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Get with the Guidelines -- Stroke program could be global model

The American Heart Association/American Stroke Association's Get With The Guidelines®–Stroke program could be a foundation for improving stroke care globally, according to a study published in Circulation: Journal of the American Heart Association.

Researchers assessed Get With The Guidelines–Stroke in the Taiwan Stroke Registry with 30,599 stroke admissions between 2006 and 2008. They found that the guidelines, in general, were applicable to Taiwan's stroke data.

They identified three important Get With The Guidelines–Stroke standard practices that would improve outcomes of ischemic (or clot-caused) stroke in Taiwan:

• Based on comparison between Get With The Guidelines–Stroke and Taiwan Stroke Registry data, Taiwan is far behind in administering the clot-busting tissue plasminogen activator (tPA). Studies have shown that tPA can reduce the effects of stroke and reduce permanent disability, if given within three hours of stroke onset. U.S. data suggest that more than 70 percent of qualified patients receive tPA at Get With The Guidelines–Stroke hospitals compared to less than 9 percent in the Taiwan Stroke Registry. The registry represents 39 academic and community hospitals in the country.

• Giving aspirin or a comparable drug to stroke patients upon discharge is standard practice under the Get With The Guidelines–Stroke guidelines — lowering risk of recurrent stroke other cardiovascular events and death. Adherence to this guideline for stroke prevention is 85.5 percent in the Taiwan Stroke Registry and 98.9 percent at Get With The Guidelines–Stroke hospitals in the United States.

• Administering blood thinners to prevent blood clot formation and stroke in patients with irregular heartbeats is a Get With The Guidelines–Stroke standard practice, shown in studies to reduce recurrent stroke, other cardiovascular events and death by about 50 percent. Only 28.3 percent of stroke patients in the Taiwan Stroke Registry with a severe type of irregular heart beat (atrial fibrillation) received a blood thinner, compared to 98.4 percent at Get With The Guidelines–Stroke hospitals.

"The World Health Organization ranks stroke as the world's second leading cause of death, so improving quality of stroke care is a global priority, despite diverse healthcare economies across nations," said Chung Y. Hsu, M.D., Ph.D., study author and chair professor at China Medical University in Taichung, Taiwan. "We looked at whether Get With The Guidelines–Stroke, which has been successful in improving stroke care in the Unites States, would be applicable across national and economic boundaries — especially in countries spending much less than the United States in stroke-related care."

In Taiwan, stroke is the third leading cause of death, and the cost to treat each stroke patient there is about one-tenth what it costs in the United States, said Hsu, principal investigator of the Taiwan Stroke Registry.

"Our data indicate that there is room for improvement in the quality of stroke prevention and care in Taiwan," Hsu said. "We have identified the specific standard practices that should be strengthened in Taiwan and want to heighten awareness among relevant government agencies, professional societies, hospitals and patients and their families in Taiwan of the need to work together to improve the quality of stroke prevention and care using the Get With The Guidelines–Stroke model. Other countries, outside the Unites States, can also apply the same strategies."

There were a few exceptions to the applicability of the U.S. program to patients in Taiwan. One example is the Get With The Guidelines–Stroke recommendation to administer blood thinners to prevent blood clotting in patients hospitalized with stroke. That standard practice in the United States may be excluded in Taiwan, where the risk for developing blood clots in leg veins is substantially lower than the Western countries.

Each country should assess its quality of stroke prevention and care applying the Get With The Guidelines-Stroke program, Hsu said.

"It is advisable that the leaders at the American Heart Association/American Stroke Association conduct further studies looking at the U.S. stroke population to assess the needs among stroke patients of Asian-Pacific origin and other ethnic/racial groups," he said. "We also recommend assessing and modifying Get With The Guidelines–Stroke to meet unique needs of different populations when this valuable system for monitoring quality of stroke care is introduced into each country outside the United States."

Emphasizing research on how heart disease and stroke affect different ethnicities and cultures is a priority, said Ralph Sacco, M.D., president of the American Heart Association.

"When Get With The Guidelines was established, it was set up more for stroke centers in the Unites States," said Sacco, Miller Professor of Neurology, Epidemiology and Human Genetics at the University of Miami's Miller School of Medicine in Florida. "This study from Taiwan tells us that there are applications for these programs in other nations. Stroke is a bigger cause of death and actually more frequent in Asian countries, so any program like this could have a tremendous impact on stroke outcomes in these nations."

Co-authors, disclosures and funding information are on the manuscript.

Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association's policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and device corporations are available at www.americanheart.org/corporatefunding.

Additional resources:
For more information on stroke, visit the American Stroke Association website: strokeassociation.org.
For more information on Get WithThe Guidelines, visit www.heart.org/quality.

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