Elsevier

The Lancet Neurology

Volume 6, Issue 2, February 2007, Pages 134-139
The Lancet Neurology

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Standard method for developing stroke registers in low-income and middle-income countries: experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke)

https://doi.org/10.1016/S1474-4422(06)70686-XGet rights and content

Summary

Background

Stroke is a leading global cause of death, with an estimated 5·8 million fatal events in 2005, two-thirds of which happened in low-income and middle-income countries. In these regions, epidemiological methods to establish hospital-based stroke registers for clinical audit or studies to estimate incidence are scarce. Our aim was to ascertain whether stroke registers could be set up in geographically diverse populations in low-income and middle-income countries, using standardised data-collection manuals and methods, before recommending their wider use.

Methods

WHO's stepwise approach to stroke surveillance (STEPS Stroke) offers an entry point for countries to register stroke patients in health-information systems. The methods proposed in this strategy were tested in a feasibility study, which focused on hospitalised stroke patients in nine different surveillance sites located in five low-income and middle-income countries. Data collection was for a median of 12 months. Observed differences between men and women were adjusted for age and surveillance site with logistic-regression analyses.

Findings

A total of 5557 stroke patients were registered; 91 people whose age was missing or younger than 15 years were excluded from the analyses. Mean age was 64·2 years (SD 14·6), and 2484 (45%) participants were women. Ischaemic stroke accounted for about two-thirds of events. Half of all patients were hospitalised the same day. Stroke subtype was verified in 4913 (90%) participants by diagnostic techniques. Women had lower odds of verification of stroke subtype compared with men after adjustment for age and surveillance site (odds ratio 0·69 [95% CI 0·56–0·86]; p=0·0006).

Interpretation

STEPS Stroke can be used in diverse populations to provide data in a standardised manner in countries with little or no previous records of stroke. Future studies should concentrate on expansion beyond hospital case series by adding information for stroke patients treated outside the hospital, linked to census data for the source population from which the cases come.

Section snippets

Background

In 2005, estimates suggested that 58 million people died, and chronic diseases accounted for 35 million deaths (60%).1 Cardiovascular diseases, predominantly heart disease and stroke, are the cause of death in 17·5 million individuals. Stroke, after heart disease, is the second leading single cause of death, with 5·8 million fatal cases per year, 40% of which are in people younger than 70 years. About 15 million new acute stroke events arise every year, and about 55 million people have had a

Methods

STEPS Stroke is described in detail elsewhere.6 In brief, a standard manual, questionnaire, and data-entry strategy were developed for gathering hospital-based and population-based data for stroke, according to local needs and resources. Stroke patients were included in consecutive order, and the STEPS Stroke study site coordinator ensured complete registration of all eligible individuals.

Results

A total of 5557 stroke patients were registered. Table 1 lists participating surveillance sites together with brief details about number of people registered and over what period, the proportion of men, and mean age. For statistical analyses, 81 patients with missing values for age, and ten who were younger than 15 years, were excluded. Table 2 shows descriptive data from the combined surveillance sites. The highest number of stroke events was recorded in patients aged 65–74 years (figure).

Discussion

Findings of this feasibility study show that STEPS Stroke has fulfilled three basic requirements for an international surveillance study. First, it has generated new standardised data for stroke from low-income and middle-income countries. Second, sites in different geographical regions could adhere to a standard protocol for stroke data collection despite large differences in infrastructure and capacity for undertaking epidemiological studies of stroke; missing data were kept to a minimum.

References (14)

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