both periods were similar, with no differences in gender, age, severity, or comorbidities. There was a reduction in incidence of TIA (32.8%; p = 0.003). In both periods, intravenous thrombolysis (IV) and mechanical thrombectomy (MT) rates and intervals from door to IV/MT were similar. Patients with cardioembolic stroke and atrial fibrillation had their in-hospital stay abbreviated. The etiologic investigation was similar before and during the pandemic, but there were increases in cranial tomographies (p = 0.02), transthoracic echocardiograms (p = 0.001), chest X-rays (p < 0.001) and transcranial Doppler ultrasounds (p < 0.001). The number of cranial magnetic resonance imaging decreased in the pandemic. In-hospital mortality did not change. Discussion: The COVID-19 pandemic is associated with a reduction in TIA, without any influence on stroke profile, the quality of stroke care, in-hospital investigation or mortality. Our findings show an effective response by the local stroke care system and offer convincing evidence that interdisciplinary efforts are the ideal approach to avoiding the COVID-19 pandemic's negative effects, even with scarce resources.

Incidence, lethality, and post-stroke functional status in different Brazilian macro-regions: The SAMBA study (analysis of stroke in multiple Brazilian areas).

Background: Stroke is the second leading cause of death in Brazil. The social and financial burden of stroke is remarkable; however, the epidemiological profile remains poorly understood. Objective: The aim of this study was to report the incidence, lethality, and functional status at 30 and 90 days post-stroke in the cities of different Brazilian macro-regions. Methods: This is an observational, prospective, and population-based study, led in Canoas (South), Joinville (South, reference center), Sertãozinho (Southeast), and Sobral (Northeast) in Brazil. It was developed according to the three-step criteria recommended by the World Health Organization to conduct population-based studies on stroke. Using different sources, all hospitalized and ambulatory patients with stroke were identified and the same criteria were kept in all cities. All first events were included, regardless of sex, age, or type of stroke. Demographic and risk factor data were collected, followed by biochemical, electrocardiographic, and radiological test results. Functional status and lethality were obtained using the mRankin scale through telephonic interview (validated Brazilian version). Results: In 1 year, 932 stroke cases were registered (784 ischemic stroke, 105 hemorrhagic stroke, and 43 subarachnoid hemorrhage). The incidence rates per 100,000 inhabitants, adjusted for the world population, were 63 in Canoas, 106 in Joinville, 72 in Sertãozinho, and 96 in Sobral. The majority (70.8%) were followed for 90 days. Kaplan-Meier curves showed that 90-day survival was different among cities. Sobral, which has the lowest socioeconomic indexes, revealed the worst results in terms of lethality and functional status. Conclusion: This study expands the knowledge of stroke epidemiology in Brazil, a middle-income country with enormous socioeconomic and cultural diversity. The discrepancy observed regarding the impact of stroke in patients from Joinville and Sobral highlights the need to improve the strategic allocation of resources to meet the health priorities in each location.

The cost of stroke in private hospitals in Brazil: a one-year prospective study.

OBJECTIVE: Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. METHODS: Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. RESULTS: We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). CONCLUSIONS: Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

High five-year mortality rates of ischemic stroke subtypes: A prospective cohort study in Brazil.

BACKGROUND: Studies regarding long-term outcomes of ischemic stroke subtypes are scarce in low- and middle-income countries. We aimed to measure the five-year prognosis of ischemic stroke subtypes in Joinville, Brazil. METHODS: All first-ever ischemic strokes that occurred in Joinville in 2010 were followed-up for five years. RESULTS: We included 334 ischemic stroke patients. Over five years, 156 died, 51 had a recurrent stroke, and 128 were free of recurrent stroke. The overall cumulative risk of death was 17% (95% CI, 13% to 22%) at 30 days and 47% (95% CI, 41% to 52%) after five years. Undetermined with incomplete investigation ischemic stroke had a significantly worse survival probability (ß -4.91; 95% CI, -6.31 to -3.50; p < 0.001), followed by cardioembolic ischemic stroke (ß -3.07; 95% CI, -4.32 to -1.83; p < 0.001) and large artery disease ischemic stroke (ß -1.95; 95% CI, -3.30 to -0.60; p = 0.005). The survival probability of undetermined with negative investigation or cryptogenic ischemic stroke did not differ significantly from small artery disease ischemic stroke (ß -1.022; 95% CI, -3.37 to -1.43; p = 0.414). The five-year mortality for small artery disease ischemic stroke was 30% (95% CI, 22% to 39%) and 47% (95% CI, 35% to 60%) for large artery ischemic stroke. The risk of stroke recurrence was 2% in the first year and 5% in the second year. The proportion of disability among survivors in the first month ranged from 8% (95% CI, 3-15) for small artery disease ischemic stroke to 40% (95% CI, 30-52) for cardioembolic ischemic stroke patients. CONCLUSIONS: Cardioembolic and undetermined with incomplete investigation ischemic stroke sub-types have a poor long-term prognosis. An alarming finding was that our patients with both small and large artery ischemic stroke had higher five-year mortality rates compared with subjects from high-income countries.

The cost of stroke in a public hospital in Brazil: a one-year prospective study.

OBJECTIVE: Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. To measure the costs of stroke care in a public hospital in Joinville, Brazil. METHODS: We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. RESULTS: We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. CONCLUSIONS: Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

Prevalence of obesity among stroke patients in five Brazilian cities: a cross-sectional study.

OBJECTIVE: There is gap in knowledge about obesity prevalence in stroke patients from low- and middle-income countries. Therefore, we aimed to measure the prevalence of overweight and obesity status among patients with incident stroke in Brazil. METHODS: In a cross-sectional study, we measured the body mass index (BMI) of ischemic and hemorrhagic stroke patients. The sample was extracted in 2016, from the cities of Sobral (CE), Sertãozinho (SP), Campo Grande (MS), Joinville (SC) and Canoas (RS). RESULTS: In 1,255 patients with first-ever strokes, 64% (95% CI, 62-67) were overweight and 26% (95%CI, 24-29) were obese. The obesity prevalence ranged from 15% (95%CI, 9-23) in Sobral to 31% (95%CI, 18-45) in Sertãozinho. Physical inactivity ranged from 53% (95%CI, 43-63) in Sobral to 80% (95%CI, 73-85) in Canoas. CONCLUSIONS: The number of overweight patients with incident stroke is higher than the number of patients with stroke and normal BMI. Although similar to other findings in high-income countries, we urgently need better policies for obesity prevention.

Five-year survival, disability, and recurrence after first-ever stroke in a middle-income country: A population-based study in Joinvile, Brazil.

Background Information about long-term outcomes after stroke in developing countries provided by population-based methodologies is scarce. Aim This study aimed to know outcomes five years after a first-ever stroke in Joinville, Brazil. Methods Data were extracted from the Joinville Stroke Registry about all patients who had strokes in Joinville in 2010 and were followed up to 2015. Stroke recurrence, Kaplan-Meier survival probabilities, functional outcomes, and causes of death were ascertained at 30 days, six months, one and five years. Results A total of 399 strokes were studied. The mean age was 64 (standard deviation 16) years. After five years, 52% (95% confidence interval: 47-57%) survived and 20% (95% confidence interval: 15-26%) of the survivors had modified Rankin scale scores >2. More than half of these patients were institutionalized in nursing or home care settings. The average risk of death per year was ≈7%. Survival rates were significantly lower for subarachnoid hemorrhage and primary intracerebral hemorrhage than for ischemic stroke. The five-year recurrence rate was 12% (95% confidence interval: 9-15%). The index stroke was the cause of death in three quarters of the patients. Conclusions The results showed that 68% of the patients with stroke were either dead or disabled five years after first-ever stroke. This percentage is similar to proportions of other recent cohorts from developed countries, despite the lower age of the patients in this study.

Joinville stroke biobank: study protocol and first year's results.

Aiming to contribute to studies that use detailed clinical and genomic information of biobanks, we present the initial results of the first Latin American Stroke Biobank. METHODS: Blood samples were collected from patients included in the Joinville Stroke Registry and four Brazilian cities. Demographic socio-economic data, cardiovascular risk factors, Causative Classification System for Ischemic Stroke, Trial of Org 10172 in Acute Stroke Treatment and National Institutes of Health scores, functional stroke status (modified Rankin) and brain images were recorded. Additionally, controls from both geographic regions were recruited. High-molecular-weight genomic DNA was obtained from all participants. RESULTS: A total of 2,688 patients and 3,282 controls were included. Among the patients, 76% had ischemic stroke, 12% transient ischemic attacks, 9% hemorrhagic stroke and 3% subarachnoid hemorrhage. Patients with undetermined ischemic stroke were most common according the Trial of Org 10172 in Acute Stroke Treatment (40%) and Causative Classification System for Ischemic Stroke (47%) criteria. A quarter of the patients were under 55 years of age at the first-ever episode. CONCLUSIONS: We established the Joinville Stroke Biobank and discuss its potential for contributing to the understanding of the risk factors leading to stroke.

Incidence and functional outcome of atrial fibrillation and non-atrial fibrillation- related cardioembolic stroke in Joinville, Brazil: a population-based study.

Among ischemic strokes, cardioembolic (CE) stroke has the worst outcome. We measured the incidence of atrial fibrillation (AF) and non-AF related CE strokes, previous anticoagulant use, and the 90-day functional outcome. Using multiple overlapping sources, we included all CE strokes that occurred in 2015 in Joinville, Brazil. Of the 374 ischemic strokes, 23% (84) were CE. The CE age-adjusted incidence, per 1,000 person-years, was 0.14 (0.11-0.17). Of the 26 patients with known prior AF, 73% (19) were not anticoagulated, 77% (20) had a CHA2DS2VASc score ≥ 3 and 81% (21) had a HAS-BLED score < 3. After three months, approximately one third of those 26 patients died or became disabled. The incidence of CE stroke in our sample was lower than in other population-based studies. The opportunity for anticoagulation was missed in one third of cases.

Intravenous rtPA versus mechanical thrombectomy in acute ischemic stroke: A historical cohort in Joinville, Brazil.

Groundbreaking results concerning ischemic stroke (IS) hyperacute treatment worldwide were published in 2014 and 2015. We aimed to compare functional status after 3 months in patients treated with intra-arterial thrombectomy (IAT) and those treated with intravenous thrombolysis (IVT) alone in Joinville, Brazil. From the Joinville Stroke Registry, we extracted and compared all consecutive IVT patients treated with r-tPA within 4.5 h in the period 2009-2011 versus all consecutive IAT treated within 6 h with the Solitaire FR device plus IVT in the period 2012-2014. We registered 82 patients in the IVT group and 31 patients in the IAT group. At hospital admission, patients in the IAT group were significantly younger (p < 0.001), had a higher educational level (p = 0.001), had a slightly higher prevalence of atrial fibrillation (p = 0.057) and had more severe strokes measured by the NIH stroke scale (p = 0.011). After 90 days, 45% of patients in the IAT group and 27% in the IVT group were independent (0-1 points) according to the modified Rankin scale (adjusted odds ratio: 4.53; 95% CI: 1.22 to 16.75). Symptomatic hemorrhage was diagnosed in 10% of patients in both groups (p = 1.0). The 90-day case-fatality was 39% (32/82) in the IVT group and 26% (8/31) in the IAT group (p = 0.27). In this small cohort, a greater rate of functional independence was achieved in patients treated with IAT plus IVT, compared with patients treated with IVT lysis alone. Our "real-world" findings are consistent with results of controlled, randomized clinical trials.

The cost of stroke in private hospitals in Brazil: a one-year prospective study / O custo do AVC em hospitais privados no Brasil: um estudo prospectivo

ABSTRACT Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. Objective To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. Methods Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. Results We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). Conclusions Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

RESUMO Poucos estudos determinam o custo do AVC em países de baixa e média renda nos setores privados. Objetivos Mensurar o custo hospitalar do tratamento do(a): AVC isquêmico com e sem reperfusão cerebral, hemorragia intracerebral primária (HIP), hemorragia subaracnóidea e ataque isquêmico transitório (AIT) em hospitais privados de Joinville, Brasil. Métodos Estudo prospectivo de custo de doença. Os custos médicos e não médicos dos pacientes admitidos com qualquer tipo de AVC ou AIT foram consecutivamente verificados em 2016-17. Os valores foram ajustados ao índice do deflator do produto interno bruto e à paridade do poder de compra. Resultados Nós incluímos 173 pacientes. A mediana de custo por paciente foi de US$ 3.827 (IQR: 2.800-8.664) para os 131 pacientes com AVC isquêmico; US$ 2.315 (1.692-2.959) para os 27 pacientes com AIT; US$ 16.442 (5.108-33.355) para os 11 pacientes com HIP e US$ 28.928 (12.424-48.037) para os quatro pacientes com HSA (p < 0,00001). Para seis pacientes submetidos à trombólise intravenosa, a mediana do custo por paciente foi de US$ 11.463 (8.931-14.291) e, para quatro pacientes submetidos à trombectomia intra-arterial, a mediana de custo por paciente foi de US$ 35.092 (31.833-37.626; p < 0,0001). Uma correlação direta foi encontrada entre custo e tempo de permanência (r = 0,67, p < 0,001). Conclusão O AVC é uma doença cara. Em ambiente privado, os custos da reperfusão cerebral foram de três a dez vezes superiores aos tratamentos habituais do AVC isquêmico. Portanto, estudos de custo-efetividade são urgentemente necessários em países de baixa e média rendas.

The cost of stroke in a public hospital in Brazil: a one-year prospective study / Custo do AVC em um hospital público no Brasil: um estudo prospectivo de um ano

ABSTRACT Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. Objective To measure the costs of stroke care in a public hospital in Joinville, Brazil. Methods We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. Results We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. Conclusions Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

RESUMO Os países de baixa e media renda enfrentam orçamentos apertados na saúde, não somente devido aos novos recursos terapêuticos, mas relacionado ao custo oneroso do tratamento do acidente vascular cerebral. No entanto, poucos dados prospectivos sobre os custos do AVC, incluindo reperfusão cerebral de países de baixa e média renda estão disponíveis. Objetivo Mensurar os custos do atendimento ao AVC em um hospital público. Métodos Avaliamos prospectivamente todos os custos médicos e não médicos de pacientes internados com diagnóstico de acidente vascular cerebral ou AIT durante 1 ano, analisamos os custos por tipo de AVC e tratamento, tempo de permanência e comparamos os custos hospitalares com o reembolso governamental. Resultados Foram avaliados 274 pacientes. O custo total em um ano foi de US$ 1.307,114; o governo reembolsou o hospital no valor de US$ 1.095.118. Encontramos uma correlação linear significativa entre LOS e custos (r = 0,71). A mediana do custo do AVCI em 134 pacientes que não sofreram reperfusão cerebral (National Institutes of Health Stroke Scale [NIHSS] mediana = 3) foi de US$ 2.803; para pacientes submetidos a alteplase intravenosa (IV) (NIHSS 10), a mediana foi de US$ 5.099 e para os pacientes submetidos a trombectomia intra-arterial (IA) (NIHSS > 10), o custo mediano foi de US$ 10.997. A mediana do custo de uma hemorragia intracerebral primária, hemorragia subaracnóidea e AIT foram de US$ 2.436, US$ 8.031 e US$ 2.677, respectivamente. Conclusões Os tratamentos de reperfusão foram duas a quatro vezes mais caros do que o tratamento conservador. Estudo de custo-efetividade para o tratamento do AVC são necessários.

Prevalence of obesity among stroke patients in five Brazilian cities: a cross-sectional study / Prevalência de excesso de peso em pacientes com acidente vascular cerebral em cinco cidades brasileiras

ABSTRACT Objective There is gap in knowledge about obesity prevalence in stroke patients from low- and middle-income countries. Therefore, we aimed to measure the prevalence of overweight and obesity status among patients with incident stroke in Brazil. Methods In a cross-sectional study, we measured the body mass index (BMI) of ischemic and hemorrhagic stroke patients. The sample was extracted in 2016, from the cities of Sobral (CE), Sertãozinho (SP), Campo Grande (MS), Joinville (SC) and Canoas (RS). Results In 1,255 patients with first-ever strokes, 64% (95% CI, 62-67) were overweight and 26% (95%CI, 24-29) were obese. The obesity prevalence ranged from 15% (95%CI, 9-23) in Sobral to 31% (95%CI, 18-45) in Sertãozinho. Physical inactivity ranged from 53% (95%CI, 43-63) in Sobral to 80% (95%CI, 73-85) in Canoas. Conclusions The number of overweight patients with incident stroke is higher than the number of patients with stroke and normal BMI. Although similar to other findings in high-income countries, we urgently need better policies for obesity prevention.

RESUMO Objetivo Há uma lacuna de conhecimento sobre a prevalência de obesidade em pacientes com AVC (acidente vascular cerebral) de países de baixa e média renda. Portanto, objetivamos medir a prevalência de sobrepeso e obesidade entre pacientes com AVC no Brasil. Métodos Em um estudo transversal, medimos o índice de massa corporal (IMC) em pacientes com AVC isquêmico e hemorrágico. A amostra foi extraída em 2016, nas cidades de Sobral (CE), Sertãozinho (SP), Campo Grande (MS), Joinville (SC) e Canoas (RS). Resultados Entre 1255 casos de AVC, 64% (95%CI, 62-67) apresentavam sobrepeso e 26% (95%CI, 24-29) obesidade. A prevalência de obesidade variou de 15% (95%CI, 9-23) em Sobral a 31% (95%CI, 18-45) em Sertãozinho. Conclusões A quantidade de pacientes com AVC e IMC anormal é maior do que a de pacientes com AVC e IMC normal. Embora esta prevalência seja similar às de países de alta renda, precisamos urgentemente de melhores políticas de prevenção da obesidade. Atividade física deveria ser parte da prescrição médica.