Abstract
Stroke is a major medical problem and one of the leading causes of mortality and disability all over in Europe. However, there are significant East–West differences in stroke care as well as in stroke mortality and morbidity rates. Central and Eastern European countries that formerly had centralized and socialist health care systems have serious and similar problems in organizing health and stroke care 20 years after the political transition. In Central and Eastern Europe, stroke is more frequent, the mortality rate is higher, and the victims are younger than in Western Europe. High-risk patients live in worse environmental conditions, and the socioeconomic consequences of stroke further weaken the economic development of these countries. To address these issues, a round table conference was organized. The main aim of this conference was to discuss problems to be solved related to acute and chronic stroke care in Central and Eastern European countries, and also, to exchange ideas on possible solutions. In this article, the discussed problems and possible solutions will be summarized, and introduce ‘The Budapest Statement of Stroke Experts of Central and Eastern European countries’.
East–West Differences
Approximately 20 years after the political transition, Central and Eastern European (CEE) countries that formerly had centralized and socialist health care systems have very similar problems in organizing health care and also, in organizing stroke care. Stroke is one of the most frequent causes of morbidity and mortality in these countries that results in a greater loss of quality-adjusted life than any other disease, and because of that, it has a serious socioeconomic impact. While stroke is a major medical issue and one of the leading causes of mortality and disability all across Europe, there are wide variations between European countries in both stroke incidence and mortality rates (1). In CEE, stroke is more frequent, the mortality rate is higher, and the victims are younger than in Western Europe. Stroke affects a considerable number of patients at their productive age, further increasing the economic burden on healthcare and social welfare. For example, the risk of dying from a stroke in Hungary in the group of working age is four times higher in men and three times higher among women than the European average (2). In Serbia, stroke is the first cause of death among women, and the second, after cardiovascular diseases, among men (3). According to a study published in 2010, Romania is in the top 5 after Russia, China, and Bulgaria regarding the number of deaths due to stroke with 452·8 deaths per 100 000 population for men and 257·0 deaths per 100 000 population for women (4). Among European countries, stroke mortality is one of the highest in Russia, and life expectancy is the lowest in this country (5).
In 2004, a specialized action plan, the Mannheim Declaration of Stroke in Eastern Europe, was established in Mannheim-Heidelberg, Germany, at the 14th European Stroke Conference, in order to achieve a decent level of stroke care and to diminish death and permanent disability caused by stroke in this stranded region (6). But still, the positive tendency of decreasing stroke mortality and morbidity could not be seen in all CEE countries. Moreover, neurologists from CEE countries are poorly represented at editorial boards of stroke-related scientific media. Obviously, editorial board representation is not proportional with the social burden of stroke but more likely reflects national scientific output. Also, the participation of CEE countries in clinical trials is low as compared with the Western average. It is also very well known that the study of stroke has been neglected in less developed countries (7).
To address these issues, a round table conference was organized in Budapest, Hungary. The main aim of this conference was to discuss problems to be solved related to acute and chronic stroke care in CEE countries and, also, to exchange ideas on possible solutions. The present article focuses on CEE stroke care, discusses some region-specific problems, and offers some possible solutions that were proposed on this particular meeting.
National Programs to Improve Primary Prevention
East–west differences in stroke incidence and stroke mortality are well established in large epidemiological studies and are most probably due to higher prevalence of the most common modifiable risk factors for stroke in these countries (8). Importantly, standardized death rates for cerebrovascular diseases vary inversely with life expectancy at birth that is remarkably higher in Western Europe than in CEE countries. This epidemiological east–west gap is not reflected by most quality indicators of acute stroke care, e.g. total number of acute stroke units, acute care hospital beds per 100 000 inhabitants, or number of physicians per 100 000 inhabitants, whereas the gross domestic product and total health expenditure do seem to determine this difference. Results of several studies suggest that national per capita income is a predictor of stroke risk, and also, it is the strongest predictor of mortality and disability-adjusted life years loss rates, even after adjustment for cardiovascular risk factors. In CEE, relatively more high-risk patients live in worse environmental conditions as compared with Western countries (8). The socioeconomic consequences of stroke further weaken the economic development of these societies. Therefore, prevention and treatment of stroke are already recognized health priorities in most CEE countries but still more efforts should be taken in order to reach the Western European standards (9).
Since many risk factors (such as level of systolic blood pressure, total and Low-density lipoprotein, diabetes mellitus, physical inactivity, obesity, and tobacco smoking) have been associated with the development of neurovascular disorders, the prevalence of stroke can be significantly reduced by changing lifestyle. Therefore, it seems reasonable to conclude that stroke prevention programs intending to reduce the major prevalent risk factors are essential. Among the risk factors, the prevalence of hypertension and obesity is increasing, while there are less smokers and alcohol abusers in CEE countries (e.g. in Slovakia and Serbia) than they were before (10,11). In Poland, the rate of patients with atrial fibrillation and the prevalence of hyperlipidemia also dropped among stroke patients. However, there can be significant differences in the distribution of risk factors within a single country (12).
In several CEE countries, for example in Serbia, there are no national programs for stroke/atherosclerosis prevention. Although there are various possibilities to organize prevention programs (e.g. in Primary Prevention Centers in Serbia), most often hospital-based physicians diagnose and start to treat risk factors. In the Republic of Croatia, the main objective of the foundation of the Croatian Society for Neurovascular Disorders in 2001 was the prevention of stroke. The goal of this program was intended to be achieved by collection and processing of epidemiological data on various risk factors for the development of neurovascular disorders, analysis of differences observed, establishment of the patient registry, designing diagnostic and therapeutic algorithms and recommendations, studying the quality of life in individuals with a history of stroke, and conference activities for prevention of neurovascular diseases. The society lead to the establishment of a prevention center that provides risk factor measurement, carotid duplex ultrasound imaging, and also this center gives professional advices on stroke prevention to individuals. The second goal of the program is the education of not only the public but physicians (general practitioners and neurologists) as well. For this case, there are organized annual summer stroke schools, or different teaching courses and symposia on stroke prevention and management. In Slovenia, the public awareness is also low; since 2006, there are annual stroke symposia; there is a national stroke awareness day and other events in order to educate the public and medical personnel as well. Romania started the National Program for Health Evaluation in 2007, having as one of its objectives the detection and treatment of principal risk factors for cerebrovascular diseases. A sustained campaign through mass media regarding improvement to a healthy lifestyle began at the same time and it is still in progress. In the Russian Federation, the Federal Anti-Stroke Program started in 2008. Promotion of healthy lifestyle is one of the main goals, primarily via mass media programs, or via education at obligatory school classes. Health screening of the population (risk assessment, promotion of individual prevention programs, follow-up on high risk groups) is also an important part of this primary prevention program. Efforts to reduce exposure to well-established stroke risk factors may remain the focus of interventions to reduce future stroke burden. Certainly, such programs require an improvement in socioeconomic standards of less wealthy countries.
Insufficient Rate of Thrombolysis (TL) in CEE Countries
Intravenous TL with recombinant tissue plasminogen activator (rt-PA) is approved worldwide for the treatment of selected patients with acute ischemic stroke in 4,5 hour time window. In TL frequency, similar east–west gap exists as in other aspects of stroke care. National CEE guidelines follow basically the current European stroke guidelines, or in some cases, these are combined with the local practice. In Bulgaria, for instance, since 2012 the inclusion criteria for TL are the same that in other countries in Europe (13). In the Czech Republic, the first patient was thrombolysed intravenously in 1998 (14), and it is a standard therapy of ischemic stroke since 2004 (15). In 2009, 59 centers performed intravenous TL in this country, but still, only 2·5% of stroke patients are treated this way (16). In Croatia, for example, 4–5% of hospitalized stroke patients receive TL. In Bulgaria, the first TL was performed in 2005·(17). At the end of 2009, TL can be performed in 34 hospitals, mostly in large cities; however, it is still only 10% of the hospitals if private hospitals are not included (18). There is a huge difference among the number of TLs in different regions within some CEE countries, and also, there is a huge unevenness in the number stroke beds as well as in the efficacy of in-hospital care and stroke units. In Hungary, TL is applied in approximately 3% of all stroke cases in large cities but in less than 1% of cases nationwide (In 2010, 770 TL were performed in a country of 10 million people). In Romania, TL is available only in Bucharest, the capital, covering around 2 million people, 10% of the total population of the country. In Bulgaria, the stroke incidence and mortality are higher at the rural than at the urbanized areas, while the rate of hospitalization is higher among the urban population (19). Generally, the ratio of thrombolysed stroke patients in CEE countries is still low; however, the number of TLs and the number of centers providing TL is growing.
The late arrival of stroke patients to a hospital providing TL often prevents the broad application of this therapy. The recognition of stroke symptoms, the fast transfer, the available computed tomography (CT) imaging, and available stroke center are all important parts of the chain of stroke management before TL. There is good evidence from the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) registry that patients treated with TL in Poland have longer stroke onset-to-needle (the interval between stroke onset and starting thrombolytic treatment) and door-to-needle (the interval between arriving at the hospital and starting thrombolytic treatment) times than the European average. They also have higher three-month mortality (20). The shortening of the stroke onset-to-needle time requires well-organized services. The first main barrier of acute stroke management is the recognition of stroke symptoms. A principal cause of this problem is considered to be the lack of knowledge of stroke risk factors and warning signs. The recognition of stroke symptoms is meaningless, however, unless it leads to adequate reactions. Czech authors published the results of a survey, entitled ‘Calling 911 in response to stroke. A nationwide study assessing the definitive behavior’ (21). This study was based on a structured questionnaire with answers from 650 households in the Czech Republic. This study evaluated the public's knowledge on stroke, on risk factors, and on warning signs, and also, it evaluated the behavioral patterns and reactions to given stroke symptoms of the average population. It proved that only 27% of the population would call 911, 33% would call a physician, and the rest 40% would wait without calling a physician in the case of having an acute stroke patient around. Calling 911 was not driven by knowledge of risk factors or warning signs but rather by awareness of the seriousness and treatability of stroke. People who knew this were about twice as likely to call 911 than others. They were more likely to call the emergency number in response to stroke symptoms if they were older, or more educated. The evidences further indicate that education of the public is highly important. Based on the answers from this cited study, press, television, brochures, handouts, and posters in doctors' offices are the most preferable sources to obtain more knowledge on stroke.
Continuous education of not only the public but also the primary care providers such as paramedics and general practitioners is of high importance, because the late delivery of patients because of logistic problems is another key impediment of thrombolytic treatment. Dissemination of simple guidelines to primary care and local emergency departments are possible opportunities to improve TL rates. In Hungary (Debrecen), the regular meetings with the emergency transport service proved to be efficient in order to avoid the recurrence of former misdiagnosis. Also, in order to shorten the transport time, the ambulance notifies the hospital and the cardiorespiratorically stable patients are transferred directly to the CT.
Need for a Sufficient Number of Stroke Units
Treatment in stroke units, where a multidisciplinary team specialized in stroke management is available, decreases mortality, death, dependency, and need for institutional care (22). Because of that, all stroke patients should be treated in a stroke unit, and healthcare systems should provide access of high-technology medical and surgical stroke care for acute stroke patients when required (23).
The availability of stroke units providing TL determinates the stroke onset-to-door time (the interval between stroke onset and arriving at the hospital). Evidently, with increasing the number of stroke centers performing TLs, the delivery time decreases. A model has been developed (considering geographical factors, population density, and road density), if there were seven stroke centers in Hungary (93 000 km2), the average transfer time would be 61·5 min, but with 23 centers, the average time could be reduced to about 38·9 min (24). In Poland, as a result of the National Program of Stroke Prevention and Treatment and later the National Program of Prevention and Treatment of Cardiovascular Diseases (POLKARD) the number of stroke units has increased from three (in 1997) to 111 (in 2007), whereas the projected need is 120 (25,26).
Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred by interactive audiovisual media in order to consulting, and sometimes for the purpose of remote medical procedures or examinations. Telemedicine appears to be helpful to use for TL in hospitals without in-house neurologist providing the possibility of immediate referral. Another advantage of telemedicine is the favorable cost–benefit ratio. Additionally, it can be used not only for stroke treatment but for education (e.g. postgraduate teaching of physicians) as well. Among others, telemedicine is available in Austria, Croatia, and in some hospitals in Hungary. In Slovenia, for example, where the lack of specialists is a crucial problem, and there are only three stroke units where neurologist is present 24/7, telemedicine or ‘telestroke’ would be important too (27). Briefly, telemedicine is very useful and should be more widely accepted and used in more CEE countries.
The door-to-needle time is also an important element within the time window of TL. The effective organization of acute stroke care is very important at the level of the ward, since local problems and small changes can influence the door-to-needle time and consequently, the number of TLs. The local statistics and evaluation of all steps until TL can be surprisingly helpful in reducing the time taken for TL to be started in patients with ischemic stroke. Nevertheless, improvement in the decrease of the stroke onset-to-door and door-to-needle time should be achieved by a more efficient organization of prehospital and in-hospital stroke care (28).
Stroke patients are the majority of inpatients of neurology clinics in most CEE countries, meaning that most of the neurological cases are stroke cases in this region. The leading role of clinical neurology in acute stroke care is visible in most but not all European countries. Stroke units have been shown to be necessary elements for the acute care of stroke patients and are superior to other forms of hospital stroke care; however, recently, emergency departments tend to take over TL. This situation might change neurology to an outpatient profession with closing most inpatient units in the future. As in some other CEE countries, in Bulgaria, there are few number of stroke units, created more recently. Stroke patients are treated in different units such as at neurology wards at community hospitals, wards/clinics of intensive care at state regional hospitals, or intensive care units at neurology departments, mainly in university hospitals. In the Czech Republic, the number of stroke units increased during the past years (in 2007, there were 51 stroke units); however, approximately 40% of stroke patients are admitted instead of neurology to the internal medicine departments. Internists treat a high ratio of stroke patients in Hungary as well, even if the closer observation (transcranial Doppler monitoring and regular Glasgow Coma scale recording, treatment of an accompanying diagnosis, and observation at intensive care unit (ICU)) is financed better. In order to decrease the nonsufficient stroke care, the amount of reimbursement should vary according to the effectiveness (e.g. performing CT in time). The establishment of more stroke centers is necessary. Coexisting vascular centers (interdisciplinary team with cardiologists, angiologists, and neurosurgeons) with central laboratories are also needed with common database.
Although it is not a general problem, some CEE countries hamper by a lack of neurologists. For example, in the Czech Republic and in Romania and Hungary, a high number of doctors emigrate from the country. Migration of doctors and nurses is appreciable. Certainly, efforts shall be taken at governmental levels to decrease this tendency. In the Russian Federation or in Slovenia, the number of neurologists is also not sufficient. In many hospitals, internists take care of stroke patients. Therefore, education and training of neurologists for working at stroke units is of high importance. Improving this situation, in Slovenia, electronic teaching materials (DVDs) and written guidelines has recently been introduced in native language (29,30).
Lack in Facilities for Postacute Care
Stroke patients leaving neurology wards can be discharged home needing rehabilitation or long-term care in the community. Another option is to refer patients to a postacute rehabilitation department or hospital. Others can be discharged only to a nursing home. This last option is usually chosen when the family is not able to take care of the person with poststroke disability at home. Typically, elderly people who are severely impaired fall into this category. In CEE, the lack of enough (or any) rehabilitation and nursing facilities frequently results in prolonged hospital stay; therefore, the capacity of nursing homes and rehabilitation units should be increased (28). For long-term-care, usually only nonrehabilitation-specific, general home-care services are available. In Romania, many efforts are made to create neurorehabilitation units for stroke patients. Rehabilitation at home settings is also supposed to be more effective and more widely available. With the aim of improving this situation, forming of volunteers' groups including nurses, patients, or relatives (at least two volunteers) would be useful. These groups could visit poststroke patients, in order to give advices on everyday life. Such groups should be supported by different foundations.
The secondary prevention of stroke includes strategies to reduce the risk of stroke recurrence. These strategies, which should be specific to the underlying etiology, include risk factor modification, the use of antithrombotic or anticoagulant drugs, surgery, or endovascular treatments. As an example, in Poland, risk factor control is regularly achieved by the administration of acetylsalicylic acid, statins, and antihypertensive drugs. However, only a low (10%) percentage of patients with atrial fibrillation receive oral anticoagulant treatment. In this case, maybe the introduction of new types of anticoagulant will improve this ratio. In the Czech Republic, antihypertensive drugs, statins, and aspirin are widely used, but, uncommonly, clopidogrel was restricted for cardiologist only. In Romania, acetylsalicylic acid, acetylsalicylic acid + dypiridamole, clopidogrel, ticlopidine, and triflusal are used as antiplatelet agents for secondary prophylaxis of stroke, but unfortunately, some of these drugs are very expensive, and their price is not covered by the national health insurance. In Poland, an increase in the use evidence-based treatments such as TL, aspirin, and statins can be observed. Moreover, the decreased use of unproven medications like nootropic agents is noticeable.
Regular feedback from general practitioners and regular neurological control of patients are important elements of the successive risk reduction. There are new initiatives to improve the compliance of patients. In Hungary (e.g. Debrecen), the phone numbers of patients are registered, and computer program determines the date of the next visit and stores the date. The software sends an automatic SMS message to the patient some days before the visit to be due, as a reminder.
Financial Limitations
Almost all CEE countries face serious financial problems regarding stroke care (31). In numerous CEE countries, like in Hungary, or in the Czech Republic, the diagnosis related groups (DRGs) system is in use (28). Throughout Hungary, the cost of TL is reimbursed by the National Healthcare Fund in only 26 stroke centers, while approximately 37 stroke centers are ready to provide thrombolytic treatment in this country, and this number of units would be needed and optimal. Hospital stroke care is financed by this DRG system, and the expenditure is restricted by the so-called performance volume limit for hospitals. If the hospital is over this monthly limit, no further costs are reimbursed even if more patients are admitted. Obviously, TL should be taken out from this monthly limit system. With the current financing system, many hospitals cannot afford a significant increase in the number of patients with stroke treated with rt-PA. Similarly, in Bulgaria, a small number of hospitals having permission to perform TL, and also, there is a financial restriction for reimbursement. In Serbia, from 2010, there is special financial stimulation of the hospital staff for each trombolysed patient.
National Stroke Registries should be Established
Due to the lack of a uniform data source, collecting reliable data on different indicators of stroke care is often quite difficult. Quantitative data on health services and stroke care are based on a number of different sources. In some CEE countries, national stroke registries exist and help in stroke care quality improvement. For example, in Russia, the National Stroke Registry exists since 2000. From 2007, the stroke registry is in use in Slovakia as well, and now, approximately 5500 cases are included. Information were collected on stroke type, localization of stroke, age, gender of patients, risk factors, duration of hospitalization, past treatment, etc. In Poland, data were collected in the POLKARD registry from 2003 to 2008. Now, every stroke case has to enter the National Mandatory Stroke Registry that provides reliable information on stroke care. On the contrary, in Serbia, there is no national stroke registry; however, a national database called National Stroke Thrombolysis Register was created. This register provides information about all patients receiving rt-PA treatment for acute ischemic stroke in Serbia for a prospective, ongoing, multicenter, open, observational study called Serbian Experience with Thrombolysis in Ischemic Stroke (32–34). Some noticeable data from this study are as follows. In Serbia, the number of TLs has increased in the past few years. As compared with the SITS-MOST study, the ratio of young patients receiving TL was higher, more than 48% of patients were younger than 55 years (16,3234). In numerous CEE countries (e.g. in Hungary, in Romania, or in Bulgaria), there are no national stroke registries established. Although the Slovenian stroke registry exists since 2000, only a few hospitals use it, and data are not regularly updated (27). In Slovenia, stroke incidence and mortality are considered very high, but there are no real data on these ratios, because practically there is no active national stroke registry (27,3536). Because the quality control of stroke treatment is fundamentally based on registries, national registries are very important. For this reason, registries should be established, and participants shall be forced some ways to provide data, for example, with payment restrictions in case of data withholding.
In summary, the main tasks in CEE countries are education, prevention, improvement of the rate of TL, the promotion of guideline-directed therapies, increasing the capacity of nursing homes and rehabilitation units, organization of national stroke registries, joining to clinical trials, and getting involved into international research and educational programs.
The governments of these countries should elaborate country-specific programs. Finally, in this article, we introduce the statement of stroke experts of CEE countries that was declared as a result of this round table meeting in Budapest, Hungary.
Optimizing stroke care in Central–Eastern Europe: The Budapest statement of stroke experts of CEE countries
Stroke mortality trends changed considerably in the last 20 years in CEE countries, but the standardized stroke death rates are still much higher in CEE than in Western European countries, indicating the need for urgent further measures to decrease the burden of stroke in this region.
Although some progress has been made, public education should be further improved regarding the importance of lifestyle and other modifiable stroke risk factors, and the recognition of stroke.
Continuous professional education in the field of stroke should be supported and endorsed by government, and scientific society programs and grants.
Stroke prevention and treatment should also be a priority in governmental healthcare programs.
Guidelines for management and treatment standards (European Stroke Organisation (ESO) guidelines) should be followed, and local health care authorities in CEE countries should identify the most important country-specific tasks together with stroke specialists. As stroke is a neurological disorder, stroke units should preferably be set up in neurological wards. The evidence-based acute interventions should be supervised by neurologists trained in stroke management.
Governmental healthcare authorities of individual CEE countries should allocate adequate resources to comply with prevention and treatment needs.
International scientific organizations (European Stroke Organization (ESO), World Stroke Organization (WSO), European Federation of Neurological Societies (EFNS), European Neurological Society (ENS)) should dedicate special programs including workshops (with the assistance of the Central and East European Stroke Society) and other events in their working program, such as in international conferences (e.g. European Stroke Conference), offering special grants for neurologists in training from CEE countries, involving researchers of CEE countries in EU projects, and other research activities.
Furthermore, a program of representation should be installed to be reached by 2012: leading stroke-related journals/periodicals and organizations mentioned above should include CEE countries with adequate representation (including executive functions, editorial boards, scientific and program committees, etc).