Table 1 Scoping review articles (key details)

1. Albertino, Joana, Ana, et,al. nd [33]

Urban Hospitals.

(Central hospitals, public hospitals, military hospitals & private clinics)

Retrospective & prospective

August 1, 2005 - July 31, 2006

651 cases

Incidence, characteristics & short-term consequences of hospitalizations for stroke in Maputo and Mozambique

− 531 pts. (81.6%) with first stroke

− 601 cases (92.3%) confirmed by CT scan (83.4%) or necropsy (8.9%)

− 351 (58.4%) ischemic, 242 (40.3%) hemorrhagic, & 8 (1.3%) subarachnoid hemorrhage

-Ischemic events increased continuously with age (higher in men 45 to 64 yrs)

-Incidence of haemorrhagic stroke rose up to 74 years (yrs) of age; declining thereafter

− 15% of stroke events occurred in subjects aged 45 yrs. (??and higher/lower/exactly)

− 60% of pts. arrived at hospital on same day as symptom onset

-Most prevalent risk factor was hypertension (86.6 to 96.0%)

− 254 pts. (101 ischemic & 133 hemorrhagic stroke events) died during 28-day follow-up period

2. Yan, Li, Chen, et.al. 2016 [34]

Review

2015

17 included systematic reviews, observational cohort studies, meta-analyses, & case reports

-Risk factors for stroke

-Primary prevention of stroke

-Treatment of stroke during the acute stage

-Secondary prevention

-Stroke rehabilitation

- History of hypertension, current smoking, diabetes mellitis, diet risk score, physical inactivity, alcohol intake, psychosocial stress & depression, & cardiac causes

-Guidelines for stroke diagnosis: patient history, physical examination, neurological examination & stroke scales, & diagnostic tests

- Primary preventive approaches: blood pressure control & promotion & maintenance of healthy lifestyle: not starting to smoke, & smoking cessation for smokers, no binge drinking, being physically active, & a healthy diet with adequate fruit & vegetable intake, reduced dietary trans-fat intake, & reduced sodium intake

-Intravenous thrombolysis approved as evidence-based treatment for acute ischemic stroke

-Mechanical thrombectomy in combination with pharmacological thrombolysis improved functional outcomes

- Pts. who received organized inpatient care in a SU were more likely to be alive, independent, & living at home 1 yr after stroke

-Secondary prevention of stroke: blood pressure control, antiplatelet & lipid-lowering therapy, homocysteine-lowering therapy, self-management, & family support

-Stroke rehabilitation: inpatient, home, & community-based programs, including physical, occupational, speech, & recreation therapies

- Availability of & access to rehabilitation services low in LMICs

-Factors for limited accessibility: poor physician knowledge of the role of rehabilitation; lack of rehabilitation components in the standard of care; long intervals from stroke onset to admission to rehabilitation; infrequent, unskilled, & short-lived provision of rehabilitation care; & inadequate public insurance or financial support for rehabilitation care

3. El Sayed, El Zahran & Tamim, 2014 [35]

Urban hospital

Retrospective chart review

87 pts.

Pt characteristics & outcomes

Barriers to rt-PA utilization

Mean age of 71.9 yrs.; most pts. arrived by private transport (85.1%): weakness & loss of speech most common presenting signs (56.3%); 37.9% of pts. presented within 4.5 h of symptom onset

Nine pts. (10.3%) received rt-PA2 groups (rt-PA versus non rt-PA) with similar outcomes (mortality, symptomatic intracerebral hemorrhage, mRs scores, & residual deficit at hospital discharge)

rt-PA utilization was higher than expected

Delayed presentation barrier to rt-PA administration

4. Ashraf, Maneesh, Praveenkumar, et.al. 2015 [36]

Urban Hospital. India

Cross-sectional prospective study (Jan- Dec 2012

264 pts.

Factors contributing to delay in hospital arrival

Median delay = 12 h.

Distance from hospital, history of coronary artery disease, & presence of hemiplegia

5. Tirschwell, TGN, Ly, Van Ngo et.al. 2012 [37]

Urban Hospital (n = 1)

Vietnam

Prospective cohort study

754 pts.

Patient characteristics

Clinical predictors of 28-day mortality for admitted pts.

328 (43.5%) ischemic, 356 (48.5%) hemorrhagic

Risk factors: for ischemic stroke: atrial fibrillation, lower prevalence of hypertension, & previous history of stroke

Pts. with ischemic stroke less likely to have disturbed consciousness & speech disturbances, likely to have observed weakness, lower mean systolic & diastolic blood pressures, & higher mean total cholesterol levels

28-day crude mortality was 20.3% for pts. with ischemic stroke & 51.0%???; overall 37%

28-day predictor of poor outcome: hemorrhagic stroke type, worse pre-stroke Modified Rankin Scale (mRS), disturbed consciousness, absence of observed weakness at presentation, higher diastolic blood pressure, higher glucose levels, current tobacco smoking, & history of hypercholesterolemia

Strongest predictor: limited access to evidence-based standards of care due to limited local resources, & local evidence.

6. Robert & Zamzami, 2014 [38]

Saudi Arabia

Literature review

Incidence, prevalence type, risk factors of stroke; influence of age, gender differences, neuropsychiatric manifestations, health-related quality of life (QOL), LOS (LOS), medical care, & rehabilitation.

Low incidence & prevalence of stroke compared to Western countries

Ischaemic stroke predominated; Sub-Arachnoid Haemorrhage very rare

Important risk factors: hypertension, diabetes mellitus, coronary diseases, & smoking

Men at higher risk than women

Depression not frequent

Low QOL in pts. from Saudi Arabia compared with other countries

Age & functional status influenced HRQOL

Stroke severity, nature & other medical complications: predictors of LOS

Ministry of Health offers rehabilitation services; have one active stroke center

Research on stroke, establish SUs, increase public awareness, train health care providers, & increase the rehabilitation centers

7. Mohd Nordin, et.al. 2012 [39]

Urban Hospital. (n = 1)

Retrospective study from June to October 2010 for pts. 2006–2009

557 pts.

Individuals receiving rehabilitation services, their functional status on discharge

1. Ischemic stroke highest stroke subtype (66.4%)

2. No research on causes of ischemic stroke in Malaysians

3. 62.7% received rehabilitation during hospitalization: daily physiotherapy & occupational therapy

4. 3.0 days mean time from diagnosis of stroke to initiation of rehabilitation

5. Mean disability level at discharge = 3.5

6. Highest level of function at discharge: walking, then standing from sitting, followed by bed mobility & sitting up from supine (47, 25, 15, 12%)

7. > 50% of pts. had mRS score > 3 on discharge

8. Inadequate rehabilitation services for acute & sub-acute stroke survivors

8. Badachi, Mathew, Prabhu et.al. nd [40]

Tertiary care center, South India

100 consecutive acute ischaemic events

Failure of pts. to recognize stroke symptoms, awareness of thrombolysis as a treatment modality, failure of patient’s relative to recognize stroke,failure of primary care physician to recognize stroke,transport delay, lack of neuroimaging & thrombolysis facility in 1st hospital of arrival, & non-affordability

1. Poor recognition of stroke symptoms by pts., relatives, & primary health care physicians; hence prehospital delay; attributed to lack of knowledge of stroke symptoms & hesitation to initiate treatment

2. No facilities for neuroimaging & thrombolysis for most tertiary hospital

3. Low utilization of thrombolytic therapy due to high cost

4. Inadequate ambulance services, especially in rural areas

5. Education efforts & awareness

6. Training of emergency physicians

7. Improve infrastructure in district hospitals

8. r-TPA should be available at subsidized rates

9. Neuroimaging facilities should be improved & made affordable

10. Uses of dedicated ambulance services

11. Stroke prevention programs on thrombosis needed

9. Ossou-Nguiet, Sossoumihen, Matali et.al. 2017 [41]

Urban Hospital (n = 1)

Case report

1

Inadequate availability of IV thrombolysis & mechanical thrombectomy interventions in SU.

1. Pt received IV thrombolysis only & died 24-h after admission

2. The unavailability of mechanical thrombectomy interventions

3. Few radiologists & MRI in sub -Saharan Africa

4. Need for enough medical personnel & appropriate equipment in SUs

10. Linda, Sebastiana, & Vanessa, 2009 [42]

Urban Hospital. (n = 1)

Retrospective study

195 pts. (94 admitted before initiating SU, 101 thereafter)

Outcome of multidisciplinary stroke care in limited-resource settings

1. Inpatient mortality dropped from 33% (n = 31) to 16% (n = 16)

2. Referral to inpatient rehabilitation increased from 5% (n = 53) to 19% (n = 513) at discharge

3. Standardized investigation and evaluation of stroke admissions was better

4. Initiation of secondary prevention strategies was achieved

5. Prevention & treatment of complications of stroke was also achieved

6. Evaluation by multidisciplinary rehabilitation team was better achieved in SUs than in general ward

7. Staff education in stroke care & standardized discharge & rehabilitation planning was also better achieved in SU, compared to general wards

8. Involvement of relatives in SU was better achieved than in general wards

11. Gould, Asare, Akpalu et.al. nd [43]

Ghana

Review of local services for stroke care, assist with service plans, provide multidisciplinary education & training, & practical case-based problem solving

1. Need for frontline staff to improve delivery of stroke care

2. Establishment of Ghana’s first SU

12. Donia et.al. 2017 [44]

Urban Hospital. Egypt

Case report (Oct, 2016)

1

Administration of rTPA, dose, recommended administration time & availability of 2 in hospitals

Partial improvement during 3-month period after rTPA administration

13. Leonard, Michael, George et.al. 2017 [45]

Urban hospitals. (n = 11)

A non-probabilistic purposive sampling technique used for recruitment

descriptive study:

Nov 2015 - Apr 2016

11 participants (neurologists & physician specialists)

& medical officers (general physicians).

evaluating available acute stroke services

1. Availability of designated accident & emergency departments

2. Limited functional diagnostic & assessment services

3. Specific stroke clinical guidelines in all study hospitals

4. Few SUs available

5. No functional & standardised multidisciplinary team was evident

6. No provision of thrombolysis using tPA reported

7. Surgical procedures not conducted in any study hospital

8. Fewer/absence of stroke specialist

9. No direct health policy support from the state or national level for stroke care

14. Clarke, 2013 [46]

Review of stroke evidence

I reviewer

Effect of multidisciplinary stroke care & possible future direction

1. Pre-hospital & acute services improved recognition of stroke, established rapid specialist assessment resulting in more accurate diagnose & quality care

2. Thrombolysis can be safely administered up to six hours after witnessed stroke onset

3. Rehabilitation is key to stroke care

4. Rehabilitation interventions remain limited in some areas

5. Rehabilitation should commence as early as possible after stroke

6. SU team includes physiotherapists, occupational therapists, speech & language therapists, stroke physicians, nurses & healthcare assistants

7. Multidisciplinary team care resulted in long-term reductions in death, dependency & need for institutional care, facilitate earlier discharge to home increases likelihood pts. will regain independence in activities supporting daily living, & result in fewer pts. requiring long-term institutional care

8. Multidisciplinary team approach most effective way of providing high-quality stroke services

9. Need for early referral to clinical psychologists or psychiatrists to provide interventions when need arises

10. Co-ordinated multidisciplinary teamwork made improvements in quality of care in pts. with stroke

15. Al Khathaami, Algahtani, Alwabel, Alosherey, Kojan, & Aljumah et.al. 2011 [47]

Urban hospital, Saudi Arabia

Situation analysis study. Phone interviews.

83 Neurologist.

Views & beliefs about current stroke care in the country, system deficiencies, attitude towards

t-PA use, logistics required to provide optimal stroke care, & the priorities needed for improvement

1. 71% of neurologists rated the care provided to stroke pts. at 6 or below on a scale between 1 (very poor) & 10 (best care)

2. Deficiencies in stroke care starting from prevention & education at the community level to post-stroke rehabilitation

3. Lack of thrombolysis program to the existing shortage of resources

4. Need for improvement

16. Ogungbo, Ushewokunze, Mendelow et.al. 2005 [48].

Nigeria

Situation analysis

Not specified

How to improve management of stroke

1. Population strategy by implementing Public awareness programs, Life style modification strategies

2. Introduction of stroke study groups & development of local guidelines among physicians

17. Rahil, Afshin, Anahid et.al. 2012 [49]

Letter to the Editor. Iran

Cost-effectiveness of rTPA in developing countries

1. No studies on cost-effectiveness of rTPA in developing countries

2. Studies done revealed rTPA as cost-effective in developed countries

3. Few rehabilitation centres in developing countries

18. Baatiema, Chan, Sav et.al. 2017 [50].

Hospitals across Africa

Systematic review using PRISMA

4 non experimental studies with 330 study participants between 2009 & 2016

Clinical efficacy of SUs

Thrombolytic therapy

2. Less deaths (16%) Vs 33% prior SU

3. LOS 6.8 days compared to 5.1 days i general wards

4. Stroke referrals to inpatient rehab was higher than to general ward, (19% vs 5%)

5. Though not significant, patient access to CT brain scan was higher, 16%, in SU compared to 13% in the general medical ward

6. Improved pt. outcomes with use of thrombolytic therapy

7. Thrombolytic therapy can generate optimal patient outcomes in Africa

8. Imperative for policymakers to increase efforts to increase the use of thrombolytic therapy in hospital settings to reduce the current disproportionately high stroke burden in Africa

19. Rhoda A, Cunningham N, Azaria, 2015 [51]

Hospitals (n = 3) R, South Africa & TZ

Retrospective

452 pts.

-Time from stroke onset to admission

-in-patient physio & rehabilitation

Time interval stroke onset to admission 6.8, 0.3, & 1.2 days

LOS stay; 8.2, 7.38, & 12.19 for R, SA, & TZ respectively

40,68%, & 98% of pts. with stroke in R, TZ, & SA respectively, received physio-rehabilitation, 2 sessions/week in R & TZ, & 3 in SA

20. Olaleye & Lawal, 2017 [52]

(Urban hospital Nigeria)

Retrospective

783 pts.

Inpatient physio rehabilitation

1. Mean LOS = 16.2 days

2. Referral rate for PT high (75.8%)

3. Mean time from admission to referral for PT = 3 days

4. Majority (63.4%) of pts. referred utilized PT; mean number of PT sessions during in-patient care = 8.7

5. Utilization of in-patient PT significantly associated with reduced LOS