The burden of stroke
The rate of new strokes and stroke deaths, when adjusting for age, has decreased over the last two decades in all European countries. Decreasing rates of new strokes are generally attributed to successful prevention strategies, e.g. hypertension control and smoking cessation. On average, improvements have been larger in Western European countries – increasing the already existing difference between East and West.
However, due to the ageing of the European population and the strong association between stroke risk and age, the numbers of people having a stroke continues to rise. Using data from the Global Burden of Disease study 2015, and demographic projections obtained from Eurostat (statistical office of the EU), a 34% increase in total number of stroke events in the EU between 2015 and 2035 is predicted.
Together with the welcome improvement in survival rates, there are increasing numbers of people living with the effects of stroke, needing specialist supportive care and rehabilitation, resulting in a growing burden of stroke on families, societies and health care systems.
In 2015, direct healthcare costs alone added up to €20 billion in the EU, while indirect costs of stroke due to the opportunity cost of informal care by family and friends and lost productivity caused by morbidity or death were estimated to be another €25 billion. Reducing the incidence of stroke and the likelihood of long-term disability will help to bring down these costs[6, 7].
Stroke is preventable, but public knowledge about the risk factors for stroke is low. The impact of educational campaigns aiming to change behaviour is largely short-lived.
The proportion of the population with one or more risk factors for stroke is significant. High blood pressure, the most important risk factor for stroke, is significantly under-treated. The proportion of people with known high blood pressure who achieve adequate blood pressure control is well below half. Atrial fibrillation (AF, an abnormal heart rhythm with rapid and irregular beating), another important risk factor, is often not diagnosed until after a stroke event, or not treated according to widely available, national, evidence-based guidelines.
In stroke care, “time is brain”: patients with suspected stroke need to be admitted to hospital wherever possible, assessed and treated as appropriate within a few hours, to improve their outcomes.
However, public awareness of stroke as a medical emergency is poor. An international European study showed that about one in five people could not identify any stroke symptoms and only about half would call an ambulance. Many educational campaigns are being undertaken, but most are not systematically evaluated for their impact.
Similarly, in most European countries there is no evidence that training of medical staff involved in emergency stroke care is implemented and monitored systematically. Many regions have improved their pre-and in-hospital emergency care pathways. There is an opportunity to learn from these experiences and try to replicate them elsewhere.
Improvements in survival have been made particularly since the implementation of stroke units and thrombolysis (clot-busting) treatment. There have been significant increases in the number and quality of stroke units in Europe. However, despite their inclusion in European and national guidelines, it is estimated that only about 30% of european stroke patients receive stroke unit care. Variations between countries, but particularly also between different areas within countries, are large. Rural and remote areas often have poor access.
In order to improve the quality of care received in stroke units, internationally agreed standards of stroke unit care based on evidence and expert opinion have been developed. A system of official accreditation has been introduced on a European level, and also national level in several countries, but uptake is very variable as it is mostly voluntary.
The benefit of thrombolysis is well established. However, thrombolysis rates are still significantly below expectations. Barriers to the delivery of thrombolysis are numerous and complex, depending on the local context: pre-and in-hospital delays, a lack of specialised units or staff, lack of diagnostic equipment, insufficient funding, and decentralised systems of stroke care have all been linked to lower thrombolysis rates.
rehabilitation and supporting longer-term needs
For many countries, there is very little information on the rehabilitation therapies that stroke survivors receive, especially once they have left hospital. Few countries audit rehabilitation services, and there are inconsistencies in the standards used to measure adherence to guidelines across Europe.
The type and quality of therapies that patients can access often depend on where they live. For example, specialist rehabilitation may only be available in large urban areas. Occupational therapy and psychological support are either very limited or not available at all to stroke patients in several countries. Patients can experience long delays in starting rehabilitation because of a lack of capacity in rehabilitation centres or in the community.
Once patients have been discharged from acute care, access to further rehabilitation is also very variable between and within countries. In around two in five EU countries, outpatient therapies are not generally available. Only a small minority of EU countries have local arrangements to offer stroke survivors a follow-up review with a therapist or doctor, and again, actual practice can vary substantially within a country.
Health insurers and national health authorities rarely offer support with adjusting to life after stroke, such as programmes to support people who want to return to work. In the last 5-10 years most European countries have cut funding of some services that support disabled people, such as training that helps people return to work.
Stroke support organisations (SSOs) exist at a national level in nearly all EU countries. They aim to offer practical, emotional and advocacy support for stroke survivors and their families and, often, promote stroke prevention awareness and action. There is a need for more information on the reach and impact of SSOs.