Survey: Israelis get poor treatment for strokes

Health Ministry vows to change policy.

Although Prime Minister Ariel Sharon's doctors at Hadassah-University Hospital's stroke unit said they treated him like "any other patient," some 93 percent of Israeli stroke victims receive less-than-optimum care because - unlike Hadassah - the hospitals they go to have no dedicated stroke treatment facility. This is disclosed in the first national survey of acute cerebrovascular disease, just published in the January issue of the Israel Medical Association Journal. Asked to comment by The Jerusalem Post Health Ministry deputy director-general Dr. Yitzhak Berlovich admitted that the authorities had not yet allocated the resources to deal with the subject since it is "relatively new, as in most Western countries, and we have not yet formulated a comprehensive policy." Dr. David Tanne and Dr. Natan Bornstein of Tel Aviv University's Sackler School of Medicine and others working on behalf of the National Acute Stroke Israeli Survey Group, wrote the article coincidentally before the prime minister's first mild stroke and second devastating one became headline news. Because there had been no nationwide data on the management of strokes, they studied all 2,174 cases of stroke patients admitted to 28 general hospitals in February and March 2004. This number of patients was no smaller than the average number hospitalized with heart attacks during an equivalent period. Of the stroke patients, 89 percent suffered an ischemic stroke (the type, caused by a blood clot, that Sharon suffered the first time), while 7% had intercranial hemorrhaging (ICH) - in the remainder, the type was not identified. If the blood clot is in an accessible part of the brain and if the patient was brought in quickly enough, medication can be given to dissolve the clot and restore the blood supply to that part of the brain. This minimizes and can even eliminate brain damage. But the researchers note that only 0.5% of Israelis with an acute ischemic stroke received expensive but highly effective rt-PA therapy, compared to 7% of corresponding patients in Canada. "The recent approval of rt-PA therapy for treatment of acute ischemic stroke in Israel highlights the need for organized urgent stroke care that can be available for patients afflicted with acute stroke," they wrote. In addition, CT or MRI scans of carotid arteries on both sides of the neck - to see if they are clogged and need to be treated to prevent another stroke - were performed on only about 2% of stroke patients, compared to 80% in Canadian hospitals. The researchers stressed that having specially trained specialists in a hospital stroke unit can significantly improve treatment and long-term outcome, reducing the death rate and extent of disability. Stroke prevention, treatment and rehabilitation on a high standard throughout Israel required massive investment in infrastructure and manpower, Berlovich told The Post. "We cannot do this by ourselves; we need Finance Ministry consent and participation," he said. But Berlovich said he could not fault the Treasury, and did not blame his own ministry for "neglect," because of the "newness" of the subject. "We have a National Stroke Council," he said, "but we intend to go into this matter even more in depth and hold a consensus conference involving all the relevant experts." Special stroke units today are like trauma centers were a decade or more ago, when it was realized that having specialists to quickly treat physical trauma significantly improved survival rates and reduced long-term disability, Berlovich said. Although Sharon's strokes heightened public awareness, the health system is anyway "at a stage in which changing policy is vital," he said. The mean age of the admitted stroke patient in the national survey was 71 +/- 13 years, and 47% were women. Of ICH patients, 28% died during hospitalization, and 67% died later or remained with severe disability; 34% died within three months of their brain hemorrhage. Of those with ischemic stroke, 7% died in the hospital and 41% died later or suffered severe disability, and 14% died within three months. The average patient arrived at the hospital within two or three hours of the onset of symptoms, the authors wrote. But once they got there, treatment facilities varied, even though the significant improvement in diagnosis and care has led to the development of clinical guidelines for treating stroke. Quickly discovering the cause of the first stroke, they explained, is vital in preventing a recurrent stroke; about a quarter of the patients surveyed had previously had a stroke. They added that very few Israelis know the symptoms of stroke (although this undoubtedly has increased due to the publicity resulting from Sharon's illness), "indicating the need for public education regarding the warning signs of stroke and the need for immediate presentation to hospital by emergency medical services." The researchers conclude their article by declaring that "guidelines for acute stroke in Israel are adopted and adhered to" in a "limited extent" despite the major burden of cerebrovascular disease in the country. "Reorganization is imperative in the health systems available for patients afflicted with acute stroke."