Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study

Peter Langhorne* (Corresponding Author), Martin J. O'Donnell, Siu Lim Chin, Hongye Zhang, Denis Xavier, Alvaro Avezum, Nandini Mathur, Melanie Turner, Mary Joan Macleod, Patricio Lopez-Jaramillo, Albertino Damasceno, Graeme J. Hankey, Antonio L. Dans, Ahmed Elsayed, Charles Mondo, Mohammad Wasay, Anna Czlonkowska, Christian Weimar, Afzal Hussein Yusufali, Fawaz Al HussainLiu Lisheng, Hans-Christoph Diener, Danuta Ryglewicz, Nana Pogosova, Romana Iqbal, Rafael Diaz, Khalid Yusoff, Aytekin Oguz, Xingyu Wang, Ernesto Penaherrera, Fernando Lanas, Okechukwu S. Ogah, Adesola Ogunniyi, Helle K. Iversen, German Malaga, Zvonko Rumboldt, Daliwonga Magazi, Yongchai Nilanont, Annika Rosengren, Shahram Oveisgharan, INTERSTROKE collaborators, Salim Yusuf

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

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Background Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels.
Methods We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month.
Findings We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14–1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12–1·72) irrespective of other patient and service characteristics.
Interpretation Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes.
Original languageEnglish
Pages (from-to)2019-2027
Number of pages9
JournalThe Lancet
Issue number10134
Early online date17 May 2018
Publication statusPublished - 19 May 2018

Bibliographical note

The current analysis was supported by a grant from Chest, Heart and Stroke Scotland. The main INTERSTROKE study was funded by the Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Vastra Gotaland (Sweden), and through unrestricted grants from several pharmaceutical companies with major contributions from AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Swedish Heart and Lung Foundation, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network. The Department of Neurology at the University Duisburg-Essen received research grants awarded to H-CD from the German Research Council (DFG), German Ministry of Education and Research (BMBF), European Union, National Institutes of Health, Bertelsmann Foundation, and Heinz-Nixdorf Foundation.


  • stroke unit
  • stroke management
  • outcome
  • antiplatelet therapy
  • care processes


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