Community-Organized Stroke Care System in Rural China

Keywords: Incidence; Mortality; Disability; Thrombolysis; rural China

Abstract

Background: It is a great challenge to improve stroke patient’s outcome, especially in rural China.

Aims and/or hypothesis: The aim of this study was to explore a proper organized stroke care (OSC) model for better medical care of stroke patients in rural China,

Methods: OSCs were established in three towns in Lianyungang City, which key elements were availability of facilities, trained stroke teams, workflows, administrative support, strong leadership, written care protocols, continuing professional promotion, and health education. To evaluate the effect of one year OSC intervention on improving stroke patient’s outcome, the rates of disability and mortality were investigated in 939 participants from OSCs and controls.

Results: The investigation showed that there were significant increases of the awareness rate of stroke (from 49.4% to 57.5%), the six-hour hospitalization rate (from 8.7% to 13.6%), the two-way referral rate (from 55.2% to 63.4%), the thrombolysis rate (from 1.7% to 3.9%), the antithrombotic rate (from 75.8% to 82.1%), and the blood lipid-lowering rate (from 52.8% to 60.3% ) in OSC, compared to the control (P<0.05). Meanwhile, the rates of disability (from 48.1% to 38.4%) and mortality (from 10.1% to 6.5%) significantly decreased in OSC, relative to the control (P<0.05).

Conclusions: The OSC model established in the study can effectively improve the outcome of patients with stroke. This model will bring stroke patients huge benefits if it is extend to other rural areas in China.

Trial registration: chictr.org: ChiCTR-RCH-13003408

Word count: 2722

Background

Stroke is not only a major healthcare problem [1] but also a serious economic burden to society [2]. World Health Organization report shows that stroke is the second leading cause of death in the world, responsible for 9.9% of all deaths worldwide, which over 85% of these deaths occurred in developing countries [3]. In China, stroke has become the first leading cause of death [4] and long-term disability. More than 7 million individuals currently suffer from stroke, and 2 million individuals are newly diagnosed to suffer from stroke each year [5, 6]. In rural region, stroke epidemic is more serious relative to urban region. Based on a recent epidemiological survey, the stroke incidence in rural China was higher than that observed in urban China. Moreover, the increase of the annual incidence and mortality of stroke has accelerated in rural Chinese adults. [7]. Because majority of Chinese population live in rural areas, and rural areas suffer from a shortage of healthcare resources for a long time, it is warranted to explore effective intervention measures for controlling and preventing stroke in rural China.

Aims and/or hypothesis:

Since the past decade, stroke unit has been established as a standard care of stroke. Several randomized studies have shown that management of patients in a community-based organized stroke care system (OSC) is associated with significant reductions in mortality and morbidity in both the acute and long-term periods after a stroke. However, the setup of OSCs has been established in only a few big cities, and OSCs are still scarce in rural region in China due to the paucity of resources. Therefore, we managed to set up the OSC in Lianyungang City. The purpose of this study was to evaluate the effects of this OSC on 1-year survival and long-term outcomes after first-ever stroke.

Methods

Subjects

OSCs were established in the three towns of Tashan, Haitou, and Banzhuan in Ganyu County of Lianyungang City (Fig. 1) in Dec. 2010. The program principals from the three towns were organized to study and receive concentrated training in each quarter in 2011, provided by a neurological expert from Director Term. The training content includes: 1) stroke prevalence; 2) risk factors and preventive measures of stroke; 3) the procedure of diagnosis and treatment of stroke and the two-way referral system; 4）screen of the population at high risk for stroke. Each doctor in charge in the Village Stroke Rooms is in charge of 100~500 community residents. In every two months, these doctors were organized to study and receive concentrated training. The concentrated training content includes: 1) the definition of stroke and diagnosis criteria; 2) the early symptoms of stroke; 3）the first aid for stroke; 4) the two-way referral system for stroke; 5) health promotion and follow-up for stroke. Every month, lectures regarding the purpose of health promotion were held for community residents. The brochure and disks for health education were disturbed to community residents. The brochure and disks for health education involves the secondary prevention of stroke; the prevention and treatment of hypertension, diabetes mellitus, and hyperlipidemia; identification of early symptom of stroke, and rehabilitation of stroke.

To evaluate the effect of OSCs on stroke patient’s outcome, Zhewang, Jinshan, and Chengtou towns were selected as the control team according to the similar economic levels, habits and adjacently geographical locations. Data of first-ever stroke patients were prospectively collected in the OSCs and control teams. All acute stroke patients were admitted within 28 days of the onset and verified by using head CT/MRI. Baseline data of all cases including age, sex, stroke risk factors, types of investigations, types of stroke were collected. Regarding the study of the efficacy of treatment, mortality rate, neurological and medical complications, and the mean length of stay were used as selected endpoints. The study excluded following patients: 1）patients with a history of strokeï¼›2）patients with nonvascular diseases such as cerebral infarctioncaused by trauma, abscess or tumor; 3）patients with hemorrhagic brain strokeï¼›4）patients transient ischemic attack.

All patients of first-ever stroke in both the OSCs and control teams were quarterly monitored in 2011. Medical workers in Village Stroke Room collected the data of the endpoint and medical workers in Township Stroke Station verified the data through letters, telephone calls, and interview. The endpoint events were finally evaluated by neurosurgeons according to medical history, neurological examination, and computed tomography diagnosis. All patients provided written informed consent. The research protocol has been approved by institutional research ethics board of the First People’s Hospital of Lianyungang City (lygyyll: 201026).

Definitions

Awareness rates of stroke were defined as the numbers of investigated community residents who know how to prevent stroke as a percent of investigated community residents. Visit rates within two weeks were defined as the numbers of investigated community residents who visited a doctor within two weeks after onset of stroke as a percent of investigated community residents. Six-hour hospitalization rates were defined as the numbers of stroke patients who landed in hospital within six hours after onset of stroke as a percent of the stroke inpatients. Thrombolytic rates, rates of antithrombosis, and rates of reducing blood lipids were determined to assess treatment status. Disability rates and mortality rates were used to assess efficacy of stroke treatment.

Statistical analysis

The data were input into computer with the software package of EXCEL. Continuous variables were compared by independent t test. Categorical variables were compared by Chi-square test. Statistical significance was defined as a level of 0.05 by a two-tailed test. All statistical calculations were performed using SPSS 16.0 statistical software.

Results

There were a total of 468 patients in OSCs and 471 patients in control during one year of the study period. The average age of patients and the male to female ratio were slightly higher in OSCs than in control, but the difference was not statistically significant (Table1). No significant difference existed concerning education status between the two studied groups (Table1).

Baseline levels were similar between the two study groups in awareness rate of stroke, visit rate within two weeks, six-hour hospitalization rate, and two-way referral rate (Table 2). After one year intervention, awareness rate of stroke, six-hour hospitalization rate, and two-way referral rate were significantly higher in OSCs than in control. Although there was no significant difference in the visit rate within two weeks (P=0.08) between OSCs and control groups after intervention, the visit rate within two weeks in OSCs was significantly higher after intervention than the baseline level (P=0.005).

The status of diagnostic exams was investigated. Before intervention, no significant differences were observed in the availability of diagnostic exams between OSCs and the control. After intervention, only biochemical test did not show significant difference between the OSCs and the control. However, it showed significantly high the availability of biochemical test than the baseline level (P=0.000).

The availability of therapeutic measures was also assessed. No differences were observed between OSCs and the control in baseline levels (Table 2). After one-year intervention, OSCs showed significantly high thrombolytic therapy ratio, antithrombotic therapy ratio, and blood lipid-lowering therapy ratio relative to the control (P＜0.05).

Therapeutic efficacies were evaluated. Baseline levels of disability ratio and mortality ratio were slightly higher in OSCs than in control, but differences were not significant (Table 2). After one-year intervention, disability ratio and mortality ratio were significantly lower in OSCs than in control.

Discussion

Despite the structure and organization of OSCs currently implemented vary significantly, clinical trials and meta-analysis have consistently demonstrated stroke patients receiving organized inpatient care in an OSC are more likely to be alive, and independent [8]. However, the percentage of stroke patients accessible to OSC service remains very low in many countries, perhaps due to a shortage of adequate resources. For example, such OSCs are currently confines to few metropolises such as Beijing, Shanghai and Tianjin. There is still no an OSC in the vast rural areas. To explore a proper OSC model for improving the medical care of stroke patients in rural China, we established an OSC in Lianyungang City under the support of the Health Bureau of Lianyungang City and Ganyu County. Key elements of this OSC include availability of facilities, trained stroke teams, workflows, administrative support, strong leadership, written care protocols, continuing professional promotion, and health education. The observational study showed this OSC model improved patient outcomes compared to general medical wards. After one-year intervention, disability ratio decreased from 54.6% to 38.4%, and mortality ratio decreased from 11.4% to 6.5%, suggesting that the OSC model reported here is effective in reducing mortality and better functional recovery. Given that the stroke is a common disease and huge rural population, adoption of this OSC model in rural China may benefit huge number of patients with stroke.

The OSC is involved in multiple factors. It is difficult to know which factors of the OSC service cause it to be successful. The health education of residents may be one factor contributing to better outcomes in OSCs compared to general medical wards. In this study, one year of health education led to an increase in awareness rate of stroke from 47.8% to 57.5%. However, we noticed that the baseline of awareness rate in the study is relatively low. This result might be associated with low resident literacy levels. In both control and intervention group, only about 20 % people have received education above senior high school.

The majority of strokes are due to blockage of an artery in the brain by a blood clot. Thrombolytic therapy is indeed a powerful intervention that significantly reduces death or dependency [9]. In this study, the OSC promoted the use of thrombolytic therapy, with thrombolysis rates increasing from 1.4% to 3.9%. Nonetheless, thrombolysis rate remained low, compared to 3～8.5% of thrombolysis rate for acute ischemic stroke in America [10]. The barrier to thrombolysis includes：1) There lacks adequate preparation for thrombolytic therapy. 2) Many rural residents don’t take the early symptoms of stroke serious due to low education levels. 3) Many family can’t afford the expensive thrombolytic medicine, which is unavailable to Medicaid patients. 4) Many doctors are reluctant to use thrombolytic medicine due to potential risk and strained relations between doctors and patients in current China. Thrombolysis rate should be seen as the top priorities for OSC improvement. To establish and perfect OSC, we should raise awareness of rural residents about early utilization of thrombolytic medicine, and obtain more supports from government.

Conclusions

In conclusion, the OSC model provided here is effective, and has the potential to improve the care of patients with stroke in rural China. It is our hope that the evidence shown in the study will provide a rational for policy making and ultimately brings benefit to the care of stroke patients in rural China. Next, more efforts in health education should be taken to better control stroke-related loss in huge rural area in China.

List of abbreviations

OSC, organized stroke care system

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