Argentina's unanswered stroke health-care question
Authors: Adrian Burton
Journal: The Lancet Neurology (2018)

Stroke prevention is on the medical agenda in Argentina. Improving stroke recognition and treatment is too. But if health-care coverage for stroke remains far from universal, won't the impact of any progress be necessarily reduced? Adrian Burton investigates. Julio Fernández, Head of Interventional Neurosurgery at the Hospital Ángel Cruz Padilla in San Miguel de Tucumán (Argentina) and Stroke Prevention Program Coordinator of the Tucumán Province's Ministry of Health, has a petition open. His aim: to have Argentina's senators pass a law ensuring that treatment for stroke be made universally available. Currently, stroke is not a condition that either the country's social security or private health care systems are obliged to cover; costly additional policies that specifically cover stroke are required. Hospitals cannot recover the costs of treating patients who do not have these policies, and cannot take them in. Bizarrely, stroke is theoretically covered by the so-called public system, which provides health care to those who have no social security or private policy—but this public system is resource-starved and struggles to provide basic services to its users. For a country making attempts to reduce its stroke burden, passing a law that obliges its complex health-care system to provide the necessary treatment to all its citizens might seem like a much needed first step. Oct, 31 2015, saw the publication of the Declaration of Santiago de Chile, a document sponsored by the American Heart Association and American Stroke Association, promoting the scaling up of stroke prevention and treatment in the Americas. The signatories urged countries throughout the region to prioritise strategies that would better organise their stroke care systems, and to allocate the financial and human resources required to tackle the burden of stroke. They had good reason. In most Latin American countries, stroke is the second leading cause of mortality. For Argentina, the most recent evidence suggests an incidence for stroke of 76 in 100 000 people per year, with someone affected every nine minutes. In response, prevention messages are now being developed and transmitted. For example, Oct, 29, 2017, saw Argentina's first Stroke Walk as a World Stroke Day activity. Centring on a 3 km walk to raise stroke awareness, leaflets explaining risk factors were handed out, and people had the opportunity to have their blood pressure taken and to determine their stroke risk. “In 2017 the event was held in Buenos Aires”, explains Maria Martha Esnaola y Rojas, Head of Neurology at the Hospital Dr César Milstein (Buenos Aires, Argentina), who was pivotal in the event's organisation. “But for 2018, we have expanded to the rest of the country, with stroke walks, aerobic classes, information sessions, and pamphlets to inform people about the dangers of stroke and how to avoid them.” And after years of a lack of health policies for stroke, information on risk factors is now also available via national and regional government websites. In addition, and rather like the FAST campaign in the USA and UK, a mneumonic (the 5 Cs) is being promoted to help people recognise the symptoms of stroke and act accordingly. Certainly, opportunities for Argentina's health-care system to prevent strokes have been missed. For example, a 2014 analysis of data from the Argentine national stroke registry (ARENAS) revealed that about 50% of patients with high cholesterol were not taking statins before their first stroke, and that preventive antithrombotic treatment was scarce. Yet, counter-intuitively, the incidence of stroke in the country has actually been falling. A study published in 2016 reported a significant reduction in stroke incidence between 2000 and 2011 across all socioeconomic groups. “As shown by a National Risk Factor Survey of Argentina, the reason for this might lie in that different health messages have led to people smoking less, to more people doing exercise and using less salt in their meals, etc, and to antihypertensive drugs being more widely used”, explains Luciano Sposato, Associate Professor of Neurology at the University of Western Ontario (London, Ontario, Canada), who in 2009 unsuccessfully proposed a law similar to that envisaged by Fernández. However, success in educating the public about the risks of stroke, and what to do should one strike, remains essential. A recent Argentine study reports that about 75% of people who experience a stroke do not reach a hospital within the 4·5 h treatment window, attributable in large degree to a lack of knowledge about stroke symptoms among the general population. “In fact, even though our study population was well educated, with over half having a [university] degree, only 21% of patients thought of their initial symptoms as suggestive of stroke”, explains Maximiliano Hawkes, Assistant Professor of Neurology at the Mayo Clinic (Rochester, MN, USA). “Knowing the symptoms tripled the chance of having a consultation within 6 hours. These kinds of figures show just how important it is that people can recognise a stroke and know that they have to act fast.” Recent work confirms that while many Argentinians know the risk factors for stroke, few know about its prevalence, severity, treatment, or the existence of transient ischaemic attacks. But it's not just public knowledge that needs sharpening. The same Argentine study, and others, also indicate that patients arriving at a centre with a stroke are commonly first assessed by non-neurologists—and that their misdiagnosis rates can be alarmingly high. A corrective initiative—an interactive online course on integral stroke management for non-neurologists and neurologists alike, offered by the Fundación ACV VIDA—includes the clinical recognition of stroke. The country is also trying to improve diagnosis rates through the use of telemedicine. The Tucumán Province, for example, is developing a system via which patients far from hospitals can be remotely diagnosed quickly by specialists, and brought to a hospital by helicopter if necessary. Deficiencies in acute stroke care, however, remain obvious. “An alarmingly low proportion of stroke patients receive the thrombolytics known to reduce disability”, laments Sposato. “And except for a minority of centres, training in, and access to, new technologies such as endovascular thrombectomy are limited. The utilisation of the scarce available resources needs to be optimised by developing polices for the creation of regional stroke centres.” This need explains the country's growing interest in the Angels Initiative. “This has just been launched in our country”, says Esnaola. “Through it we hope stroke management will improve at every step: from pre-hospital evaluation to immediate transport, door-to-needle time, the organisation of stroke units, and the prevention of acute and post-acute complications.” Esnaola is also starting the Argentinian Stroke Patient's Organization with the support of the World Stroke Organization. “Through this, we will try to give support to stroke survivors and their care givers and help them return to their social, recreational, and labour activities.” “However, all of these efforts could be somewhat academic if treatment is not available to everyone”, says Fernández, whose petition follows his submission of a proposal of law (number 3231/2017) that stroke treatment be mandatorily covered by social security (provided through different public insurance bodies known as obras sociales) and private health-care systems. “In the Tucumán Province we have resolved the problem for people covered by the public system by taking the decision, via the Province's Ministry of Health, to make thrombolytics or thrombectomy available at accredited centres to patients who require them. Such treatment is not available at public hospitals everywhere, much less in Buenos Aires where public hospitals can be poorly resourced. But we have also made agreements with a number of obras sociales so that people paying their social security via them within the Province can be treated at private hospitals. The trouble is that some 45% of the Province's population who have their health coverage through other social security providers, such as the Pensioners' Union, with which no agreement has been reached, or who have private schemes, are left unprotected.” The answer to all this, Fernádez insists, is to make it law that all health-care financing bodies cover stroke treatment. A system of accredited hospitals could then be developed in which people covered by the different systems could receive their treatment rapidly. “This would immediately magnify the efforts of these other groups working on everything from prevention to the improvement of medical intervention. It is incredible that we have the ability to treat stroke much better than we [currently] do in Argentina, but we are prevented from doing so by the absence of a law.” However, not everyone is entirely on-board with the need for a law. “I believe it is critical to educate the population and medical care givers about stroke”, says Sebastian F Ameriso, Chief of the Comprehensive Stroke Center at the Institute for Neurological Research FLENI (Buenos Aires, Argentina). “Also, we as stroke physicians should generate reliable epidemiological data to highlight the importance of the disease in our population. Taking care of these tasks appears more important than generating a law about stroke care. There are no laws to mandate coverage for cancer, pneumonia or heart attacks. However, no one in the public or private sector would dare not provide proper assistance for these conditions. These laws may have a large media impact, but they may also be dangerous, as, on their road to full application, they may suffer changes and addendums, such as permanently excluding post-acute treatment, which might do more harm than good.” With particular regard to Latin America, however, the Declaration of Santiago de Chile states: “We realize the lack of health insurance coverage is associated with increased cardiovascular risk, including stroke risk.” It also calls for policies that support “Universal healthcare that includes access to pre-hospital care, stroke care and essential services and medications.” Neither aspiration seems too far removed from the hopes of the 96,000 people (and rising) who had, at the time of writing, signed Fernandez's petition. No date has yet been set for the proposal's debate.