There is an urgent need for stroke providers to strategise a comprehensive plan for management of the ever-increasing number of stroke survivors, writes Professor Dr Noor Azah Abd Aziz
IT has become a tradition, unfortunately, that during Ramadan, buffet spreads become more of a norm all over the country. It is also a well-known fact that people tend to overeat during this month, especially during iftar. What makes it worse is that the large meal is not followed by physical activity and this can lead to a health crisis. One of its outcomes is stroke.
Stroke is still one of the top leading causes of death in this country and in 2012, there were 50,000 reported stroke cases — new and recurrent. The annual admission of new stroke cases increased from 12 per cent in 2003 to 55 per cent in 2008.
Data from a retrospective study — the first looking at the direct medical cost of in-patient — of 813 stroke cases in Universiti Kebangsaan Malaysia Medical Centre, found that a patient’s length of stay was on average 10 days. The cost of care per patient/admission was RM3,696.40, with the large part going to human resources (RM1,343.90 or 36 per cent of total cost) and medication (RM867.30 or 23.5 per cent of total cost).
The total cost of care for stroke patients constitutes approximately 16 per cent of the country’s per capita gross domestic product, which is substantial. This study however, did not calculate long-term care as it stopped when patients left the hospital after discharge.
There is lack of data on the long-term survival and sequela of stroke patients in the country. But we believe the numbers represent a tip of the iceberg of the actual picture of stroke in this country. Taking into consideration two major factors — the increasing trend of ageing population and the epidemic of cardiovascular-related illnesses — the number of new cases could double or even triple in the very near future.
LONG-TERM CARE
With all these factors, stroke may surpass diabetes or kidney disease in terms of health expenditures and public care burden. The main reason for lack of data in long-term care of stroke here is due to the general perception among public and health practitioners that it is mainly an acute incident with irreversible long-term sequela (if any).
This common perception is prevalent among Southeast Asian countries due to poor understanding of the overall stroke spectrum, especially the availability of promising rehabilitation intervention and structured long-term care for stroke survivors.
A survey conducted among physicians managing public healthcare services in the country found that despite the large number of recorded stroke survivors, primary care clinics only see two out of 100 patients monthly, with estimated total stroke patients treated per year at each centre less than 40. The majority of patients seen were referred for transfer of care from tertiary care with no further follow-up and mainly no avenue for shared care practice.
Although primary care physicians are aware of the needs for further rehabilitation, referral for rehabilitation remained low and mainly referred to a single discipline rehabilitation intervention such as physiotherapy, occupational therapy, speech and language therapy.
These findings clearly identified the gaps of managing stroke patients in the community. Despite the recent move to include stroke as one of the disease priorities for National Reduction in non-communicable disease prevalence, providing a structured long-term care management in stroke are still sluggish.
MORE REHABILITATION
A concurrent qualitative focus group study, looking into the views on long term rehabilitation for people with stroke in a developing country, was carried out among rehabilitation professionals and people with stroke recently.
Both groups agreed that people with stroke may benefit from more rehabilitation compared to amount of services currently available. They agreed that the unavailability of long-term rehabilitation services were multifactorial, including shortage of manpower, scarcity of specialised transport vehicles, low awareness and misconceptions about the needs and goals of rehabilitation, and resource limitation.
It had proposed the initiation of community-stroke rehabilitation centres and structured training for family members to conduct home-based therapy as prospective strategies in overcoming the barriers of service provision in the community.
Both studies, although conducted among different cohorts, were similar in their findings. This is hardly surprising as there is urgent need for stroke providers in the community to strategise a comprehensive plan for management of the ever-increasing number of stroke survivors in the community.
While academicians and doctors are conducting more researches as to find ways to resolve public health burden due to stroke, there are simple measures that people can take to reduce the risks. One of them is the age-old advice of moderation in food intake together with increase in physical activities.
Ramadan is a period of observance, so observing the iftar in the most moderate manner is perhaps the first step. We also advice regular health screening starting from the age of 35 to be a part of healthy lifestyle measures.
Regular assessment on blood pressure, cholesterol and glucose level together with friendly advice from your family doctor might save you from regrettable sequela brought about by stroke in future.
The writer is Professor of Family Medicine and head of Industry and Community Office at Universiti Kebangsaan Malaysia Faculty of Medicine