Estrategia En Ictus Del Sistema Nacional De Salud

Objectives

Spain’s Stroke Strategy, approved by the Interterritorial Council of the National Health System on 26 November 2008, positions stroke as a major public-health, disability and social-burden priority within the National Health System Quality Plan. It seeks to improve the quality, equity and effectiveness of stroke prevention, treatment, rehabilitation and outcomes throughout Spain.[1][2][3][4]

• Reduce stroke incidence, mortality, disability, dependency and the wider burden on individuals, families, health services and society.[5][6][7][8]
• Ensure equitable prospects of recovery regardless of a person’s place of residence or circumstances of stroke onset, through access to efficient and appropriately organised care.[9][10][11]
• Organise action across five strategic lines: health promotion and primary and secondary prevention; acute stroke care; rehabilitation and reintegration; training; and research.[12][10][13]
• Strengthen primary prevention through cardiovascular-risk assessment, early detection and control of hypertension, diabetes, dyslipidaemia, obesity, smoking, harmful alcohol use, physical inactivity and other modifiable factors.[14][15][16][7]
• Improve public recognition of warning symptoms and encourage immediate contact with emergency medical services to reduce delays in accessing care.[2][8][17]
• Increase timely access to acute specialised treatment, including Stroke Units, Stroke Teams, the Stroke Code, neuroimaging, thrombolysis and transfer to reference services.[18][8][19][20]
• Target more than 80% survival at one month and independence for 70% of survivors at three months, while increasing the proportion of patients receiving specific treatment within three hours of symptom onset.[8]
• Provide early, individualised and multidisciplinary rehabilitation that assesses disability, supports functional recovery and enables personal, social and occupational reintegration.[21][22][23]
• Support patients, families and carers through health education, discharge planning, accessible information, training and coordinated health and social care.[22][24][25][26]
• Develop continuing professional training and interdisciplinary research to improve the efficacy, effectiveness and efficiency of stroke promotion, prevention, treatment, rehabilitation and care.[27][28][29][30]

Implementation

Implementation is based on coordinated national and autonomous-community action within a universal, publicly financed National Health System. The Strategy combines common objectives and service standards with regional responsibility for implementation, taking account of available resources, regional competences and locally organised service networks.[6][31][32][10]

• Coordinate governance through the Ministry of Health and Consumer Affairs, the Directorate-General of the National Health System Quality Agency, the Office for Health Planning and Quality, the Health Information Institute, autonomous communities, professional societies, allied health professionals and patient organisations.[1][33][34][32]
• Use an Institutional Committee of autonomous-community representatives to assess the relevance and feasibility of objectives, alongside a Technical Committee that identifies care-pathway deficiencies and develops evidence-informed recommendations.[32]
• Implement objectives progressively through autonomous-community health services, which hold responsibility for delivery of their stroke plans and programmes.[32][13]
• Organise acute care as a territorial network connecting primary care, out-of-hospital emergency services, hospital emergency departments, Stroke Units, Stroke Teams and high-technology referral hospitals.[11][35][36][37]
• Activate the Stroke Code across each autonomous community to support rapid recognition, pre-notification, stabilisation, transfer and hospital preparation, regardless of whether the patient first contacts primary care, emergency services or a non-reference hospital.[38][8][19]
• Ensure that basic health areas can access a reference Stroke Unit or Team within 60 minutes and that hospitals treating stroke or transient ischaemic attack use a clinical pathway, protocol or care process.[19][20]
• Use Stroke Units as multidisciplinary functional structures for acute treatment, monitoring, rehabilitation, education, guideline coordination and research; use Stroke Teams with transfer arrangements where dedicated units are not feasible.[11][39][40]
• Use telemedicine, transport protocols and, where appropriate, air transport to overcome geographical barriers and connect smaller hospitals with specialist neurological expertise.[40][19][41][42]
• Deliver prevention principally through primary care, combining opportunistic risk assessment during consultations with active recruitment and follow-up of people at elevated risk.[7][43][44]
• Provide rehabilitation through early multidisciplinary assessment, individual plans, appropriate referral between inpatient, outpatient, home and long-term settings, and shared electronic information where possible.[22][24][45][46]
• Develop regional systems linking health and social-care resources, including carer support, technical aids, home adaptations, patient associations, social services and urgent responses where carers cannot continue.[24][27]
• Monitor implementation through a National Health System information system, agreed questionnaires and qualitative reporting, with a follow-up committee involving all autonomous communities agreeing data items and completion criteria.[47]
• Track indicators including annual hospital discharge rates for stroke, primary-care hypertension coverage, prevention coverage and prevalence measures, behavioural risk factors, and overall and premature stroke mortality.[47][48][49][50]
• Support research through priority calls, accredited networks and the Neurovascular Cooperative Research Network, involving hospitals, universities, research centres, the ministry responsible for health and autonomous communities.[29][30]

Monitoring & Evaluation

The Strategy establishes a National Health System monitoring model intended to support systematic, continuous evaluation of implementation across national and autonomous-community stroke plans and programmes. Indicators were developed for all five strategic lines with support from the Health Information Institute, and the evaluation and information-system section includes descriptive information, indicators and a qualitative report.[32][10]

• Measure primary prevention through annual primary-care coverage indicators for diagnosed hypertension, diabetes and obesity, and through triennial survey-based prevalence and behavioural indicators for hypertension, diabetes, obesity, smoking and physical activity.[48][49][50]
• Calculate coverage, prevalence and behavioural measures as a percentage of the relevant surveyed, registered or health-card population, and disaggregate results by autonomous community, sex and, for survey measures, age group.[48][49][50]
• Track overall and premature stroke mortality annually per 100,000 population, using age-adjusted rates standardised to the European population and reporting by autonomous community and sex.[50][51]
• Use National Health System clinical information systems, the National Health Survey, hospital-discharge registers, cause-of-death records and National Statistics Institute population estimates as data sources.[47][48][49][50]
• Combine quantitative National Health System indicators with an agreed questionnaire, with a follow-up committee involving all autonomous communities responsible for agreeing data items and completion criteria.[47]

The framework also specifies outcome and service-delivery objectives for acute care, including one-month survival, three-month functional independence, treatment within three hours, access to a reference Stroke Unit or team within 60 minutes, Stroke Code implementation, and use of clinical pathways.[8][19][52][23]Acute-care monitoring includes vital signs, general medical and neurological status, validated scales such as the National Institutes of Health Stroke Scale, and thrombolysis safety and effectiveness through the required European observational registry.[18][53]

• Monitor stroke risk factors and follow-up programmes for people at risk, including five-year adherence to preventive treatment among patients with stroke or transient ischaemic attack.[7][43]
• Maintain stroke registers in hospitals with Stroke Units and referral hospitals, alongside clinical, nursing, diagnostic and transport protocols.[36][54]
• Assess rehabilitation through an early individual plan, baseline disability assessment, end-of-programme functional assessment and discharge reporting to primary care.[21][22]
• Record continuing-training activity, credits and attendance by professional group, and link research activity to Strategy objectives, project budgets, funding sources and outputs.[55]
• Evaluate public-information campaigns through knowledge-retention surveys, post-intervention access times and, where available, stroke registers.[56]

Available evidence identifies important information gaps in pre-hospital care, ambulatory primary and specialist care, coordination and organisational effectiveness; electronic health records and qualitative ad hoc data collection are proposed to address these weaknesses.[30][47]Although qualitative monitoring fields cover plan inclusion, management objectives, measurement systems, implementation status and results, the supplied extracts do not provide a complete national reporting timetable, quantified performance targets for all indicators, or a detailed accountability process.[51][20][57]

Costing & Financing

Stroke imposes a substantial health, social and economic burden. It is estimated to consume 3% to 4% of healthcare expenditure in high-income countries, with 76% of direct healthcare costs occurring in the first year after stroke, principally through hospital care.[58]European studies estimated first-year costs of 20,000 to 30,000 euros, while one Spanish study estimated 5,338 euros.[58]

• Recognise informal care as a major cost component: estimates for Spain range from 801.7 million euros to 1,243.9 million euros under a base case, rising to 1,125.3 million euros to 1,746.0 million euros under an upper scenario that attributes additional hours to comorbidities.[59]
• Include direct non-healthcare costs, such as social and family care, and indirect costs associated with incapacity and lost work, when considering the overall burden.[58]
• Recognise that paediatric stroke has an estimated mean first-year cost of 43,000 US dollars.[60]
• Prioritise organised Stroke Units, specialised care and intravenous fibrinolytic treatment, which are described as reducing disability-related or overall care costs without increasing treatment cost.[61][39][35]

Public financing, universality, equity and comprehensive continuity of services are foundational principles of the National Health System.[6]The Strategy is intended to operate within available resources and the autonomous communities’ areas of competence, but no overall Strategy budget, allocation formula, funding gap, resource-mobilisation plan or wider economic assumptions are specified.[10]

Explicit research funding includes 2,947,124 euros for 30 stroke research projects funded by the Carlos III Health Institute during 2006-2007, and 2,272,647 euros for the Neurovascular Cooperative Research Network across recent years, including 1,099,800 euros in 2007 and 1,172,847 euros in 2008.[28][29]