Stroke care in Spain. What do we have? What do we need?

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Neurologa. 2011;26(8) care in Spain. What do we have? What do we need?E. Dez-Servicio deUniversidadKEYWOStroke uStroke cNationalStrategyPALABRUnidadeAsistencEstrategde Ictus Please ciNeurologa. CorrespoE-mail a2173-5808/$Tejedor , B. Fuentes Neurologa y Centro de Ictus, rea de Neurociencias, Instituto de Investigacin IdIPAZ, Hospital Universitario La Paz, Autnoma de Madrid, Madrid, SpainRDSnits;are; StrokeAbstract The high level of scientic evidence which supports the recommendations for thecare of acute stroke in stroke units (SUs) with a good health care network, does not correspondto the level of introduction in Spain. In this regard, the Cerebrovascular Diseases Study Group(GEECV) of the Spanish Society of Neurology has taken the initiative to conduct the NationalSurvey of Stroke Care that will help to determine the real situation in acute stroke manage-ment in Spain just before the approval of the National Stroke Strategy (NSS) by the Ministry ofHealth and concludes that in the rst semester of 2009 there were 39 SUs, unevenly distributedwith higher concentration in Madrid and Barcelona. Although the approval of the NSS was amajor achievement, much remains to be done to meet the objectives. We thank the GEECVsinitiative, which gives us an X-ray of the, not very satisfactory, state of stroke care in Spainin December 2008, highlighting some achievements and the many shortcomings. Therefore, wemust continue to improve, rene our data collection with records that include all availableresources and all the stroke patients attended. We invite GEECV to carry out a second study toevaluate the impact of NSS and to serve as a stimulus to achieve a substantial improvement instroke care in Spain, closer to the recommendations of the new PASI document. 2011 Sociedad Espaola de Neurologa. Published by Elsevier Espaa, S.L. All rights reserved.AS CLAVEs de ictus;ia del rictus;ia NacionalSituacin asistencial del ictus en Espana. Qu tenemos? Qu nos falta?Resumen El alto grado de evidencia cientca en el que se sustentan las recomendacionessobre la asistencia de los pacientes con ictus agudo en unidades de ictus (UI) con una buena redasistencial no se corresponde con el grado de implantacin de las mismas en Espana. En estesentido, el Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV) de la SEN ha tomadola iniciativa de elaborar la Encuesta nacional de la asistencia del ictus que ayuda a conocercmo era sta justo antes de aprobarse la Estrategia Nacional del Ictus (ENI) por el Ministerio deSanidad y concluye que en el primer semestre del ano 2009 existan 39 UI, distribuidas de formadesigual con mayor concentracin en Madrid y Barcelona. Aunque la rma de la ENI ha supuestoun importante logro, todava queda mucho por hacer para cumplir los objetivos planteados.Es motivo de satisfaccin esta iniciativa del GEECV, que nos aporta una radiografa de lasituacin de la atencin del ictus en Espana a diciembre de 2008, que no es muy satisfactoriate this article as: Dez-Tejedor E, Fuentes B. Situacin asistencial del ictus en Espana. Qu tenemos? Qu nos falta?2011;26:4458.nding author.ddress: (E. Dez-Tejedor). see front matter 2011 Sociedad Espaola de Neurologa. Published by Elsevier Espaa, S.L. All rights reserved.446 E. Dez-Tejedor, B. Fuentesy que alumbra algn logro y muchas carencias, por lo que hemos de continuar mejorando,perfeccionando nuestra recogida de datos mediante registros que incluyan todos los recursosdisponibles en la atencin del ictus y los pacientes atendidos. Invitamos al GEECV a realizar unsegundo trabajo que evale el impacto de esta ENI y que sirva de estmulo para conseguir unamejora continua y sustancial de la situacin en Espana, y aproximarnos a las recomendaciones sana. PuFor mana major theat best, to since the 1that speciaprogress, lEuropean Sknown as when the tacute stroka stroke unscientic epatients isassociationogy SocietyDeclarationwhen necethe variousup-to-dateable to be they can oproblem, wquality posage, SpainRegional Hearly speciation of speto cover thSince thstrating ththese unitsof acute sof intravenselected ccurrently sreperfusionStroke in reducingan evidencrandomizedsent a cosduration oout this imwith a hights extendand severitsis, they habeen estimcialatedeles recse stmplean Uhis s (GEsibilke crolourve thegy.10s wepproc soke cald b to tationASI)e toof th of ser w caret theand in thpitalke r careitiones. Iked thein Nodel nuevo documento Plan de atencin 2011 Sociedad Espaola de Neurologreservados.y years, caring for stroke has been suffering fromrapeutic nihilism, with patients being entrusted,the natural course of their condition. Fortunately,980s, studies have begun to be published showinglist attention in ictus has an impact on patientseading the World Health Organization and thetroke Council to issue in 1995 what has becomethe Helsinborg Declaration,1 ratied in 2006,2arget set was to achieve, for all patients with ane, early specialist assessment and treatment init (SU). In addition, however, over and above thevidence, specialized neurological care for stroke a clear demand of modern society. Thus, thes of neurology patients and the Spanish Neurol- (SEN) drafted back in 2000 the so-called Madrid, setting out the right of all citizens to be seenssary by an expert with specic competencies in neurological pathologies, with access to the most diagnostic and therapeutic techniques, and to becared for in specic interdisciplinary units wherebtain all assistance necessary for their healthith assurances that this care will be of the highestsible.3 In his report on subsequent brain dam-s Ombudsman included a recommendation for theealth Authorities: stress should be placed on thealized care of stroke patients through the cre-cic stroke units or specialist stroke teams so ase entire population.4e results of the rst randomized studies demon-e efcacy of SU were published in the 1980s, have become the cornerstone for the treatmenttroke. Subsequently, in the 1990s, the efcacyous brinolytic treatment was demonstrated inases of acute cerebral infarction and we areeeing major advances in the development of therapies.units have been shown to be clearly effective mortality and better functional recovery, withe level of I (grade A recommendation) based on5for spebe treNonething theat thetheir iEuropeIn tGroupresponof stroof NeuCare SbeforeStrateAs iable rascientiof stroIt shouthankspublicPlan (Pof cartance groupstogethtiatedset ouinside mentsof hosof strostrokein addgrammhas picwithinlished studies and meta-analyses. They also repre-t-effective measure, as they shorten the meanf patient stays and increase their survival with-plying a larger number of institutionalizations,er number of independent patients. Their bene- to all types of ictus and are independent of agey.6,7 In addition, in comparison with thromboly-ve a larger potential target population as it hasated that 83% of patients would be candidatesto the techits wordingtives of theand Consumhomogenizments Heacare plans,secondary rehabilitatitaria del ictus.blicado por Elsevier Espaa, S.L. Todos los derechosist management at an SU, versus 10% who could with intravenous thrombolysis in the rst 3 h.8s, the high degree of scientic evidence underly-ommendations on care for acute stroke patientsroke units does not correspond to the degree ofmentation in Spain, nor even in the whole of thenion.ense, the SENs Cerebrovascular Diseases StudyECV) has taken the initiative and assumed theity for drawing up a snapshot of the situationare in Spain at the end of 2008, and this issuega presents the results of the National Strokey,9 which helps to show what it was like just Ministry of Health approves the National Strokell known, in recent years there has been consider-chement between the Health Authorities and thecieties, which has culminated in the preparationre plans at both regional and national levels.1115e pointed out that these documents have arisenhe drive given by the SENs GEECV through the and dissemination of the Stroke Health Care, published in 2006, which established the levels be provided for this condition and the impor-e Stroke Code,13 recently revised11), as well as totroke experts in a number of regions that have,ith their respective Regional Governments, ini- plans for acute stroke. These documents have bases for implementing the Stroke Code bothoutside the hospital context, as well as improve-e levels of care through an increase in the numbers with an SU, stroke teams, and the emergenceeference centres, together with the creation of networks interconnecting these levels of care, to the adaptation of specic rehabilitation pro-N parallel, the Ministry of Health and Social Policy up the baton and has drafted the stroke strategy National Health System (SNS).10 This was pub-vember, 2008, with the participation, in additionnical committee of stroke experts responsible for, of an institutional committee with representa- Regional Governments and the Ministry of Healther Affairs, as it was then. The strategy aims toe stroke care, committing the Regional Govern-lth Departments to develop and implement these reecting the basic strategic lines (primary andprevention of stroke, care in the acute phase,ion and return to normal life, as well as trainingStroke care in Spain. What do we have? What do we need? 447and research) and the necessary indicators for their assess-ment (these indicators can be extracted from the SNS datasystem and are combined with specic information compiledusing questionnaires agreed within the strategys monitoringcommittee).Althougthe Inter-THealth Depimplied a developmeimprove stapplicationorder to acunderstandcorrectly twhich, in athat can bthe other, onaire undewith the paIn the srst half otributed aclarge conccoincide inber of throhaving regstroke coAlthougin Spain ismake certalished hereto the impstage is a lthat may himplementbe outdatethe strategation in theprotocols, codes, proas neurosoresonance although tsituation oStrategy wtwo main vintravenouods. Thus,(prior to thanalysis ofit might bdecided prAlso, thinhabitant,and territotaken evalthat somehospitals wavailable ilocated qustroke.The analysis of thrombolytic dispersion may be inu-enced by this fact, so it would be useful to reect not onlythe absolute gures for treatments performed in a year,which are surprisingly low in some regions, but also the per-centage of treatments applied among all the patients withmic , the perentspplyi has lan hwith9% ireases ald byal bed mto erem tld bourcthers dantiol goas N the lly, snapembuatioachierial mproion pof thethery go stae theECV Natie itsntinu caretioned.1enc Euroly Intup mllstroion 27;23:laraclarach the signing of the National Stroke Strategy byerritorial Health Council and, therefore, all theartments of the 17 Regional Governments hasmajor achievement that tends to stimulate thent of specic plans helping to standardize androke care throughout Spain and accelerate its in the regions, there is still a lot of work to do inhieve the targets set. It is certainly necessary to the situation we started from 2008 so as to assesshe effects of the implementation of this strategy,ddition, proposed an assessment using indicatorse extracted from the SNS on one hand and, onbtaining specic information through a question-rtaken by this strategys monitoring committee,rticipation of all the Regions.10urvey presented here, it is concluded that, in thef 2009, there were 39 SUs, albeit unevenly dis-ross the country. Thus, it is possible to observe aentration of SUs in Madrid and Barcelona, which being the most active with regard to the num-mbolytic treatments administered and, also, inional stroke care plans in place with the use ofdes before the approval of the national strategy.h this kind of survey of the status of stroke care very important and welcome, it is necessary toin considerations in connection with the one pub-. First of all, the publication of the data priorlementation of the SNS stroke strategy at thisittle tardy and there is no analysis of the changesave already occurred, whether or not due to itsation. The data may therefore be considered tod and, to a certain extent, redundant as, wheny was drawn up, an analysis was made of the situ- different regions to reect the number that hadclinical practice guidelines, clinical routes, stroketocols for intravenous brinolysis, SUs, as wellnology resources, diffusion/perfusion magneticand neurovascular interventionism.10 Secondly,he goal proposed in this survey is to study thef stroke care in Spain at the moment the Strokeas approved (November, 2008), the analysis of theariables (SUs and number of patients treated withs thrombolysis) was considered for different peri- the intravenous thrombolysis data refer to 2008e publication of the national strategy), but the the SUs refers to the rst half of 2009, whene possible to nd a new incorporation, possiblyior to the signing of the said strategy.e analysis of the ratio of stroke unit beds per without taking into account population densityrial dispersion, is an aspect that may lead to mis-uations as no consideration is given to the fact stroke patients may not really be referred toith an SU, such as when there is no stroke unitn all the provinces in the region, or when it isite far from where the patient has suffered theischaereasonbolysisof patiway, aple, itcare pments was inccode.It ientailemationsurveyity, or not seit wouall resseen.AnocollectinterveoriginaSystemamongFinaus a of Decthis sitsome territotinue icollectimage Nonis a veter theanalyzthe GEof thisachievtial costrokemendapublishRefer1. TheEargro2. Kjerat2003. Decdecstroke arriving at the emergency room. For this indicator of the number of intravenous throm-formed should be adjusted for the total number with ischaemic stroke arriving at hospitals. In thisng this analysis in the Region of Madrid, for exam-been seen that the implementation of the strokeas managed to increase the percentage of treat- intravenous brinolysis performed at SUs, whichn 2008 and 23.3% in 2009,16,17 clearly reecting related to the better operation of the strokeso necessary to consider the possible biases conducting a survey of this kind, mainly infor-iases as the data provided by different peopleight be subject to a certain degree of subjectiv-rors of perception or interpretation, and they doo have been sufciently veried. In this sense,e more practical to use records that includees available for stroke care and the patients interesting aspect of the survey is that it alsota on the hospitals performing neurovascularnism, an aspect not contemplated among thels and recommendations of the National Healthational Stroke Strategy and due to be includednew indicators.this initiative by the SENs GEECV, which providesshot of the situation of stroke care in Spain aser, 2008, is a source of satisfaction, even thoughn is not very satisfactory and has brought to lightvements and a lot of shortcomings, with hugeinequalities, which means that we have to con-ving. But it is essential for us to perfect our datarocess to achieve a true magnetic resonancee stroke care situation in Spain.less, even with all these limitations, this surveyod contribution that allows us to understand bet-rting point at the end of 2008 so as to be able to progress made over the last 2 years, so we invite to conduct a second study assessing the impactonal Stroke Strategy and so serve as a stimulus to more widespread implementation and substan-ous improvement of the situation with regard to in Spain, so as to come closer to the recom-s contained in the new PASI document recently1espean ad Hoc Consensus Group. European Strategies forervention in Stroke. A report of an ad hoc consensuseeting. Cerebrovasc Dis. 1996;6:31524.m T, Norrving B, Shatchkute A. Helsingborg Decla-006 on European stroke strategies. Cerebrovasc de Madrid. Available from: madrid.pdf448 E. Dez-Tejedor, B. Fuentes4. Defensor del Pueblo. Dano cerebral sobrevenido en Espana.Un acercamiento epidemiolgico y sociosanitario; 2005.Available from: Stroke Unit Trialists Collaboration. Organised inpatient(stroke unit) care for stroke. Cochrane Database Syst Rev.2007;4:CD000197.6. Fuentes B, Diez Tejedor E. Stroke unit: a cost-effective careneed. Neurologia. 2007;22:45666.7. Fuentes B, Diez-Tejedor E. Stroke units: many questions, someanswers. Int J Stroke. 2009;4:2837.8. Gilligan AK, Thrift AG, Sturm JW, Dewey HM, Macdonell RA,Donnan GA. Stroke units, tissue plasminogen activator, aspirinand neuroprotection: which stroke intervention could providethe greatest community benet? Cerebrovasc Dis. 2005;20:23944.9. Anlisis de la asistencia al ictus en Espana: Resultados de laEncuesta nacional Ictus del Grupo de Estudio de EnfermedadesCerebrovasculares. Neurologa. 2011;26:44954.10. Ministerio de Sanidad y Poltica Social. Estrategia en ictus delSNS; 2008. Available from: Masjuan J, lvarez-Sabn J, Arenillas J, Calleja S, Castillo J,Dvalos A, et al. Plan de asistencia sanitaria al ictus II 2010.Documento de consenso elaborado por un Comit ad hoc delGrupo de Estudio de Enfermedades Cerebrovasculares (GEECV)de la Sociedad Espanola de Neurologa (SEN). Neurologa. 2010,doi:10.1016/j.nrl.2010.05.008.12. De Lecinana-Cases MA, Gil-Nunez A, Diez-Tejedor E. Relevanceof stroke code, stroke unit and stroke networks in organizationof acute stroke carethe Madrid acute stroke care program.Cerebrovasc Dis. 2009;27 Suppl. 1:1407.13. Alvarez Sabin J, Alonso de Lecinana M, Gallego J, Gil-Peralta A,Casado I, Castillo J, et al. Plan for stroke healthcare delivery.Neurologia. 2006;21:71726.14. Asociacin Madrilena de Neurologa y Servicio Madrileno deSalud. Atencin a los pacientes con ictus en la Comunidadde Madrid. Consejera de Sanidad; 2009. Available from: Publicaciones FA&cid=1142553237007&idConsejeria=1109266187266&idListConsj=1109265444710&language=es&pagename=ComunidadMadrid%2FEstructura&pid=1109265444699&sm=110926584400415. Gallofre M, Abilleira S, Tresserras R, De la Puente ML. The strokeprogramme of Catalonia. Med Clin (Barc). 2009;133:58993.16. Reig G, Garca-Pastor A, Fuentes B, Alonso de Lecinana M,Calleja P, Serna C, et al. The Madrid stroke-care regionalstrategy. Early follow-up and evaluation. Preliminary results.Cerebrovasc Dis. 2010;29 Suppl. 2:210.17. Dez Tejedor E, Fuentes Gimeno B, Rodrguez Balo A, Alonso deLecinana M, Egido J, Gil Nnez A, et al. Advantages of a spe-cial stroke assistance network. Madrid Acute Stroke Program.Cerebrovasc Dis. 2008;25 Suppl. 2:189.Stroke care in Spain. What do we have? What do we need?References