Occurrence, presentation, costs and three-month outcomes of stroke in Viet Nam

Background - Stroke is the third most common cause of death in the world and is projected to be the second leading cause by the year 2020. Although rates of stroke mortality have decreased in high income countries (HICs) in recent decades, the burden of stroke may be increasing in low and middle income countries (LMICs) but information is scarce. To address this critical lack of data for Viet Nam, five studies of stroke occurrence, costs of treatment and short-term outcomes were conducted. Methods - The first study involved surveillance of 5,017 admissions of stroke patients over 12 months at a tertiary public teaching hospital in Ho Chi Minh City. To obtain information on outcomes at three months, 450 consecutive patients with first-ever stroke were followed-up. The remaining four studies of this thesis present findings from this follow-up study. Results - Principal surveillance findings were that the median age of patients was 65.0 years, ischaemic stroke was the dominant type, the majority of admissions were for first-ever events, and the signs and symptoms of stroke were similar in Viet Nam as elsewhere. Around one-half of patients had scores on the modified Rankin Scale (mRS) corresponding to most severe disability (mRS=4/5). The estimated incidence of hospital-admitted stroke was 105.6 per 100,000 person-years, and the confirmed case-fatality at 28 days was 12.2%. Case-fatality and functional outcomes at 3 months after stroke were assessed in the second study. With minimal loss to follow-up, case-fatality at 3 months was 10.4% and one-third of survivors had most severe disability (mRS=4/5). Over three months, one-half of patients had improved functional status and one-quarter had worsened, with male patients having greater improvement. In the third study, information for 437 patients in the cohort was used to estimate the costs of stroke treatment. Average total costs per stroke admission were USD 963 comprising USD 560 for direct medical cost, USD 171 for direct non-medical cost, and USD 240 for indirect costs. Health insurance halved out-of-pocket direct medical costs. Severity of stroke, length of stay and household wealth were the major predictors of cost. The reliability and validity of the Duke Health Profile (DHP) for assessing the Health Related Quality of Life (HRQoL) of stroke patients was examined in the fourth study of 108 patients and 94 caregivers of patients. They completed the DHP questionnaire and a comparison instrument, the EQ-5D. Each was re-administered after 1 week. Intra-class correlations ranged from 0.60 to 0.86 (patient test-retest) and from 0.55 to 0.98 (patient-proxy agreement). Correlations between DHP and EQ-5D dimensions were strongest for similar constructs (r=0.53–0.66). The HRQoL of 373 stroke survivors at 3 months was assessed in the fifth study. Their average DHP overall score (58.7) and EQ-5D utility score (0.67) were lower than those from comparable general population samples. Female sex, increasing age, lower SES, severe stroke at admission time and poor functional status at 3 months were predictors of poorer HRQoL. Conclusions and implications - Young age at stroke onset relative to patients in HICs, and the high proportion with moderate-to-severe disability, confers a high burden of stroke in Viet Nam. The similar clinical presentation suggests that campaigns used in HICs to raise awareness of early signs and symptoms could be adopted in Viet Nam. The comparable factors associated with stroke occurrence and with functional outcomes prompt application of strategies for prevention and management of stroke that are effective in HICs. Despite relatively short average length of stay, the total costs of treatment amounted to 2 and 3 times the median monthly income of insured and non-insured patients, respectively. Broader health insurance coverage of the Vietnamese population would help to bridge the gap. The overload of patients in the stroke unit at this hospital signals the need for more stroke units to be established in other hospitals in HCMC and surrounds. Measurements of HRQoL with the DHP, which has moderate reliability and validity for use with stroke patients in Viet Nam, demonstrated that stroke reduces the reported psychological well-being of survivors, and particularly that of female patients.