Community-Based Stroke System of Care for Chinese Rural Areas
Background and Purpose—Stroke system of care plays key roles both in providing effective therapies and in improving the overall outcome of patients with stroke. Our purpose was to develop and evaluate the system in Chinese rural areas.
Methods—A stroke system of care was developed from November 2009 to November 2010 in 3 townships in Ganyu County. An additional 3 matched townships were invited as controls. We first investigated stroke management in these townships and then implemented stroke system of care and an education campaign in the 3 intervention townships. The effectiveness of the system was then evaluated.
Results—There were 1036 patients with new stroke among 344 345 subjects in the 6 rural communities. The incidence of stroke in the rural areas was 301/100 000, and the mortality rate was 55/100 000. The proportions significantly increased in the intervention communities after the implementation of the stroke system of care and education campaign when compared with the control communities, including patients presenting at rural hospitals within 3 hours of symptom onset (13.6% versus 8.7%; P=0.017), diagnosed by computed tomographic scanning within 24 hours of admission (65.3% versus 58.5%; P=0.034), and received thrombolytic treatment (3.9% versus 1.7%; P=0.038). During the 1-year follow-up, 32 (6.5%) patients with stroke in the intervention communities and 48 (10.1%) in the control communities died. The disability rate of stroke was significantly reduced in the intervention communities at postintervention (38.4% versus 48.1%; P=0.001).
Conclusions—A stroke system of care would be reliable and practical in Chinese rural areas.
Clinical Trial Registration—URL: http://www.chictr.org. Unique identifier: ChiCTR-RCH-13003408.
In developing China, the annual stroke mortality rate is ≈116/100 000 in cities and 111/100 000 in rural areas, which has surpassed heart disease to become the leading cause of adult death.1 In addition, China has 2.5 million new stroke cases each year and 7.5 million stroke survivors.2 Recently, a 21-year observational study from the Sino-MONICA-Beijing Project reported that the incidence rate of hemorrhagic stroke declined by 1.7%, and the incidence rate of ischemic stroke increased by 8.7% annually on average.3 Thus, the rising incidence and effect of stroke have created a huge burden on the Chinese healthcare system.2,4
In 2005, the American Stroke Association’s Task Force made recommendations for the establishment of stroke systems of care to optimize patient care and management processes, as well as improve patient outcomes.5 A fully functional stroke system of care would reduce stroke-related deaths by 2% to 3% annually.6 Poststroke disability would also be reduced, which would improve the quality of life and reduce the burden on patients, their families, and governments.6 In Europe, the Helsingborg Declaration of 2006 set new targets on the overall aims and goals of 5 aspects of stroke management (organization of stroke services, management of acute stroke, prevention, rehabilitation, and evaluation of stroke outcome and quality assessment) to be achieved by 2015.7 Of all patients with stroke in Europe, 39.4% were admitted to a stroke unit,8 which is the key basic measure of stroke service quality. The reported proportion of patients treated at stroke units ranged from 31% in Canada,9 51% in Australia,10 78% in the United Kingdom,11 and ≈80% in the Scandinavian countries.12
Rural facilities lack the infrastructure necessary for delivering quality of stroke care—namely, prehospital stroke screens, written protocols, diagnostic technologies, and access to neurologists.13,14 Thus, proper access to coordinated stroke systems of care remains a concern in Chinese rural areas.15
In 2009, the Ministry of Health initiated the Stroke Screening, Prevention, and Treatment Project, to explore stroke system of care applicable to Chinese populations. The Chinese National Center for Stroke Care Quality Control and Management was also established to address this leading cause of death and improve stroke care. On the basis of these programs, we developed and implemented a stroke system of care in rural communities in Ganyu County, Lianyungang, Jiangsu Province. The purpose of this study was to describe the epidemiological characteristics of acute stroke in rural areas and evaluate the effectiveness of a stroke system of care on stroke management in rural communities after an education campaign.
Subjects and Methods
Development of a Rural Stroke System of Care
From November 2009 to November 2010, we developed a rural stroke system of care (Figure I in the online-only Data Supplement) in Ganyu County, Lianyungang. The People’s Hospital of Ganyu County was selected as the county stroke unit, which served as a referral center for rural hospitals in Ganyu County. There was a dynamic infrastructure encompassing integrated emergency medical services, an emergency department with multispecialty staff support, a stroke unit equipped with trained staff, and written care protocols. The development of the stroke unit is shown in Table I in the online-only Data Supplement. The rural stroke system of care consisted of 4 different types of acute care facilities (Table II in the online-only Data Supplement).
Three township hospitals in Tashan, Haitou, and Banzhuang of Ganyu County were randomly selected as the township stroke stations. At the start of the study, these hospitals lacked medical infrastructure and trained personnel, and only general physicians were present. All village health stations administrated by the 3 townships were incorporated as village stroke rooms. There were only 1 or 2 village doctors, and no medical infrastructures were present at the village health stations. After the evaluation of a physician, patients with presumptive acute stroke who were evaluated at the township hospitals or village health stations would be transferred to the People’s Hospital of Ganyu County within 30 minutes. The First People’s Hospital of Lianyungang City, which is a tertiary hospital, was a comprehensive stroke center that possessed acute stroke teams, full clinical care protocols, an integrated emergency department, and emergency medical service staff trained in acute stroke management. This center also provided 24-hour emergency neuroimaging and offered continuing medical education for the staff.
An organizational structure (Figure) set up in Lianyungang is as follows: 3 teams were instituted (leader team, director team, and executive team) and referred to as 3T, and 3 different types of acute care facilities were implemented (county stroke unit, township stroke station, and village stroke room) and referred to as USR. The leader team was comprised a medical specialist, as well as nursing and allied health staff with stroke expertise. The director team included a neurologist, a neurosurgeon, an endovascular neurointerventionalist, a radiologist, an emergency medicine specialist, and a physical therapist who were on-call and available for consultation within 30 minutes. The executive team consisted of all village doctors and physicians in hospitals at the county level or below. In addition, we performed a director team, county stroke unit, township stroke station, and village stroke room management model (Figure II in the online-only Data Supplement), where the director team directed the county stroke unit, the latter directed the township stroke station, and the village stroke room was directed by the township stroke station. All of the organizations were monitored by the leader team.
We analyzed the medical facilities and trained personnel in these hospitals and provided necessary support. General physicians at the 3 township hospitals were invited to attend an interactive workshop held by the People’s Hospital of Ganyu County, where 3T-USR structure was introduced. Evidence-based guidelines for the management of stroke were also discussed. A similar workshop was held every month. The People’s Hospital of Ganyu County established links with the First People’s Hospital of Lianyungang City for comprehensive stroke management, which included the development of protocols, targeted educational programs, and toolkits with the establishment of a stroke network and a Website dedicated to stroke materials. The toolkits included criteria for selecting patients for thrombolytic treatment, as well as post-thrombolysis management and patient transfer. The toolkits were then distributed to the 3 township stroke stations and all village stroke rooms. Stroke meetings featuring the kits were held by the First People’s Hospital of Lianyungang City every month to promote their use in the rural communities. A telephone system was piloted in a rural facility to allow 2-way interactive consultation with stroke neurologists. The People’s Hospital of Ganyu County regulated, monitored, planned, and coordinated prehospital emergency medical services and hospital emergency programs. Once a presumptive diagnosis of acute ischemic stroke was made, patients in township hospitals or village health stations were transferred rapidly to the People’s Hospital of Ganyu County for probable thrombolytic treatment within 3 hours of symptom onset.
The education campaign was targeted at the public and health professionals in the 3 intervention townships. A community-specific public education campaign was conducted to raise the residents’ awareness of stroke. In addition, health professionals were trained and assessed, and those who passed the tests were eligible to participate in this study. In the 3 intervention townships, room-based and station-based stroke educational sessions (online-only Data Supplement) were performed in the 87 village stroke rooms and the 3 township stroke stations, respectively. Moreover, school-based stroke educational sessions (online-only Data Supplement) were held at the People’s Hospital of Ganyu County. Materials for community education, including signs and symptoms of stroke, risk factors, treatment, and rehabilitation, were written by physicians with acute stroke expertise and distributed to every education organization.
Evaluation of the Rural Stroke System of Care
On the basis of geographical location, economic condition, and lifestyle, we invited another 3 townships (Jinshan adjacent to Tashan, Zhewang adjacent to Haitou, and Chengtou adjacent to Banzhuang) to participate as controls. Demographic characteristics between the control communities and the intervention communities are shown in Table III in the online-only Data Supplement. A total of 344 345 subjects were recruited in the 6 rural communities in Ganyu County, 198 029 in the intervention communities, and 146 316 in the control communities. We first investigated the stroke incidence of these populations from November 2010 to November 2011. A stroke system of care was subsequently implemented, and the education campaign was performed in the 3 intervention communities. Patients with a new stroke were enrolled and followed up within 1 year to evaluate the effectiveness of the stroke system of care.
All of the rural communities in the 3 intervention townships and the 3 control townships in our study were enrolled in the Chinese Stroke Primary Prevention Trial. Population disease monitoring was in accordance with the World Health Organization’s Monitoring of Trends and Determinants of Cardiovascular Disease project.16 New onset stroke was defined as the first occurrence of stroke identified by radiographic diagnosis (computed tomographic/MRI scan) and clinical diagnosis within 28 days. We assessed the populations by door-to-door or telephone inquiries to verify the new cases of stroke. Ethics and quality committee approval was obtained from each of the hospitals for data collection. Written informed consents were obtained from patients with stroke who agreed to participate in this study.
Data analysis was performed in 2012 using SPSS software (version 16.0). A descriptive analysis was performed on demographic variables. To compare the variables before and after the implementation of the stroke system of care and community education campaign, a χ2 test was conducted for nonparametric values. Using SNPTEST software package, a Cochran–Armitage tendency test was used to analyze the distribution of stroke incidence and death in different age groups. The effect of stroke on life expectancy was assessed by a stroke-cause life table.
Epidemiology of Stroke
There were 1036 patients with new stroke (507 men and 529 women) among 344 345 subjects in the 6 communities. The incidence of stroke was 301/100 000 (294/100 000 among men and 308/100 000 among women). Of the 1036 patients with new stroke, 188 (92 men and 96 women) died within 1 year of onset. The mortality rate of stroke was 55/100 000 (53/100 000 in men and 56/100 000 in women). In addition, the mortality and incidence rates of stroke increased with age, with the highest rates being observed in people aged >75 years (Table IV in the online-only Data Supplement). Furthermore, it was estimated that the average stroke-cause eliminated life expectancy in the 6 communities was 7.38 years. For the populations aged 55 to 64 years and 65 to 74 years, the proportion of eliminated life expectancy substantially increased to 23.66% and 18.97%, respectively (Table V in the online-only Data Supplement).
Baseline Characteristics of Patients With Stroke
No significant differences were found with regard to age, female sex, medical history, or other risk factors (Table 1).
Prehospital Care Indices
Of 522 patients with a new stroke in the intervention communities, 468 agreed to be enrolled in the 1-year follow-up study. Of 514 patients with new stroke in the control communities, 471 were enrolled. The proportion of patients with stroke who were aware of the common signs and symptoms of stroke significantly increased in the intervention communities after the intervention. Similarly, the proportion of patients admitted within 3 hours of acute stroke onset and transferred to the Ganyu County People’s Hospital were also higher after the intervention (Table 2).
At preintervention, 56.2% of patients with stroke in the intervention communities and 54.8% in the control communities were diagnosed by computed tomography within 24 hours of admission. At postintervention, the proportion significantly increased in the intervention communities. In addition, other tests or determinations methods were performed in more patients with a new stroke in the intervention communities than in the control communities (Table 3).
Only 1.1% of patients with acute stroke in the control communities and 1.4% in the intervention communities were available for thrombolytic treatment at preintervention. At postintervention, the proportion increased significantly in the intervention communities (Table 4).
At preintervention, the fatality rate was similar between the intervention communities and the control communities. At the 1-year follow-up, 32 (6.5%) patients with stroke in the intervention communities and 48 (10.1%) in the control communities died. Importantly, the fatality rate and disability rate substantially decreased at postintervention in the intervention communities (Table 4).
This report is the first to describe the development and implementation of a stroke system of care for comprehensive acute stroke care in Chinese rural communities in Ganyu County, Lianyungang, Jiangsu Province. On the basis of this system, the organizational structure of 3T-USR supported a network of clinicians to implement evidence-based guidelines in acute stroke care. Our results showed that the incidence of stroke was 301/100 000 and the mortality rate was 55/100 000 for all ages in the rural area, and stroke was more prevalent in older people (≥75 years), which were similar findings as those obtained from other studies.1,17 In addition, stroke had a significant effect on life expectancy, especially for patients with stroke aged 55 to 74 years. Therefore, the primary prevention of stroke should particularly be focused on these populations.
Stroke systems of care can improve outcomes of acute stroke, but they also require public awareness to facilitate prompt activation of emergency medical services, as well as provide appropriate protocols for screening, transport, and prehospital notification.14,18,19 In the 3 rural communities implementing a stroke system of care, 47.8% of enrolled subjects were aware of signs and symptoms of acute stroke at preintervention; however, this proportion increased to 57.5% at postintervention. The proportion of patients with stroke admitted within 3 hours of symptom onset substantially increased from 6.8% to 13.6% because of the intervention. More stroke patients were also admitted to the rural hospitals or transferred to the county level hospital if required. Computed tomographic scanning was used in 65.3% patients with stroke within 24 hours of admission. Awareness of this knowledge increased the appropriate use of an emergency response number, resulting in timely presentation to the emergency department/stroke unit to ensure rapid evaluation.20,21 On the basis of our data, the education campaign targeted at the public and health professionals clearly played a role in reducing time delays and increasing the number of patients who received timely treatment of acute stroke.
Despite the established clinical benefits of intravenous tissue-type plasminogen activator (tPA), only a small fraction of patients with ischemic stroke received the treatment.22,23 On the basis of Chinese National Stroke Registry, 1.6% received intravenous tPA from September 2007 to August 2008,24 which was less than Western countries with organized stroke care (such as 3%–8.5% in the United States).25 However, the tPA treatment rate was much lower in Chinese rural areas because of unequal resource distribution and limited health services. Currently, evidence-based treatments, such as thrombolysis within 3 hours, aspirin, and admission to stroke units, are more commonly used for patients with acute stroke.26–30 Our study shows that the proportion of patients with ischemic stroke receiving thrombolytic treatment significantly increased from 1.4% to 3.9% after the intervention in the intervention communities. Moreover, more patients with stroke received antithrombotic and lipid-lowering agents at postintervention. Some patients with acute ischemic stroke did not receive intravenous tPA because they were delayed in presentation to an emergency department, or a hospital could not implement an intravenous tPA protocol, or they had medical contraindications.31 In our study, the stroke system of care resulted in more patients with stroke being transferred to the stroke unit and receiving thrombolytic treatment.
The World Health Organization’s Monitoring of Trends and Determinants of Cardiovascular Disease study showed that the percentage of stroke cases that were fatal in Beijing was 18.3% in men and 13.5% in women in 2004.3 In addition, ≥75% of stroke survivors have different degrees of disability and decreased life quality.2 In our study, the fatality rate decreased to 6.5% and the disability rate also markedly reduced to 38.4% after the intervention. Timely treatment reduced neurological damage and, therefore, these interventional strategies played an important role in stroke treatment and prognosis. A stroke system of care and an educational campaign targeted to the public and health professionals should be recommended in all rural communities.
There were some limitations in the study. We selected 3 communities as controls based on the geographic location, economic condition, and lifestyle, but we could not totally eliminate differences between the 2 groups of communities. More patients with stroke in the intervention communities may have contributed to the higher rate of early presentation in the hospitals. In addition, the transfer of patients to the county-level hospital may have increased the proportion of patients receiving thrombolysis. However, this was a specific aim of the system. Indeed, in most Chinese rural areas, patients with stroke had no access to thrombolytic therapy before implementation of the stroke system of care.
In summary, this is the first study to develop, implement, and evaluate a stroke system of care in Chinese rural areas. We also confirmed that this system is reliable and practical. Community education can increase public knowledge of stroke and shorten the period of time between stroke onset and hospital presentation. Implementation of the system led to more patients with stroke receiving thrombolytic treatment and less disability. Therefore, this system should be widely implemented in Chinese rural areas.
We appreciate the cooperation of the patients and many investigators in the First People’s Hospital of Lianyungang City, the People’s Hospital of Ganyu County, and local hospitals and clinical centers in Lianyungang, Jiangsu Province, China.
Sources of Funding
The study was supported by the Health Bureau of Jiangsu Province with grant H10509 to Mingli He, and the National Natural Science Foundation of China with grants 81270333 and 81322002 to Yibo Wang.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.114.006030/-/DC1.
- Received May 5, 2014.
- Revision received June 12, 2014.
- Accepted June 16, 2014.
- © 2014 American Heart Association, Inc.
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