Patient-level and system-level determinants of stroke fatality across 16 large hospitals in Ghana and Nigeria: a prospective cohort study. Issue 4 (April 2023)

• Record Type: Journal Article
• Authors: Sarfo, Fred S; Akpa, Onoja M; Ovbiagele, Bruce; Akpalu, Albert; Wahab, Kolawole; Obiako, Reginald; Komolafe, Morenikeji; Owolabi, Lukman; Ogbole, Godwin; Fakunle, Adekunle; Okekunle, Akinkunmi Paul; Asowata, Osahon J; Calys-Tagoe, Benedict; Uvere, Ezinne O; Sanni, Taofeek; Olowookere, Samuel; Ibinaiye, Philip; Akinyemi, Joshua O; Arulogun, Oyedunni; Jenkins, Carolyn; Lackland, Daniel T; Tiwari, Hemant K; Isah, Suleiman Y; Abubakar, Sani A; Oladimeji, Adebayo; Adebayo, Philip; Akpalu, Josephine; Onyeonoro, Ugochukwu; Ogunmodede, James A; Akisanya, Cynthia; Mensah, Yaw; Oyinloye, Olalekan I; Appiah, Lambert; Agunloye, Atinuke M; Osaigbovo, Godwin O; Adeoye, Abiodun M; Adeleye, Osimhiarherhuo Ohifemen; Laryea, Ruth Y; Olunuga, Taiwo; Ogah, Okechukwu S; Oguike, Wisdom; Ogunronbi, Mayowa; Adeniyi, Wasiu; Olugbo, Obiabo Y; Bello, Abiodun H; Ogunjimi, Luqman; Diala, Samuel; Dambatta, Hamisu A; Singh, Arti; Adamu, Sheila; Obese, Vida; Adusei, Nathaniel; Owusu, Dorcas; Ampofo, Michael; Tagge, Raelle; Fawale, Bimbo; Yaria, Joseph; Akinyemi, Rufus O; Owolabi, Mayowa O;
• Is Part Of: Lancet. Volume 11:Issue 4(2023)
• Page Start: e575
• Page End: e585
• Publication Date: 2023-04
• Subjects: World health -- Periodicals; 362.105
• DOI: 10.1016/S2214-109X(23)00038-4
• Languages: English
• ISSNs: 2214-109X

Abstract

Summary: Background: Every minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria. Methods: The Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs. Findings: Overall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07–1·33); systolic blood pressure, 1·02 (1·01–1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm 3, 1·48 (1·22–1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13–1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31–2·33); and aspiration pneumonia, 1·79 (1·16–2·77). Interpretation: Studies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted. Funding: US National Institutes of Health. Translations: For the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.