Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania

Abstract

Objective: Given the high post-stroke mortality and disability and paucity of data on the quality of stroke care in Sub-Saharan Africa, we sought to characterize the implementation of stroke-focused treatments and 90-day outcomes of neuroimaging-confirmed stroke patients at the largest referral hospital in Tanzania.

Design: Prospective cohort study.

Setting: Muhimbili National Hospital (MNH) in Dar es Salaam, July 2016-March 2017.

Participants: Adults with new-onset stroke (<14 days), confirmed by head CT, admitted to MNH.

Main outcomes measures: Modified Rankin scale (mRS) and vital status.

Results: Of 149 subjects (mean age 57; 48% female; median NIH stroke scale (NIHSS) 19; 46% ischemic stroke; 54% hemorrhagic), implementation of treatments included: dysphagia screening (80%), deep venous thrombosis prophylaxis (0%), aspirin (83%), antihypertensives (89%) and statins (95%). There was limited ability to detect atrial fibrillation and carotid artery disease and no acute thrombolysis or thrombectomy. Of ischemic subjects, 19% died and 56% had severe disability (mRS 4-5) at discharge; 49% died by 90 days. Of hemorrhagic subjects, 33% died and 49% had severe disability at discharge; 50% died by 90 days. In a multivariable model, higher NIHSS score but not dysphagia, unconsciousness, or patient age was predictive of death by 90 days.

Conclusions: The 90-day mortality of stroke presenting at MNH is 50%, much higher than in higher income settings. Although severe stroke presentations are a major factor, efforts to improve the quality of care and prevent complications of stroke are urgently needed. Acute stroke interventions with low number needed to treat represent challenging long-term goals.

Keywords: Africa; developing countries; equity in healthcare; intracranial hemorrhage; ischemic stroke; mortality; needs assessment; patient outcomes; quality measurement.

Figure 1

Flow chart of subjects by the study’s inclusion and exclusion criteria. Computed tomography (CT).

Figure 2

Modified Rankin Scale (mRS) scores (A) and Kaplan–Meier survival curves (B) of subjects by stroke type.