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Wiyarta E, Fisher M, Kurniawan M, Hidayat R, Geraldi IP, Khan QA, Widyadharma IPE, Badshah A, Pandian JD. Global Insights on Prehospital Stroke Care: A Comprehensive Review of Challenges and Solutions in Low- and Middle-Income Countries. J Clin Med 2024; 13:4780. [PMID: 39200922 PMCID: PMC11355367 DOI: 10.3390/jcm13164780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Revised: 08/07/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Stroke is a leading cause of disability and mortality worldwide, and it disproportionately affects low- and middle-income countries (LMICs), which account for 88% of stroke fatalities. Prehospital stroke care delays are a crucial obstacle to successful treatment in these settings, especially given the limited therapeutic window for thrombolytic treatments, which may greatly improve recovery chances when initiated early after stroke onset. These delays are caused by a lack of public understanding of stroke symptoms, sociodemographic and cultural variables, and insufficient healthcare infrastructure. This review discusses these issues in detail, emphasizing the disparities in stroke awareness and reaction times between locations and socioeconomic classes. Innovative options for reducing these delays include the deployment of mobile stroke units and community-based educational campaigns. This review also discusses how technology improvements and personalized educational initiatives might improve stroke awareness and response in LMICs. The primary goal is to give a thorough assessment of the challenges and potential remedies that might serve as the foundation for policy reforms and healthcare improvements in LMICs, eventually improving stroke care and lowering disease-related mortality and disability.
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Affiliation(s)
- Elvan Wiyarta
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Dr. Cipto Mangunkusumo National Hospital, Central Jakarta, Jakarta 10430, Indonesia; (M.K.); (R.H.)
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
| | - Mohammad Kurniawan
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Dr. Cipto Mangunkusumo National Hospital, Central Jakarta, Jakarta 10430, Indonesia; (M.K.); (R.H.)
| | - Rakhmad Hidayat
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Dr. Cipto Mangunkusumo National Hospital, Central Jakarta, Jakarta 10430, Indonesia; (M.K.); (R.H.)
| | | | - Qaisar Ali Khan
- Department of Medicine, Khyber Teaching Hospital, Peshawar 25120, Pakistan (A.B.)
| | - I Putu Eka Widyadharma
- Department of Neurology, Faculty of Medicine, Universitas Udayana, Bali 80361, Indonesia
| | - Aliena Badshah
- Department of Medicine, Khyber Teaching Hospital, Peshawar 25120, Pakistan (A.B.)
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Shrestha GS, Nepal G, Prust ML. Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings. Semin Neurol 2024; 44:105-118. [PMID: 38485125 DOI: 10.1055/s-0043-1778638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Rani, Biratnagar, Nepal
| | - Morgan Lippitt Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Silva GS, Rocha E. Developing Systems of Care for Stroke in Resource-limited Settings. Semin Neurol 2024; 44:119-129. [PMID: 38513704 DOI: 10.1055/s-0044-1782617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.
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Affiliation(s)
- Gisele Sampaio Silva
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Neurology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eva Rocha
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
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Liu S, Lv Y, Zhang Y, Suo H, Wang F, Gao S. Global trends and burden of stroke attributable to particulate matter pollution from 1990 to 2019. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2024; 274:116205. [PMID: 38503105 DOI: 10.1016/j.ecoenv.2024.116205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/08/2024] [Accepted: 03/09/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To investigate the association between particulate matter and the incidence, disability, and mortality of stroke, we reported the burden of stroke attributable to particulate matter (PM2.5) pollution, including ambient particulate matter pollution (APMP) and household air pollution from solid fuels (HAP), from 1990 to 2019. METHODS We retrieved the detailed data on the burden of stroke attributable to PM2.5 from the Global Burden of Disease (GBD) 2019. The number of disability-adjusted life-years (DALYs) and deaths, age-standardized death rates (ASMR), and age-standardized disability-adjusted life-years rates (ASDR) attributable to PM2.5 were estimated by age, sex, geographical location, socio-demographic index (SDI), and stroke subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage). The estimated annual percentage change (EAPC) was calculated to assess the trends in ASDR and ASMR during the period 1990-2019. RESULTS Regarding stroke subtypes, the proportion of ischemic stroke burden is increasing, while intracerebral hemorrhage carries the heaviest burden. Both APMP and HAP contributed the most to stroke-related deaths and DALYs of stroke among the elderly populations and males. The highest ASDR and ASMR of stroke attributable to APMP were in the middle SDI regions, especially in East Asia. For HAP, the highest ASDR and ASMR were in the low SDI regions, mainly in Oceania. From 1990-2019, in terms of the EAPC results, APMP caused an increased burden of stroke, whereas the impact of HAP significantly fell. The most pronounced increase in ASDR and ASMR for strokes attributed to APMP were in the low-middle SDI and low SDI regions, particularly among the 25-35 age group. CONCLUSIONS Stroke attributed to PM2.5 is a global health problem, and the patterns and trends were heterogeneous across APMP and HAP. Targeted interventions should be formulated for APMP and HAP.
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Affiliation(s)
- Siqi Liu
- Department of Toxicology, School of Public Health, Harbin Medical University, Heilongjiang Province, China
| | - Yanming Lv
- Department of Toxicology, School of Public Health, Harbin Medical University, Heilongjiang Province, China
| | - Ya Zhang
- Department of Toxicology, School of Public Health, Harbin Medical University, Heilongjiang Province, China
| | - Huimin Suo
- Department of Toxicology, School of Public Health, Harbin Medical University, Heilongjiang Province, China
| | - Fan Wang
- Department of Epidemiology, School of Public Health, Harbin Medical University, Heilongjiang Province, China
| | - Shuying Gao
- Department of Toxicology, School of Public Health, Harbin Medical University, Heilongjiang Province, China.
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Gajurel BP, Nepal G, Jaiswal V, Ang SP, Nain P, Shama N, Ruchika F, Bohara S, Kharel S, Yadav JK, Medina JRT, Shrestha AB. Utilization rates of intravenous thrombolysis for acute ischemic stroke in Asian countries:: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35560. [PMID: 37861564 PMCID: PMC10589571 DOI: 10.1097/md.0000000000035560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Despite intravenous thrombolysis (IVT) being used for the treatment of acute ischemic stroke (AIS) for over two decades, its accessibility remains limited in various regions of the world. The Asian region, which experiences the highest age-standardized incidence of AIS, currently lacks comprehensive data on the utilization of IVT. AIMS This study aimed to provide precise estimates of IVT usage for AIS in Asian countries. METHODS A literature search was conducted on PubMed and Google using appropriate search terms. English language, peer reviewed articles published after 2010 were included in the analysis. The pooled proportion was calculated utilizing the DerSimonian and Laird random-effects model. Additionally, a subgroup analysis was conducted, taking into account factors such as the study's country, the economic status of the country, specific Asian regions, publication year (before 2015 and from 2015 onwards), study location, study setting, hospital stroke protocol, and national stroke guidelines. RESULTS 67 observational studies with 778,046 patients with AIS were included in the meta-analysis. The overall utilization rate of IVT was found to be 9.1%. High-income countries had a higher rate (11.3%) compared to lower-middle-income (8.1%) and upper-middle-income countries (9%). Central and North Asia had the highest rate (17.5%) and Southeast Asia had the lowest rate (6.8%). Studies conducted after 2015 had a higher thrombolysis rate (11.3%) compared to those before 2015 (1.5%). Presence of hospital stroke protocols (10.7%) and national stroke guidelines (10.1%) were associated with higher thrombolysis rates. CONCLUSION The overall utilization rate of IVT for AIS in Asia stood at 9.1%, showcasing noteworthy disparities across countries, regions, and income brackets. To improve thrombolysis rates in the region, addressing prehospital delays, increasing public awareness, and implementing stroke protocols and national guidelines are key strategies.
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Affiliation(s)
- Bikram Prasad Gajurel
- Department of Neurology, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Biratnagar, Nepal
| | | | - Song Peng Ang
- Division of Internal Medicine, Rutgers Health/Community Medical Center, NJ
| | - Priyanshu Nain
- Department of Medicine, Maulana Azad Medical College, New Delhi, India
| | - Nishat Shama
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | - F.N.U. Ruchika
- Department of Surgery, JJM Medical College, Davangere, India
| | - Sujan Bohara
- Department of Internal Medicine, Nepalese Army Institute of Health Science, Kathmandu, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | | | - Jillian Reeze T. Medina
- Manila Central University - Filemon D. Tanchoco Medical Foundation College of Medicine, Philippines
| | - Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
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Nguyen CP, Lahr MMH, van der Zee DJ, van Voorst H, Roos YBWEM, Uyttenboogaart M, Buskens E. Cost-effectiveness of tenecteplase versus alteplase for acute ischemic stroke. Eur Stroke J 2023; 8:638-646. [PMID: 37641549 PMCID: PMC10472948 DOI: 10.1177/23969873231174943] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Alteplase is widely used as an intravenous thrombolytic drug in acute ischemic stroke (AIS). Recently however, tenecteplase, a modified form of tissue plasminogen activator, has been shown to increase early recanalization rate and has proven to be non-inferior with a similar safety profile compared to alteplase. This study aims to evaluate the cost-effectiveness of 0.25 mg/kg tenecteplase versus 0.9 mg/kg alteplase for intravenous thrombolysis in AIS patients from the Dutch healthcare payer perspective. METHODS A Markov decision-analytic model was constructed to assess total costs, total quality-adjusted life year (QALY), an incremental cost-effectiveness ratio, and incremental net monetary benefit (INMB) of two treatments at willingness-to-pay (WTP) thresholds of €50,000/QALY and €80,000/QALY over a 10-year time horizon. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analysis were conducted to test the robustness of results. Clinical data were obtained from large randomized controlled trials and real-world data. RESULTS Treatment with tenecteplase saved €21 per patient while gaining 0.05 QALYs, resulting in INMB of €2381, clearly rendering tenecteplase cost-effective compared to alteplase. Importantly, tenecteplase remained the cost-effective alternative in all scenarios, including AIS patients due to large vessel occlusion (LVO). Probabilistic sensitivity analysis proved tenecteplase to be cost-effective with a 71.0% probability at a WTP threshold of €50,000/QALY. CONCLUSIONS Tenecteplase treatment was cost-effective for all AIS patients (including AIS patients with LVO) compared to alteplase. The finding supports the broader use of tenecteplase in acute stroke care, as health outcomes improve at acceptable costs while having practical advantages, and a similar safety profile.
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Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Management and Economic, Hanoi University of Pharmacy, Vietnam
| | - Maarten MH Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Barriers and Facilitators of Pharmacoeconomic Studies: A Review of Evidence from the Middle Eastern Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137862. [PMID: 35805521 PMCID: PMC9265831 DOI: 10.3390/ijerph19137862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Abstract
The world is facing a continuous increase in medical costs. Due to the surge in disease prevalence, medical science is becoming more sensitive to the economic impact of medications and drug therapies. This brings about the importance of pharmacoeconomics, which is concerned with the effective use of health resources to optimize the efficiency and costs of medications of treatment for the best outcomes. This review was conducted to find out the potential barriers and facilitators to implementing pharmacoeconomic studies in the Middle Eastern region having both high- and low-income countries. The varying economies in the region depict diverse healthcare systems where implementation of pharmacoeconomics faces a large number of challenges and is also aided by numerous facilitators that contribute to the growth of its implementation. In this context, we have reviewed the status of pharmacoeconomics in Middle Eastern countries in research databases (Google Scholar, MEDLINE, Science Direct and Scopus) using keywords (“pharmacoeconomics”, “barriers”, “facilitators”, “Middle East”). The study reported that Yemen, Syria, Palestine, Iran, Iraq, Jordan and Lebanon are the lowest-income countries in the Middle East and the implementation of pharmacoeconomics is the poorest in these states. The UAE, Saudi Arabia and Israel are high-income rich states where economic aspects were comparatively better but still a large number of barriers hinder the way to its effective implementation. These include the absence of national governing bodies, the lack of data on the effectiveness of medications, the absence of sufficient pharmacoeconomic experts and the lack of awareness of the importance of pharmacoeconomics. The main facilitators were the availability of pharmacoeconomic guidelines, the encouragement of pharmacoeconomic experts and the promotion of group discussions and collaborations between researchers and policymakers. Cost-benefit analysis is still evolving in Middle Eastern countries, and there is a great need for improvement so that states can effectively benefit from cost analysis tools and utilize their health resources. In this regard, governments should develop national governing bodies to evaluate, implement pharmacoeconomics at the local and state levels and bring about innovation in the field through further research and development incorporating all sectors of pharmacy and pharmaceutics. The data presented in this research can further be extended in future studies to cover the various domains of pharmacoeconomics including cost-minimization analysis, cost-effectiveness analysis and cost-benefit analysis and their applications within the healthcare sectors of Middle Eastern countries.
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Yadav JK, Nepal G, Shing YK, Banerji RR, Gajurel BP. An opportunity to improve Acute Ischemic Stroke care in the South Asian region through telestroke services. Ann Med Surg (Lond) 2021; 72:103115. [PMID: 34888047 PMCID: PMC8636765 DOI: 10.1016/j.amsu.2021.103115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/21/2021] [Indexed: 11/13/2022] Open
Abstract
The South Asian region accounts for more than 40% of the stroke burden of the developing world and is the highest contributor to global stroke mortality. Despite proven treatment guidelines, the limited number of neurologists, the number of dedicated stroke centers and the fact that most of these facilities are urban-centric renders poor access to thrombolysis in this region, especially in the rural areas. Studies have shown that thrombolysis using telestroke services are comparable to face-to-face thrombolysis. Telestroke, conducted through low-cost media such as smartphones or laptops, may form a cost-effective solution to improve access to appropriate stroke care in a resource-limited setting such as that of the South Asian region.
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Affiliation(s)
- Jayant Kumar Yadav
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore
| | - Rohit Raman Banerji
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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