Stroke
Stroke is one of the leading causes of death and disability in India with its prevalence rate of around 175 to 300 per 100 thousand population in rural and urban areas respectively. Mortality is also very high ranging from 5-40% depending on the geographical distribution.
Acute treatment within few hours of stroke onset includes Thrombolysis with or without Thrombectomy. Generally, Thrombolysis is the standard of care in Stroke management since 1998 in the western world. However, it has not got its prominence in India mainly due to cost, patient education, and failure in outreach. Since mortality from stroke is higher in rural areas, more focus is required to optimize care for stroke victims.
Post-Stroke care mainly focuses on Secondary Prevention. Given the expensive nature of medications, Secondary Stroke Prevention also has not gained much importance.
Stroke Rehabilitation which constitutes the mainstay of positive outcome measures has taken a backseat, again mainly due to training inadequacy, misdirected treatment protocols, and lack of infrastructure. Private stroke centers on the other hand are doing a good job in the Rehabilitation Arena but rural hospitals are lacking those facilities in Neurorehabilitation.
The government is trying to focus on early diagnosis, management, infrastructure, public awareness, and capacity building at various levels of health care for all the non-communicable diseases including Stroke. The government of India has started the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS), but the positive impact of these organizations are yet to be seen.
Hence a combined effort from both the government and the private sector is needed to tackle the stroke epidemic in India.
In comparison, Rural India’s population constitutes 65 % versus 35 % of the urban population. The graph above depicts a huge disparity in case-fatality rate when rural India is compared with the urban territory. This must be addressed as soon as possible via community outreach programs, telemedicine, population education, and private-public-government cooperation. This might narrow the gap and help stroke outcomes.
NeuroZone is deploying Telemedicine Technology to help Rural Stroke Patients in both acute and chronic setting for Clinical Care and Rehabilitation.
To achieve this, we need a sophisticated State-of-the-Art Stroke-Unit* to handle all neurological conditions.
Hence as the First step towards our goal, we started a STROKE UNIT* (NeuroZone April 2019) in Mysore which has served as a Clinical Hub for neurological issues catering 1.5 million population of Mysore city and Rural area.
Our Next goal is to deploy mobile telemedicine to collect data as per the WHO recommended steps (Discussed below).
The last step would be to use this data and implement telemedicine in treating patients both clinically and rehabilitation wise using an evidence-based approach.
*Stroke-Unit is a multidisciplinary team comprising of Doctors, Nurses, Rehabilitation therapists, Social workers who discuss and plan comprehensive coordinated patient care through regular meetings. Stroke-Unit could provide the most effective population intervention in stroke care. There will be multidisciplinary assessment, problem identification, and short-term and long-term goal setting. Stroke units typically include active involvement of care providers (including family members) in the rehabilitation process with a program of on-going education and training.
Stroke unit implementation remains a big challenge in India. At present in India there are approximately 35 stroke units, including ours for a population of 1.3 billion. They are primarily situated in urban private sector hospitals. Many of the private hospitals lack CT scan facility and this results in crucial time being lost. On the other hand, public hospitals lack a dedicated team to manage stroke patients. Unavailability of CT scan is also an issue in smaller public hospitals as in private hospitals. One, out of every 3 patients with stroke are not accessing appropriate healthcare due to non-affordability, usage of alternative medicines, and difficulty in conveyance.
World Health Organization (WHO) has recommended a 3-step approach (STEPS Stroke) to assist low-income and middle-income countries to improve stroke outcome:
Step-1: Data collection from hospitalized patients – Demographics, Risk factors, Vitals, Treatment protocols.
Step-2: Data collection from non-hospitalized fatal stroke cases in the community after proper validation from death certificates, verbal autopsy or from direct autopsies.
Step-3: Data collection from non-fatal and non-hospitalized cases in the community.
- Cost: Since only private hospitals have the ability to cater stroke treatment and rehabilitation which are expensive, Rural patients are having difficulty to access evidence-based treatment.
- Complementary and alternative medicine: Patients are seeking alternative medicine for stroke care due to various issues including cost, availability, and traditional value among others. This aspect of patient intervention, during the post stroke phase hampers the rehabilitation process.
- Rehabilitation: Lack of Physiotherapists, Lack of Stroke-Units, Lack of Primary Stroke Rehabilitation training centers are few barriers encountered.
- Placement: Stroke victims before being discharged back to community need placement wherein, they are trained with physical and occupational therapy. India has only few centers, but they are expensive.
- Secondary prevention drugs: Early initiation of treatments for secondary stroke prevention is associated with an 80% reduction in risk of early recurrent stroke. A standard secondary stroke prevention treatment will address multiple vascular risk factors and will usually consist of an antiplatelet agent, a lipid lowering drug mainly HMG-CoA reductase inhibitors (Statins), and an antihypertensive agent. Monitoring of oral anticoagulant therapy is a major problem for cardioembolic stroke in India. Newer oral anticoagulants are expensive making them unavailable for poor and underserved stroke victims.
In India, there is a huge burden of stroke with significant regional variations. Stroke units, thrombolysis, and rehabilitation are predominantly available in private urban areas. Rural infrastructure for stroke care is extremely primitive and needs an organized effort from both the private sector and government to tackle the rising stroke burden in India. NeuroZone is attempting to bridge this disparity and bring NeuroCare to the doorsteps of the underserved populations.
Doctors
- Introduction
- Solution
- Our Effort
- Barriers
- Conclusion
Stroke is one of the leading causes of death and disability in India with its prevalence rate of around 175 to 300 per 100 thousand population in rural and urban areas respectively. Mortality is also very high ranging from 5-40% depending on the geographical distribution.
Acute treatment within few hours of stroke onset includes Thrombolysis with or without Thrombectomy. Generally, Thrombolysis is the standard of care in Stroke management since 1998 in the western world. However, it has not got its prominence in India mainly due to cost, patient education, and failure in outreach. Since mortality from stroke is higher in rural areas, more focus is required to optimize care for stroke victims.
Post-Stroke care mainly focuses on Secondary Prevention. Given the expensive nature of medications, Secondary Stroke Prevention also has not gained much importance.
Stroke Rehabilitation which constitutes the mainstay of positive outcome measures has taken a backseat, again mainly due to training inadequacy, misdirected treatment protocols, and lack of infrastructure. Private stroke centers on the other hand are doing a good job in the Rehabilitation Arena but rural hospitals are lacking those facilities in Neurorehabilitation.
The government is trying to focus on early diagnosis, management, infrastructure, public awareness, and capacity building at various levels of health care for all the non-communicable diseases including Stroke. The government of India has started the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS), but the positive impact of these organizations are yet to be seen.
Hence a combined effort from both the government and the private sector is needed to tackle the stroke epidemic in India.
In comparison, Rural India's population constitutes 65 % versus 35 % of the urban population. The graph above depicts a huge disparity in case-fatality rate when rural India is compared with the urban territory. This must be addressed as soon as possible via community outreach programs, telemedicine, population education, and private-public-government cooperation. This might narrow the gap and help stroke outcomes.
NeuroZone is deploying Telemedicine Technology to help Rural Stroke Patients in both acute and chronic setting for Clinical Care and Rehabilitation.
To achieve this, we need a sophisticated State-of-the-Art Stroke-Unit* to handle all neurological conditions.
Hence as the First step towards our goal, we started a STROKE UNIT* (NeuroZone April 2019) in Mysore which has served as a Clinical Hub for neurological issues catering 1.5 million population of Mysore city and Rural area.
Our Next goal is to deploy mobile telemedicine to collect data as per the WHO recommended steps (Discussed below).
The last step would be to use this data and implement telemedicine in treating patients both clinically and rehabilitation wise using an evidence-based approach.
*Stroke-Unit is a multidisciplinary team comprising of Doctors, Nurses, Rehabilitation therapists, Social workers who discuss and plan comprehensive coordinated patient care through regular meetings. Stroke-Unit could provide the most effective population intervention in stroke care. There will be multidisciplinary assessment, problem identification, and short-term and long-term goal setting. Stroke units typically include active involvement of care providers (including family members) in the rehabilitation process with a program of on-going education and training.
Stroke unit implementation remains a big challenge in India. At present in India there are approximately 35 stroke units, including ours for a population of 1.3 billion. They are primarily situated in urban private sector hospitals. Many of the private hospitals lack CT scan facility and this results in crucial time being lost. On the other hand, public hospitals lack a dedicated team to manage stroke patients. Unavailability of CT scan is also an issue in smaller public hospitals as in private hospitals. One, out of every 3 patients with stroke are not accessing appropriate healthcare due to non-affordability, usage of alternative medicines, and difficulty in conveyance.
World Health Organization (WHO) has recommended a 3-step approach (STEPS Stroke) to assist low-income and middle-income countries to improve stroke outcome:
Step-1: Data collection from hospitalized patients - Demographics, Risk factors, Vitals, Treatment protocols.
Step-2: Data collection from non-hospitalized fatal stroke cases in the community after proper validation from death certificates, verbal autopsy or from direct autopsies.
Step-3: Data collection from non-fatal and non-hospitalized cases in the community.
- Cost: Since only private hospitals have the ability to cater stroke treatment and rehabilitation which are expensive, Rural patients are having difficulty to access evidence-based treatment.
- Complementary and alternative medicine: Patients are seeking alternative medicine for stroke care due to various issues including cost, availability, and traditional value among others. This aspect of patient intervention, during the post stroke phase hampers the rehabilitation process.
- Rehabilitation: Lack of Physiotherapists, Lack of Stroke-Units, Lack of Primary Stroke Rehabilitation training centers are few barriers encountered.
- Placement: Stroke victims before being discharged back to community need placement wherein, they are trained with physical and occupational therapy. India has only few centers, but they are expensive.
- Secondary prevention drugs: Early initiation of treatments for secondary stroke prevention is associated with an 80% reduction in risk of early recurrent stroke. A standard secondary stroke prevention treatment will address multiple vascular risk factors and will usually consist of an antiplatelet agent, a lipid lowering drug mainly HMG-CoA reductase inhibitors (Statins), and an antihypertensive agent. Monitoring of oral anticoagulant therapy is a major problem for cardioembolic stroke in India. Newer oral anticoagulants are expensive making them unavailable for poor and underserved stroke victims.
In India, there is a huge burden of stroke with significant regional variations. Stroke units, thrombolysis, and rehabilitation are predominantly available in private urban areas. Rural infrastructure for stroke care is extremely primitive and needs an organized effort from both the private sector and government to tackle the rising stroke burden in India. NeuroZone is attempting to bridge this disparity and bring NeuroCare to the doorsteps of the underserved populations.
