Stroke care in Spain. What do we have? What do we need?
KEYWOStroke uStroke cNationalStrategy
Please ciNeurologa. Correspo
2173-5808/$Tejedor , B. Fuentes
Neurologa y Centro de Ictus, rea de Neurociencias, Instituto de Investigacin IdIPAZ, Hospital Universitario La Paz, Autnoma de Madrid, Madrid, Spain
Abstract The high level of scientic evidence which supports the recommendations for thecare of acute stroke in stroke units (SUs) with a good health care network, does not correspondto the level of introduction in Spain. In this regard, the Cerebrovascular Diseases Study Group(GEECV) of the Spanish Society of Neurology has taken the initiative to conduct the NationalSurvey of Stroke Care that will help to determine the real situation in acute stroke manage-ment in Spain just before the approval of the National Stroke Strategy (NSS) by the Ministry ofHealth and concludes that in the rst semester of 2009 there were 39 SUs, unevenly distributedwith higher concentration in Madrid and Barcelona. Although the approval of the NSS was amajor achievement, much remains to be done to meet the objectives. We thank the GEECVsinitiative, which gives us an X-ray of the, not very satisfactory, state of stroke care in Spainin December 2008, highlighting some achievements and the many shortcomings. Therefore, wemust continue to improve, rene our data collection with records that include all availableresources and all the stroke patients attended. We invite GEECV to carry out a second study toevaluate the impact of NSS and to serve as a stimulus to achieve a substantial improvement instroke care in Spain, closer to the recommendations of the new PASI document. 2011 Sociedad Espaola de Neurologa. Published by Elsevier Espaa, S.L. All rights reserved.
AS CLAVEs de ictus;ia del rictus;ia Nacional
Situacin asistencial del ictus en Espana. Qu tenemos? Qu nos falta?
Resumen El alto grado de evidencia cientca en el que se sustentan las recomendacionessobre la asistencia de los pacientes con ictus agudo en unidades de ictus (UI) con una buena redasistencial no se corresponde con el grado de implantacin de las mismas en Espana. En estesentido, el Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV) de la SEN ha tomadola iniciativa de elaborar la Encuesta nacional de la asistencia del ictus que ayuda a conocercmo era sta justo antes de aprobarse la Estrategia Nacional del Ictus (ENI) por el Ministerio deSanidad y concluye que en el primer semestre del ano 2009 existan 39 UI, distribuidas de formadesigual con mayor concentracin en Madrid y Barcelona. Aunque la rma de la ENI ha supuestoun importante logro, todava queda mucho por hacer para cumplir los objetivos planteados.Es motivo de satisfaccin esta iniciativa del GEECV, que nos aporta una radiografa de lasituacin de la atencin del ictus en Espana a diciembre de 2008, que no es muy satisfactoria
te this article as: Dez-Tejedor E, Fuentes B. Situacin asistencial del ictus en Espana. Qu tenemos? Qu nos falta?2011;26:4458.nding author.ddress: firstname.lastname@example.org (E. Dez-Tejedor).
see front matter 2011 Sociedad Espaola de Neurologa. Published by Elsevier Espaa, S.L. All rights reserved.
446 E. Dez-Tejedor, B. Fuentes
y que alumbra algn logro y muchas carencias, por lo que hemos de continuar mejorando,perfeccionando nuestra recogida de datos mediante registros que incluyan todos los recursosdisponibles en la atencin del ictus y los pacientes atendidos. Invitamos al GEECV a realizar unsegundo trabajo que evale el impacto de esta ENI y que sirva de estmulo para conseguir unamejora continua y sustancial de la situacin en Espana, y aproximarnos a las recomendaciones
For mana major theat best, to since the 1that speciaprogress, lEuropean Sknown as when the tacute stroka stroke unscientic epatients isassociationogy SocietyDeclarationwhen necethe variousup-to-dateable to be they can oproblem, wquality posage, SpainRegional Hearly speciation of speto cover th
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y years, caring for stroke has been suffering fromrapeutic nihilism, with patients being entrusted,
the natural course of their condition. Fortunately,980s, studies have begun to be published showinglist attention in ictus has an impact on patientseading the World Health Organization and thetroke Council to issue in 1995 what has becomethe Helsinborg Declaration,1 ratied in 2006,2
arget set was to achieve, for all patients with ane, early specialist assessment and treatment init (SU). In addition, however, over and above thevidence, specialized neurological care for stroke
a clear demand of modern society. Thus, thes of neurology patients and the Spanish Neurol-
(SEN) drafted back in 2000 the so-called Madrid, setting out the right of all citizens to be seenssary by an expert with specic competencies in
neurological pathologies, with access to the most diagnostic and therapeutic techniques, and to becared for in specic interdisciplinary units wherebtain all assistance necessary for their healthith assurances that this care will be of the highestsible.3 In his report on subsequent brain dam-s Ombudsman included a recommendation for theealth Authorities: stress should be placed on thealized care of stroke patients through the cre-cic stroke units or specialist stroke teams so ase entire population.4
e results of the rst randomized studies demon-e efcacy of SU were published in the 1980s,
have become the cornerstone for the treatmenttroke. Subsequently, in the 1990s, the efcacyous brinolytic treatment was demonstrated inases of acute cerebral infarction and we areeeing major advances in the development of
therapies.units have been shown to be clearly effective
mortality and better functional recovery, withe level of I (grade A recommendation) based on
for spebe treNonething theat thetheir iEurope
In tGroupresponof stroof NeuCare SbeforeStrate
As iable rascientiof stroIt shouthankspublicPlan (Pof cartance groupstogethtiatedset ouinside mentsof hosof strostrokein addgrammhas picwithinlished studies and meta-analyses. They also repre-t-effective measure, as they shorten the meanf patient stays and increase their survival with-plying a larger number of institutionalizations,er number of independent patients. Their bene-
to all types of ictus and are independent of agey.6,7 In addition, in comparison with thromboly-ve a larger potential target population as it hasated that 83% of patients would be candidates
to the techits wordingtives of theand Consumhomogenizments Heacare plans,secondary rehabilitatitaria del ictus.blicado por Elsevier Espaa, S.L. Todos los derechos
ist management at an SU, versus 10% who could with intravenous thrombolysis in the rst 3 h.8
s, the high degree of scientic evidence underly-ommendations on care for acute stroke patientsroke units does not correspond to the degree ofmentation in Spain, nor even in the whole of thenion.ense, the SENs Cerebrovascular Diseases StudyECV) has taken the initiative and assumed theity for drawing up a snapshot of the situationare in Spain at the end of 2008, and this issuega presents the results of the National Strokey,9 which helps to show what it was like just
Ministry of Health approves the National Stroke
ll known, in recent years there has been consider-chement between the Health Authorities and thecieties, which has culminated in the preparationre plans at both regional and national levels.1115
e pointed out that these documents have arisenhe drive given by the SENs GEECV through the
and dissemination of the Stroke Health Care, published in 2006, which established the levels
be provided for this condition and the impor-e Stroke Code,13 recently revised11), as well as totroke experts in a number of regions that have,ith their respective Regional Governments, ini-
plans for acute stroke. These documents have bases for implementing the Stroke Code bothoutside the hospital context, as well as improve-e levels of care through an increase in the numbers with an SU, stroke teams, and the emergenceeference centres, together with the creation of
networks interconnecting these levels of care, to the adaptation of specic rehabilitation pro-N parallel, the Ministry of Health and Social Policy
up the baton and has drafted the stroke strategy National Health System (SNS).10 This was pub-vember, 2008, with the participation, in addition
nical committee of stroke experts responsible for, of an institutional committee with representa-
Regional Governments and the Ministry of Healther Affairs, as it was then. The strategy aims to
e stroke care, committing the Regional Govern-lth Departments to develop and implement these
reecting the basic strategic lines (primary andprevention of stroke, care in the acute phase,ion and return to normal life, as well as training
Stroke care in Spain. What do we have? What do we need? 447
and research) and the necessary indicators for their assess-ment (these indicators can be extracted from the SNS datasystem and are combined with specic information compiledusing questionnaires agreed within the strategys monitoringcommittee).
Althougthe Inter-THealth Depimplied a developmeimprove stapplicationorder to acunderstandcorrectly twhich, in athat can bthe other, onaire undewith the pa
In the srst half otributed aclarge conccoincide inber of throhaving regstroke co
Althougin Spain ismake certalished hereto the impstage is a lthat may himplementbe outdatethe strategation in theprotocols, codes, proas neurosoresonance although tsituation oStrategy wtwo main vintravenouods. Thus,(prior to thanalysis ofit might bdecided pr
Also, thinhabitant,and territotaken evalthat somehospitals wavailable ilocated qustroke.
The analysis of thrombolytic dispersion may be inu-enced by this fact, so it would be useful to reect not onlythe absolute gures for treatments performed in a year,which are surprisingly low in some regions, but also the per-centage of treatments applied among all the patients with
mic , the
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the lly, snapembuatioachierial mproion pof thethery go
Euroly Intup mllstroion 27;23:laraclarach the signing of the National Stroke Strategy byerritorial Health Council and, therefore, all theartments of the 17 Regional Governments has
major achievement that tends to stimulate thent of specic plans helping to standardize androke care throughout Spain and accelerate its
in the regions, there is still a lot of work to do inhieve the targets set. It is certainly necessary to
the situation we started from 2008 so as to assesshe effects of the implementation of this strategy,ddition, proposed an assessment using indicatorse extracted from the SNS on one hand and, onbtaining specic information through a question-rtaken by this strategys monitoring committee,rticipation of all the Regions.10
urvey presented here, it is concluded that, in thef 2009, there were 39 SUs, albeit unevenly dis-ross the country. Thus, it is possible to observe aentration of SUs in Madrid and Barcelona, which
being the most active with regard to the num-mbolytic treatments administered and, also, inional stroke care plans in place with the use ofdes before the approval of the national strategy.h this kind of survey of the status of stroke care
very important and welcome, it is necessary toin considerations in connection with the one pub-. First of all, the publication of the data priorlementation of the SNS stroke strategy at thisittle tardy and there is no analysis of the changesave already occurred, whether or not due to itsation. The data may therefore be considered tod and, to a certain extent, redundant as, wheny was drawn up, an analysis was made of the situ-
different regions to reect the number that hadclinical practice guidelines, clinical routes, stroketocols for intravenous brinolysis, SUs, as wellnology resources, diffusion/perfusion magneticand neurovascular interventionism.10 Secondly,he goal proposed in this survey is to study thef stroke care in Spain at the moment the Strokeas approved (November, 2008), the analysis of theariables (SUs and number of patients treated withs thrombolysis) was considered for different peri-
the intravenous thrombolysis data refer to 2008e publication of the national strategy), but the
the SUs refers to the rst half of 2009, whene possible to nd a new incorporation, possiblyior to the signing of the said strategy.e analysis of the ratio of stroke unit beds per
without taking into account population densityrial...