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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 93-97

Point prevalence study for stroke in Saudi Arabia: A cross-sectional survey


1 National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
2 Research Center, King Fahad Medical City, Riyadh, Saudi Arabia

Date of Web Publication13-Sep-2019

Correspondence Address:
Dr. Humariya Heena
Research Center, King Fahad Medical City, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_142_18

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  Abstract 


Background: Stroke, a cerebrovascular disease, is the second-most common cause of mortality worldwide while it ranks third among other causes of disability. The incidence of stroke in the Middle East is even higher than in developed countries. Despite the increasing disease burden, presently, there is only one established acute stroke unit at King Fahad Medical City in Riyadh, Saudi Arabia. Objective: The objective of the study is to assess the number of stroke patients admitted to different units in all hospitals across Riyadh city at one point of time. Materials and Methods: A cross-sectional survey was conducted in 30 hospitals distributed across Riyadh in 2016 and included newly diagnosed stroke patients. Data were extracted using case report forms depicting all patient data collected during admission to the specified hospital wards. Descriptive statistics were used to describe the quantitative and categorical variables. Results: Of the total of 30 hospitals invited to participate, only 3 (10%) hospitals agreed to participate. A total of 33 stroke patients were admitted to these hospitals, majority (27 [81.8%]) were admitted to internal medicine, 5 (15.2%) to surgery, and 1 (3%) to a neurosurgery unit. The prevalence of stroke among patients with age groups of 51–60, 61–70, and >80 years was higher in men than women. Conclusion: More epidemiological studies on stroke need to be conducted in different regions of the Middle East for effective planning and management. Further, other key areas to be improved include the development of wellequipped and trained health-care providers, collaboration of a multidisciplinary team, and raising public awareness.

Keywords: Middle East, point prevalence, Saudi Arabia, stroke, stroke units


How to cite this article:
Memon I, Abu-Shaheen A, Heena H, Al-Tannir M. Point prevalence study for stroke in Saudi Arabia: A cross-sectional survey. Saudi J Health Sci 2019;8:93-7

How to cite this URL:
Memon I, Abu-Shaheen A, Heena H, Al-Tannir M. Point prevalence study for stroke in Saudi Arabia: A cross-sectional survey. Saudi J Health Sci [serial online] 2019 [cited 2019 Oct 22];8:93-7. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/2/93/261539




  Introduction Top


Stroke, a cerebrovascular disease is the second-most common cause of mortality worldwide while it ranks third among other causes of disability after ischemic heart disease. As per the 2013 update from the Global Burden of Disease Study, although the mortality and disability-adjusted life year (DALYs) rates have declined globally from 1990 to 2013, the absolute numbers of stroke-related deaths, stroke survivors, new incidents, and DALYs lost (102 million) in 2013 showed a marked increase, i.e., 1.4- to 1.8-fold for ischemic stroke (IS) and 1.2- to 1.9-fold for haemorrhagic stroke (HS).[1]

Globally, the proportional contribution of stroke-related DALYs and deaths due to stroke compared to all diseases increased from 1990 (3.54% [95% UI 3.11–4.00%] and 9.66% [95% UI 8.47–10.70%]) to 2013 (4.62% [95% UI 4.01–5.30%] and 11.75% [95% UI 10.45–13.31%], respectively).[1]

The incidence and prevalence of stroke in the Middle East have increased drastically in the last decade exceeding that of developed countries. A systematic review found that the incidence rate of stroke in Middle East countries (22.7–250/100,000 population per year in 2000–2014) have even crossed the rates in developed countries (crude stroke incidence rates of 112–223 per 100,000 population per year in 2000–2008). In the Kingdom of Saudi Arabia (KSA) with a population of >28 million, stroke is one of the fastest growing cerebrovascular disease leading to increased morbidity and mortality thereby increasing social and economic burden in the Kingdom.[2],[3] Although there is a lack of data on the prevalence of stroke in Arabia, a recent study conducted by the Ministry of Health (MOH) reported the prevalence to be 29/100,000 populations per year.

Early intervention and management of stroke patients not only reduces the mortality but also reduces the disability and improve survival and independence.[4]

Survival and reduction in disability in stroke patients are strongly associated with processes of care (such as early feeding, early mobilization, and measures to prevent aspiration) carried out in stroke units.[4] Multidisciplinary teams which include speech and language therapists, physiotherapists, occupational therapists, and dieticians contributes toward quality patient care.[5]

Previous studies showed a positive outcome in patients who were admitted to stroke units or organized stroke care as compared to medical wards. It has been seen that stroke unit care reduced patient mortality, increased independence, and reduced the rate of institutionalization in hemorrhagic as well as IS.[4],[6],[7]

Furthermore, it has been suggested that the effectiveness of stroke units may be attributable to protocols and standardized assessments which are followed in there. Stroke units perform a careful assessment of patients for dysphagia, mobility, feeding, and a higher threshold for urinary catheters. It has also been noted that early assessment reduces the risk of secondary complications such as chest infections, urinary tract infections, and venous thromboembolism associated with stroke.[4],[8]

Despite the increasing burden of the disease, presently, there is only one established acute stroke unit at King Fahad Medical City (KFMC) in Riyadh under the MOH.[9] In order to deliver quality care to stroke patients in the future, it is of utmost importance to setup more acute stroke units with specialized geriatric beds. Specialized geriatric beds have been proved to be a cost-effective way of managing stroke patients worldwide (both elderly and young stroke survivors who can contribute to the community even after suffering from this disabling condition).[10] Furthermore, the other requirement is to develop a multidisciplinary team which can ensure a holistic approach for the management of stroke patients. The aim of the present study is to assess the number of stroke patients admitted to different units in all hospitals across Riyadh city in Saudi Arabia at one point in time.


  Materials and Methods Top


Study design

A cross-sectional survey was conducted in 30 hospitals distributed across the entire Riyadh Province, KSA, in 2016. The Institutional Review Board at KFMC approval was obtained before the initiation of the survey.

Recruitment of the hospital

All hospitals were sent an invitation letter to participate in the study through an e-mail. A copy of questionnaire and cover sheet describing the study aims and procedures were also sent along with the invitation letter. No response after three trials of the invitation was considered as refusal of the hospital to participate in the survey.

Inclusion/exclusion criteria

All patients with a new diagnosis of stroke were invited to take part in this study. Patients with stroke history and admitted with the different diagnosis were excluded from the study.

Data collection tool

Data collection was done using case report forms depicting all patients data collected during admission to the specified hospital wards.

The case report form consisted of three sections. The first section of the questionnaire gathered demographic data including age, gender, educational level, monthly income, and area of residence. The second section identified the place where symptoms occurred, and the number of stroke patients admitted to different units. The third section assessed the current radio-diagnostic modalities and the in-hospital stroke services provided. The use of medications was determined by checking the previous and currently prescribed stroke medications.

The answers to these questions will give an idea on the required number of beds for establishing a stroke unit along with the clinical and allied health staff (such as physiotherapist, internist, and neurologist) needed to look after stroke patients.

Statistical analysis

Statistical tests were performed using SPSS, version 22.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to describe the quantitative and categorical variables.

Ethics approval

The study was conducted after seeking approval from the institutional review board.


  Results Top


Demographics

A total of 30 hospitals were invited to participate in this study, of which only three hospitals agreed to participate in achieving a response rate of 10%. In total, 33 stroke patients were admitted to these hospitals. The sociodemographic characteristics of the patients are presented in [Table 1]. Eight (25.0%) patients were >80 years of age. The number of male patients were 22 (66.7%) while 21 (63.6%) among all the patients were literate patients. Information about the income of the patients was unknown for more than half of the patients, i.e., 21 (63.6%).
Table 1: Sociodemographic characteristics of participants

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Number of stroke patients admitted to different units and place of symptoms

Majority of the patients, i.e., 27 (81.8%) were admitted to internal medicine, whereas 5 (15.2%) of them were admitted to surgery units and 1 (3.0%) of them to a neurosurgery unit [Table 2]. The place of occurrence of stroke was unknown for more than half of the patients, i.e., 20 (60.6%).
Table 2: Number of beds occupied by stroke patients in different units and places where symptoms occurred

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Current radio-diagnostic modalities performed in stroke patients

Magnetic resonance imaging, magnetic resonance angiogram, and ultrasound were performed only in 7 (21.9%) patients, whereas computed tomography scan and electrocardiogram were performed in 21 (65.6%) and 17 (53.1%) of the patients, respectively [Table 3].
Table 3: Current radio-diagnostic modalities of the stroke patients

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In-hospital services

Tissue plasminogen activator, while 24 (72.7%) received inpatient rehabilitation. 29 (87.9%) patients were seen by a physiotherapist, while only 6 (18.2%) participants were seen by a stroke therapist [Table 4].
Table 4: In-hospital services provided to the stroke patients

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Medications history

[Table 5] shows the previous medications history of patients. The two most frequently prescribed medications were aspirin 22 (66.7%) and simvastatin 20 (60.6%).
Table 5: Previous medications prescribed for participants

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Prevalence of stroke

The prevalence of stroke among patients with the age groups of 51–60, 61–70, and >80 years was higher in men compared to women with the same age group [Table 6].
Table 6: Age- and gender-specific prevalence of the stroke patients

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  Discussion Top


Our results reveal various valuable insights regarding the number of stroke patients admitted to different units among the participated hospitals. The study showed that 81.8% of participants were admitted to internal medicine, whereas, few were admitted to surgery and neurosurgery units. Furthermore, majority of patients (87.9%) were treated by a physiotherapist, and only 18.2% of patients were treated by a specialized stroke therapist. Few studies in the past have compared the level of patient care in stroke units to that of general medical wards. These studies found that acute care stroke units can improve patient survival and independency while reducing the need of hospitalization and length of inpatient stay when compared to general medical wards.[6],[11],[12] However, the difference in mortality did not differ significantly between the stroke units and general medical wards.[6],[12],[13] It is a prerequisite that finances are attributed for stroke units which can help promote patient independency and reduce the length of hospital stays especially for the aging population of Saudi Arabia.[11]

Age is recognized to be one of the major risk factors for stroke.[14] As per the recent statistics from the United Nations on world aging population, there is an increasing trend in the old-age (aged >60 years) population which climbed to 962 million in 2017 from 382 million in 1980.[15] As per the estimates, by 2050, the number of nonagenarians worldwide will be reaching 56.9 million. This age group is known to have the higher prevalence and incidence of stroke, impacting morbidity, and mortality.[14] Our study revealed that the prevalence of stroke was higher in men in comparison to women within the age groups of 51–70 and > 80 years. Our results were consistent with the study by Akbar and Mushtaq who also showed that stroke occurs more commonly in 60s and is predominant among males in Saudis,[16] a finding similar to what has been reported by others.[17],[18],[19] Another recent study from Saudi Arabia showed that stroke was more common in the 61–70 years of age group, as compared to the 20–30 years and 31–40 years of age groups.[20] The study results were supported by another study which also reported that stroke occurred with a higher frequency in the 61–70 years of age groups, whereas the frequency was least in the 30–40 years of age group.[21] However, the present study had several limitations. First, the sample size was very small as only three hospitals participated in the survey. Second, patient information such as place of occurrence of stroke, area of residence of the patient, and their income bracket were not well recorded in the hospitals. All these factors further warrant larger studies in the future.


  Conclusion Top


In Saudi Arabia, published researches on the prevalence of stroke from different parts of the country are lacking. Considering the increase in stroke prevalence in Middle East region, this study along with similar research is vital for the planning of effective stroke management. The other important aspects which are to be focused on for effective management of stroke patients are the development of wellequipped stroke units, training of health-care providers, collaboration of a multidisciplinary team, and raising public awareness.

Acknowledgments

We would like to thank the grant management department at King Fahad Medical City for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res 2017;120:439-48.  Back to cited text no. 1
    
2.
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Robert AA, Zamzami MM. Stroke in Saudi Arabia: A review of the recent literature. Pan Afr Med J 2014;17:14.  Back to cited text no. 3
    
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How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke unit trialists collaboration. Stroke 1997;28:2139-44.  Back to cited text no. 4
    
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NHS Improvement. Strole. Mind the Gap: Ways to Enhance Therapy Provision in Stroke Rehabilitation. Available from: http://www.stroke-in-stoke.info/otherfiles/mind%20t hegap2011.pdf. [Last accessed on 2018 May 30].  Back to cited text no. 5
    
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Trialists' Collaboration SU. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013;9.  Back to cited text no. 6
    
7.
Rønning OM, Guldvog B. Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: A quasi-randomized controlled trial. Stroke 1998;29:586-90.  Back to cited text no. 7
    
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Evans A, Perez I, Harraf F, Melbourn A, Steadman J, Donaldson N, et al. Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet 2001;358:1586-92.  Back to cited text no. 8
    
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Al Khathaami AM, Algahtani H, Alwabel A, Alosherey N, Kojan S, Aljumah M. The status of acute stroke care in Saudi Arabia: An urgent call for action! Int J Stroke 2011;6:75-6.  Back to cited text no. 9
    
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Canavan M, Ni Mhaille G, Mulkerrin EC. Development of acute stroke units – A cost effective reconfiguration which benefits patients. QJM 2012;105:99-102.  Back to cited text no. 10
    
11.
Sun Y, Paulus D, Eyssen M, Maervoet J, Saka O. A systematic review and meta-analysis of acute stroke unit care: What's beyond the statistical significance? BMC Med Res Methodol 2013;13:132.  Back to cited text no. 11
    
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Cabral NL, Moro C, Silva GR, Scola RH, Werneck LC. Study comparing the stroke unit outcome and conventional ward treatment: A randomized study in Joinville, Brazil. Arq Neuropsiquiatr 2003;61:188-93.  Back to cited text no. 12
    
13.
Rønning OM, Guldvog B. Stroke unit versus general medical wards, II: Neurological deficits and activities of daily living: A quasi-randomized controlled trial. Stroke 1998;29:586-90.  Back to cited text no. 13
    
14.
Orzuza G, Zurrú MC. Epidemiological aspects of stroke in very old patients. Cardiovasc Hematol Disord Drug Targets 2011;11:2-5.  Back to cited text no. 14
    
15.
United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2017 – Highlights. Available from: https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights.pdf. [Last accessed on 2018 May 30].  Back to cited text no. 15
    
16.
Akbar DH, Mushtaq M. Clinical profile of stroke: The experience at King Abdulaziz University hospital. J Sci Res Med Sci 2001;3:35-8.  Back to cited text no. 16
    
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Al-Jishi AA, Mohan PK. Profile of stroke in Bahrain. Neurosciences (Riyadh) 2000;5:30-4.  Back to cited text no. 17
    
18.
Yaqub BA, Shamena AR, Kolawole TM, Patel PJ. Cerebrovascular disease in Saudi Arabia. Stroke 1991;22:1173-6.  Back to cited text no. 18
    
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Awada A, al Rajeh S. The Saudi stroke data bank. Analysis of the first 1000 cases. Acta Neurol Scand 1999;100:265-9.  Back to cited text no. 19
    
20.
Al-Jadid MS, Robert AA. Determinants of length of stay in an inpatient stroke rehabilitation unit in Saudi Arabia. Saudi Med J 2010;31:189-92.  Back to cited text no. 20
    
21.
Al-Eithan MH, Amin M, Robert AA. The effect of hemiplegia/hemiparesis, diabetes mellitus, and hypertension on hospital length of stay after stroke. Neurosciences (Riyadh) 2011;16:253-6.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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