Patrice Lindsay

Stroke remains the second-leading cause of death and the third-leading cause of death and disability combined (as expressed by disability-adjusted life-years lost - DALYs) in the world. The estimated global cost of stroke is over US$721 billion (0.66% of the global GDP). From 1990 to 2019, the burden (in terms of the absolute number of cases) increased substantially (70.0% increase in incident strokes, 43.0% deaths from stroke, 102.0% prevalent strokes, and 143.0% DALYs), with the bulk of the global stroke burden (86.0% of deaths and 89.0% of DALYs) residing in lower-income and lower-middle-income countries (LMIC). This World Stroke Organisation (WSO) Global Stroke Fact Sheet 2022 provides the most updated information that can be used to inform communication with all internal and external stakeholders; all statistics have been reviewed and approved for use by the WSO Executive Committee as well as leaders from the Global Burden of Disease research group.

The Canadian Hypertension Education Program reviews the hypertension literature annually and provides detailed recommendations regarding hypertension diagnosis, assessment, prevention, and treatment. This report provides the updated evidence-based recommendations for 2015. This year, 4 new recommendations were added and 2 existing recommendations were modified. A revised algorithm for the diagnosis of hypertension is presented. Two major changes are proposed: (1) measurement using validated electronic (oscillometric) upper arm devices is preferred over auscultation for accurate office blood pressure measurement; (2) if the visit 1 mean blood pressure is increased but < 180/110 mm Hg, out-of-office blood pressure measurements using ambulatory blood pressure monitoring (preferably) or home blood pressure monitoring should be performed before visit 2 to rule out white coat hypertension, for which pharmacologic treatment is not recommended. A standardized ambulatory blood pressure monitoring protocol and an update on automated office blood pressure are also presented. Several other recommendations on accurate measurement of blood pressure and criteria for diagnosis of hypertension have been reorganized. Two other new recommendations refer to smoking cessation: (1) tobacco use status should be updated regularly and advice to quit smoking should be provided; and (2) advice in combination with pharmacotherapy for smoking cessation should be offered to all smokers. The following recommendations were modified: (1) renal artery stenosis should be primarily managed medically; and (2) renal artery angioplasty and stenting could be considered for patients with renal artery stenosis and complicated, uncontrolled hypertension. The rationale for these recommendation changes is discussed.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.

Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a β-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates.

Hypertension Canada’s 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

Every two seconds, someone across the globe suffers a symptomatic stroke. ‘Silent’ cerebrovascular disease insidiously contributes to worldwide disability by causing cognitive impairment in the elderly. The risk of cerebrovascular disease is disproportionately higher in low to middle income countries where there may be barriers to stroke care. The last two decades have seen a major transformation in the stroke field with the emergence of evidence-based approaches to stroke prevention, acute stroke management, and stroke recovery. The current challenge lies in implementing these interventions, particularly in regions with high incidences of stroke and limited healthcare resources. The Global Stroke Services Action Plan was conceived as a tool to identifying key elements in stroke care across a continuum of health models. At the minimal level of resource availability, stroke care delivery is based at a local clinic staffed predominantly by non-physicians. In this environment, laboratory tests and diagnostic studies are scarce, and much of the emphasis is placed on bedside clinical skills, teaching, and prevention. The essential services level offers access to a CT scan, physicians, and the potential for acute thrombolytic therapy, however stroke expertise may still be difficult to access. At the advanced stroke services level, multidisciplinary stroke expertise, multimodal imaging, and comprehensive therapies are available. A national plan for stroke care should incorporate local and regional strengths and build upon them. This clinical practice guideline is a synopsis of the core recommendations and quality indicators adapted from ten high quality multinational stroke guidelines. It can be used to establish the current level of stroke services, target goals for expanding stroke resources, and ensuring that all stages of stroke care are being adequately addressed, even at the advanced stroke services level. This document is a start, but there is more to be done, particularly in the realm of primary prevention. Despite differences in resource availability, the message we wish to convey is that stroke awareness, education, prevention, and treatment should always be feasible. Communities and institutions should set goals to continuously expand their stroke service capabilities. This document is intended to augment stroke advocacy efforts throughout the world, providing a strategic plan for optimizing stroke outcomes.

Herein, updated evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in Canadian adults are detailed. For 2014, 3 existing recommendations were modified and 2 new recommendations were added. The following recommendations were modified: (1) the recommended sodium intake threshold was changed from ≤ 1500 mg (3.75 g of salt) to approximately 2000 mg (5 g of salt) per day; (2) a pharmacotherapy treatment initiation systolic blood pressure threshold of ≥ 160 mm Hg was added in very elderly (age ≥ 80 years) patients who do not have diabetes or target organ damage (systolic blood pressure target in this population remains at < 150 mm Hg); and (3) the target population recommended to receive low-dose acetylsalicylic acid therapy for primary prevention was narrowed from all patients with controlled hypertension to only those ≥ 50 years of age. The 2 new recommendations are: (1) advice to be cautious when lowering systolic blood pressure to target levels in patients with established coronary artery disease if diastolic blood pressure is ≤ 60 mm Hg because of concerns that myocardial ischemia might be exacerbated; and (2) the addition of glycated hemoglobin (A1c) in the diagnostic work-up of patients with newly diagnosed hypertension. The rationale for these recommendation changes is discussed. In addition, emerging data on blood pressure targets in stroke patients are discussed; these data did not lead to recommendation changes at this time. The Canadian Hypertension Education Program recommendations will continue to be updated annually.

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care guideline highlights key elements involved in the initial assessment, stabilization, and treatment of patients with transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and acute venous sinus thrombosis. The most notable change in this 5th edition is the addition of new recommendations for the use of endovascular therapy for patients with acute ischemic stroke and proximal intracranial arterial occlusion. This includes an overview of the infrastructure and resources required for stroke centers that will provide endovascular therapy as well as regional structures needed to ensure that all patients with acute ischemic stroke that are eligible for endovascular therapy will be able to access this newly approved therapy; recommendations for hyperacute brain and enhanced vascular imaging using computed tomography angiography and computed tomography perfusion; patient selection criteria based on the five trials of endovascular therapy published in early 2015, and performance metric targets for important time-points involved in endovascular therapy, including computed tomography-to-groin puncture and computed tomography-to-reperfusion times. Other updates in this guideline include recommendations for improved time efficiencies for all aspects of hyperacute stroke care with a movement toward a new median target door-to-needle time of 30 min, with the 90th percentile being 60 min. A stronger emphasis is placed on increasing public awareness of stroke with the recent launch of the Heart and Stroke Foundation of Canada FAST signs of stroke campaign; reinforcing the public need to seek immediate medical attention by calling 911; further engagement of paramedics in the prehospital phase with prehospital notification to the receiving emergency department, as well as the stroke team, including neuroradiology; updates to the triage and same-day assessment of patients with transient ischemic attack; updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The goal of these recommendations and supporting materials is to improve efficiencies and minimize the absolute time lapse between stroke symptom onset and reperfusion therapy, which in turn leads to better outcomes and potentially shorter recovery times.

Background and Purpose— Value-based health care aims to bring together patients and health systems to maximize the ratio of quality over cost. To enable assessment of healthcare value in stroke management, an international standard set of patient-centered stroke outcome measures was defined for use in a variety of healthcare settings. Methods— A modified Delphi process was implemented with an international expert panel representing patients, advocates, and clinical specialists in stroke outcomes, stroke registers, global health, epidemiology, and rehabilitation to reach consensus on the preferred outcome measures, included populations, and baseline risk adjustment variables. Results— Patients presenting to a hospital with ischemic stroke or intracerebral hemorrhage were selected as the target population for these recommendations, with the inclusion of transient ischemic attacks optional. Outcome categories recommended for assessment were survival and disease control, acute complications, and patient-reported outcomes. Patient-reported outcomes proposed for assessment at 90 days were pain, mood, feeding, selfcare, mobility, communication, cognitive functioning, social participation, ability to return to usual activities, and health-related quality of life, with mobility, feeding, selfcare, and communication also collected at discharge. One instrument was able to collect most patient-reported subdomains (9/16, 56%). Minimum data collection for risk adjustment included patient demographics, premorbid functioning, stroke type and severity, vascular and systemic risk factors, and specific treatment/care-related factors. Conclusions— A consensus stroke measure Standard Set was developed as a simple, pragmatic method to increase the value of stroke care. The set should be validated in practice when used for monitoring and comparisons across different care settings.

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met. In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases. Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

Television advertising has been associated with significant increases in the knowledge of the warning signs of stroke among Ontarians aged 45 and older. However, to date there has been little data on the relationship between knowledge of the warning signs of stroke and behavior.Data on presentation to regional and enhanced district stroke center emergency departments were obtained from the Registry of the Canadian Stroke Network for a 31-month period between mid 2003 and the beginning of 2006. Public opinion polling was used to track knowledge of the warning signs of stroke among Ontarians aged 45 and older.The public's awareness of the warning signs of stroke increased during 2003 to 2005, decreasing in 2006 after a 5-month advertising blackout. There was a significant increase in the mean number of emergency department visits for stroke over the study period. A campaign effect independent of year was observed for total presentations, presentation within 5 hours of last seen normal, and presentation within 2.5 hours. For TIAs there was a strong campaign effect but no change in the number of presentations by year.Continuous advertising may be required to build and sustain public awareness of the warning signs of stroke. There are many factors that may influence presentation for stroke and awareness of the warning signs may be only one. However, results of this study suggest there may be an important correlation between the advertising and emergency department presentations with stroke, particularly for TIAs.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.

Each year more than 50,000 Canadians experience a stroke and more than 300,000 currently live with its effects. Despite the evidence supporting best practices in stroke care, significant gaps in translating this knowledge into action remains in Canada. An interdisciplinary working group of the Canadian Stroke Strategy was formed to develop best-practice recommendations relevant to Canadian health care. The working group used a rigorous process to develop the guidelines, which included reviewing existing stroke recommendations and research literature, and consulting a national interprofessional consensus panel. The Canadian Best Practice Recommendations for Stroke Care consist of 24 recommendations based on the strongest evidence and address topics that span the full continuum of stroke care. Implementation and dissemination of these recommendations is in progress. Bringing about change will require political will and collaboration throughout the health care system.

To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009.For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease.A Cochrane collaboration librarian conducted an independent MEDLINE search from 2007 to August 2008 to update the 2008 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence.For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered.All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

The large and increasing burden of stroke in Latin American countries, and the need to meet the UN and WHO requirements for reducing the burden from non-communicable disorders (including stroke), brought together stroke experts and representatives of the Ministries of Health of 13 Latin American countries for the 1st Latin American Stroke Ministerial meeting in Gramado, Brazil, to discuss the problem and identify ways of cooperating to reduce the burden of stroke in the region. Discussions were focused on the regional and country-specific activities associated with stroke prevention and treatment, including public stroke awareness, prevention strategies, delivery and organisation of care, clinical practice gaps, and unmet needs. The meeting culminated with the adoption of the special Gramado Declaration, signed by all Ministerial officials who attended the meeting. With agreed priorities for stroke prevention, treatment, and research, an opportunity now exists to translate this Declaration into an action plan to reduce the burden of stroke.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals, and the evidence suggests one-third or more will experience vascular-cognitive impairment, and/or intractable fatigue, either alone or in combination. The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. The three consequences of stroke that are the focus of the this guideline (poststroke depression, vascular cognitive impairment, and fatigue) have high incidence rates and significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes. Significant practice variations and gaps in the research evidence have been reported for initial screening and in-depth assessment of stroke patients for these conditions. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact patient recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community. Additionally, building system capacity to ensure access to appropriate specialists for treatment and ongoing management of stroke survivors with these conditions is another great challenge.

The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention, the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

To develop and apply a systematic approach to identify and define valid, relevant, and feasible measures of emergency department (ED) clinical performance.An extensive literature review was conducted to identify clinical conditions frequently treated in most EDs, and clinically relevant outcomes to evaluate these conditions. Based on this review, a set of condition-outcome pairs was defined. An expert panel was convened and a Modified-Delphi process was used to identify specific condition-outcome pairs where the panel felt there was a link between quality of care for the condition and a specific outcome. Next, for highly rated condition-outcome pairs, specific measurable indicators were identified in the literature. The panelists rated these indicators on their relevance to ED performance and need for risk adjustment. The feasibility of calculating these indicators was determined by applying them to a routinely collected data set.Thirteen clinical conditions and eight quality-of-care outcomes (mortality, morbidity, admissions, recurrent visits, follow-up with primary care, length of stay, diagnostics, and resource use) were identified from the literature (104 pairs). The panel selected 21 condition-outcome pairs, representing eight of 13 clinical conditions. Then, the panel selected 29 specific clinical indicators, representing the condition-outcome pairs, to measure ED performance. It was possible to calculate eight of these indicators, covering five clinical conditions, using a routinely collected data set.Using a Modified-Delphi process, it was possible to identify a series of condition-outcome pairs that panelists felt were potentially related to ED quality of care, then define specific indicators for many of these condition-outcome pairs. Some indicators could be measured using an existing data set. The development of sound clinical performance indicators for the ED is possible, but the feasibility of measuring them will be dependent on the availability and accessibility of high-quality data.

HomeStrokeVol. 46, No. 6New Strategy to Reduce the Global Burden of Stroke Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBNew Strategy to Reduce the Global Burden of Stroke Valery L. Feigin, MD, PhD, Rita Krishnamurthi, PhD, Rohit Bhattacharjee, MPH, Priya Parmar, MSc, Alice Theadom, PhD, Tasleem Hussein, BSc, Mitali Purohit, MBioEnt, Patria Hume, PhD, Max Abbott, PhD, Elaine Rush, PhD, Nikola Kasabov, PhD, Ineke Crezee, PhD, Stanley Frielick, PhD, Suzanne Barker-Collo, PhD, P. Alan Barber, MD, PhD, Bruce Arroll, MBChB, PhD, Richie Poulton, PhD, Yogini Ratnasabathy, MD, MSc, Martin Tobias, MBBCh, Norberto Cabral, MD, MSc, PhD, Sheila C.O. Martins, MD, PhD, Luis E.T.A. Furtado, MD, Patrice Lindsay, PhD, Gustavo Saposnik, MD, MSc, Maurice Giroud, MD, PhD, Yannick Béjot, MD, PhD, Werner Hacke, MD, PhD, Man Mohan Mehndiratta, MD, DM, Jeyaraj Durai Pandian, MD, DM, Sanjeev Gupta, MPT (MS), BPT, Vasantha Padma, MD, Dipes Kumar Mandal, MD, DM, Yoshihiro Kokubo, MD, PhD, Norlinah Mohamed Ibrahim, MBBCH, MRCP, Ramesh Sahathevan, PhD, Hua Fu, MB, PhD, Wenzhi Wang, PhD, Liping Liu, MD, Zeng-Guang Hou, PhD, António Freire Goncalves, MD, PhD, Manuel Correia, MD, Yury Varakin, MD, PhD, Michael Kravchenko, PhD, Michael Piradov, MD, PhD, Mohammed Saadah, MD, Amanda G. Thrift, PhD, Dominique Cadilhac, PhD, Stephen Davis, MD, PhD, Geoffrey Donnan, MD, PhD, Alan D. Lopez, PhD, Graeme J. Hankey, MD, PhD, Annick Maujean, PhD, Elizabeth Kendall, PhD, Michael Brainin, MD, Foad Abd-Allah, MD, Natan M. Bornstein, MD, Valeria Caso, MD, PhD, Juan Manuel Marquez-Romero, MD, MSc, Rufus O. Akinyemi, PhD, Nasser F. Bin Dhim, PhD, Bo Norrving, MD, Shireen Sindi, PhD, Miia Kivipelto, MD, PhD, Shanthi Mendis, PhD, M. Arfan Ikram, MD, PhD, Albert Hofman, MD, PhD, Saira Saeed Mirza, MD, MSc, Peter M. Rothwell, FMedSci, Peter Sandercock, MA, DM, Raad Shakir, MD, Ralph L. Sacco, MD, MS, Antonio Culebras, MD, Gregory A. Roth, MD, MPH, Maziar Moradi-Lakeh, MD, MPH, Christopher Murray, PhD, K.M. Venkat Narayan, MD, George A. Mensah, MD, David Wiebers, MD, PhD and Andrew E. Moran, MDRIBURST Study Collaboration Writing Group Valery L. FeiginValery L. Feigin From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies (V.L.F., R.K., R.B., P.P., A.T.), Faculty of Health and Environmental Sciences (P.H., M.A., E.R.), Information Technology (T.H.), Research and Innovation Office (M.P.), Knowledge Engineering and Discovery Research Institute (N.K.), Translation and Interpreting Department (I.C.), and Centre for Learing and Teaching (S.F.), Auckland University of Technology, Auckland, New Zealand; School of Psychology, University of Auckland, Auckland, New Zealand (S.B.-C.); Department of Neurology, University of Auckland, Auckland, New Zealand (P.A.B.); School of Public Health, University of Auckland, Auckland, New Zealand (B.A.); Department of Preventive and Social Medicine, Otago University, Dunedin, New Zealand (R.P.); Older People Care, Waitemata DHB, Auckland, New Zealand (Y.R.); Health Intelligence, Ministry of Health, Wellington, New Zealand (M.T.); Joinville Stroke Register, University of Joinville Region, Joinville, Brazil (N.C.); Hospital de Clinicas de Porto Alegre, Hospital Moinhos de Vento, Ministry of Health, Brazil (S.C.O.M.); Department of Neurology, Universidade Federal do Ceará, Sobral-Ceará, Brazil (L.E.T.A.F.); Stroke Foundation of Canada, Ottawa, Canada (P.L.); Department of Medicine and Health Policy, Management and Evaluation University of Toronto, Toronto, Canada (G.S.); Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (M.G., Y.B.); Department of Neurology, Ruprecht Karl University Heidelberg, Heidelberg, Germany (W.H.); Janakpuri Super Speciality Hospital, New Delhi, India (M.M.M.); Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.); Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi, India (S.G.); All India Institute of Medical Sciences, New Delhi, India (V.P.); Stroke Foundation of Bengal, Kolkata, West Bengal, India (D.K.M.); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan (Y.K.); UKM Medical Center, Kuala Lumpur, Malaysia (N.M.I., R.S.); School of Public Health, Fudan University, Shanghai, China (H.F.); Beijing Neurosurgical Institute, Beijing, China (W.W.); Capital Medical University, Beijing, China (L.L.); Institute of Automation, Beijing, China (Z.-G.H.); University Hospital of Coimbra, Coimbra, Portugal (A.F.G.); Serviço de Neurologia, Hospital de Santo Antóni, Portugal (M.C.); Research Center of Neurology, Moscow, Russia (Y.V., M.K., M.P.); University of Emirates, Abu-Dhabi, United Arab Emirates (M.S.); Department of Medicine, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); The Royal Melbourne Hospital (S.D.), Florey Institute of Neuroscience and Mental Health (G.D.), and Public Health (A.D.L.), University of Melbourne, Parkville, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (G.J.H.); Griffith University, Brisbane, Australia (A.M., E.K.); Center for Clinical Neurosciences, Danube University, Vienna, Austria (M.B.); Cairo University, Cairo, Egypt (F.A.-A.); Tel Aviv Sourasky Medical Center, Neurology Department, Tel-Aviv University, Tel-Aviv, Israel (N.M.B.); Stroke Unit, Perugia, Perugia, Italy (V.C.); HGZ 2, IMSS Aguascalientes, Aguascalientes, Mexico (J.M.M.-R.); Federal Medical Centre Abeokuta, Abeokuta, Nigeria (R.O.A.); Health Informatics Department, Saudi Electronic University, Saudi Arabia (N.F.B.D.); Department of Neurology, Lund University, Lund, Sweden (B.N.); Department of Epidemiology (S.S.) and Aging Research Center, Center for Alzheimer Research (M.K.), Karolinska Institutet, Stockholm, Sweden; Noncommunicable Diseases, World Health Organization, Geneva, Switzerland (S.M.); Erasmus University Medical Center, Rotterdam, The Netherlands (M.A.I., A.H., S.S.M.); Nuffield Department of Neuroscience, Oxford University, Oxford, United Kingdom (P.M.R.); Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Neurology, Imperial College NHS Trust, London, United Kingdom (R.S.); Department of Neurology, Miller School of Medicine, University of Miami (R.L.S.); Department of Neurology, SUNY Upstate Medical University, Syracuse, NY (A.C.); Division of Cardiology, Department of Medicine (G.A.R.), Institute for Health Metrics and Evaluation (G.A.R., M.M.-L., C.M.), University of Washington, Seattle; Emory University, Atlanta, GA (K.M.V.N.); Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Neurology, Mayo Clinic, Rochester, MN (D.W.); and Division of General Medicine, Columbia University Medical Center, NY (A.E.M.). , Rita KrishnamurthiRita Krishnamurthi From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies (V.L.F., R.K., R.B., P.P., A.T.), Faculty of Health and Environmental Sciences (P.H., M.A., E.R.), Information Technology (T.H.), Research and Innovation Office (M.P.), Knowledge Engineering and Discovery Research Institute (N.K.), Translation and Interpreting Department (I.C.), and Centre for Learing and Teaching (S.F.), Auckland University of Technology, Auckland, New Zealand; School of Psychology, University of Auckland, Auckland, New Zealand (S.B.-C.); Department of Neurology, University of Auckland, Auckland, New Zealand (P.A.B.); School of Public Health, University of Auckland, Auckland, New Zealand (B.A.); Department of Preventive and Social Medicine, Otago University, Dunedin, New Zealand (R.P.); Older People Care, Waitemata DHB, Auckland, New Zealand (Y.R.); Health Intelligence, Ministry of Health, Wellington, New Zealand (M.T.); Joinville Stroke Register, University of Joinville Region, Joinville, Brazil (N.C.); Hospital de Clinicas de Porto Alegre, Hospital Moinhos de Vento, Ministry of Health, Brazil (S.C.O.M.); Department of Neurology, Universidade Federal do Ceará, Sobral-Ceará, Brazil (L.E.T.A.F.); Stroke Foundation of Canada, Ottawa, Canada (P.L.); Department of Medicine and Health Policy, Management and Evaluation University of Toronto, Toronto, Canada (G.S.); Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (M.G., Y.B.); Department of Neurology, Ruprecht Karl University Heidelberg, Heidelberg, Germany (W.H.); Janakpuri Super Speciality Hospital, New Delhi, India (M.M.M.); Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.); Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi, India (S.G.); All India Institute of Medical Sciences, New Delhi, India (V.P.); Stroke Foundation of Bengal, Kolkata, West Bengal, India (D.K.M.); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan (Y.K.); UKM Medical Center, Kuala Lumpur, Malaysia (N.M.I., R.S.); School of Public Health, Fudan University, Shanghai, China (H.F.); Beijing Neurosurgical Institute, Beijing, China (W.W.); Capital Medical University, Beijing, China (L.L.); Institute of Automation, Beijing, China (Z.-G.H.); University Hospital of Coimbra, Coimbra, Portugal (A.F.G.); Serviço de Neurologia, Hospital de Santo Antóni, Portugal (M.C.); Research Center of Neurology, Moscow, Russia (Y.V., M.K., M.P.); University of Emirates, Abu-Dhabi, United Arab Emirates (M.S.); Department of Medicine, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); The Royal Melbourne Hospital (S.D.), Florey Institute of Neuroscience and Mental Health (G.D.), and Public Health (A.D.L.), University of Melbourne, Parkville, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (G.J.H.); Griffith University, Brisbane, Australia (A.M., E.K.); Center for Clinical Neurosciences, Danube University, Vienna, Austria (M.B.); Cairo University, Cairo, Egypt (F.A.-A.); Tel Aviv Sourasky Medical Center, Neurology Department, Tel-Aviv University, Tel-Aviv, Israel (N.M.B.); Stroke Unit, Perugia, Perugia, Italy (V.C.); HGZ 2, IMSS Aguascalientes, Aguascalientes, Mexico (J.M.M.-R.); Federal Medical Centre Abeokuta, Abeokuta, Nigeria (R.O.A.); Health Informatics Department, Saudi Electronic University, Saudi Arabia (N.F.B.D.); Department of Neurology, Lund University, Lund, Sweden (B.N.); Department of Epidemiology (S.S.) and Aging Research Center, Center for Alzheimer Research (M.K.), Karolinska Institutet, Stockholm, Sweden; Noncommunicable Diseases, World Health Organization, Geneva, Switzerland (S.M.); Erasmus University Medical Center, Rotterdam, The Netherlands (M.A.I., A.H., S.S.M.); Nuffield Department of Neuroscience, Oxford University, Oxford, United Kingdom (P.M.R.); Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Neurology, Imperial College NHS Trust, London, United Kingdom (R.S.); Department of Neurology, Miller School of Medicine, University of Miami (R.L.S.); Department of Neurology, SUNY Upstate Medical University, Syracuse, NY (A.C.); Division of Cardiology, Department of Medicine (G.A.R.), Institute for Health Metrics and Evaluation (G.A.R., M.M.-L., C.M.), University of Washington, Seattle; Emory University, Atlanta, GA (K.M.V.N.); Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Neurology, Mayo Clinic, Rochester, MN (D.W.); and Division of General Medicine, Columbia University Medical Center, NY (A.E.M.). , Rohit BhattacharjeeRohit Bhattacharjee From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies (V.L.F., R.K., R.B., P.P., A.T.), Faculty of Health and Environmental Sciences (P.H., M.A., E.R.), Information Technology (T.H.), Research and Innovation Office (M.P.), Knowledge Engineering and Discovery Research Institute (N.K.), Translation and Interpreting Department (I.C.), and Centre for Learing and Teaching (S.F.), Auckland University of Technology, Auckland, New Zealand; School of Psychology, University of Auckland, Auckland, New Zealand (S.B.-C.); Department of Neurology, University of Auckland, Auckland, New Zealand (P.A.B.); School of Public Health, University of Auckland, Auckland, New Zealand (B.A.); Department of Preventive and Social Medicine, Otago University, Dunedin, New Zealand (R.P.); Older People Care, Waitemata DHB, Auckland, New Zealand (Y.R.); Health Intelligence, Ministry of Health, Wellington, New Zealand (M.T.); Joinville Stroke Register, University of Joinville Region, Joinville, Brazil (N.C.); Hospital de Clinicas de Porto Alegre, Hospital Moinhos de Vento, Ministry of Health, Brazil (S.C.O.M.); Department of Neurology, Universidade Federal do Ceará, Sobral-Ceará, Brazil (L.E.T.A.F.); Stroke Foundation of Canada, Ottawa, Canada (P.L.); Department of Medicine and Health Policy, Management and Evaluation University of Toronto, Toronto, Canada (G.S.); Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (M.G., Y.B.); Department of Neurology, Ruprecht Karl University Heidelberg, Heidelberg, Germany (W.H.); Janakpuri Super Speciality Hospital, New Delhi, India (M.M.M.); Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.); Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi, India (S.G.); All India Institute of Medical Sciences, New Delhi, India (V.P.); Stroke Foundation of Bengal, Kolkata, West Bengal, India (D.K.M.); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan (Y.K.); UKM Medical Center, Kuala Lumpur, Malaysia (N.M.I., R.S.); School of Public Health, Fudan University, Shanghai, China (H.F.); Beijing Neurosurgical Institute, Beijing, China (W.W.); Capital Medical University, Beijing, China (L.L.); Institute of Automation, Beijing, China (Z.-G.H.); University Hospital of Coimbra, Coimbra, Portugal (A.F.G.); Serviço de Neurologia, Hospital de Santo Antóni, Portugal (M.C.); Research Center of Neurology, Moscow, Russia (Y.V., M.K., M.P.); University of Emirates, Abu-Dhabi, United Arab Emirates (M.S.); Department of Medicine, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); The Royal Melbourne Hospital (S.D.), Florey Institute of Neuroscience and Mental Health (G.D.), and Public Health (A.D.L.), University of Melbourne, Parkville, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (G.J.H.); Griffith University, Brisbane, Australia (A.M., E.K.); Center for Clinical Neurosciences, Danube University, Vienna, Austria (M.B.); Cairo University, Cairo, Egypt (F.A.-A.); Tel Aviv Sourasky Medical Center, Neurology Department, Tel-Aviv University, Tel-Aviv, Israel (N.M.B.); Stroke Unit, Perugia, Perugia, Italy (V.C.); HGZ 2, IMSS Aguascalientes, Aguascalientes, Mexico (J.M.M.-R.); Federal Medical Centre Abeokuta, Abeokuta, Nigeria (R.O.A.); Health Informatics Department, Saudi Electronic University, Saudi Arabia (N.F.B.D.); Department of Neurology, Lund University, Lund, Sweden (B.N.); Department of Epidemiology (S.S.) and Aging Research Center, Center for Alzheimer Research (M.K.), Karolinska Institutet, Stockholm, Sweden; Noncommunicable Diseases, World Health Organization, Geneva, Switzerland (S.M.); Erasmus University Medical Center, Rotterdam, The Netherlands (M.A.I., A.H., S.S.M.); Nuffield Department of Neuroscience, Oxford University, Oxford, United Kingdom (P.M.R.); Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Neurology, Imperial College NHS Trust, London, United Kingdom (R.S.); Department of Neurology, Miller School of Medicine, University of Miami (R.L.S.); Department of Neurology, SUNY Upstate Medical University, Syracuse, NY (A.C.); Division of Cardiology, Department of Medicine (G.A.R.), Institute for Health Metrics and Evaluation (G.A.R., M.M.-L., C.M.), University of Washington, Seattle; Emory University, Atlanta, GA (K.M.V.N.); Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Neurology, Mayo Clinic, Rochester, MN (D.W.); and Division of General Medicine, Columbia University Medical Center, NY (A.E.M.). , Priya ParmarPriya Parmar From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies (V.L.F., R.K., R.B., P.P., A.T.), Faculty of Health and Environmental Sciences (P.H., M.A., E.R.), Information Technology (T.H.), Research and Innovation Office (M.P.), Knowledge Engineering and Discovery Research Institute (N.K.), Translation and Interpreting Department (I.C.), and Centre for Learing and Teaching (S.F.), Auckland University of Technology, Auckland, New Zealand; School of Psychology, University of Auckland, Auckland, New Zealand (S.B.-C.); Department of Neurology, University of Auckland, Auckland, New Zealand (P.A.B.); School of Public Health, University of Auckland, Auckland, New Zealand (B.A.); Department of Preventive and Social Medicine, Otago University, Dunedin, New Zealand (R.P.); Older People Care, Waitemata DHB, Auckland, New Zealand (Y.R.); Health Intelligence, Ministry of Health, Wellington, New Zealand (M.T.); Joinville Stroke Register, University of Joinville Region, Joinville, Brazil (N.C.); Hospital de Clinicas de Porto Alegre, Hospital Moinhos de Vento, Ministry of Health, Brazil (S.C.O.M.); Department of Neurology, Universidade Federal do Ceará, Sobral-Ceará, Brazil (L.E.T.A.F.); Stroke Foundation of Canada, Ottawa, Canada (P.L.); Department of Medicine and Health Policy, Management and Evaluation University of Toronto, Toronto, Canada (G.S.); Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (M.G., Y.B.); Department of Neurology, Ruprecht Karl University Heidelberg, Heidelberg, Germany (W.H.); Janakpuri Super Speciality Hospital, New Delhi, India (M.M.M.); Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.); Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi, India (S.G.); All India Institute of Medical Sciences, New Delhi, India (V.P.); Stroke Foundation of Bengal, Kolkata, West Bengal, India (D.K.M.); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan (Y.K.); UKM Medical Center, Kuala Lumpur, Malaysia (N.M.I., R.S.); School of Public Health, Fudan University, Shanghai, China (H.F.); Beijing Neurosurgical Institute, Beijing, China (W.W.); Capital Medical University, Beijing, China (L.L.); Institute of Automation, Beijing, China (Z.-G.H.); University Hospital of Coimbra, Coimbra, Portugal (A.F.G.); Serviço de Neurologia, Hospital de Santo Antóni, Portugal (M.C.); Research Center of Neurology, Moscow, Russia (Y.V., M.K., M.P.); University of Emirates, Abu-Dhabi, United Arab Emirates (M.S.); Department of Medicine, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); The Royal Melbourne Hospital (S.D.), Florey Institute of Neuroscience and Mental Health (G.D.), and Public Health (A.D.L.), University of Melbourne, Parkville, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (G.J.H.); Griffith University, Brisbane, Australia (A.M., E.K.); Center for Clinical Neurosciences, Danube University, Vienna, Austria (M.B.); Cairo University, Cairo, Egypt (F.A.-A.); Tel Aviv Sourasky Medical Center, Neurology Department, Tel-Aviv University, Tel-Aviv, Israel (N.M.B.); Stroke Unit, Perugia, Perugia, Italy (V.C.); HGZ 2, IMSS Aguascalientes, Aguascalientes, Mexico (J.M.M.-R.); Federal Medical Centre Abeokuta, Abeokuta, Nigeria (R.O.A.); Health Informatics Department, Saudi Electronic University, Saudi Arabia (N.F.B.D.); Department of Neurology, Lund University, Lund, Sweden (B.N.); Department of Epidemiology (S.S.) and Aging Research Center, Center for Alzheimer Research (M.K.), Karolinska Institutet, Stockholm, Sweden; Noncommunicable Diseases, World Health Organization, Geneva, Switzerland (S.M.); Erasmus University Medical Center, Rotterdam, The Netherlands (M.A.I., A.H., S.S.M.); Nuffield Department of Neuroscience, Oxford University, Oxford, United Kingdom (P.M.R.); Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Neurology, Imperial College NHS Trust, London, United Kingdom (R.S.); Department of Neurology, Miller School of Medicine, University of Miami (R.L.S.); Department of Neurology, SUNY Upstate Medical University, Syracuse, NY (A.C.); Division of Cardiology, Department of Medicine (G.A.R.), Institute for Health Metrics and Evaluation (G.A.R., M.M.-L., C.M.), University of Washington, Seattle; Emory University, Atlanta, GA (K.M.V.N.); Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Neurology, Mayo Clinic, Rochester, MN (D.W.); and Division of General Medicine, Columbia University Medical Center, NY (A.E.M.). , Alice TheadomAlice Theadom From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies (V.L.F., R.K., R.B., P.P., A.T.), Faculty of Health and Environmental Sciences (P.H., M.A., E.R.), Information Technology (T.H.), Research and Innovation Office (M.P.), Knowledge Engineering and Discovery Research Institute (N.K.), Translation and Interpreting Department (I.C.), and Centre for Learing and Teaching (S.F.), Auckland University of Technology, Auckland, New Zealand; School of Psychology, University of Auckland, Auckland, New Zealand (S.B.-C.); Department of Neurology, University of Auckland, Auckland, New Zealand (P.A.B.); School of Public Health, University of Auckland, Auckland, New Zealand (B.A.); Department of Preventive and Social Medicine, Otago University, Dunedin, New Zealand (R.P.); Older People Care, Waitemata DHB, Auckland, New Zealand (Y.R.); Health Intelligence, Ministry of Health, Wellington, New Zealand (M.T.); Joinville Stroke Register, University of Joinville Region, Joinville, Brazil (N.C.); Hospital de Clinicas de Porto Alegre, Hospital Moinhos de Vento, Ministry of Health, Brazil (S.C.O.M.); Department of Neurology, Universidade Federal do Ceará, Sobral-Ceará, Brazil (L.E.T.A.F.); Stroke Foundation of Canada, Ottawa, Canada (P.L.); Department of Medicine and Health Policy, Management and Evaluation University of Toronto, Toronto, Canada (G.S.); Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (M.G., Y.B.); Department of Neurology, Ruprecht Karl University Heidelberg, Heidelberg, Germany (W.H.); Janakpuri Super Speciality Hospital, New Delhi, India (M.M.M.); Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.); Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi, India (S.G.); All India Institute of Medical Sciences, New Delhi, India (V.P.); Stroke Foundation of Bengal, Kolkata, West Bengal, India (D.K.M.); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan (Y.K.); UKM Medical Center, Kuala Lumpur, Malaysia (N.M.I., R.S.); School of Public Health, Fudan University, Shanghai, China (H.F.); Beijing Neurosurgical Institute, Beijing, China (W.W.); Capital Medical University, Beijing, China (L.L.); Institute of Automation, Beijing, China (Z.-G.H.); University Hospital of Coimbra, Coimbra, Portugal (A.F.G.); Serviço de Neurologia, Hospital de Santo Antóni, Portugal (M.C.); Research Center of Neurology, Moscow, Russia (Y.V., M.K., M.P.); University of Emirates, Abu-Dhabi, United Arab Emirates (M.S.); Department of Medicine, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); The Royal Melbourne Hospital (S.D.), Florey Institute of Neuroscience and Mental Health (G.D.), and Public Health (A.D.L.), University of Melbourne, Parkville, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (G.J.H.); Griffith University, Brisbane, Australia (A.M., E.K.); Center for Clinical Neurosciences, Danube University, Vienna, Austria (M.B.); Cairo University, Cairo, Egypt (F.A.-A.); Tel Aviv Sourasky Medical Center, Neurology Department, Tel-Aviv University, Tel-Aviv, Israel (N.M.B.); Stroke Unit, Perugia, Perugia, Italy (V.C.); HGZ 2, IMSS Aguascalientes, Aguascalientes, Mexico (J.M.M.-R.); Federal Medical Centre Abeokuta, Abeokuta, Nigeria (R.O.A.); Health Informatics Department, Saudi Electronic University, Saudi Arabia (N.F.B.D.); Department of Neurology, Lund University, Lund, Sweden (B.N.); Department of Epidemiology (S.S.) and Aging Research Center, Center for Alzheimer Research (M.K.), Karolinska Institutet, Stockholm, Sweden; Noncommunicable Diseases, World Health Organization, Geneva, Switzerland (S.M.); Erasmus University Medical Center, Rotterdam, The Netherlands (M.A.I., A.H., S.S.M.); Nuffield Department of Neuroscience, Oxford University, Oxford, United Kingdom (P.M.R.); Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Neurology, Imperial College NHS Trust, London, United Kingdom (R.S.); Department of Neurology, Miller School of Medicine, University of Miami (R.L.S.); Department of Neurology, SUNY Upstate Medical University, Syracuse, NY (A.C.); Division of Cardiology, Department of Medicine (G.A.R.), Institute for Health Metrics and Evaluation (G.A.R., M.M.-L., C.M.), University of Washington, Seattle; Emory University, Atlanta, GA (K.M.V.N.); Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Neurology, Mayo Clinic, Rochester, MN (D.W.); and Division of General Medicine, Columbia University Medical Center, NY (A.E.M.). , Tasleem HusseinTasleem Hussein From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies (V.L.F., R.K., R.B., P.P., A.T.), Faculty of Health and Environmental Sciences (P.H., M.A., E.R.), Information Technology (T.H.), Research and Innovation Office (M.P.), Knowledge Engineering and Discovery Research Institute (N.K.), Translation and Interpreting Department (I.C.), and Centre for Learing and Teaching (S.F.), Auckland University of Technology, Auckland, New Zealand; School of Psychology, University of Auckland, Auckland, New Zealand (S.B.-C.); Department of Neurology, University of Auckland, Auckland, New Zealand (P.A.B.); School of Public Health, University of Auckland, Auckland, New Zealand (B.A.); Department of Preventive and Social Medicine, Otago University, Dunedin, New Zealand (R.P.); Older People Care, Waitemata DHB, Auckland, New Zealand (Y.R.); Health Intelligence, Ministry of Health, Wellington, New Zealand (M.T.); Joinville Stroke Register, University of Joinville Region, Joinville, Brazil (N.C.); Hospital de Clinicas de Porto Alegre, Hospital Moinhos de Vento, Ministry of Health, Brazil (S.C.O.M.); Department of Neurology, Universidade Federal do Ceará, Sobral-Ceará, Brazil (L.E.T.A.F.); Stroke Foundation of Canada, Ottawa, Canada (P.L.); Department of Medicine and Health Policy, Management and Evaluation University of Toronto, Toronto, Canada (G.S.); Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (M.G., Y.B.); Department of Neurology, Ruprecht Karl University Heidelberg, Heidelberg, Germany (W.H.); Janakpuri Super Speciality Hospital, New Delhi, India (M.M.M.); Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.); Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi, India (S.G.); All India Institute of Medical Sciences, New Delhi, India (V.P.); Stroke Foundation of Bengal, Kolkata, West Bengal, India (D.K.M.); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan (Y.K.); UKM Medical Center, Kuala Lumpur, Malaysia (N.M.I., R.S.); School of Public Health, Fudan University, Shanghai, China (H.F.); Beijing Neurosurgical Institute, Beijing, China (W.W.); Capital Medical University, Beijing, China (L.L.); Institute of Automation, Beijing, China (Z.-G.H.); University Hospital of Coimbra, Coimbra, Portugal (A.F.G.); Serviço de Neurologia, Hospital de Santo Antóni, Portugal (M.C.); Research Center of Neurology, Moscow, Russia (Y.V., M.K., M.P.); University of Emirates, Abu-Dhabi, United Arab Emirates (M.S.); Department of Medicine, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); The Royal Melbourne Hospital (S.D.), Florey Institute of Neuroscience and Mental Health (G.D.), and Public Health (A.D.L.), University of Melbourne, Parkville, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia (G.J.H.); Griffith University, Brisbane, Australia (A.M., E.K.); Center for Clinical Neurosciences, Danube University, Vienna, Austria (M.B.); Cairo University, Cairo, Egypt (F.A.-A.); Tel Aviv Sourasky Medical Center, Neurology Department, Tel-Aviv University, Tel-Aviv, Israel (N.M.B.); Stroke Unit, Perugia, Perugia, Italy (V.C.); HGZ 2, IMSS Aguascalientes, Aguascalientes, Mexico (J.M.M.-R.); Federal Medical Centre Abeokuta,

<h3>Objective:</h3> To evaluate the association between the presence of integrated systems of stroke care and stroke case-fatality across Canada. <h3>Methods:</h3> We used the Canadian Institute of Health Information9s Discharge Abstract Database to retrospectively identify a cohort of stroke/TIA patients admitted to all acute care hospitals, excluding the province of Quebec, in 11 fiscal years from 2003/2004 to 2013/2014. We used a modified Poisson regression model to compute the adjusted incidence rate ratio (aIRR) of 30-day in-hospital mortality across time for provinces with stroke systems compared to those without, controlling for age, sex, stroke type, comorbidities, and discharge year. We conducted surveys of stroke care resources in Canadian hospitals in 2009 and 2013, and compared resources in provinces with integrated systems to those without. <h3>Results:</h3> A total of 319,972 patients were hospitalized for stroke/TIA. The crude 30-day mortality rate decreased from 15.8% in 2003/2004 to 12.7% in 2012/2013 in provinces with stroke systems, while remaining 14.5% in provinces without such systems. Starting with the fiscal year 2009/2010, there was a clear reduction in relative mortality in provinces with stroke systems vs those without, sustained at aIRR of 0.85 (95% confidence interval 0.79–0.92) in the 2011/2012, 2012/2013, and 2013/2014 fiscal years. The surveys indicated that facilities in provinces with such systems were more likely to care for patients on a stroke unit, and have timely access to a stroke prevention clinic and telestroke services. <h3>Conclusion:</h3> In this retrospective study, the implementation of integrated systems of stroke care was associated with a population-wide reduction in mortality after stroke.

The Guidelines International Network (G-I-N) aims to promote high quality clinical guideline development and implementation. Guideline-based performance measures are a key implementation tool and are widely used internationally for quality improvement, quality assurance, and pay for performance in health care. There is, however, no international consensus on best methods for guideline-based performance measures. In order to address this issue, the G-I-N Performance Measures Working Group aimed to develop a set of consensus-based reporting standards for guideline-based performance measure development and re-evaluation.Methodology publications on guideline-based performance measures were identified from a systematic literature review and analyzed. Core criteria for the development and evaluation process of guideline-based performance measures were determined and refined into draft standards with an associated rationale and description of the evidence base. In a two-round Delphi-process, the group members appraised and approved the draft standards. After the first round, the group met to discuss comments and revised the drafts accordingly.Twenty-one methodology publications were reviewed. The group reached strong consensus on nine reporting standards concerning: (1) selection of clinical guidelines, (2) extraction of clinical guideline recommendations, (3) description of the measure development process, (4) measure appraisal, (5) measure specification, (6) description of the intended use of the measure, (7) measure testing/validating, (8) measure review/re-evaluation, and (9) composition of the measure development panel.These proposed international reporting standards address core components of guideline-based performance measure development and re-evaluation. They are intended to contribute to international reporting harmonization and improvement of methods for performance measures. Further research is required regarding validity, acceptability, and practicality.

Background. In 2005, a prehospital stroke screening tool was implemented in Toronto, Ontario, Canada. Patients identified by paramedics through the use of this tool in the field were transported to a regional stroke center under an acute stroke protocol. Objective. To determine the positive predictive value (PPV) of the Ontario Prehospital Stroke Screening Tool for identification of acute stroke at a single stroke center. Methods. We conducted a retrospective analysis of consecutive patients transported to a regional stroke center under the prehospital acute stroke protocol over a 12-month period. Final diagnoses, treatments, andoutcomes were abstracted from a provincial registry. Rates of fibrinolysis were compared with those for the 12-month period prior to implementation of the stroke protocol. Results. Three hundred twenty-five patients were triaged under the emergency medical services (EMS) acute stroke protocol over the study period. The PPV of the screening tool was 89.5% (95% confidence interval [CI]: 85.7–92.7%) for acute stroke. Thirty-four patients (11%) had nonstroke conditions, with the most common being seizure (4%). The rate of administration of tissue plasminogen activator (tPA) for all patients with suspected stroke increased from 5.9% to 10.1% (p = 0.04) compared with the rate in the 12-month period prior to implementation of the acute stroke protocol. The tPA rate for patients arriving under the stroke protocol was 17.2%. Most patients (75%) receiving tPA arrived from outside the hospital catchment area. Conclusions. In this preliminary study, the Ontario Prehospital Stroke Screening Tool had a high PPV for acute stroke andappeared to be effective for identifying patients who required triage to a single regional stroke center. Following implementation of a citywide acute stroke protocol using this screening tool, we observed an increase in the number of patients who were eligible for andreceived fibrinolysis at our stroke center

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Background and Purpose— Evidence-based stroke care has been shown to improve patient outcomes and may reduce health system costs. Cost savings, however, are poorly quantified. This study assesses 4 aspects of stroke management (rapid assessment and treatment services, thrombolytic therapy, organized stroke units, and early home-supported discharge) and estimates the potential for cost avoidance in Canada if these services were provided in a comprehensive fashion. Methods— Several independent data sources, including the Canadian Institute of Health Information Discharge Abstract Database, the 2008–2009 National Stroke Audit, and the Acute Cerebrovascular Syndrome Registry in the province of British Columbia, were used to assess the current status of stroke care in Canada. Evidence from the literature was used to estimate the effect of providing optimal stroke care on rates of acute care hospitalization, length of stay in hospital, discharge disposition (including death), changes in quality of life, and costs avoided. Results— Comprehensive and optimal stroke care in Canada would decrease the number of annual hospital episodes by 1062 (3.3%), the number of acute care days by 166 000 (25.9%), and the number of residential care days by 573 000 (12.8%). The number of deaths in the hospital would be reduced by 1061 (14.9%). Total avoidance of costs was estimated at $682 million annually ($307.4 million in direct costs, $374.3 million in indirect costs). Conclusions— The costs of stroke care in Canada can be substantially reduced, at the same time as improving patient outcomes, with the greater use of known effective treatment modalities.

Background and Purpose— The purpose of this study was to assess recent trends in the admission and mortality rates for subarachnoid hemorrhage in Canada. Methods— This retrospective cross-sectional study was based on data retrieved from the Canadian Institute for Health Information for all patients diagnosed with subarachnoid hemorrhage in Canada between 2004 and 2015. Adjusted admission rate, in-hospital mortality rates, and discharge disposition were calculated. Results— A total of 19 765 patients were diagnosed with subarachnoid hemorrhage between 2004 and 2015. The mean age was 58.1 years, and 40.3% were men. The annual hospitalization rate was 6.34 per 100 000 person-years, declining by −0.67% annually. In-hospital mortality rate was 21.5%. Conclusions— The Canadian subarachnoid hemorrhage admission and mortality rates are lower than previously reported, with a declining trend.

The 2008 update of the Canadian Best Practice Recommendations for Stroke Care includes 4 new topics: prehospital care, evaluation and treatment of transient ischemic attack and minor stroke, reduction of complications during hospitalization and management of vascular cognitive impairment in stroke.• The time window for delivery of thrombolytic therapy for acute ischemic stoke has been extended, from 3 to 4.5 hours.• The recommendations incorporate the themes of discharge planning and stroke in children where appropriate.

To provide recommendations on screening for hypertension in adults aged 18 years and older without previously diagnosed hypertension.Evidence was found through a systematic search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews (EBM Reviews), from January 1985 to September 2011. Study types were limited to randomized controlled trials, systematic reviews, and observational studies with control groups.Three strong recommendations were made based on moderate-quality evidence. It is recommended that blood pressure measurement occur at all appropriate primary care visits, according to the current techniques described in the Canadian Hypertension Education Program recommendations for office and ambulatory blood pressure measurement. The Canadian Hypertension Education Program criteria for assessment and diagnosis of hypertension should be applied for people found to have elevated blood pressure.After review of the most recent evidence, the Canadian Task Force on Preventive Health Care continues to recommend blood pressure measurement during regular physician visits.

Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.

The use of thrombolysis in acute stroke is an important indicator of the quality of stroke care, because it requires health care providers to work collaboratively, rapidly and accurately to optimize patient outcomes. We sought to assess the quality of hyperacute stroke care in Canada using the rate of thrombolysis as the key indicator.We used national administrative data and a chart audit in a retrospective cohort design. We identified discharge diagnoses of stroke in the 10 Canadian provinces between 2008 and 2009. We drew a sample (over-weighted by population and hospital size) for a detailed chart review that was focused on identifying indicators of acute stroke care. We determined the proportions of thrombolysis use, complications and outcomes, adjusted for age and sex and stratified by type of hospital.Our final audit sample included 9588 patient charts, representative of 88% of the 43 651 cases of stroke for which patients were admitted to hospital in Canada. A total of 5.4% (95% confidence interval [CI] 5.1-5.6) of patients with stroke and 6.1% (95% CI 5.8-6.4) of patients with ischemic stroke received thrombolysis. Comprehensive stroke centres used thrombolysis in about one-third of ischemic cases - double the rate seen in primary stroke centres. Often (35%-49% of the time), thrombolysis was not given owing to an interval of more than 4.5 hours between stroke onset and arrival at hospital.The use of thrombolysis for acute stroke in Canada remains low and is limited by delays in both the arrival of patients to hospital and the in-hospital processes of neuroimaging and thrombolysis administration. Our data show the critical need for concerted national efforts to improve education regarding the treatment of acute stroke and speed up stroke management in the hospital setting.

KEY POINTS The goal of the Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) process is to give all Canadian health care providers easy access to a comprehensive and practical set of harmonized guideline recommendations. Clinicians claim that there are too many guidelines

The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients.This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country's development or income status, to drive global improvement in stroke services.Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries.The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries.We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

The progress that has been made in preventing and treating stroke since 2000, when the Joint Stroke Strategy Working Group tabled its blueprint report, Towards an Integrated Stroke Strategy, is very encouraging. The evaluation results demonstrate that the Ontario Stroke System has had positive measurable impacts on access to stroke-related services, the integration and coordination of stroke care, treatment for stroke, and client and provider satisfaction.

Stroke is a major cause of morbidity and mortality and rapid treatment is critical to patient outcomes. This paper looks at the effect of paid television advertising campaigns upon the general public's knowledge of the warning signs of stroke and emergency department (ED) stroke presentations.Data for the study includes results of nine random-digit dialing telephone surveys conducted among Ontario adults aged 45 and over. The mean number of ED presentations for all strokes and for transient ischemic attacks (TIA) were obtained from the Registry of the Canadian Stroke Network (RCSN).Polls indicated that long advertising campaigns were associated with significant increases in the public's knowledge of stroke warning signs, while shorter campaigns were associated with much smaller increases. Time (as represented by month) was the single most important factor determining the mean number of ED presentations for total stroke but was not for TIAs. Campaign status (on or off the air) had a strong and significant effect on ED presentations when the advertising campaigns were long; when the advertising campaigns were shortened, there was no campaign effect.Long, intermittent campaigns are effective in increasing the public's awareness of the warning signs of stroke and may have a significant effect on ED presentations for stroke and TIA. Public awareness of stroke warning signs declines during advertising black-outs, so short campaigns are less effective.

This is a summary of the theme, key new recommendations, and supporting science of the 2011 Canadian Hypertension Education Program (CHEP). In 2011, the ACCORD trial challenged current blood pressure treatment targets for people with diabetes. After consideration of multiple factors relating to the ACCORD trial design and its reporting, the current treatment target of <130/80 mm Hg was not changed. A meta-analysis implicated angiotensin receptor blockers in causing cancer; however, weaknesses in the meta-analysis and ongoing close scrutiny of the issue by the U.S. Food and Drug Administration precluded any changes in current CHEP recommendations. New expert opinion-based recommendations were added to assist the management of hypertension in the setting of acute stroke. To promote healthier blood pressure in Canadians, CHEP emphasizes the need for all Canadians-in particular, health care professionals and their organizations-to more actively work with different levels of government to implement healthy public policies. These should build community capacity to promote healthy behaviours with the goal of the prevention of hypertension and its consequences. To aid a substantive knowledge translation gap, health care professionals and people with hypertension can now receive regular CHEP updates by signing up at the Web sites htnupdate.ca and www.myBPsite.ca.

ObjectiveDespite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators.

Prehospital delays are a major obstacle to timely reperfusion therapy in acute ischemic stroke. Stroke sign recognition, however, remains poor in the community. We present an analysis of repeated surveys to assess the impact of Face, Arm, Speech, Time (FAST) public awareness campaigns on stroke knowledge.Four cross-sectional surveys were conducted between July 2016 and January 2019 in the province of Quebec, Canada (n = 2,451). Knowledge of FAST stroke signs (face drooping, arm weakness and speech difficulties) was assessed with open-ended questions. A bilingual English/French FAST public awareness campaign preceded survey waves 1-3 and two campaigns preceded wave 4. We used multivariable ordinal regression models weighted for age and sex to assess FAST stroke sign knowledge.We observed an overall significant improvement of 26% in FAST stroke sign knowledge between survey waves 1 and 4 (odds ratio [OR] = 1.26; 95% CI: 1.02, 1.55; p = 0.035). After the last campaign, however, 30.5% (95% CI: 27.5, 33.6) of people were still unable to name a single FAST sign. Factors associated with worse performance were male sex (OR = 0.68; 95% CI: 0.53, 0.86; p = 0.002) and retirement (OR = 0.54; 95% CI: 0.35, 0.83; p = 0.005). People with lower household income and education had a tendency towards worse stroke sign knowledge and were significantly less aware of the FAST campaigns.Knowledge of FAST stroke signs in the general population improved after multiple public awareness campaigns, although it remained low overall. Future FAST campaigns should especially target men, retired people and individuals with a lower socioeconomic status.

"Burden of care" is a term that describes the effects of the multifaceted stressors associated with providing care to an ill family member. Descriptions of burden of care in acute care populations, such as families of patients who have had coronary artery bypass grafting, are very limited. The three purposes of this study were to describe the burden of care in families of coronary artery bypass grafting surgery patients, to compare the burden of care in families grouped by length of stay, and to provide evidence for the validity of the Caregiving Burden Scale in acute care populations. A survey was done using a longitudinal design over the first six weeks following coronary artery bypass grafting surgery. The 124 spouses of coronary artery bypass grafting surgery patients who participated reported a moderate degree of burden in caring for post cardiac surgery family members. Providing emotional support, taking over household tasks, and monitoring patients' conditions created the greatest burden for the participants. Length of stay in hospital did not have an impact on burden of care. The analysis of the data supports the validity of the Care-giving Burden Scale when used in the cardiac surgery population. (Prog Cardiovasc).

Although age-standardized stroke occurrence has been decreasing, the absolute number of stroke events globally, and in Canada, is increasing. Stroke surveillance is necessary for health services planning, informing research design, and public health messaging. We used administrative data to estimate the number of stroke events resulting in hospital or emergency department presentation across Canada in the 2017-18 fiscal year.Hospitalization data were obtained from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database and the Ministry of Health and Social Services in Quebec. Emergency department data were obtained from the CIHI National Ambulatory Care Reporting System (Alberta and Ontario). Stroke events were identified using ICD-10 coding. Data were linked into episodes of care to account for readmissions and interfacility transfers. Projections for emergency department visits for provinces/territories outside of Alberta and Ontario were generated based upon age and sex-standardized estimates from Alberta and Ontario.In the 2017-18 fiscal year, there were 108,707 stroke events resulting in hospital or emergency department presentation across the country. This was made up of 54,357 events resulting in hospital admission and 54,350 events resulting in only emergency department presentation. The events resulting in only emergency department presentation consisted of 25,941 events observed in Alberta and Ontario and a projection of 28,409 events across the rest of the country.We estimate a stroke event resulting in hospital or emergency department presentation occurs every 5 minutes in Canada.

South Asian groups experience a higher burden of stroke and poorer functional outcomes after stroke than their White counterparts. However, within the stroke literature, there has been little focus on the unique poststroke needs of the South Asian community and opportunities for community-based services to address these needs.What is the current knowledge base related to the experiences and needs, including unmet needs of people living with stroke and their caregivers from South Asian communities living in high-income countries?This is a protocol for a review that intends to synthesise existing studies of the poststroke experiences and needs of individuals from South Asian communities to uncover opportunities for community-based resources to address these needs.This scoping review methodology will be guided by modified Arksey and O'Malley (2005) and Joanna Briggs Institute frameworks. A search on OVID Medline, OVID Embase, OVID PsycINFO, EBSCO CINAHL, the Cochrane Library, Scopus and Global Index Medicus will be conducted to synthesise existing peer-reviewed literature (all study designs). Grey literature will be searched through detailed hand searching. Literature focusing on the poststroke experiences and needs of South Asian groups impacted by stroke residing in high-income countries will be included. Study descriptors will be extracted (eg, study location, type, methodology). Data will be analysed descriptively and thematically. Team meetings will provide opportunities for peer debriefing, thereby enhancing analytic rigour.Findings will enhance knowledge of the poststroke experiences and needs of South Asian communities living in high-income countries and identify actionable opportunities for community-based resources to address needs.Ethics approval was not required for this scoping review protocol. Community-based organisations will be consulted to provide insights into the analysis and assist with dissemination. Dissemination of findings will also occur through a publication and academic presentations.

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.220138][1] Points clés L’objectif du projet C-CHANGE (Canadian Cardiovascular Harmonized National Guideline Endeavour), une initiative d’harmonisation des lignes directrices nationales de prévention et de

Background The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources. Methods A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings. Results HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks. Conclusions Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.

To identify and explore the learning and support needs of patients and families during the waiting period before cardiac surgery.Prospective, cross-sectional cohort survey design.University-affiliated tertiary cardiovascular care center in mideastern Canada.One hundred forty-seven patients currently on the cardiac surgery waiting list, and 125 family members of these patients.Needs Inventory for Patients who Wait.All patients were sent a survey for themselves and one for a family member that included: a demographic profile, subjective questionnaire, and the Needs Inventory for Patients who Wait. The survey was to be completed and returned to the investigators.The return rates were 77% (113) for patients, and 70% (87) for family members. For patients and their family members, item rankings were highly correlated for areas in which they wanted information (r = 0.84), and for areas that caused them the most concern (r = 0.91). Family members were also concerned about caring for the patient before and after surgery. The number of weeks on the waiting list (< 1 month to > 6 months) did not change the concerns of patients and family.This survey identifies some of the educational and support needs of patients undergoing cardiac surgery and their family members. Patients are concerned about their health and survival until the surgical procedure, as well as about the success of the procedure. Families share patients' concerns and have an additional concern regarding how to support the patient during the perioperative stage. The needs identified by patients and their families in this survey were found to be stable over time, and within the realm of nursing practice to address.

Stroke is a global health problem. However, very little is known about stroke care in low- to middle-income countries. Obtaining country-specific information could enable us to develop targeted programs to improve stroke care. We surveyed neurologists from 12 countries (Chile, Georgia, Nigeria, Qatar, India, Lithuania, Kazakhstan, Indonesia, Denmark, Brazil, Belgium, and Bangladesh) using a web-based survey tool. Data were analyzed both for individual countries and by income classification (low income, lower middle income, upper middle income, and high income). Six percent (n = 200) of 3123 targeted physicians completed the survey. There was a significant correlation between income classification and access and affordability of head computed tomography scan (ρ = .215, P = .002), transthoracic echocardiogram (ρ = .181, P = .012), extracranial carotid Doppler ultrasound (ρ = .312, P ≤ .000), cardiac telemetry (ρ = .353, P ≤ .000), and stroke treatments such as intravenous thrombolysis (ρ = .276, P ≤ .001), and carotid endarterectomy (ρ = .214, P ≤ .004); stroke quality measures such as venous thromboembolism prophylaxis during hospital stay (ρ = .163, P ≤ .022), discharge from hospital on antithrombotic therapy (ρ = .266, P ≤ .000), consideration for acute thrombolytic therapy (ρ = .358, P ≤ .000), and antithrombotic therapy prescribed by end of hospital day 2 (ρ = .334, P ≤ .000). However, there was no significant correlation between income classification and the access and affordability of antiplatelet agents, vitamin K antagonists and statins, anticoagulation for atrial fibrillation/flutter, statin medication, stroke education, and assessment for rehabilitation. Our study shows that it is possible to get an overview of stroke treatment measures in different countries by conducting an internet-based survey. The generalizability of the findings may be limited by the low survey response rate. Stroke is a global health problem. However, very little is known about stroke care in low- to middle-income countries. Obtaining country-specific information could enable us to develop targeted programs to improve stroke care. We surveyed neurologists from 12 countries (Chile, Georgia, Nigeria, Qatar, India, Lithuania, Kazakhstan, Indonesia, Denmark, Brazil, Belgium, and Bangladesh) using a web-based survey tool. Data were analyzed both for individual countries and by income classification (low income, lower middle income, upper middle income, and high income). Six percent (n = 200) of 3123 targeted physicians completed the survey. There was a significant correlation between income classification and access and affordability of head computed tomography scan (ρ = .215, P = .002), transthoracic echocardiogram (ρ = .181, P = .012), extracranial carotid Doppler ultrasound (ρ = .312, P ≤ .000), cardiac telemetry (ρ = .353, P ≤ .000), and stroke treatments such as intravenous thrombolysis (ρ = .276, P ≤ .001), and carotid endarterectomy (ρ = .214, P ≤ .004); stroke quality measures such as venous thromboembolism prophylaxis during hospital stay (ρ = .163, P ≤ .022), discharge from hospital on antithrombotic therapy (ρ = .266, P ≤ .000), consideration for acute thrombolytic therapy (ρ = .358, P ≤ .000), and antithrombotic therapy prescribed by end of hospital day 2 (ρ = .334, P ≤ .000). However, there was no significant correlation between income classification and the access and affordability of antiplatelet agents, vitamin K antagonists and statins, anticoagulation for atrial fibrillation/flutter, statin medication, stroke education, and assessment for rehabilitation. Our study shows that it is possible to get an overview of stroke treatment measures in different countries by conducting an internet-based survey. The generalizability of the findings may be limited by the low survey response rate.

Objective This paper describes the integration of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach into their clinical preventive guideline development process by the new Canadian Task Force on Preventive Health Care. Study Design The GRADE approach focused the analytic framework and key questions on patient-important benefits and harms related to screening that incorporated detection, treatment, and follow-up. It also led to an explicit consideration of values and preferences and resource implications on the basis of the recommendations. Results There are challenges, however, in incorporating the GRADE approach to clinical prevention, as the randomized controlled trials in this field have needed to be very large and of long duration, given the rare occurrence of primary outcome events in asymptomatic individuals. We provide examples of how we met these challenges in relation to developing clinical guidelines for screening for breast cancer, cervical cancer, diabetes, hypertension, and depression in primary care settings. Conclusion The focus on the patient-important outcomes was helpful in estimating effectiveness of screening approaches and providing explicit detailing of the basis of our recommendations across subgroups.

HomeStrokeVol. 43, No. 12Is There Evidence That Performance Measurement in Stroke Has Influenced Health Policy and Changes to Health Systems? Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBIs There Evidence That Performance Measurement in Stroke Has Influenced Health Policy and Changes to Health Systems? Dominique A. Cadilhac, PhD, Bhasker Amatya, MPH, Erin Lalor, PhD, Anthony Rudd, PhD, Patrice Lindsay, PhD and Kjell Asplund, PhD Dominique A. CadilhacDominique A. Cadilhac From the National Stroke Research Institute, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (D.A.C.); Stroke and Ageing Research Centre, Southern Clinical School, Monash University Clayton, Victoria, Australia (D.A.C.); Royal Melbourne Hospital, Melbourne, Australia (B.A.); National Stroke Foundation, Melbourne, Victoria, Australia (E.L.); King’s College London, University of London, London, UK (A.R.); Canadian Stroke Network, Ottawa, Ontario, Canada (P.L.); Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden (K.A.). Search for more papers by this author , Bhasker AmatyaBhasker Amatya From the National Stroke Research Institute, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (D.A.C.); Stroke and Ageing Research Centre, Southern Clinical School, Monash University Clayton, Victoria, Australia (D.A.C.); Royal Melbourne Hospital, Melbourne, Australia (B.A.); National Stroke Foundation, Melbourne, Victoria, Australia (E.L.); King’s College London, University of London, London, UK (A.R.); Canadian Stroke Network, Ottawa, Ontario, Canada (P.L.); Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden (K.A.). Search for more papers by this author , Erin LalorErin Lalor From the National Stroke Research Institute, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (D.A.C.); Stroke and Ageing Research Centre, Southern Clinical School, Monash University Clayton, Victoria, Australia (D.A.C.); Royal Melbourne Hospital, Melbourne, Australia (B.A.); National Stroke Foundation, Melbourne, Victoria, Australia (E.L.); King’s College London, University of London, London, UK (A.R.); Canadian Stroke Network, Ottawa, Ontario, Canada (P.L.); Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden (K.A.). Search for more papers by this author , Anthony RuddAnthony Rudd From the National Stroke Research Institute, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (D.A.C.); Stroke and Ageing Research Centre, Southern Clinical School, Monash University Clayton, Victoria, Australia (D.A.C.); Royal Melbourne Hospital, Melbourne, Australia (B.A.); National Stroke Foundation, Melbourne, Victoria, Australia (E.L.); King’s College London, University of London, London, UK (A.R.); Canadian Stroke Network, Ottawa, Ontario, Canada (P.L.); Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden (K.A.). Search for more papers by this author , Patrice LindsayPatrice Lindsay From the National Stroke Research Institute, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (D.A.C.); Stroke and Ageing Research Centre, Southern Clinical School, Monash University Clayton, Victoria, Australia (D.A.C.); Royal Melbourne Hospital, Melbourne, Australia (B.A.); National Stroke Foundation, Melbourne, Victoria, Australia (E.L.); King’s College London, University of London, London, UK (A.R.); Canadian Stroke Network, Ottawa, Ontario, Canada (P.L.); Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden (K.A.). Search for more papers by this author and Kjell AsplundKjell Asplund From the National Stroke Research Institute, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (D.A.C.); Stroke and Ageing Research Centre, Southern Clinical School, Monash University Clayton, Victoria, Australia (D.A.C.); Royal Melbourne Hospital, Melbourne, Australia (B.A.); National Stroke Foundation, Melbourne, Victoria, Australia (E.L.); King’s College London, University of London, London, UK (A.R.); Canadian Stroke Network, Ottawa, Ontario, Canada (P.L.); Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden (K.A.). Search for more papers by this author Originally published1 Dec 2012https://doi.org/10.1161/STROKEAHA.111.617894Stroke. 2012;43:3413–3420IntroductionOver the past 20 years or more, use of meta-analysis and establishment of clinical guidelines for stroke have provided a strong evidence base for performance measurement. Performance measurement, defined as the evaluation of organizational or clinical practice activities and outcomes against agreed standards,1,2 has been used to identify care gaps. With the associated development in health services research, this has laid the foundation for providing evidence for health policy decisions.Performance measures may be designed to assess the structural environment (eg, the organizational features of health facilities), processes of care (such as adherence to recommended clinical interventions), or outcomes (eg, mortality). Furthermore, performance measures may be used to monitor the quality of care within an individual institution or across the health care system, to compare different institutions over time (benchmarking), to provide information to the consumers in choosing health care providers, or to promote quality improvement activities.3,4 Performance measurement results provide valuable information for strategic planning by organizations, policy-makers, and funding providers.2Health policy may be broadly defined as a statement of actions to achieve goals for health care usually reflecting priorities and values for increasing well-being in a society and/or the optimal allocation of health resources.5 It is generally agreed that health policy should be based on the best and most current scientific evidence.5 Performance measurement offers policy-makers information to make judgments on the extent to which various aspects of the health system meet policy goals.2 However, it is uncertain what impact efforts to monitor health care performance have had on policy and/or health systems in the area of stroke. Examples in which performance measurement can be linked to stroke policy may include policy documents on clinical guidelines or strategic plans, financial incentives or reimbursement criteria for stroke care, credentialing standards for health care organizations or clinicians, regulations or legislation for how care between different sectors of the health system operate, and programs of routine (or mandated) data collection such as registries.The purpose of this review was to explore what evidence exists that performance measurement in stroke has influenced health policy and health systems. We assumed that there would be studies designed to measure temporal relationships between measuring performance followed by changes to health policy or health systems (Figure 1); however, many of these concepts are interwoven and not necessarily linear. It was not possible to cover all aspects of policy reform based on performance measurements. Therefore, we sought to answer some specific questions. What is the evidence that performance measurement has influenced health policy and changes to health systems? To what extent have clinical guidelines influenced the development of performance measures?In addition, the authors chose to provide a case study specific to each of their own countries to illustrate the temporal and nonlinear relationship between performance measurement initiatives and health policy formulation related to hospital care for stroke.Materials and MethodsThis narrative review includes 3 stages: (1) a systematic approach for searching relevant peer-reviewed and gray literature; (2) a -qualitative appraisal of the included literature to group and report on the main themes from stage 1; and (3) provision of case studies on the temporal relationship between performance measurement and the establishment of policy-related activities related to hospital care for stroke in Australia, Canada, Sweden, and the United Kingdom. These case studies are used to illustrate the relationship between each of the main themes described in stage 2.Peer Review Literature Search StrategyA comprehensive search of the literature published from January 1990 to September 2010, was undertaken using EbscoHost to search various electronic databases, which included Medline, CINHAL, and PsycINFO. A structured search also was conducted separately using Embase and Cochrane Library databases. A search for systematic reviews and clinical trials (filter) using the PubMed database was conducted, and PubMed Clinical alerts were set-up to identify literature published from September 2010 to November 2010. No restrictions were applied with respect to research design. Medical subject heading search terms were used for all databases and a key word search was used if the medical subject heading term was unavailable. Table 1 provides an outline of the search terms used. The detailed search strategy is available in Supplementary Table I. We did not include financial, legislative, or economic search terms. This is because these terms were too specific given the broad nature of our research questions, and we thought relevant literature based on these issues would indirectly be identified from the key search terms of “health policy,” “healthcare reform,” or “healthcare quality improvement program.”Table 1. Outline of Search Terms Used for Literature Search*†MeSH TermsOther TermsPerformance measurementQuality indicators, healthcarePerformance indicators Clinical indicatorsQuality of careHealth indicatorsBenchmarkingPerformance measuresQuality assurance, healthcareQuality measuresPatient safetyOrganization* benchmarkingClinical practice guidelinesConditionStrokeCerebrovascular accident or CVATransient ischemic attack or TIAOutcomesOutcome assessment, healthcareAccess to health careHealth policyPatient outcomeHealthcare outcomeHealthcare policyHealthcare reformHealthcare evaluationHealthcare policy, developmentPolicy/position/consensus statementCondition specific servicesManaged care programDisease management programStroke centre Stroke serviceStroke programHealthcare quality improvement programCVA indicates cerebrovascular accident; MeSH, medical subject headings; TIA, transient ischemic attack.*Terms were searched using English and United States English spelling. MeSH is the United States National Library of Medicine’s controlled vocabulary used for indexing articles for MEDLINE/PubMed. MeSH terminology provides a consistent way to retrieve information that may use different terminology for the same concepts (http://www.ncbi.nlm.nih.gov/mesh, accessed November 10, 2010).†Financial incentives/payments were not included.Article Identification and SelectionTitles of articles were first reviewed (by author B.A.) to exclude those that did not address the review questions. Abstracts were then appraised (by authors B.A. and D.C.) based on the eligibility criteria. Publications for which authors reported performance measurements for stroke were included if they met the following criteria: the title or abstract was relevant to the review purpose; adequate articulation of methods; and the main purpose of the study included 1 of the following: (1) development of health policy; (2) reform and/or restructure of health system/health policy; (3) use of performance data to provide evidence of an impact on health policy and changes to health systems; and (4) the impact of various performance measurement activities on health care outcomes.Publications were excluded if: studies were not related to health care delivery and studies were not published in English. The bibliographies of identified articles were scrutinized for additional references. A manual search of relevant journals such as Stroke, Journal of Stroke and Cerebrovascular Diseases, Quality and Safety in Health Care, British Medical Journal, BMC Health Services Research, and The Lancet was also undertaken for the same review period.Gray Literature SearchA search of the gray literature was performed to identify existing performance measurement and quality improvement programs in stroke, and to identify any relevant reports, health technology assessments, or other related materials. A topic search was conducted using Internet search engines such as Google, Google Scholar, and MS search, and by combining the following terms: “stroke,” “cerebrovascular accident” or “stroke center,” “stroke program,” “stroke service performance measurements,” “performance measurements,” “quality indicators,” “clinical indicators;” “health policy,” “healthcare outcomes,” and“quality improvement.” A list of specific government and nongovernment web sites, such as World Health Organization, Canadian Stroke Network, International Society for Quality in Health Care (USA), and National Health Service (UK), were also searched (Supplementary Table II). Results were scrutinized to remove duplications identified from >1 source.Analysis and Interpretation MethodsPotentially relevant publications were retrieved in full text and independently assessed for inclusion by the 2 reviewers. A descriptive summary of the included studies was then undertaken with additional gray literature included when relevant. Data extracted was then grouped in broad themes related to performance measurement and policy (by D.C. and B.K.). Disagreements were resolved through discussion and consensus among the reviewers, and the other coauthors provided additional relevant literature that may have been inadvertently omitted.ResultsThe peer review literature search identified a potential 815 articles, 7 of which were duplicates (Figure 2). Fifty of these articles met the abstract inclusion criteria, and 7 of these also were identified from the bibliographies of relevant articles or from the gray literature search. Overall, 34 relevant articles were retrieved for full text review. Ten articles did not meet the inclusion criteria (Supplementary Table III) and the remaining 24 were reviewed. The 24 articles covered a range of broad topics that were not mutually exclusive and represented several different countries6–29 (Table 2, Figure 2).Details of each article and the main quantitative finds regarding change to health policy or health systems are summarized in Supplementary Table IV. Overall, the quality of the existing evidence varied, and most studies were descriptive or narrative reviews (Table 2, Supplementary Table IV). The included publications varied in the methodology used, making any direct comparisons problematic. Among the articles we reviewed, there were a number of performance measurement programs that had been established to improve the quality of stroke care, which may have a direct or indirect impact on policy developments and health system reform.Table 2. Summary of Overall Literature Review*Policy ThemePerformance Measurement MethodsMain FindingsImproving overall evidence-based care delivery in hospitals and clinical guidelinesClinical audit Clinical registriesClinical registries when established for several years can be used to show changes across various performance measures and in health outcomes and can be used to develop comprehensive clinical quality improvement programs7,13,17,21 Clinical audits and registries reveal heterogeneity in practice across individual hospitals and regions6,9,11,20,29Few assessments of rehabilitation services have been reported to know how well guideline recommendations have been implemented28Performance measurements can be used to base credentialing standards for stroke services and the changes to clinical practice after credentialing15,19Performance monitoring can be used to show the influence on the quality of hospital care given different health insurance schemes or programs8,14,18,22–26Establishment of stroke unitsSurveysClinical auditClinical registriesClinical registries when established for several years can be used to show increases in strokeunit access and better management of patients when cared for on stroke units compared with other types of inpatient care7Clinical audits and organizational surveys are also effective for providing the temporal progress in access to stroke units10,12,16,21,27*Further details of individual studies are provided in Supplementary Table III.Download figureDownload PowerPointFigure 2. Summary of literature search strategy and included articles.In this article, 2 main themes were identified from our review and are presented in detail. They cover the relationship between clinical guidelines and performance measurement using registries and clinical audit and a description of policy for establishing stroke units (SUs) as a direct and indirect response to the influence of performance measurement on health systems. To illustrate each of the 2 major themes more fully, an outline of the temporal progress of performance measurement and policy development is provided for Australia, Canada, Sweden, and the United Kingdom as case studies.Clinical Guideline Development, Performance Monitoring, and Influence on Other Policy InitiativesOur results confirm that the temporal relationship between performance measurement, clinical guideline development, and health policy developments is not always linear. There is limited evidence of clinical guidelines having been used as the basis for establishing performance-monitoring activities, such as cross-sectional national clinical audits and prospective clinical registries that include all eligible patients.23,30–33 Performance measurement therefore may be an indirect link to demonstrate the potential impact of clinical guidelines on health care over time. However, some performance monitoring programs predate formal establishment of national clinical guidelines and have been adapted over time to measure processes of care relevant to these guidelines that reflect best available evidence (Table 3).29,34 As an example, the Canadian Stroke Network includes performance measures as part of the stroke guideline document, which was a major step in using performance measurement to drive system change and policy in that country. This was motivated by evidence of persisting gaps in translating best available scientific evidence into clinical practice.23Table 3. Summary of Case Studies of Guidelines and Reports on Policy in Relation to Performance Measurement and Health Systems Development for Stroke in Hospitals From Four Countries*AustraliaCanadaSwedenUnited KingdomYearsGuidelines/Policy DocumentsPerformance Measurements/PolicyGuidelines/Policy DocumentsPerformance Measurements/PolicyGuidelines/Policy DocumentsPerformance Measurements/PolicyGuidelines/Policy DocumentsPerformance Measurements/Policy1991–1995Better Health Outcomes for Australians (goals/targets)Ontario Stroke StrategyWHO consensus documentThe Helsingborg Declarationin Treatment of Stroke inEuropeNational stroke quality register (Riks-Stroke) established, covering acute phase and a 3-mo follow-up1996–2000Clinical Practice Guidelines: Preventionof strokeNational Stroke StrategyRegional stroke strategies, programs and guidelinesNational hospital outcomes program. National Hospital Survey report.National Health priority areas: Cardiovascular health reportCoordinated strokeStrategy launched and piloted Regional stroke strategyAudit of current stroke practices in hospitalFirst national stroke guidelinesAll hospitals admitting acute stroke patients included in the stroke quality registerNational framework for assessing performance, including stroke deathHealth outcome indicators: Stroke, a reportNational sentinel audit of stroke report: regional variation in stroke care2001–2005National Stroke Unit Program Report, Clinical Guidelines for Acute Stroke Management National Strategy for Heart, Stroke, and Vascular Health in Australia Clinical guidelines for strokerehabilitationRegional stroke care outcomesmeasurements and plans National Stroke Unit Program Report, including performance indicatorsStroke Services model and formativeevaluationNational Hospital SurveyCanadian Stroke Network launchedCanadian Stroke Network’s vision for datainfrastructure to monitor stroke treatmentRegistry of the Canadian Stroke Network(RCSN) establishedFinal indicators for evaluating TelestrokeUpdate of the national strokeguidelines, now including priority-settingFirst report from the quality register Swedvasc, including carotid surgery, with public access to between-hospital comparisonsNational Service Framework for Older People with milestone on stroke unitsFirst and second editions of National Clinical Guidelines for StrokeNational Sentinel Audit (2nd to 4th rounds), The Scottish Stroke Care Audit (SSCA) established2006–2010National Service Improvement for Heart, Stroke, and Vascular Disease Updated clinical guidelines for acute stroke managementNational stroke auditNational Stroke Rehabilitation AuditNational Stroke Clinical Indicators SetAustralian Stroke Clinical Registry (AuSCR) pilotedCanadian Best Practice Recommendationsfor Stroke Care (with updates) Development of Stroke Distinction program for recognizing acute and inpatient rehabilitation stroke centers and regional stroke programsUpdate and expansion of Stroke Best Practice recommendations. Several implementation and educational tools and resources, including Stroke Unit GuideIndicators for secondary stroke preventionSPIRIT database to collect data on stroke prevention and care indicatorsNational set of stroke-specific outcomemeasurement toolsStroke Best Practice recommendations including performance measuresFirst Canadian Stroke Audit data collection completedUpdate of national stroke guidelines StrokeCompetence Certification for stroke unit staffNational stroke guidelines now including 26 quality indicatorsPublic access to between-hospital comparisons of stroke care performanceIntroduction in Riks-Stroke of a 12-mofollow-up of all stroke survivorsNational Stroke Strategy with 10-y plan to deliver radical improvements in stroke careThird Edition of National Clinical GuidelinesNICE guidelines on Acute Stroke and TIAImplementation of radical reorganization of stroke care in London (London Stroke Strategy)National Audit Office report: Reducing Brain Damage; faster access to better stroke careNational Sentinel Audit (5th and 6th rounds)First report from UK National carotid endarterectomy audit NICE Quality Standards for StrokeOrganizational Audit Round 7 ReportProspective acute stroke audit (SINAP) startsNICE indicates National Institute for Health and Clinical Excellence; SINAP, Stroke Improvement National Audit Programme; SPIRIT, Stroke Performance Indicators for Reporting, Improvement, and Translation; TIA, transient ischemic attack; UK, United Kingdom; WHO, World Health Organization.*Comprehensive information is available in Supplementary Table V.Overall, we found that registries and clinical audits provide feedback to local stroke professionals, administrators, and politicians so they can evaluate or monitor adherence to desired standards, compare present data with that of the past, and make appropriate changes to clinical practice or policy. The findings from these systems of regular or continuous data monitoring offer policy-makers the opportunity for securing health system improvements and accountability. For example, Appelros7 evaluated the Riks-Stroke Swedish register and reported changes in stroke outcome such as case fatality, living conditions, and daily activity performance in relation to fluctuations in registration of cases. Benefits of this registry have included demonstrated increases in the access to SUs (from ≈50% in 1994 to 86.5% in 2009) and reductions in delays in arriving to hospital after stroke onset (median 4 hours in 1996 to ≈2.5 hours in 2009), and have provided evidence about the costs of care in Sweden for patients with stroke.35–37 In Spain, a stroke program was commenced as part of a comprehensive Stroke Strategy in 2004. As a part of this initiative, Abilleira et al6 assessed the quality of in-hospital stroke care across the Catalonia region before and after the release of new stroke guidelines along with territory-based interventions delivered by the stroke program. The main results of this audit provided evidence that the quality of in-hospital stroke care was heterogeneous across hospital levels and could be improved.6 However, these authors did not describe if the results of the audit and associated performance feedback initiatives to clinicians led to changes in policy or health system priorities by the relevant authorities.Authors from the United States also have used registries to show substantial improvements across various performance measures (eg, dysphagia screening, lipid testing, and smoking cessation counseling) over time. For example, low rates of adherence to performance measures (eg, use of emergency medical services for transport to hospitals, time to receive thrombolytic therapy for ischemic stroke) were identified for ongoing attention by George et al17 representing the Paul Coverdell National Acute Stroke Registry. The authors also explained that a collaborative, state-based, and hospital-based quality improvement registry could be used to develop comprehensive stroke care protocols and to identify disparities in care by ethnicity, geographic region, and gender, enabling targeted improvements to achieve greater quality of care for various patients with stroke. The benefit of this approach is that various quality improvement initiatives and focused discussions on barriers and opportunities to implement best practices as part of regional collaborations with hospitals can be undertaken.17 Censullo and Chiu13 have assessed 13 comprehensive quality measures based on recommendations derived from the Brain Attack Coalition comprehensive center guidelines at a tertiary hospital in the United States. The authors highlighted that having standardized methodology for quantitative quality assessment provided a tool to evaluate the quality and capability of comprehensive stroke centers with selected measures used for certification processes. The results from these studies highlighted how systems of performance measurement could be used to form the basis of clinical quality improvement programs and could be used to base broader stroke policy on credentialing standards for hospitals.The relationships between clinical guideline development, performance monitoring, and other policy initiatives were also outlined by Park and Schwamm25 in their narrative review describing various aspects of care delivery models for stroke in the United States and other developed countries. These authors described various successful initiatives and their implications on health policy and health system changes, highlighting where performance measurement, including certification processes by The Joint Commission and use of registries, had been used to monitor the effects of policy change over time. These authors emphasized that the success of various programs to improve use of evidence-based medicine stemmed from a format of performance measurement and providing structured feedback. For example, the American Stroke Association adapted its already successful “Get with the Guidelines” program in coronary artery disease into Get with the Guidelines Stroke, which used a quality improvement model that incorporates sharing of best practices, collaborative learning sessions, and an online patient management tool for data collection and performance measurement to improve stroke care delivery within hospitals.25Various authors have emphasized the importance of policy reform in ensuring optimal stroke care delivery.5,14,25,38 Crawford et al14 used performance measurement to demonstrate that differing health insurance policies were associated with significant differences in adherence to recommended processes of patient care. The authors compared patients with stroke in the Republic of Ireland, where there is a mixed public and private health coverage policy, with patients treated in Northern Ireland, which has universal free hospital health care. Northern Ireland performed significantly better on 15 of 16 quality of care (Sentinel Audit) items.14 The implications of this work for policy are significant and highlight the influence of a number of differences in the policy environments of these countries.14Performance Measurement Influencing Policy for Stroke Unit EstablishmentOrganized management in SUs is regarded as the most generalizable and effective intervention for acute stroke care.39 In many countries there have been policies developed to increase access to SUs. In countries like the United Kingdom, Australia, Austria, Finland, Sweden, and Canada, routine organizational surveys of hospitals, clinical audit, and/or registries have been used to demonstrate the increases in, access to, and the number of SUs.32–34,40–42 For example, Irwin et al21 presented the results of 3 rounds of National Stroke Audit in England, Wales, and Northern Ireland. The data were used to show that standards of care on SUs were notably better than in general wards. Evidence from repeated audits in the United Kingdom also have shown that 68% of patients spend at least 50% of their admission in a SU in 2008 compared with only 18% in 1998.43 The results of the United Kingdom National Sentinel Audit have been quoted in the National Aud

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Alexander A. Leung, MD MPH, Kara Nerenberg, MD MSc, Stella S. Daskalopoulou, MD PhD, Kerry McBrien, MD MPH, Kelly B. Zarnke, MD MSc, Kaberi Dasgupta, MD MSc, Lyne Cloutier, RN PhD, Mark Gelfer, MD, Maxime Lamarre-Cliche, MD, Alain Milot, MD MSc MD, Peter Bolli, MD, Guy Tremblay, MD, Donna McLean, RN NP PhD, Sheldon W. Tobe, MD MSc(HPTE), Marcel Ruzicka, MD PhD, Kevin D. Burns, MD, Michel Vallee, MD PhD, G.V. Ramesh Prasad, MBBS MSc, Marcel Lebel, MD, Ross D. Feldman, MD, Peter Selby, MBBS MHSc, Andrew Pipe, CM MD, Ernesto L. Schiffrin, MD PhD, Philip A. McFarlane, MD PhD, Paul Oh, MD, Robert A. Hegele, MD, Milan Khara, MBChB, Thomas W. Wilson, MD, S. Brian Penner, MD, Ellen Burgess, MD, Robert J. Herman, MD, Simon L. Bacon, PhD, Simon W. Rabkin, MD, Richard E. Gilbert, MD PhD, Tavis S. Campbell, PhD, Steven Grover, MD MPA, George Honos, MD, Patrice Lindsay, RN PhD, Michael D. Hill, MD MSc, Shelagh B. Coutts, MD, Gord Gubitz, MD, Norman RC. Campbell, MD, Gordon W. Moe, MD MSc, Jonathan G. Howlett, MD, Jean-Martin Boulanger, MD, Ally Prebtani, MD, Pierre Larochelle, MD, Lawrence A. Leiter, MD, Charlotte Jones, MD PhD, Richard I. Ogilvie, MD, Vincent Woo, MD, Janusz Kaczorowski, PhD, Luc Trudeau, MD, Robert J. Petrella, MD PhD, Swapnil Hiremath, MD MPH, Denis Drouin, MD, Kim L. Lavoie, PhD, Pavel Hamet, MD PhD, George Fodor, MD PhD, Jean C. Gregoire, MD, Richard Lewanczuk, MD PhD, George K. Dresser, MD PhD, Mukul Sharma, MD MSc, Debra Reid, PhD RD, Scott A. Lear, PhD, Gregory Moullec, PhD, Milan Gupta, MD, Laura A. Magee, MD MSc, Alexander G. Logan, MD, Kevin C. Harris, MD MHSc, Janis Dionne, MD, Anne Fournier, MD, Genevieve Benoit, MD, Janusz Feber, MD, Luc Poirier, BPharm MSc, Raj S. Padwal, MD MSc, Doreen M. Rabi, MD MSc, for the CHEP Guidelines Task Force

Increased blood pressure is a leading risk of death, accounting for half of all cardiovascular disease (CVD).[1][1] Hypertension is both highly preventable and controllable.[1][1] Up to 80% of hypertension is directly, through excess sodium and deficient potassium, or indirectly, through obesity,

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals, and the evidence suggests one-third or more will experience vascular-cognitive impairment, and/or intractable fatigue, either alone or in combination. The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. The three consequences of stroke that are the focus of the this guideline (poststroke depression, vascular cognitive impairment, and fatigue) have high incidence rates and significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes. Significant practice variations and gaps in the research evidence have been reported for initial screening and in-depth assessment of stroke patients for these conditions. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact patient recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community. Additionally, building system capacity to ensure access to appropriate specialists for treatment and ongoing management of stroke survivors with these conditions is another great challenge.

We provide an updated estimate of adult stroke event rates by age group, sex, and stroke type using Canadian administrative data. In the 2017-2018 fiscal year, there were an estimated 81,781 hospital or emergency department visits for stroke events in Canada, excluding Quebec. Our findings show that overall, the event rate of stroke is similar between women and men. There were slight differences in stroke event rate at various ages by sex and stroke type and emerging patterns warrant attention in future studies. Our findings emphasize the importance of continuous surveillance to monitor the epidemiology of stroke in Canada.

Mivacurium is a new non-depolarizing muscle relaxant consisting of three stereoisomers. The two active isomers (cis-trans and trans-trans) undergo rapid metabolism by plasma cholinesterase (t1/2 beta < 2 min). Due to its rapid elimination, the need for reversal of mivacurium-induced neuromuscular block is controversial, and to date there have been no studies evaluating reversal of deep blocks. The object of the current investigation was to establish the lowest effective dose of edrophonium required to reverse deep mivacurium-induced neuromuscular block. One hundred ASA Class I and II patients undergoing outpatient surgery in two teaching institutions were studied in this randomized, placebo-controlled double-blind trial. Under balanced propofol/nitrous oxide/alfentanil anaesthesia, a continuous infusion of mivacurium was adjusted to maintain between 5-10% of control T1 amplitude. Upon completion of surgery, neuromuscular block was reversed by injecting normal saline (Group PLAC), edrophonium 0.125 mg.kg-1 (Group EDR-1), 0.25 mg.kg-1 (Group EDR-2), or 0.50 mg.kg-1 (Group EDR-3), in addition to a corresponding dose of atropine. Spontaneous recovery, from a T1 response of < 10% to a TOF ratio > or = 0.7, required 13.5 +/- 2.6 min (PLAC Group). In comparison, patients in the EDR-1 group required 9.2 +/- 2.6 min (P < 0.01). Higher doses of edrophonium conferred no advantage. Four patients (4%) had not achieved a TOF ratio of > or = 70%, 20 min after reversal, and required additional edrophonium. Two patients (PLAC group), had dibucaine numbers and cholinesterase levels consistent with an EUEA genotype, whereas the two patients with delayed recovery in the EDR-1 group had characteristics of a normal genotype. We conclude that a very low dose of edrophonium (0.125 mg.kg-1) hastens reversal of deep mivacurium-induced neuromuscular block by approximately four minutes, and that edrophonium doses exceeding 0.125 mg.kg-1 provide no additional benefit. Heterozygous patients with atypical plasma cholinesterase levels, as well as certain individuals with normal dibucaine numbers and plasma cholinesterase activity, are at risk for prolonged neuromuscular block, but the block is easily reversed with edrophonium.

Abstract Background In 2018, the Heart and Stroke Foundation of Canada transformed its approach to organizational strategic planning and priority-setting. The goal was to generate impact from bench to bedside to community, to improve the health of Canadians. It engaged researchers, clinician scientists, health systems leaders, and community members including people with lived experience (PWLE) on six Mission Critical Area (MCA) councils, each of which was co-chaired by a researcher or clinician scientist and a person with lived experience. Together, council members were tasked with providing advice to Heart &amp; Stroke about the most relevant and impactful priorities of our time. The aim of this research was to explore the value of the MCA councils to Heart &amp; Stroke, and to council members themselves. The research questions focused on understanding the process of managing and participating on the councils, the challenges and outcomes. Methods Using an integrated knowledge translation approach, we conducted a case study with developmental evaluation over a 2-year time period (2018–2020). We collected qualitative data from various sources (Heart &amp; Stroke team responsible for managing the councils, council co-chairs, council members, and key informants). We collected documents and analysed them for contextual background. Results Participants noted that the MCA councils continuously evolved over the 2 years in various ways: from an uncertain direction to a concrete one, better integrating the voice of PWLE, and increased cohesiveness within and across MCA councils. This evolution was achieved in parallel with successes and challenges at three levels: the MCA councils and its members, Heart &amp; Stroke, and Canadians. The MCA councils were disbanded in 2020, yet learnings, developments, initiatives and established partnerships remain as their legacy. Conclusions Heart &amp; Stroke’s intended objectives for the MCA councils, to promote engagement and dialogue among community members including PWLE, clinician scientists, and researchers, and to provide advice into Heart &amp; Stroke’s strategic renewal process, were achieved. This collaborative structure and process for PWLE engagement within a community of multidisciplinary clinician scientists and researchers is possible yet requires flexibility, commitment to stakeholder relationship management, and considerable resources. These findings may be helpful for other not-for-profit and funding organizations interested in engaging the public and other stakeholders into their organizational activities.

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care guideline highlights key elements involved in the initial assessment, stabilization, and treatment of patients with transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and acute venous sinus thrombosis. The most notable change in this 5th edition is the addition of new recommendations for the use of endovascular therapy for patients with acute ischemic stroke and proximal intracranial arterial occlusion. This includes an overview of the infrastructure and resources required for stroke centers that will provide endovascular therapy as well as regional structures needed to ensure that all patients with acute ischemic stroke that are eligible for endovascular therapy will be able to access this newly approved therapy; recommendations for hyperacute brain and enhanced vascular imaging using computed tomography angiography and computed tomography perfusion; patient selection criteria based on the five trials of endovascular therapy published in early 2015, and performance metric targets for important time-points involved in endovascular therapy, including computed tomography-to-groin puncture and computed tomography-to-reperfusion times. Other updates in this guideline include recommendations for improved time efficiencies for all aspects of hyperacute stroke care with a movement toward a new median target door-to-needle time of 30 min, with the 90th percentile being 60 min. A stronger emphasis is placed on increasing public awareness of stroke with the recent launch of the Heart and Stroke Foundation of Canada FAST signs of stroke campaign; reinforcing the public need to seek immediate medical attention by calling 911; further engagement of paramedics in the prehospital phase with prehospital notification to the receiving emergency department, as well as the stroke team, including neuroradiology; updates to the triage and same-day assessment of patients with transient ischemic attack; updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The goal of these recommendations and supporting materials is to improve efficiencies and minimize the absolute time lapse between stroke symptom onset and reperfusion therapy, which in turn leads to better outcomes and potentially shorter recovery times.

Figure:The OBI system.The four pillars of OBI's system drive improvement to individual brain health. Galvanize pan-Ontario partnerships;engage with the world.Improving entrepreneurial and management capacity to build a thriving knowledge economy and neurocluster in Ontario.Putting patients at the centre of a multi-dimensional approach to the investigation of critical brain disorders.Standardizing clinical data to accelerate discovery, improve patient care and foster healthcare efficiencies.Encouraging early and active industry partnership to get promising ideas to markets-and patients-faster.Enable knowledge translation and catalyze education for the public. Training and entrepreneurship Mechanisms to engage and support industryCentralized patient information systemsHigh-impact translational programs

Free accessAbstractFirst published online July 2010P75– Recommendations are not enough: Creating a toolbox to support stroke guideline uptakePatrice Lindsay, PhD, Presenter, Mark Bayley, MD, and Linda Kelloway, MNVolume 143, Issue 1_supplhttps://doi.org/10.1016/j.otohns.2010.04.099

This article provides the scientific rationale and background information for the Canadian Hypertension Education Program's 2012 recommendations for the management of hypertension. It also summarizes the key new recommendations and the theme for 2012, which is the prevention of hypertension. The full recommendations are available at www.hypertension.ca.

ABSTRACT: Background: Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province. Methods: Using administrative data from the Canadian Institute for Health Information’s (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015. Results: From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p &lt; 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p &lt; 0.001). Interpretation: At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.

The field of neuroscience nursing and, in particular, nursing people with stroke has evolved significantly over the past two decades. Nurses working with people who have had a stroke and their families are called upon to use advanced assessment skills, apply nursing diagnoses across the whole continuum of care, and identify and implement a wide range of interventions. Indeed, in a recent Canadian study on the implementation of stroke best practices, nurses were identified as playing a leading role in many aspects of stroke care and recovery. As the volume of research evidence across disciplines mounts, nurses are challenged to “keep up on the latest”...

Background and Purpose— Value-based health care aims to bring together patients and health systems to maximize the ratio of quality over cost. To enable assessment of healthcare value in stroke management, an international standard set of patient-centered stroke outcome measures was defined for use in a variety of healthcare settings. Methods— A modified Delphi process was implemented with an international expert panel representing patients, advocates, and clinical specialists in stroke outcomes, stroke registers, global health, epidemiology, and rehabilitation to reach consensus on the preferred outcome measures, included populations, and baseline risk adjustment variables. Results— Patients presenting to a hospital with ischemic stroke or intracerebral hemorrhage were selected as the target population for these recommendations, with the inclusion of transient ischemic attacks optional. Outcome categories recommended for assessment were survival and disease control, acute complications, and patient-reported outcomes. Patient-reported outcomes proposed for assessment at 90 days were pain, mood, feeding, selfcare, mobility, communication, cognitive functioning, social participation, ability to return to usual activities, and health-related quality of life, with mobility, feeding, selfcare, and communication also collected at discharge. One instrument was able to collect most patient-reported subdomains (9/16, 56%). Minimum data collection for risk adjustment included patient demographics, premorbid functioning, stroke type and severity, vascular and systemic risk factors, and specific treatment/care-related factors. Conclusions— A consensus stroke measure Standard Set was developed as a simple, pragmatic method to increase the value of stroke care. The set should be validated in practice when used for monitoring and comparisons across different care settings.

April 21, 2016April 5, 2016Free AccessGeospatial Mapping of Alberta Province (P6.050)Prasanna Venkatesan Eswaradass, Michael Hill, Rick Swartz, Jamey Rosen, and Patrice LindsayAuthors Info & AffiliationsApril 5, 2016 issue86 (16_supplement)https://doi.org/10.1212/WNL.86.16_supplement.P6.050 Letters to the Editor

Introduction: Improvements in stroke patient care have led to increases in stroke survivors. However, these survivors are prone to hospital readmission, a burden for both patients and health system deserving of greater investigation. We hypothesize rates and risk factors for stroke patient readmission are not consistent across age. Thus, our aim was to characterize age related patterns of post stroke readmission including trends in patient and healthcare factors. Methods: Using the Discharge Abstract Database, a collection of hospital discharge records maintained by the Canadian Institute for Health Information, patients aged 18+ discharged with the main diagnosis of stroke/TIA between 2003-2014 were identified. Three age groups (18-44, 45-64, 65+) were determined for comparison of age related trends in stroke readmission. Trends were identified using the Cochran-Armitage and Jonckheere-Terpstra tests for binary and larger categorical events respectively. Kaplan-Meier analysis for 90-day recurrence, Chi-squared and multivariable Cox regression analysis for probability and risk of readmission were also performed. Results: A total of 267,768 patients had at least one stroke admission and were discharged alive. The mean age overall was 72 ±14.34 where 4% were aged 18-44, 23% aged 45-64, and 73% aged 65+. The younger groups were predominantly male and the oldest more female (p&lt;0.0001). There were 48,078 (18%) patients readmitted to hospital of which 69% had a recurrent stroke. Rates of death and recurrence were highest among older patients (p&lt;0.0001). Older patients had longer hospital stay than young (p&lt;0.0001), suffered more comorbidities (p&lt;0.0001), and more discharges to long-term care (p&lt;0.0001). Patients aged 18-44 had the shortest time to readmission (mean=478 ±729 days, p&lt;0.0001) and were more likely to be treated by a neuro-specialist. Cohen’s Kappa analysis revealed patients aged 18-44 had the highest agreement between index and recurrent stroke type (κ=0.44 (95%CI 0.38-0.49)) Conclusions: Age related differences in stroke readmission is evident. With this information better targeted treatment and prevention strategies can be implemented.

Resume Objectif Presenter des recommandations concernant le depistage de l’hypertension chez les adultes de 18 ans et plus qui n’ont pas recu anterieurement de diagnostic d’hypertension. Qualite des donnees Les donnees probantes sont tirees d’une recension systematique dans MEDLINE, EMBASE et la base de donnees des syntheses systematiques de la Collaboration Cochrane (EBM Reviews), de janvier 1985 a septembre 2011. Les types d’etudes retenues se limitaient aux etudes randomisees controlees, aux syntheses systematiques et aux etudes observationnelles avec groupes temoins. Message principal Trois fortes recommandations se sont degagees de donnees probantes de qualite moderee. Il est recommande de mesurer la pression arterielle a toutes les consultations appropriees en soins primaires, conformement aux techniques actuelles decrites dans les recommandations du Programme educatif canadien sur l’hypertension pour la mesure de la pression arterielle en cabinet et en soins ambulatoires. Les criteres du Programme educatif canadien sur l’hypertension pour l’evaluation et le diagnostic de l’hypertension devraient s’appliquer aux personnes chez qui on observe une pression arterielle elevee. Conclusion A la suite d’un examen des plus recentes donnees probantes, le Groupe d’etude canadien sur les soins de sante preventifs continue de recommander la mesure de la pression arterielle lors des consultations periodiques aupres du medecin.

Background / Purpose: Organized stroke care within the rehabilitation setting has improved functional outcomes and enable stroke patients to re-integrate within the communities. The Evidence Based Systematic Review for stroke recommends that mild stroke patients with a FIM ® &gt; 80 could receive therapy within the community. However, in Ontario, approximately 20% of mild stroke patients continue to be admitted to inpatient rehabilitation. The purpose of this study is to identify the differences between the mild stroke patients being admitted to inpatient rehabilitation and being discharged home directly from acute care and propose a triage system for the mild stroke population. Methods: A retrospective chart audit was conducted for acute stroke discharges from two regional stroke centres in Ontario. The cohort included patients with a most responsible diagnosis of stroke and a completed AlphaFIM ® Instrument assessment. Stroke cases that had a Projected Full FIM ® score derived from the AlphaFIM ® Instrument with a score &gt; 80, we’re stratified into two groups:discharged home and discharged to inpatient rehabilitation. Data was analyzed using a full and step wise regression model to determine which indicators impacted the discharge disposition. Results: There were 813 patients were eligible for inclusion. The mean age of participants was 72 years, and 54% were males. Overall, 33% of mild stroke patients were admitted to inpatient rehabilitation. The results of the analysis did not explain why so many mild stroke patients are admitted to inpatient rehabilitation. There was a trend toward mild stroke patients with aphasia, inattention and cognitive impairments being admitted to inpatient rehabilitation; however, this was not statistically significant. These two groups did not differ in rates of recurrent stroke or re-admission to hospital at follow-up. Conclusion: The results of this research indicates that milder stroke patients with a Projected Full FIM ® &gt; 80 may effectively be managed in the community if appropriate rehabilitation services are available. Further research is warranted to evaluate functional outcomes of stroke patients within the community rehabilitation setting in order to determine its efficiencies.

Background: Dementia prevalence is rising, and will double in the next 20 years. This study sought to understand the prevalence of dementia in hospitalized patients with stroke and TIA, differences in characteristics and impact on outcomes. Methods: Using the Canadian Institute of Health Information (CIHI) Discharge Abstract Database (DAD), all acute stroke and TIA admissions from April 2003 to March 2015 in Canada (excluding Quebec) were analyzed. Concurrent dementia at time of admission was assessed based on hospital diagnostic codes. Characteristics and in-hospital outcomes were compared in patients with vs. without dementia using chi-square and logistic regression. Results: During the observed period 464,741 patients were admitted to hospital for cerebrovascular syndromes (ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage (SAH) and TIA). Of those, 29,812 (6.4%) had a concurrent diagnosis of dementia, including 8.4% of patients ≥65 years. People with dementia had older median age (84 vs. 75 years; p&lt;0.01), were more often female (59.6% vs. 49.3%; p&lt;0.01) and more often had Charlson-Deyo comorbidity index ≥ 2 (62.1% v. 38.4%; p&lt;0.01). They were less likely admitted with SAH (1.3% vs. 5.3%; p&lt;0.01) and more likely coded as strokes with unidentified subtype (29.4% vs. 20.8%; p&lt;0.01). Median length of stay (13 vs. 7 days; p&lt;0.01) was longer. Patients with dementia were less likely discharged to another acute care facility (7.6% vs. 14.7%; p&lt;0.01), rehabilitation facility (5.4% vs. 12.0%; p&lt;0.01) or home independently (22.9% 48.9%; p&lt;0.01); other outcomes are shown in the Table. Conclusions: Approximately 1 in 10 hospitalized stroke and TIA patients age ≥65 has coded dementia. Patients with stroke or TIA and dementia have higher mortality, face significantly more dependence after stroke and utilize greater healthcare resources than stroke patients without dementia. Early care planning and coordination are essential to optimize outcomes.

Introduction: In Canada, approximately 12% of acute stroke patients are admitted to long-term care (LTC; or residential aged care) facilities following an acute stroke event. An additional 20-30% of patients are discharged home from hospital with referral for community-based homecare. Training programs for health care providers in these settings is variable and at times inconsistent with best practices. Internationally, focus is now shifting from a predominant inpatient acute care focus, to one encompassing ongoing care and support in the community for people living with stroke. In 2015, an educational resource called Taking Action for Optimal Community &amp; Long Term Stroke Care (TACLS) was launched across Canada to ensure the appropriate knowledge and skills of front line care providers for stroke survivors in community and LTC facilities; the focus of this resource is on rehabilitation and recovery. Methods: The purpose of this interactive session is to introduce the TACLS resource and to engage health professionals in an examination of current international community based rehabilitation and recovery programs. The discussion/workshop will allow participants to examine, compare and contrast components of the TACLS program with programs being developed or offered elsewhere. Results: As health care providers helping stroke survivors live well and longer means investing in the use of best practice tools and resources that fit the local context and organizational practices. Bringing together international opinions and observations around post-stroke community care will allow cross-collaboration and inter-professional networking opportunities that ultimately will benefit patients living with stroke in community based settings. Discussion: As care shifts from hospital to community based settings, the importance of tools available to support stroke survivors in this area of the care continuum is essential. In Canada, utilizing the HSF education resource (TACLS) provides information to support community based health care providers working with people who have had a stroke in helping them achieve optimal outcomes, regain their best level of functioning, and live meaningful lives.

April 27, 2017April 18, 2017Free AccessUtilization of Carotid Revascularization for Ischemic Stroke/TIA: A Canadian Perspective (P5.276)Mohamed Najm, Patrice Lindsay, Michael D Hill, Andrew Demchuk, and Bijoy MenonAuthors Info & AffiliationsApril 18, 2017 issue88 (16_supplement)https://doi.org/10.1212/WNL.88.16_supplement.P5.276 Letters to the Editor

à la révision d'articles pour le journal.La révision par les pairs est une composante essentielle à la crédibilité et au succès d'une revue médicale.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Aged preparations of polysaccharide fromE. coli were highly effective in inducing a lethal shock in rats bearing a tumor. This effect may be increased by some medications, while various steroid hormones afforded an efficient protection.

Background: Management of transient ischemic attacks (TIA) in specialized stroke centres and prevention clinics have been shown to decrease stroke recurrence and mortality. The impact of these services on a population level are unknown. We aimed to analyze whether modern medical management of TIA has decreased the rate of stroke recurrence and mortality over time in Ontario. Methods: Administrative data from the Canadian Institute for Health Information’s Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS) database 2003-2015 were analyzed and rates of stroke recurrence and mortality were calculated. Results: From 2003 to 2015 in Ontario, there were an increasing number of discharges from emergency departments (ED) and a decreasing number of discharges from hospitals. Linear regressions of stroke recurrence at 24 hours, 48 hours, day 7, 30, 90, 180, and 1 year after a TIA showed significantly faster decline between 2003-2015 (p &lt;0.01). Overall stroke recurrence at 1 year decreased from 5.8% to 2.7% between 2003 and 2015, a rate greater than could be explained just from increasing numbers of people labelled as TIA. From 2003-2015, mortality after ED discharge following a TIA decreased from 1.3% to 0.3% (p&lt;0.001), also a greater decline than expected. Interpretations: There is increasing outpatient management of TIAs in Ontario. The observed decline in stroke recurrence was greater than can be explained by referral bias alone, and the increasingly negative slopes of these lines from 24 hours to 1 year suggest a cumulative benefit of improved TIA management over time rather than just increased labelling of low-risk patients. On a population-level, stroke recurrence and mortality after TIA have declined from 2003 to 2015 with a province-wide system of organized stroke care. In contrast to other studies that have shown reduced stroke recurrence and mortality at specialized centres, this study demonstrates the impact of these programs at a population level.

Abstract The authors have withdrawn this preprint from Research Square

Abstract Background Actively engaging people with lived experience (PWLE) in stroke-related clinical practice guideline development has not previously been implemented and evaluated despite international efforts to incorporate patient and public engagement. The purpose of this pilot project was to evaluate the feasibility, perceived value and effectiveness of a new model, the Community Consultation and Review Panel, to actively engage PWLE in the writing and review of Canadian Stroke Best Practice Recommendations (CSBPR).Methods Members of the public with lived experience relevant to CSBPR module topics, including people with stroke, family members and caregivers, were recruited to participate in two CSBPR Community Consultation and Review Panels (CCRP). The CCRP ran in parallel to scientific writing groups updating two components of the CSBPR Rehabilitation, Recovery and Community Participation module – Rehabilitation and Recovery following Stroke and Transitions and Community Participation following Stroke . With the aid of an inter-group liaison, both the scientific writing group and CCRP reviewed the updated evidence and CCRP participants added insights and context based on their personal experiences. We utilized the Patient and Public Engagement Evaluation Tool (PPEET) to obtain CCRP participant feedback.Results This model was found to be feasible, requiring 3-4 hours of staff time per week. CCRP participants rated “strongly agree” or “agree” to 14 PPEET questions indicating that they perceived the CCRP to be a positive experience and effective process, and their participation had an impact. Responses to the open-ended questions revealed that CCRP participants felt that their input and recommendations on the CCSPR were acknowledged and would benefit stroke care in Canada.Conclusions The overall success of this pilot project established the feasibility and perceived benefit of employing a participatory and collaborative model to actively engage PWLE in stroke-related clinical practice guideline development. The values, experiences and recommendations of PWLE were able to be effectively incorporated into CSBPR content to enable lived experience specific context and considerations to augment the existing scientifically rigorous writing and review process. This model is now the standard practice for all future CSBPR module development and updates and could be adapted for guideline development across other disciplines.

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We thank Dr Peter Loveridge for his comment[1][1] on our call to action in controlling hypertension in older women in the October issue of Canadian Family Physician .[2][2] The article is not meant to be a criticism of Canadian primary care physicians. We recognize, congratulate, and participate

Wednesday, April 21April 13, 2021Free AccessImproved Identification of FAST Stroke Signs in the Population After Multiple Public Awareness Campaigns in Quebec, Canada (1895)Vincent Brissette, Bastien Rioux, Francine Forget Marin, Patrice Lindsay, and Alexandre Y.- PoppeAuthors Info & AffiliationsApril 13, 2021 issue96 (15_supplement)https://doi.org/10.1212/WNL.96.15_supplement.1895 Letters to the Editor

Garnett, R. L.; MacIntyre, A.; Lindsay, P.; Barber, G. G.; Cole, C. W.; Hajjar, G.; McPhail, N. V.; Ruddy, T. D.; Stark, R.; Boisvert, D. Author Information