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A National Survey of Acute Cerebrovascular Disease in Israel: Burden, Management, Outcome and Adherence to Guidelines

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A National Survey of Acute Cerebrovascular Disease in Israel: Burden, Management, Outcome and Adherence to Guidelines Original Articles A National Survey of Acute Cerebrovascular Disease in Israel: Burden, Management, Outcome and Adherence to Guidelines David Tanne MD1,4, Uri Goldbourt PhD4, Silvia Koton PhD2,4, Ehud Grossman MD3,4, Nira Koren-Morag PhD4, Manfred S. Green MD PhD2,4 and Natan M. Bornstein MD1,4 on behalf of the National Acute Stroke Israeli Survey Group* 1 Israel Neurological Association 2 Israel Center for Disease Control (ICDC), Ministry of Health, Tel Hashomer, Israel 3 Israel Society of Internal Medicine 4 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Key words: stroke, national registry, outcome Abstract In Israel, as in the United States and most European countries, Background: There are no national data on the burden and stroke is the third most common cause of death [1]. The main management of acute cerebrovascular disease in Israel. burden of stroke, however, is the severe long-term disability Objectives: To delineate the burden, characteristics, manage- associated with it. National data on the burden and manage- ment and outcomes of hospitalized patients with acute cerebro- ment of acute stroke in Israel are lacking. As the management vascular disease in Israel, and to examine adherence to current guidelines. of acute ischemic stroke advances, widespread implementation Methods: We prospectively performed a national survey in all of optimal stroke care continues to pose enormous challenges 28 hospitals in Israel admitting patients with acute cerebrovascular for healthcare systems. Clinical guidelines have been developed events (stroke or transient ischemic attacks) during February and to provide timely and appropriate decisions for patients admit- March 2004. ted with acute stroke [2–5]. We conducted the first survey of Results: During the survey period 2,174 patients were admitted with acute cerebrovascular disease (mean age 71 ± 13 years, 47% all hospitalized patients in Israel with an acute cerebrovascular women; 89% ischemic stroke or TIA, 7% intracerebral hemorrhage event during a 2 month period in 2004 to assess the burden of and 4% undetermined stroke). Sixty-two percent of patients were acute cerebrovascular disease, characteristics of patients, man- admitted to departments of medicine and a third to neurology, of which agement, clinical outcome, and adherence to current practice only 7% were admitted to departments with a designated stroke unit. guidelines. Head computed tomography was performed during hospitalization in 93% of patients. The overall rate of urgent thrombolytic therapy for acute ischemic stroke was 0.5%. Among patients with ischemic Patients and Methods stroke or TIA, 94% were prescribed an antithrombotic medication We performed prospectively an observational survey of all con- at hospital discharge, and among those with atrial fibrillation about secutive hospitalized patients with acute cerebrovascular dis- half were prescribed warfarin. Carotid duplex was performed in 30% ease (stroke or transient ischemic attack) hospitalized in Israel’s and any vascular imaging study in 36% of patients with ischemic events. The mean (± SD) length of hospital stay was 12 ± 27 days medical centers during a 2 month period (February to March for ICH and 8 ± 11 days for ischemic stroke. Among patients with 2004). The study included all patients with acute stroke or TIA ICH, 28% died during hospitalization and 66% died or remained aged 18 or more years, hospitalized in the 28 medical centers with severe disability while for ischemic stroke the corresponding in Israel that admit patients with acute stroke. In each hospi- rates were 7% and 41% respectively. Mortality rates within 3 months tal a coordinating physician was selected to be responsible for were 34% for ICH and 14% for ischemic stroke. data collection in the hospital departments. Data were collected Conclusions: This national survey demonstrates the high burden of acute stroke in Israel and reveals discordance between prospectively. Stroke and TIA were reported in accordance with existing guidelines and current practice. The findings highlight the medical report on discharge from the hospital. Ischemic important areas for which reorganization is imperative for patients stroke and intracerebral hemorrhage were differentiated by find- afflicted with acute stroke. ings from head computerized tomography and were regarded as IMAJ 2006;8:3–7 undetermined stroke if brain CT or magnetic resonance imag- ing were not performed. Cases of subarachnoid hemorrhage and cerebral venous thrombosis were not included in the cur- * See Appendix rent survey. Whenever the coordinating physician raised doubt TIA = transient ischemic attack regarding diagnosis, a central adjudication committee made ICH = intracerebral hemorrhage the final decision. A comprehensive questionnaire – including • Vol 8 • January 2006 Acute Cerebrovascular Disease in Israel 3 Original Articles demographic characteristics, stroke severity, type and subtype, determined stroke. Women comprised nearly half of the patients diagnostic tests performed, management and clinical outcome (n=1,011, 47%). The mean age of the patients was 71 ± 13 years – was designed and completed for all patients. (men 69 ± 13 vs. women 73 ± 13 years; ICH 73 ± 12, ischemic Neurologic deficits were determined according to the Na- stroke 71 ± 13, TIA 67 ± 16). Twenty-two percent of patients tional Institute of Health Stroke Scale score, handicap using were under the age of 60. the modified Rankin scale, clinical subtypes of ischemic stroke Baseline characteristics are shown in Table 2. The most fre- using the Oxfordshire Community Stroke Project classification, quently reported risk factor was hypertension (overall 75%, age- and ischemic stroke etiology using the TOAST classification [6]. adjusted rate of 79% for ICH and 75% for ischemic stroke) fol- For uniformity of data collection, study investigators underwent lowed by dyslipidemia (46%) and diabetes mellitus (40%). Over a training and received a detailed study manual. quarter of the patients had had a prior stroke and 17% had atrial Data entry, editing and analysis were performed at the coor- fibrillation. Among patients with ischemic stroke who arrived at dinating center of the Israel Society for the Prevention of Heart the hospital 45% came by ambulance and 5% by mobile intensive Attacks. Data checks for completeness and consistency were care unit, while among those with ICH 60% came by ambulance based on the discharge medical reports attached to each pa- and 11% by mobile ICU. Over 40% of patients with ischemic tient form and on computerized data queries. Data were verified stroke and only 12% of patients with ICH arrived by private car using online checks incorporated into the data entry interface or independently. Severe neurologic deficits (NIHSS score ≥11) and by batch logical checks applied to the database following were found in 23% of patients with ischemic stroke and in 50% the data entry process. The study neurologists resolved all que- of patients with ICH, and mild deficits (NIHSS score ≤5) in 49% ries at the coordinating center, based on data from discharge of patients with ischemic stroke and in 26% of patients with ICH. summaries. Several indicators of process of care for stroke The median time (25%–75%) elapsing from arrival at the were evaluated in the survey, based on indicators derived from emergency department to undergoing head CT, available for authoritative guidelines and expert panels [Table 1]. Mortality 73% of patients, was 2.1 hours (range 1.1–4.1) for patients with and survival during the first 90 days post-hospitalization were ICH and 2.7 (1.5–9.9) for patients with ischemic stroke. Seven assessed by means of matching patients’ files with national percent of patients did not have any brain imaging. The me- mortality data. The SAS-8 software was used for statistical dian time interval elapsing from the onset of stroke symptoms analysis. Differences in age-adjusted rates were compared using to hospital arrival, available for only 53% of patients, was 1.2 the Cochran-Mantel-Haenszel chi-square test. hours (range 1.0–3.7) for patients with ICH and 4.1 (1.7–11.9) for patients with ischemic stroke. Twenty-four percent of pa- Results tients arrived within 3 hours of stroke onset. It should be noted During the 2 month survey, 2,174 patients with acute cerebro- that since data on time elapsing were missing for a substantial vascular events were hospitalized in medical centers in Israel. proportion of cases, the values presented might be biased. Of these events, 89% (n=1,938) were ischemic cerebrovascular (ischemic stroke n=1,558, 80%, and TIA n=380, 20%); 7% (n=159) ICU = intensive care unit were intracerebral hemorrhage; and the remaining 4% (n=78), in NIHSS = National Institute of Health Stroke Scale which brain imaging was not performed, were regarded as un- Table 2. Baseline characteristics, mode of transportation and stroke Table 1. Indicators of performance of care for patients with severity acute cerebrovascular events Age adjusted rates (%) Ischemic events Indicators Percent (n=1938) Use of head computerized tomography 93% Ischemic Admission to a department with a designated acute stroke unit 7% All (n=2,174) ICH stroke TIA ∗ Arrival by ambulance or mobile ICU 49% No. (%) (n=159) (n=1,558) (n=380) P Use of thrombolysis (intravenous or intraarterial) in patients with acute 0.5% Females 1011 (47%) 57% 55% 47% 0.01 ischemic stroke Hypertension 1602 (75%) 79 75 69 0.001 Use of thrombolysis (intravenous or intraarterial) in patients with
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