Establishment of Government-Initiated Comprehensive Stroke Centers for Acute Ischemic Stroke Management in South Korea
Background and Purpose—In 2008, the Ministry of Health and Welfare of South Korea initiated the Regional Comprehensive Stroke Center (CSC) program to decrease the incidence and mortality of stroke nationwide. We evaluated the performance of acute ischemic stroke management after the Regional CSC program was introduced.
Methods—The Ministry of Health and Welfare established 9 Regional CSCs in different provinces from 2008 to 2010. All Regional CSCs have been able to execute the critical processes independently for stroke management since 2011. The Ministry of Health and Welfare was responsible for program development and financial support, the Regional CSC for program execution, and the Korea Centers for Disease Control and Prevention for auditing the execution. We analyzed prospectively collected data on the required indices from 2011 and repeated the analysis the following year for comparison.
Results—After the Regional CSCs were established, the first brain image was taken within 1 hour from arrival at the emergency room for all patients with stroke; the length of hospital stay decreased from 14 to 12 days; for the rapid execution of thrombolysis, the first brain image was taken within 12 minutes; intravenous and intra-arterial thrombolysis were started within 40 and 110 minutes, respectively, after emergency room arrival; and the hospital stay of thrombolytic patients decreased from 19 to 15 days.
Conclusions—The Regional CSC program has improved the performance of acute stroke management in South Korea and can be used as a model for rapidly improving stroke management.
Stroke is the third leading cause of death in South Korea.1 The total economic burden of stroke including its medical, nonmedical, and indirect costs was estimated to be US$4.2 billion in 2008.2 The proportion of the population >65 years in South Korea was 11.0% in 2010 and is estimated to increase to 24.3% in 2030.1 Furthermore, the number of stroke cases is also estimated to increase from 105 000 in 2004 to 350 000 in 2030,3 which will consequently lead to a rapid increase in the medical economic burden in South Korea.4
The establishment of organized care centers including stroke units and centers reduce mortality and increase the survival rate.5 The United States and Europe have been trying to improve nationwide care quality of stroke through the systematic organization of stroke centers.6,7 In 2008, the Ministry of Health and Welfare (MHW) of South Korea initiated the Regional Comprehensive Stroke Center (CSC) program to decrease the incidence and mortality of stroke.4 Thus, CSCs were established in 9 local provincial regions nationwide, excluding the Seoul metropolitan area. Here, we describe initiation process of the Regional CSC program in South Korea. We also evaluated the program’s effectiveness for acute ischemic stroke management by comparing performance before and after its initiation.
Initiation of the Regional CSC Program
In 2006, 40 (48%) of 83 cerebrovascular centers that admitted >200 patients with acute ischemia via the emergency room (ER) and were equipped for emergency care for patients with acute stroke were located in the Seoul metropolitan area, which contains 21% of South Korea’s total population (10 357 000/48 297 000) in just 0.6% (605 km2) of its total area.4 A survey evaluating stroke unit services in South Korea showed that only 5 of 57 hospitals had stroke units in 2006, although intravenous thrombolysis was provided 24/7 in all hospitals.8 Furthermore, most patients with acute ischemic stroke were managed in general wards at admission. To improve the quality of care for patients with cerebrovascular and cardiovascular diseases nationwide, the MHW initiated the Regional Cardiovascular and Cerebrovascular Center project to establish regional CSCs in 2006.4 The budget for this project was included in the 2007 state budget.
Organization of the Regional CSC Program
After finalizing the budget for the Regional CSC project in 2008, the MHW selected locations nationwide (Figure) and decided on the following domains: (1) development and execution of critical processes for management of hyperacute ischemic stroke; (2) establishment of a stroke unit for patients with acute ischemic stroke; and (3) initiation of an education program for early recognition, management, and prevention of stroke. The MHW announced the program to all hospitals located outside the Seoul metropolitan area. To be designated as a Regional CSC in a local provincial region, hospitals submitted a plan to fulfill the 3 required domains. The MHW reviewed the submitted plans of each local hospital to determine their inclusion. From 2008 to 2010, 9 local hospitals outside the Seoul metropolitan area (Gangwon, Daegu-Gyeongbuk, and Jeju in 2008; Gyeongnam, Gwangju-Jeonnam, and Chungbuk in 2009; Busan-Ulsan, Jeonbuk, and Daejeon-Chungnam in 2010) were designated as Regional CSCs.
The MHW financially supported the centers to purchase the medical devices required for rapid and accurate evaluation of stroke, such as magnetic resonance imaging, computed tomography, and sonographic machines; provide devices to establish stroke units; and provide human resources to execute the critical processes for stroke management.
Each Regional CSC individually established critical processes for stroke management for 1 year after their establishment. Key practices of critical processes to initiate thrombolysis rapidly, establish a stroke unit, and provide education were included in the critical processes for each center (Table 1). Device and facility management were financially supported for the first year. Human resources were financially supported every year after reviewing the performance of each Regional CSC. The Regional CSCs ultimately fulfilled the following comprehensive roles as recommended by the Brain Attack Coalition of the United States: (1) availability of advanced imaging techniques including magnetic resonance imaging, computed tomography, digital subtraction angiography, and transcranial Doppler; (2) availability of personnel trained in vascular neurology, neurosurgery, and endovascular procedures; (3) 24/7 availability of personnel, imaging, operating room, and endovascular facilities; (4) intensive care unit facilities capable of stroke management; and (5) experience and expertise in treating patients with large ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage.9 All Regional CSCs began executing the critical processes for management of patients with acute ischemic stroke between 2009 and 2011. All 9 Regional CSCs have been able to execute their comprehensive roles for stroke management since 2011.
The performance of each Regional CSC was evaluated by the Korea Centers for Disease Control and Prevention on behalf of the MHW. The Korea Centers for Disease Control and Prevention developed 47 indices to evaluate the performance of the 3 domains set by the MWH (Table I in the online-only Data Supplement) and reviewed the achievement of the indices by each Regional CSC every month. Financial incentives for the subsequent year were determined on the basis of the performance of each Regional CSC. The annual performance of all Regional CSCs was graded on a relative scale. The bottom and top 3 centers received funding cuts and increase of ≤15%, respectively.
Data Collection and Comparisons
Since 2011, data for the indices set by the MHW were collected monthly from all 9 Regional CSCs. To evaluate the performance of stroke management after the establishment of the Regional CSCs, we analyzed prospectively collected data on the required indices from 2011 and repeated the analysis in 2012 for comparison.
Overall performance achievement was evaluated on the basis of the time from symptom onset to arrival at the ER (onset-to-door time), from ER arrival to first computed tomography or magnetic resonance image (door-to-image time), total length of hospital stay, and proportion of patients admitted to the stroke units during the initial 3 days. The performance of thrombolysis achievement for patients with hyperacute ischemic stroke was evaluated on the basis of several indices including the time from arrival to intravenous thrombolysis initiation (door-to-needle time) and intra-arterial thrombolysis initiation (door-to-puncture time), as well as onset-to-door time, door-to-image time, and total length of hospital stay. The numbers of patients who received intravenous thrombolysis within 60 minutes of ER arrival and the proportion of hyperacute patients receiving intravenous and intra-arterial thrombolysis were evaluated. The institutional review boards of the respective designated hospitals provided ethical approval for this study.
To determine whether the performance of stroke management improved after the establishment of Regional CSCs, we compared the data collected in 2011 and 2012 with those collected retrospectively from patients with stroke admitted at the 9 hospitals before the establishment of Regional CSCs in 2008. ANOVA was used to compare the mean and median time intervals of onset-to-door, door-to-image, door-to-needle, and door-to-puncture times, as well as length of admission. The χ2 test was used to compare the proportions of patients with acute ischemia who underwent intravenous or intra-arterial thrombolysis and intravenous thrombolysis within 60 minutes of arrival. All statistical analyses were performed using SPSS 19.0 (SPSS Inc, Chicago, IL). The level of significance was set at P<0.05.
The data of 13 638 patients (3842, 4626, and 5170 patients in 2008, 2011, and 2012, respectively) admitted to the 9 Regional CSCs for the treatment of acute ischemic stroke (coded as I63 according to the 10th version of International Statistical Classification of Diseases) were used (Table 2). Although the number of patients differed by location, all Regional CSCs reported an increase in the number of patients with acute ischemia after their establishment.
Changes in the Performance of Acute Ischemic Stroke Management
The sex ratio, mean age, and National Institutes of Health Stroke Scale severity scores of patients with acute ischemia did not differ before and after the establishment of the Regional CSCs (Table 3). After the establishment of the Regional CSCs, the mean onset-to-door time increased from 20 to 24 hours, door-to-image time decreased from 2 hours to 1 hour, and length of stay decreased by ≈2 days. Over 80% of patients with acute ischemic stroke were admitted to the stroke unit for initial monitoring and management of ischemic stroke, whereas the other patients were admitted to general wards.
Changes in the Performance of Thrombolytic Therapy
Among patients receiving thrombolytic therapy, the sex ratio, mean age, and National Institutes of Health Stroke Scale severity scores were similar before and after the establishment of the Regional CSCs (Table 4). Clinical variables for the execution of thrombolytic therapy improved after Regional CSC establishment. The proportion of patients receiving thrombolytic therapy increased from 8.3% to 13.6% of total patients with ischemic stroke (P=0.000). Door-to-image time for thrombolytic patients decreased from 26 to 12 minutes (P=0.000). The door-to-needle time decreased from 60 minutes (median, 51 minutes) to 41 minutes (median, 36 minutes) (P=0.000). The proportion of patients receiving intravenous thrombolysis within 60 minutes of ER arrival increased from 60% to 89%. The door-to-puncture time for intra-arterial thrombolysis decreased from 136 to 110 minutes. The proportion of patients undergoing intra-arterial thrombolysis increased from 28% in 2008 to >44% in 2012. The proportion of patients undergoing bridging intra-arterial thrombolysis after intravenous thrombolysis increased from 10% to 20%. Finally, the length of hospital stay of patients receiving thrombolytic therapy decreased from 19 to 15 days.
The present study details the successful establishment of Regional CSCs by the South Korean government; this model can be used by governments worldwide to improve stroke management rapidly.
The first significant improvement introduced by the program was decreased door-to-needle time for intravenous thrombolysis. Previous single-center trials showed that the door-to-needle time decreased to 38 and 20 minutes (mean and median, respectively).10,11 Furthermore, in 94% of cases, intravenous thrombolysis was started within 60 minutes of arrival at the center.11 However, such a reduction is more difficult to achieve on a national level. In the United States, the Target: Stroke project was initiated nationwide in 2010 to reduce the door-to-needle time.12 Accordingly, from 2010 to 2013, the door-to-needle time was reduced to 67 minutes (median) nationwide, and the proportion of patients undergoing intravenous thrombolysis within 60 minutes of arrival increased to 53.3%.13 In South Korea, after initiation of the Regional CSC program, the door-to-needle time decreased to 41 minutes (mean), and intravenous thrombolysis was started within 60 minutes of ER arrival in 89% of patients in 2012.
The second significant achievement of the Regional CSC program is the increased proportion of patients undergoing bridging or primary intra-arterial thrombolysis for acute ischemic stroke. On-call intervention teams for intra-arterial thrombolysis were also available 24/7 in the Regional CSCs, and the proportion of patients undergoing intra-arterial thrombolysis increased by 60%. Intravenous thrombolysis is recommended for rapid recanalization in patients with acute stroke.14 However, the recanalization rate in intravenous thrombolysis is insufficient, especially for large artery occlusion in the proximal middle cerebral artery or terminal internal carotid artery.15 Bridging and primary intra-arterial thrombolysis performed using mechanical thrombectomy has increased the possibility of recanalization in patients with acute ischemic stroke.16 Although recent studies failed to verify the relationship between improved recanalization rate and favorable clinical outcomes after intra-arterial thrombolysis,17–19 intra-arterial thrombolysis might help achieve good clinical outcomes in patients with acute ischemic stroke.20 To increase the probability of a good outcome, intra-arterial thrombolysis should be conducted more often for patients with acute ischemic stroke who have undergone unsuccessful intravenous thrombolysis or arrived after the time window for intravenous thrombolysis.
The roles played by the participating organizations—MHW for program development and financial support, Regional CSCs for program execution, and the Korea Centers for Disease Control and Prevention for auditing the execution—were the main factors underlying the program’s rapid success. Stroke was the second leading cause of death in middle-to-high income countries in the past decade.21 As such, nations worldwide may soon require national measures to lower the human and economic burdens of stroke by reducing its the incidence and mortality.22,23 Thus, the Regional CSC program, established by the South Korean government in association with local hospitals, could be an effective model for the rapidly improving comprehensive stroke management.
To improve further the stroke care system of Regional CSCs, more efforts are required to shorten the prehospital delay after stroke onset. The education programs of most Regional CSCs for both the public and paramedics initially focused on the early recognition of stroke symptoms and importance of the time window for thrombolytic therapy. In fact, more patients received thrombolytic therapy with no delay in onset-to-door time at the Regional CSCs. However, the onset-to-door time increased in overall patients with stroke, despite the increased number of patients with stroke. Current education programs are more balanced and include management processes for both acute stroke management and thrombolytic therapy. These programs emphasize the importance of rapid arrival at the ER of all patients with acute ischemia. The development–execution–revision process of stroke education program might be an ongoing duty of the Regional CSCs toward a complete stroke care system.
The first part of the Regional Cardiovascular and Cerebrovascular Center project was 2009 to 2013. After the successful establishment of Regional CSCs in 5 years, the MHW initiated the second part of the project from 2014 to 2018. Two more Regional CSCs were designated in Gyeongi province in 2012. The MHW added the following 2 goals to extend quality of care for stroke to people living in rural areas: (1) establishment of primary stroke centers (PSC) in rural areas, and (2) development of a network among Regional CSCs and PSCs. In other countries, despite differences in the directions and ideas for organizing nationwide infrastructure for stroke care system, PSCs are key units of organizations to provide nationwide quality care for stroke.5–7 PSCs, which aim to provide acute management of patients with stroke, could start intravenous thrombolysis after inclusion criteria evaluation. If a patient requires intra-arterial thrombolysis as bridging or primary therapy after initial therapy in a PSC, the patient will be transferred to a Regional CSC. The MHW is also planning a systematic network between PSCs and Regional CSCs to coordinate stroke management and perform thrombolysis within the time window of intra-arterial thrombolysis. The experience gained in the establishment of the Regional CSC program may play a central role in the establishment of PSCs and communication among centers in South Korea.
The South Korean government successfully established comprehensive stroke centers throughout the country. The establishment of Regional CSCs improved the overall performance of stroke management, as well as execution of thrombolysis. Through the Regional CSC program, the government provides financial support for device management and personnel to execute critical processes for acute ischemic stroke management and regularly assesses the program’s performance. Establishing PSCs in rural areas requires a stronger network among Regional CSCs and local rural hospitals.
We thank the following coordinators of the Regional Comprehensive Stroke Centers for data collection: Sangeun Yoo, MS; Jihui Kim, MS; Yeongju Kwon, RN; Mihye Lee, RN; Miyeong Kim, RN; Sujin Kang, RN; Yeongkwon Park, MS; Sujin Lee, RN; and Huijin Kim, RN.
Sources of Funding
The present study was supported by a Research Grant (2013E3301400) for public health from the Korea Centers for Disease Control and Prevention.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.114.006134/-/DC1.
- Received May 14, 2014.
- Revision received June 9, 2014.
- Accepted June 16, 2014.
- © 2014 American Heart Association, Inc.
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