Stroke management and outcomes in low-income and lower-middle-income countries: a meta-analysis of 8535 patients

Abstract

Objective: Strokes affect almost 13 million new people each year, and whereas the outcomes of stroke have improved over the past several decades in high-income countries, the same cannot be seen in low-income and lower-middle-income countries. This is the first study to identify the availability of diagnostic tools along with the rates of stroke mortality and other poststroke complications in low-income and lower-middle-income countries.

Methods: A review of the literature was completed with a search of the MEDLINE, Embase, and Scopus databases, with adherence to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they reported any outcomes of stroke in low-income and lower-middle-income countries as designated by the World Bank classification. A meta-analysis calculating pooled prevalence rates of diagnostic characteristics and stroke outcomes was completed for all endpoint variables.

Results: A total of 19 studies were included, of which 6 came from Ethiopia, 3 from Zambia, and 2 each from Tanzania and Iran. Single studies from Zimbabwe, Botswana, Senegal, Cameroon, Uganda, and Sierra Leone were included. A total of 5265 (61.7%) patients had an ischemic stroke, 2124 (24.9%) had hemorrhagic stroke, with the remaining 1146 (13.4%) having an unknown type. Among 6 studies the pooled percentage of patients presenting to hospital within 1 day was 48.37% (95% CI 38.59%-58.27%; I2 = 97.0%, p < 0.01). The pooled in-hospital mortality rate was 19.81% (95% CI 15.26%-25.31%; I2 = 91%, p < 0.01), but was higher in a hemorrhagic subgroup (27.07% [95% CI 22.52%-32.15%; I2 = 54%, p = 0.05]) when compared to an ischemic group (13.16% [95% CI 8.60%-19.62%; I2 = 87%, p < 0.01]). The 30-day pooled mortality rate was 23.24% (95% CI 14.17%-35.70%; I2 = 93%, p < 0.01). At 30 days, the functional independence (modified Rankin Scale score 0-2) pooled rate was 13.10% (95% CI 7.50%-21.89%; I2 = 82%, p < 0.01).

Conclusions: A severe healthcare disparity is present in low-income and lower-middle-income countries, where there is delayed diagnosis of strokes and increased rates of poor clinical outcomes for these patients.

Keywords: World Bank income classification; low-income countries; meta-analysis; poststroke outcomes; stroke mortality rates; vascular disorders.