Europe Launches Ambitious Plan to Elevate Stroke Care

GOTHENBURG, Sweden — Improving access to specialized stroke expertise, elevating the quality of care for all Europeans by 2030, and setting research priorities are the focus of an ambitious collaborative project led by the European Stroke Organisation.

Four overarching targets of the new Stroke Action Plan for Europe (2018 - 2030) include reducing the number of strokes in Europe by 10%, treating 90% or more of all patients in a dedicated stroke unit, creating national plans that address stroke from prevention to life after stroke, and promoting strategies that reduce stroke risk on a population level.

These targets were announced here at the 4th European Stroke Organisation Conference (ESOC) 2018.

Action is needed because less than half of the population now has access to specialized stroke care, organizers say. Current capacity contributes to this challenge.

"The biggest problem is there are not enough stroke centers in Europe," Bo Norrving, MD, professor of neurology at Lund University in Sweden and chair of the stroke action plan, told Medscape Medical News during a media briefing here at ESOC. "The second problem is the best available are not enough — patients come to our hospitals and are placed on the wrong ward."

The insufficient number of stroke unit beds signals a major disconnect between specialized stroke resources and the magnitude of stroke's burden across the continent. "There is a profound mismatch in this area," said Norrving.

Stroke remains the second leading cause of death and number one cause of long-term disability among Europeans, said Jon Barrick, co-chair of the European Stroke Action Plan and president of the Stroke Alliance for Europe (SAFE), a patient advocacy group collaborating with ESO.

"In terms of the world's great killers, stroke research is underfunded," Barrick added. "If stroke continues to be under-resourced in the way it is, it is quite credible stroke will go from the number two killer to number one."

"The Burden of Stroke in Europe" report, published by SAFE in 2017, provided a snapshot of stroke services and predictions for the future. There are, for example, €45 billion direct and indirect healthcare costs each year associated with stroke. "If everything continues as is, there will be a 35% increase in stroke by 2030. Something needs to be done," Barrick said.

Putting a more positive spin on the situation, Norrving said short-term investments to boost stroke resources and access to expertise represents "a great return on investment" over the long term compared to other conditions.

"One of the best stocks you can buy today is to invest in stroke care."

The new Stroke Action Plan announced at ESOC 2018 follows two previous attempts to improve stroke care across Europe. Advances in science, technology, and therapy for stroke care could improve the chances of success compared to the two earlier "Helsingborg Declarations" in 1995 and 2006.

"I'm actually very confident," Norrving said. "In places and countries where we have national programs and a very strong leadership, this has been very much improved."

Experience in some high-income European countries demonstrates that the overall number of strokes can be reduced, even in the face of a growing and aging population. In Sweden, for example, efforts to improve secondary prevention, treat atrial fibrillation, and address population-wide risk factors is associated with 4000 fewer people with stroke over 7 years, Norrving said.

"For both patients with a first and recurrent stroke, we see there is a dramatic decrease in the number," he added.

Expanding the Focus

Primary prevention and addressing life after a stroke are two new priorities outlined in the plan. Providing universal access to primary prevention treatments in Europe, enabling evidence-based screening and treatment programs, and controlling high blood pressure in 80% of people with hypertension are among the new goals.

Regarding life after stroke, for example, "We are particularly pleased that after many, many years, it's being recognized that stroke is not something that just happens in an instant," Barrick said. Many stroke survivors live for decades and need ongoing assistance to help them be productive and maintain their quality of life. This is particularly important, he added, because fatigue and long-term pain are often not the focus of acute stroke services.

"Unfortunately, there is relatively little reference to life after stroke in European or other national guidelines," he said. "It's as if there is no guidance on what should be done after someone leaves rehabilitation."

Supporting self-management, promoting peer support, and implementing digital self-help information are among the life-after-stroke initiatives in the action plan.

"'A life saved must also be lived,' is a saying we have at SAFE," he added.

Organization of stroke services, management of acute stroke, secondary prevention and organized follow-up, rehabilitation and evaluation of stroke outcome, and quality assessment are additional areas carried over from previous initiatives.

Collaboration Across the Continent

ESO President Valeria Caso, MD, PhD, a stroke neurologist at the University of Perugia in Italy, said the next step of the Stroke Action Plan needs to be implementation. "The targets are ambitious but, as we have seen, achievable. I am pleased to say that ESO is already working on creating the network needed to overcome inequality in stroke care in Europe."

"ESO is a scientific body," she added. "It's clear we will need to split the work with other organizations." Therefore, success of the action plan hinges on collaboration with the World Health Organization, the European Union (EU), individual nations, and other healthcare organizations, she said.

"I like what ESO is doing regarding the clear public health approach and their clear desire to reduce disparities across Europe," said Jill Farrington, coordinator for non-communicable diseases at the World Health Organization Regional Office for Europe. "I particularly like the comprehensive nature of the action plan, and the inclusion of the [two new action items] is particularly important."

Initial collaborators include ESO-EAST, an organization within ESO specifically addressing stroke care in Eastern European countries; the European Society of Cardiologists; and the World Stroke Organization.

The next step is to work with politicians, administrators, and governments to see this is accomplished, Norrving said.

"There is hope. The stroke action plan falls in line with the EU's call for effective, accessible, and resilient health systems," Barrick said. "It could be it just needed ESO and SAFE to articulate what is required."

The Stroke Action Plan will be presented to the EU Parliament in the near future.

Norrving, Barrick, Caso, and Farrington have disclosed no relevant financial relationships.

4th European Stroke Organisation Conference (ESOC) 2018. Presented May 16 and 17, 2018.

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