Friday, May 19, 2017

System limitations to stroke care in urban Tanzania

Robert W. Regenhardt, MD, PhD
Resident in Adult Neurology at MGH/BWH

System limitations to stroke care in urban Tanzania

Neurology Unit sign
The primary purpose of my visit to the Neurology Ward at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania was to enroll patients in a trial examining disability and mortality after stroke. In addition, I wanted to spend time with the team clinically for the added exposure and also think about interventions that could improve the care of this patient population. MNH was established as the Sewahaji Hospital in ~1910 and is the largest referral hospital and academic teaching hospital in Tanzania. There are >1500 inpatient beds. Each week, 1000-1200 patients are admitted to the inpatient services and 1000-1200 outpatients are seen. There is one male and one female neurology unit.

Throughout my time rounding with the team, there were several system limitations that I came across. Most of these limitations stemmed from a relative lack of funding compared to hospitals such as MGH and BWH. Unfortunately, these limitations existed from pre-hospital care to care after discharge.

In the USA, patients with acute stroke are treated with tPA if they arrive at a hospital within a 4.5 hour window in many cases. In addition to tPA, several trials in 2015 showed the very significant benefit of endovascular thrombectomy. During my 3 weeks rounding at MNH, I did not care for a single patient that received tPA. While I was told the hospital had tPA available, they almost never are able to use it as patients usually arrived well outside of the time window. One of the senior clinicians asked me how often we send patients for endovascular thrombectomy at MGH and BWH. He said he didn’t think he’d see this intervention come to east Africa in his lifetime.

After admission, the work-up of some patients is limited by insurance. Few patients complete vessel imaging (which can alter care by determining eligibility for carotid endarterectomy) and some patients are unable to complete MRI (to make sure the lesion is truly a stroke and not something else such as tumor). Furthermore, there is no telemetry on the wards to monitor for atrial fibrillation and no heart monitors are available for 30 day monitoring after discharge (to consider anticoagulation). After discahrge, there are no acute rehab facilities, so patients must go home with the care of their families and return for outpatient PT and rehabilitation.

Learning about these differences really made me appreciate the embarrassment of riches that we have here at MGH and BWH. I think the next steps will be discussing these system issues to prioritize them based on the need and feasibility of interventions. Then, the most cost effective interventions should be implemented to improve care.

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