Ireland’s thrombolysis rate reported as lower than average.

A major survey of stroke care in Europe has found significant inequalities in access to appropriate stroke care across Europe and Ireland’s thrombolysis rate, where medication is delivered to break up the clot, was reported as lower than average.

Every year, up to 1.3 million people in Europe suffer a first stroke. Acute stroke treatment strategies such as acute treatment of patients in a stroke unit, intravenous thrombolysis and thrombectomy (where the clot is mechanically removed) significantly improve the outcome for patients with ischaemic stroke and reduce its socioeconomic burden.

However, reliable data on access to and delivery of acute stroke treatment strategies throughout Europe have been lacking to date.

Therefore, the European Stroke Organisation (ESO), the European Society of Minimally Invasive Neurological Therapy (ESMINT), the European Academy of Neurology (EAN) and the patient organisation Stroke Alliance for Europe (SAFE); of which the Irish Heart Foundation is a member, surveyed stroke experts from 44 of 51 European countries on the best available information regarding national access to and delivery rates of acute stroke unit care, intravenous thrombolysis, and thrombectomy for ischaemic stroke.

The results revealed major inequalities in acute stroke treatment, with many countries reporting rates that were far below highest country rates. The survey also found that in some countries patients still have no or obviously inadequate access to appropriate acute stroke treatment.

The data for Ireland was based on 2016/17 figures compiled from HIPE data, the National Stroke Register and the National Stroke Audit.

According to the survey, intravenous thrombolysis was provided in 42/44 countries. The estimated average number of intravenous thrombolysis was 142 per million inhabitants and the highest country was 412.2. In Ireland the number of thrombolysis was 117.3 per million population or a thrombolysis rate of 11.4 per cent- proportion of ischaemic stroke patients that received thrombolysis.

Commenting Professor Joe Harbison, former National Clinical Lead for Stroke in Ireland and lead coordinator for Ireland on the ESO ESMINT survey, explained that Ireland’s thrombolysis rate was lower than the average reported but even within that, Ireland’s national figure was being pushed up by several high achieving or larger stroke units with larger volumes of patients.

“The figure in the report is 11.4 per cent but that it is being pushed up by a number of large units in Ireland. While it is lower than average, if you took the national average being 11.4 per cent and look at the number of hospitals that actually achieve 11.4 per cent, it is a good minority because they are typically larger hospitals. Some units in Ireland have thrombolysis rates of as low as 4 per cent,” he explained.

The ESO ESMINT Survey also found that the estimated average number of stroke units across the 44 countries was 2.9 per million inhabitants. The highest country rates were 9.2 and Ireland’s rate was 4.7 per million population.

Prof Harbison said that while on paper it looked like Ireland was doing very well in comparison with other countries in the number of stroke units, the reality was that acute stroke units in Ireland are frequently under staffed and under resourced.

“The [2016] National Stroke Audit showed that we had half the number of beds we needed, we haven’t opened a lot of beds since then and that was two years ago. So yes, we have got stroke units in most acute hospitals however, stroke units are not very well resourced. There are some hospitals that lack a stroke unit, or the stroke unit isn’t functioning at the level one would expect, and they are short of beds. The audit showed we had less stroke unit beds than Northern Ireland who have about one third of our population” Prof Harbison stated.

The ESO ESMINT survey also found that endovascular treatment or thombectomy was provided in 40/44 countries. The estimated average annual number of endovascular treatments was 37.1 per million inhabitants and 19.3 per 1000 annual incident strokes and the highest country rate were 111.5 and 55.9.

At 44.8 per million population Ireland’s thrombectomy rate was higher than average and it has further improved in the last two years.

Prof Harbison said that the thrombectomy service was dependent on two centres which was justifiable; one in Dublin and one in Cork. However, he added that it was also dependent on equipment that was beyond its replacement date.

Beaumont Hospital in Dublin is the only centre in the country that runs a 24/7 thrombectomy service

“Beaumont is doing by far the most work and that is dependent on a very small number of staff and critical equipment not breaking down. We are worried about the status of the imaging systems particularly in Beaumont because of the demands on it and its age.”

Commenting on the overall survey, one of the authors Professor Urs Fischer, Professor for Acute Neurology and Stroke at the University Hospital Bern in Germany, said up to 226,662 additional patients could be treated with intravenous thrombolysis and an additional 67,347 with endovascular treatment each year.

“Many stroke victims in Europe still have no access to acute stroke treatment,” he said.

According to Prof Fischer, these inequalities not only have a major impact on the patients, but also on their families and the socioeconomic burden.

“Recent studies have shown, that acute stroke treatment is highly cost effective – if you treat your patients right, you will not only improve the quality of life of the patient and his family, you will also save money for your society”.

He called for efforts to increase the number of stroke units, intravenous thrombolysis and endovascular stroke therapy.

Access to and delivery of acute ischaemic stroke treatments: A survey of national scientific societies and stroke experts in 44 European countries

European Stroke Journal

First Published July 20, 2018

https://doi.org/10.1177/2396987318786023