Heart and Stroke Foundation Stroke Report 2014: Death rates from stroke have greatly decreased over past 10 years, but with an aging population and an increase in younger people having strokes, can the system keep up?

Contents

I Introduction
II Stroke can happen at any age
III Improvements in care and treatment
IV Coordinated care
V Specialized units, specialized care
VI The power of technology
VII Rehabilitation
VIII Prevention
IX Involving patients and families
X Conclusion
XI Resources

--submitted by Ian Joiner, Patrice Lindsay and Stephanie Lawrence

I Introduction

Stroke care has come a long way in Canada. More is known about its causes and effects, and stroke services have improved and expanded in many regions. Patient outcomes are also much better. Now one-third fewer people admitted to hospital for stroke die compared with ten years ago. And on top of this, there are fewer hospitalizations from stroke in some provinces, as a result of both fewer strokes happening but also because people with mild strokes can now get appropriate services in the community. Canadians are also developing a better understanding of stroke including recognizing its signs and how to prevent it.

However, this is only part of the story and only today’s story. Stroke remains a serious health issue that affects thousands of Canadians and their loved ones. It is the second leading cause of death in the world. There are an estimated 50,000 strokes in Canada every year, or one every 10 minutes. And 315,000 Canadians are living with the effects of stroke, which can include a range of disabilities.

Gains that have been made in stroke treatment and care are about to be challenged by an aging population, more stroke patients with more complex needs, and an increase in strokes among people under 70, as well as an increase in all stroke risk factors for younger adults (aged 30–50).

The Canadian population is aging, and stroke is an age-related disease. Put simply, as more people get older, there will be more strokes. And the profile of the typical stroke patient is changing. More stroke patients arrive at hospital with multiple conditions such as hypertension, diabetes, coronary artery disease and cancer, making their treatment more complex. In fact two-thirds of stroke patients now have one or more chronic conditions and this trend is only expected to increase.

“We have seen great success when looking at stroke rates declining but as physicians, we do not treat rates, we treat patients,” says Dr. Michael Hill, Director of the Stroke Unit, Calgary Stroke Program and Heart and Stroke Foundation spokesperson. “As our population gets older there will be more strokes and more patients to treat; many of these patients will be sicker, so there will be a bigger burden on the healthcare system, on society and on families.”

II Stroke can happen at any age

At the other end of the age spectrum, strokes among younger people are increasing. Most strokes occur in people over 70, but the escalation among those under 70 is alarming. According to the new data gathered for this report, over the past decade strokes in people in their 50s have increased by 24 per cent, and for those in their 60s by 13 per cent. Even more troubling, recent international studies predict a doubling of stroke rates among younger people (defined as ages 24–64) within the next 15 years.

This poses some serious questions for our existing health system, services and resources. The Public Health Agency of Canada reports that stroke costs the Canadian economy $3.6 billion a year in physician services, hospital costs, lost wages, and decreased productivity (even more when you count indirect costs).The anticipated increase in the number of strokes will place a bigger burden on the system and families. As more stroke survivors are created, there will be a need for more services to support them throughout their recovery. Will we be able to keep up with increased demand and provide Canadians with the care and support they need?

III Improvements in care and treatment

The significant improvement in survival rates for stroke patients over the past 10 years is the result of many factors including advances in diagnosis, procedures, treatments and drug therapies, as well as the efforts of the Heart and Stroke Foundation and the Canadian Stroke Network in promoting better coordinated stroke care and best practices for healthcare professionals. In fact over the past 60 years, the death rates from cardiovascular disease and stroke have declined by more than 75 per cent. Last year this resulted in 165,000 survivors. More survivors also implies more Canadians living with different disabilities and an increased burden on the health system and caregivers.

“The influence of the Canadian Stroke Network and its partner the Heart and Stroke Foundation on overall improvements in care cannot be overstated,” says Dr. Hill. “Stroke care is better because of their efforts.  But, there is still so much more to do to make sure Canadians get the best treatment and care possible.”

Where you live matters

Stroke survival rates vary across the country. There is a better chance of surviving a stroke in Quebec or Alberta. Reasons for the differences in death rates among provinces can be complex and depend on whether a location is more urban or rural, how well stroke services are coordinated, and the services available. “Health care is provincial, not national, and varies widely across the country, not just in stroke, but in multiple areas of medicine,” says Dr. Hill.
 

Death rate from stroke by province (per 100,000 people) from lowest to highest

Canada

AB

QC

BC

ON

SK

MB

Terr

PEI

NS

NB

NL

17.9

15.9

16.7

17.5

17.9

19.2

19.9

20.4

20.9

22.0

22.4

29.9

2011–2012 30-day stroke in-hospital mortality rates standardized per 100,000 population and for age and gender

Know the signs and take action

Stroke is a medical emergency. The faster someone who is experiencing stroke gets to the right hospital and receives appropriate treatment, the better their chances of survival and recovery – with little or no disability. There is a saying that “time is brain” or put another way that “time lost is brain lost.” Brain cells die at a rate of two million per minute after stroke, so the sooner blood flow can be restored, the greater the likelihood of a good outcome.

Anyone witnessing or experiencing the signs of stroke (weakness, trouble speaking, vision problems, headache, dizziness) should call 9-1-1 (or local emergency medical services) immediately so the person can arrive at hospital by ambulance. Although 70 per cent of stroke patients arrive at hospital by ambulance, 30 per cent still do not and are putting themselves at risk. These numbers have remained unchanged since 2006, pointing to an area requiring urgent attention.

IV Coordinated care

The decrease in rates of hospitalization for stroke is a welcome improvement as heart disease and stroke combined continue to be the leading cause of hospitalization in Canada resulting in 350,000 visits annually.  

Stroke experts stress that the best way to improve stroke care for all Canadians is to have a coordinated system in place. This is often referred to as having “the right resources, in the right place, at the right time.” Putting this idea into practice is of course complicated, but the philosophy speaks to what must be done to ensure stroke patients get the best care possible throughout their diagnosis, treatment and recovery journey.  

This process begins as soon as someone calls 9-1-1. If all the right systems are in place, calling emergency medical services means a patient will arrive at the “right” hospital – a facility with stroke services. This means that the ambulance could “bypass” a closer hospital if there is an agreement in place within the region to take suspected stroke patients to a hospital that is equipped to provide emergency stroke care. It also means the hospital will be notified and prepared for the patient’s arrival. Currently almost half of hospitals across the country with stroke services have a system in place to notify them that an ambulance is arriving with a stroke patient.

“What we need to work on is educating the public so that they recognize stroke symptoms instead of ignoring them, and call 9-1-1,” says Dr. Hill. “The emergency medical staff and paramedics are the stroke patient's best advocate and they play a critical role before a suspected stroke patient reaches the hospital.”

Patients are examined once they arrive at the emergency department, and if stroke is suspected,they should be taken directly to a CT scanner which produces a computer processed x-ray of the brain. This is a crucial step as important treatment decisions will be based on the scan. If the CT scan reveals that a patient needs a clot-busting treatment (a thrombolytic drug such as tPA), it must be given as soon as possible, and within 4½ hours of experiencing stroke symptoms in order to stop or reverse the effects of a stroke.

The new data collected for this report reveal that at the best performing hospitals, more than 90 per cent of stroke patients are getting access to a CT scan within 24 hours after arrival at hospital (ideally a CT scan should happen upon arrival).But across all hospitals only 69 per cent of patients are getting a CT scan within 24 hours. This is an improvement over five years ago, yet it still leaves almost one-third of patients not getting access to this diagnostic tool quickly enough. The data also revealed that less than one-third of hospitals that provide stroke services provide tPA.

It is important to set targets for how quickly stroke patients should receive diagnosis and treatment once they arrive at hospital. However, the amount of time it takes patients to arrive at the hospital can make an even bigger difference to their recovery. Half of stroke patients take almost six hours after symptom onset to arrival at hospital. Times are longest for younger stroke patients, with half of those aged 20 to 39 taking on average 8½ hours – well outside the 4½-hour window to benefit from tPA. The bottom line is the faster stroke signs are recognized and patients get to the hospital and receive treatment, the greater their chances of a better outcome. There is still much improvement to be made.

V Specialized units, specialized care

As a means of organizing individual points of service, coordinated care is not only more effective for stroke patients, it is also the most efficient way to make use of stroke care resources –including health professionals, infrastructure, and technology.

“Coordinated stroke systems of care enable stroke patients to have access to the best treatment, from prevention all the way to rehabilitation post-stroke,” says Dr. Devin Harris, Medical Advisor, Stroke Services BC, and a Heart and Stroke Foundation spokesperson. “Stroke units, consisting of a designated ward with specially trained physicians, nurses, and therapists, have been unequivocally shown to reduce death and disability post-stroke.”

The Canadian Best Practice Recommendations for Stroke Care stress the need for coordination of patient care among all hospital departments and services, and the strength of organized stroke teams. There is strong evidence that patients who are cared for on a dedicated stroke unit with a specialized stroke team have better outcomes. (Where stroke units are not available, stroke patients can still receive effective care from staff trained in stroke best practices.) But according to the new data only one-quarter of hospitals providing stroke services have a designated stroke program and only 17 per cent have a designated stroke unit, resulting in less than optimal care for many Canadians.

“Stroke care benefits from expertise, so imagine a city of one million people with an annual rate of about 1,500 strokes,” says Dr. Hill. “One large or two medium-sized hospitals or stroke programs can manage this number relatively comfortably. This concentration of care allows expertise and programs, and systems of care to develop.  If stroke care is spread out thinner than this, to multiple hospitals, the quality of care suffers and patients do not do as well.”

Measurable improvements in stroke care over the past five years
The Stroke Services Inventory carried out by the Foundation reveals that 303 hospitals improved their stroke services between 2009 and 2013*, including:
51 more hospitals are designated as stroke centres
70 more hospitals have identified stroke teams
31 more hospitals have designated stroke units
12 more hospitals have tPA capability
48 more hospitals have telestroke capacity
* 612 hospitals responded to the 2013 survey of which 303 had also participated in the 2009 survey, thus allowing for comparisons of only those hospitals which had participated in both surveys. ]

Hospitals are certainly the best providers of most specialized acute stroke services, but some services are more efficiently delivered in other ways. One example is treatment for “mini-strokes” (called transient ischemic attacks or TIAs). These mini strokes display the same symptoms but resolve quickly and are an important warning sign of a future, more extensive stroke. While still urgent, these milder cases can be treated effectively outside of a standard in-patient acute care unit or emergency department, for example in a secondary stroke prevention clinic. These clinics – located in a hospital or in the community – have been developed specifically to help those who have experienced signs of a mild stroke, reduce their risk.

VI The power of technology

When stroke experts are not available within a facility, patients can benefit from their expertise through Telestroke. Telestroke uses various types of technology to link healthcare sites, providing diagnosis and treatment recommendations and services to stroke patients wherever they are. Currently telestroke is primarily being used for urgent cases to increase access to clot-busting drugs through consulting neurologists, and this has proven to be very effective. But there are great opportunities to use it at any point in stroke care including secondary stroke prevention and rehabilitation, stroke prevention approaches and it can be used to provide access to other specialists for example, speech-language pathologists.

Telestroke has numerous benefits to both stroke patients and the health system. It has been shown to support better outcomes in patients including reducing effects of stroke, and increasing patient satisfaction. It can address regional inequities in access to and standards of care, and reduce costs for health care and long-term social support. However, telestroke is being underutilized. The technology infrastructure is in place in more than 80 per cent of hospitals but only 44 per cent are using it for care related to stroke patients.

“Telestroke is not being used to its full potential,” says Dr. Frank Silver, Medical Director, Ontario Telestroke Program and a Heart and Stroke Foundation spokesperson. “It allows physicians and other specialists to provide care to patients who can be hundreds of miles apart. In a country as big as Canada this is an efficient and effective way to provide care for more stroke patients and we should be making better use of this technology.”

VII Rehabilitation

Because timely treatment is linked with better outcomes in stroke patients, the recovery process starts the moment that emergency medical services arrive or a patient is seen by a stroke expert. Recovery is an ongoing process that includes a range of activities in many settings taking place over months or years.

Rehabilitation is key to recovery for survivors, and the earlier it starts, the better. There have been improvements over the past decade in how quickly patients in hospital are getting access to in-patient rehabilitation, but with half of stroke patients receiving services in 13 or more days after their stroke when the ideal is closer to five to seven days, there is still much room for improvement. In many cases, rehabilitation will start in hospital and will continue with services in the community after a patient is discharged.

Unfortunately there are many gaps in rehabilitation for stroke survivors. Not enough stroke patients in any setting, in or out of hospital, have access to the rehabilitation services they need to make the best recovery possible. Only 16 per cent of all stroke patients go to in-patient rehabilitation, when recent evidence shows this number should be closer to 40 per cent based on patient outcomes and needs.

“One of the bigger challenges is the lack of data on stroke rehabilitation including information on the quality of services. This is our biggest research opportunity,” Dr. Hill says. “We need to identify new, specific and targeted therapies for stroke survivors, and we need data to be able to do this.”

Early supported discharge is another stroke care concept that has shown some success and offers even more potential, allowing stroke patients to return home or to their previous living setting as early as possible with rehabilitation services and supports in place. The benefits to this approach include better quality of life for patients and a decreased burden on the health system. The catch is that there must be services in place in the community to support patients in their recovery journey, and these are lacking in many regions. Currently 60 per cent of all stroke patients who leave hospital return home, and of these only 11 per cent have home support services organized before they leave hospital.

VIII Prevention

Prevention is critical in any discussion about stroke. Not all risk factors can be controlled but up to 80 percent of premature heart disease and stroke can be prevented. It is never too early to adopt healthy behaviours to decrease the risk of ever having a stroke, and never too late to make healthy changes – even after a stroke. The risk of having another stroke is high for five years following a first stroke, with 30 per cent of survivors having a second stroke.

Rehabilitation for stroke survivors not only helps them regain as much of their independence as possible. It also supports them to make and maintain the healthy changes they need to avoid a subsequent event and recover to the fullest extent possible.

“A great deal of the potential burden we are facing depends upon the health of the current baby boomers as they age, and whether they can better control their stroke risk factors,” says Dr. Hill. “There will always be risk factors we cannot control such as family history and age, but there is so much that we can do to prevent heart disease and stroke. By making healthy changes Canadians can make a real difference to their odds of having a first incident or of having another one.”

IX Involving patients and families

Patients and their families should be at the centre of stroke care. They should be directly involved in decision making, goal setting, and care planning throughout the care process. A well coordinated system facilitates better participation and a smoother journey for patients and their families, allowing them to move more easily between healthcare locations, services and providers.

Healthcare providers have an important role to play in educating patients and families around stroke, including understanding the nature and causes of stroke, recognizing the signs, being aware of the impact and ongoing needs of the patient, and promoting self-management. They are also in the best position to ensure care is patient-centred.  

X Conclusion

On the surface the concept of organizing a stroke system to support the best possible outcomes for stroke patients may not seem complicated. But in practice having the right resources, in the right place at the right time requires a lot of time, resources, long-term planning and commitment from individuals, organizations and governments at all levels across the country.

We have made great progress in stroke care in Canada as attested to by decreased rates of stroke, increased services, improved coordination and better outcomes for stroke patients. More than 80 per cent of Canadians who have a stroke and make it to hospital will now survive.

But there is still much room for improvement, from prevention through to care and recovery, to ensure the system continues to provide the best services possible—both for today’s stroke patients and for the growing numbers of Canadians who will experience stroke in the future.

Calls to action

What can Canadians do?

  • Make and maintain healthy changes to reduce your risk of stroke: be physically active, eat a healthy diet, be smoke-free, manage stress and limit alcohol consumption.
  • Know and control your blood pressure.
  • Understand that stroke is a medical emergency and can happen at any age. Know the symptoms of stroke and call 9-1-1 or emergency medical services immediately.
  • Become actively involved in all decisions around stroke care, treatment and rehabilitation for yourself and your loved ones.
  • Advocate for improvements to stroke systems to ensure well-resourced and coordinated systems are in place for every Canadian, regardless of location.
  • Visit http://heartandstroke.ca for more information.

What can governments and healthcare system decision makers do?

  • Take a leadership role in stroke care and continue to fund and support provincial stroke strategies leveraging the Canadian Best Practice Recommendations for Stroke Care.
  • In provinces without a stroke strategy, the government in collaboration with regional authorities should develop a comprehensive strategy, which includes an integrated approach covering prevention, treatment, rehabilitation and community re-engagement.
  • Support the development of coordinated systems of stroke care including stroke units and stroke care teams.
  • Implement and support 9-1-1 systems across each province to ensure access to timely life-saving services for all residents.
  • Develop coordinated regional bypass systems so emergency medical services can bypass non-stroke hospitals and get stroke patients to the right hospitals with the appropriate level of stroke services in a timely manner.
  • Expand telestroke infrastructure and utilization to provide access to optimal stroke services across the continuum of care (diagnosis, treatment, rehabilitation and prevention), to all Canadians including those in rural and remote regions.
  • Create more secondary prevention clinics using new and existing facilities as well as telestroke infrastructure.
  • Expand rehabilitation services for stroke patients both in hospital and in the community.
  • Develop detailed and coordinated provincial surveillance systems and other data and information infrastructure which allow for continuous tracking to address gaps across the system from prevention to treatment and care through to rehabilitation.

What can healthcare providers do?

  • Train all emergency medical staff to recognize the signs of stroke and carry out stroke protocols.
  • Implement the Canadian Best Practice Recommendations for Stroke Care.
  • Promote and implement coordinated systems of stroke care working across interdisciplinary teams.
  • Put patients and families at the centre of stroke care to increase patient satisfaction and improve outcomes.
  • Take a leadership role and advocate for stroke systems improvement, enabling all patients to receive optimal stroke care regardless of location.

* Data sources include Canadian Institute for Health Information (CIHI) Discharge Abstract Database (2003–2013), CIHI Stroke Quality Special Project 340, CIHI National Rehabilitation Reporting System (NRS) and Heart and Stroke Foundation Stroke Services Inventory of 612 Canadian hospitals.

XI Resources
 
The 2014 Stroke Report is available at http://heartandstroke.ca/strokereport2014.

Take the Heart&Stroke Risk Assessment at http://heartandstroke.ca.

Learn the signs of stroke at http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483937/k.86D8/Stroke....

Which part of stroke would you let your brain take away? Watch the video at http://www.strokemonth.ca/index.php?lang=en.

The Canadian Stroke Best Practice Recommendations present high-quality, evidence-based stroke care recommendations in a standardized framework to support healthcare professionals in all disciplines. Implementation of these recommendations is expected to contribute to reducing practice variations and closing the gaps between evidence and practice. Available at http://www.strokebestpractices.ca/Best Practices.