Abstract
Dear Readers,
In this supplement, we would like to share an overview of the European Stroke Organisation’s (ESO) implementation strategy, specifically focusing on Eastern European countries. In 2014, the ESO Executive Committee decided, in line with its mission to reduce the “Stroke Burden in Europe,” to spearhead an implementation project, having the aim of reducing the recognized disparities in stroke care within Eastern European countries, while at the same time improving patient outcomes after stroke through evidence-based treatment. The ESO decided to build upon the initiative for Central Eastern European countries, as they still had been experiencing increasing rates of stroke incidence and stroke-related mortality compared to Western Europe. 1 Moreover, significant inequalities in acute stroke treatment between and within Eastern European countries were also registered. 2
Likewise, as the Eastern European healthcare systems had developed in a similar historical context and shared a homogenous background, this would facilitate any implementation process.
Officially, the project was initiated in 2015 at the first European Stroke Conference in Glasgow, where the delegates of the “European Stroke Organisation – Enhancing and Accelerating Stroke Treatment” (ESO EAST) met for the first time. During this conference, delegates from Albania, Armenia, Azerbaijan, Bosnia, Bulgaria, Croatia, Czech Republic, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Lithuania, North Macedonia, Moldova, Poland, Romania, Russia, Serbia, Slovakia, Slovenia, Ukraine, and Uzbekistan discussed unmet needs in Eastern European countries. The participants decided to focus mainly on the following points: the suboptimal implementation of evidence-based treatments and the low number of articles from this region published in international journals indexed in the Web of Science.
In order to improve implementation, the ESO-EAST program developed a strategy based on a “detecting-understanding-reducing disparities” conceptual framework. Specifically, stroke care quality was first measured (after having developed a platform for data collection), gaps were identified in the current service delivery, and ultimately, feedback was provided to participating hospitals, followed by the application of interventions to reduce such disparities. 3
A software platform for data collection and analysis, Registry of Stroke Care Quality (RES-Q), was developed and launched in 2016, which was used to collect data for more than 90,000 patients from >750 hospitals in 56 countries between September 2016 and May 2019. Training courses on thrombolysis treatment, nursing, and research skills were also conducted. 3
In 2016, the Angels Initiative, a non-profit, non-promotional, global healthcare program supported by Boehringer Ingelheim and endorsed by ESO, joined the ESO- EAST Initiative. The main goals of the Angels Initiative are: firstly, to increase the number of stroke-ready hospitals and, secondly, to optimize the quality of existing stroke units. 4 The Angels Initiative employs consultants who provide support at hospital levels, including strategies focused on improving stroke care through standardized and improved logistics, as well as motivational tools, including awards for the achievement of pre-determined performance thresholds. One of the flagship achievements has been an increase in overall stroke-readiness in Romania: from 13 stroke-ready hospitals in 2015 to 46 in 2021. Since registering with the Angels Initiative, the median door-to-treatment times for stroke patients in Romania and Moldova have decreased by 35 min (40% reduction vs baseline) and 15 min (19% reduction vs baseline), respectively. These implementation strategies had been embedded in the European Stroke Action Plan (SAPE) for 2018 to 2030, which was prepared in cooperation with the patient organization “Stroke Alliance for Europe organization” (SAFE). Here, four overarching targets were identified: (1) reduce the absolute number of strokes in Europe by 10%, (2) treat 90% or more of all patients with stroke in Europe, (3) have national plans for stroke encompassing the entire chain of care, from primary prevention to life after stroke, (4) fully implement national strategies for multisector public health interventions, in order to promote and facilitate healthy lifestyles, and reduce environmental (including air pollution), socioeconomic and educational factors that are known to increase the risk of stroke. 5
During the COVID-pandemic, ESO-EAST, Angels, the SAPE implementation task force, and the ESO- EAST delegates worked closely together through the appropriate channels first to deal with the obstacles associated with the pandemic and also to find ways to best treat stroke patients in this challenging clinical setting. As in-person meetings were not allowed, the implementation process continued via online meetings, webinars, and teleconferences.
On 24 February 2022, with the Russian invasion of Ukraine, the ESO stroke implementation program once again was seriously jeopardized. In fact, currently, the Ukrainian health system still faces unprecedented pressure due to a continuously rising number of casualties within the targeted areas that are densely populated. Besides this, there is an ongoing emergency to effectively treat individuals afflicted with severe infectious and chronic conditions. In light of this, ESO has decided to create the ESO TASK FORCE 4 UKRAINE, led by Francesca R. Pezzella. This project will support the delivery of and access to stroke care throughout Ukraine. Presently, the task force delivers continuous education through webinars, offers free membership to Ukrainian stroke physicians, and organizes department-to-department visits for Ukrainian doctors.
Over the past 7 years of implementing ESO policies, there have been remarkable successes, as well as unanticipated failures. Albeit, the ESO-EAST community continues to flourish, with new members from countries including Belarus and Cyprus.
This supplement will share some scientific results achieved over these 7 years. Lina Palaiodimou et al., report on the quality metrics implementation in the management of acute stroke in Greece over the first 5 years of RES-Q (Registry of Stroke Care Quality) (pp. 5-15). Mehmet Topcuoglu et al., describe acute stroke management in Turkey, highlighting the current situation and future projections (pp. 16-20). The hot topic of financial implications associated with stroke is addressed in a paper authored by Hrvoje Budincevic et al., who describe the costs of ischemic stroke in Croatia (pp. 21-27). Nune Yeghiazaryan et al., share the ongoing evolvement in stroke care in Armenia, which has led to better access and delivery, mainly due to the establishment of the Armenian National Stroke Program (NSP) by the Ministry of Health in 2019, providing the necessary funding for thrombolytic therapy and thrombectomy for acute stroke care (pp. 28-34). Janika Kõrv et al., describe the developments in quality of stroke care in Estonia, sharing the importance of continuously monitoring stroke, even in those European countries regarded as top performers (pp. 35-43). 4
Moreover, Elena Terecoasă et al., provide a thorough overview of the “Quality of acute stroke care in Romania. With regards to Achievements and Gaps between 2017-2022.” (pp. 44-51), Romania is deemed a champion of the ESO-EAST/Angels Initiative program not only for its increase in the number of stroke centers and stroke units but also for its massive increase in stroke awareness throughout the country. Last but not least, Zuzana Gdovinova et al., report on how stroke care has improved in Slovakia over the last 5 years – another success story brought about by ESO EAST/Angels Initiative program. We are confident that this ESJ supplement will provide you with the necessary inspiration to improve stroke pathways in your country.