Quality of acute stroke care in Romania: Achievements and gaps between 2017 and 2022

Abstract

Romania has one of the highest incidences of stroke and one of the highest mortality rates in Europe. The mortality rate due to treatable causes is also very high and is associated with the lowest public spending on healthcare in the European Union. Nonetheless, significant achievements in acute stroke care have been made in Romania in the last 5 years, most notably the increase of the national thrombolysis rate from 0.8% to 5.4%. Numerous educational workshops and constant communication with the stroke centers led to a solid and active stroke network. Due to the joint efforts of this stroke network and the ESO-EAST project, the quality of stroke care has significantly improved. However, Romania still faces many problems: a major lack of specialists in interventional neuroradiology and consequently a low number of stroke patients treated by thrombectomy and carotid revascularization procedures, a low number of neuro-rehabilitation centers and a country-wide lack of neurologists.

Country background

European Stroke Organization (ESO) initiated a quality improvement project in 2015 dedicated to acute stroke care across Eastern Europe, having as a background the alarmingly high incidence and mortality rates in this geopolitical region and aiming to offer patients equal chances to access treatment. Romania was in a challenging situation, with one of the highest incidences of stroke and the highest mortality rate in the region. Joining ESO EAST was the first step toward improvement in the quality of stroke care and contributed essentially to creating a stroke network in our country.

An important issue for Romania is the inconsistency of the epidemiological data. The existing statistical data are usually generated by extrapolating the data that have been obtained from a reduced number of hospitals. The Integrated Unique Information System (SIUI http://siui.casan.ro/cnas/) can be used as a primary and concise source of information. However, the data are distorted due to the DRG-based coding system, which generates errors by classifying another pathology as a primary diagnosis (therefore, obtaining a higher case-mix index). Specific interventions such as thrombolysis or thrombectomy for acute ischemic stroke did not have, until recently, a corresponding code, and were therefore unreported in this system. Data belonging to the DRG-based system of county hospitals, collected through a questionnaire dedicated to Neurology Departments from these hospitals, show that between January and October 2016, 75,667 patients with acute stroke were hospitalized, leading to an incidence of 408 acute stroke cases/100,000 people. Still, more recent data demonstrate a significantly lower incidence, explained probably by the wrong classification as acute strokes of patients with a history of stroke hospitalized for other medical reasons. Data obtained by direct interviews with the leading hospitals in the country, which have departments of Neurology, show a total number of 54,000 strokes in 2019. The reported number decreased dramatically in 2020 and 2021 (with approximately 10,000 cases/year) due to the pandemic of Covid-19. A national registry for cerebrovascular diseases is necessary, but the authorities must support its management. In countries where such registries are operative, they are adequately financed, at least at the level of each healthcare institution.

The Romanian Ministry of Health initiated in 2011 a pilot project in 10 stroke centers. This project was translated in 2015 into a national health program, named Priority Action for Interventional Treatment in Acute Stroke, dedicated exclusively to financing the medication for intravenous thrombolysis (IVT) and the devices necessary for mechanical thrombectomy (MT) and endovascular treatment of ruptured aneurysms (aneurysmal subarachnoid hemorrhage). The decision was first published in 2015 as an official order of the Ministry of Health (OMS No. 450/2015) and was republished several times as the number of hospitals able to perform IVT or MT has increased. In January 2019, a decision of the Ministry of Health in cooperation with the Romanian Society of Neurology changed overnight the availability of stroke-ready hospitals in Romania by adding 32 new centers. The eligibility criteria are mentioned in Table 1. Romania is administratively organized into 42 units, 41 counties and the capital of the country – Bucharest. The counties are unequally economically developed and the situation is reflected in all levels of stroke care, from primary prevention to life after stroke. In April 2022, 46 centers (Figure 1) can perform IVT and only five centers MT (only one has been added in 7 years). A National Registry for Interventional Treatment in Ischemic Stroke (IVT and MT) was established in 2014 and all procedures are mandatory registered (www.neuroregistre.ro). The registry is administered by the Romanian Society of Neurology and has included 8213 IVT and 626 MT until March 2022. The stroke incidence does not follow a uniform distribution at the national level, being higher in the Southern and Western regions. However, in the East and Northeast regions the patients might have lower access to hospital services and therefore some stroke cases could fail to get admitted to Neurology departments and registered.

Table 1.

Criteria for eligibility as stroke ready hospital, able to perform IVT/EVT.

	Necessary facilities to perform IVT	Necessary facilities to perform EVT
Departments and clinics	Neurology	Neurology
	Radiology	Radiology
		Interventional neuroradiology
		Neurosurgery
Staff available	On-site neurologist 24/7	On-site neurologist 24/7
	On-site diagnostic radiologist 24/7	On-site diagnostic radiologist 24/7
		On-call interventional neuroradiologist 24/7
		On-site neurosurgeon 24/7
Investigations available	Brain CT scan 24/7	Brain CT scan 24/7
	CT priority for stroke patients	CT priority for stroke patients
		Cerebral angiography 24/7

Figure 1.

County distribution of neurologists/10,000 people in Romania. Data were obtained from the Romanian College of Physicians. Almost 70% of the cities/counties have <0.5 neurologists/10,000 population.

In the absence of a national stroke registry, the Registry of Stroke Quality care (RES-Q), part of the ESO-EAST project, was strongly supported by the Romanian Society of Neurology (https://qualityregistry.eu/data/national_dashboard/). The methodology for the registry was published previously by Mikulik and colab. ¹

We started to introduce data in 2017, with 10 centers. In 2022 there are 36 centers (out of 46 able to deliver IVT) that register the patients discharged from the hospital between March 1st and 31st with a diagnosis of TIA, acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and cerebral venous thrombosis.

Besides the two mentioned sources (National Registry for Interventional Treatment in Ischemic Stroke and RES-Q Registry), our data come from a direct communication inside the Romanian Stroke Network with the 46 local coordinators of the Priority Action.

Between 2017 and 2022 a total number of 10,583 patients were registered in RES-Q, with the following distribution which had small variations, determined by the variability of hospital admittance: Transient ischemic attack (3%, 9%, 5%, and 2%), ischemic stroke (80.6%–87.4%), intracerebral hemorrhage (9.4%–13.4%), cerebral venous thrombosis (0.2%–0.3%), undetermined (0.1%–0.2%), and stroke mimics 0.3% (category introduced in 2022).

Gender distribution is constant along the years (M = 51.4%, F = 48.6%), with median age 72 years for both ischemic and hemorrhagic stroke.

Intravenous thrombolysis

In 2019 the Romanian Society of Neurology has published as an order of the Ministry of Health the Standard Operating Procedure (OMS No. 17/2019, Official Monitor Part I, No. 34, January 11th 2019) for the management of the interventional treatment in acute ischemic stroke (both IVT and MT) and aneurysmal subarachnoid hemorrhage. The document covers prehospital and hospital procedures and was essential for increasing the number of IVTs, as neurologists felt more confident in applying a therapeutic method which was new for them, having an official document to rely on.

Romania is confronted with a dramatic decrease in the number of physicians due to a strong phenomenon of migration. Even if the salaries have been raised since 2018, the migration was not significantly influenced because one of the main reasons is the pauper health system, with limited resources and consequently poor conditions for a truly professional performance.

Romania has a total number of 1285 neurologists, according to the data obtained from the Romanian College of Physicians. Neurologists are concentrated in university centers and in more economically developed areas, being, nevertheless, insufficient for the demand, even in these areas. Bucharest (1.67) and Cluj-Napoca County (1.46) have the highest number of neurologists per 10,000 inhabitants, while counties like Giurgiu, Calarasi or Ialomita have less than 0.2 neurologists/10,000 people (Figure 1).

Despite these difficulties, there has been a spectacular change in the landscape of IVT in Romania in the last 3 years. The national rate of IVT increased from 0.8%, in 2017 to 5.4% in 2021 (Figure 3), with significant differences throughout the country. There are still seven counties, with a total population of 2.2 million inhabitants, where IVT is not available, while some centers, like Brasov or Emergency Hospital Floreasca in Bucharest, have a rate of IVT over 25%. In Bucharest, seven hospitals can perform IVT (two hospitals can also perform endovascular treatment). The rate of symptomatic hemorrhagic transformation is 6.07% for all IVTs registered in the national registry of interventional treatment in acute stroke.

Figure 3.

IVT rate in Romania (number of IVT/total number of ischemic strokes hospitalized during 2021). In Bucharest, there are seven hospitals that can perform IVT (SUUB-University Emergency Hospital Bucharest, University Emergency Hospital Elias, Emergency Clinical Hospital Floreasca, Military Hospital “Carol Davila,” INNBN – National Institute of Neurovascular Disorders, Colentina Hospital, Clinical Institute Fundeni). There are two IVT centers/county in Neamt (Piatra Neamt and Roman) and in Vaslui (Vaslui and Barlad). All other counties have only one center able to perform IVT.

The other project developed inside ESO EAST, ANGELS Initiative, brought an important educational support. The Romanian Society of Neurology has designated a team that organized six regional workshops for neurologists, radiologists and emergency physicians, several educational sessions dedicated to nurses, at least 10 simulations in different hospitals along the country and more than 10 educational sessions with the ambulance personnel. The educational sessions moved online during the pandemic of Covid 19.

Stroke Action Plan for Europe, 2018–2030 ² aims for a rate of IVT of 15%, which has already been achieved by some of the centers in Romania. In areas where the percentage is close to 15% we need to increase stroke awareness and to develop a functional prehospital emergency system. In areas where the rate of IVT is very low, beside what we have already mentioned, we need a governmental involvement, as the main problems are the low number of neurologists and radiologists and an insufficiently developed hospital infrastructure (almost one-third of the CT scans have ⩽ 16 slices).

Door to needle time has improved along the years but was negatively influenced by the Covid-19 pandemic. The emergency state was declared in Romania on March 16th 2020, and basically did not influence DTN registered in RES-Q in March 2020, but the difficulties that all the medical systems had to face during 30 months of distorted circuits and exhaustion of the medical personnel (ambulance and hospitals) were translated in longer DTN time intervals (Table 2).

Table 2.

Median door- to needle time interval (in minutes) registered in RES-Q registry from 2017 to 2022.

Year	2017	2018	2019	2020	2021	2022
DTN (min)	67	58	53	43	49	60

In October 2020, the working group for Priority Action published together with the Ministry of Health (OMS No. 1832/2020, published in the official Monitor Part I, No. 1008/ October 30th 2020) a pilot program for prenotification of the hospitals in case of a potential eligible patient for IVT or MT. The program was put on hold during the pandemic, as the Ambulance system was utterly overwhelmed.

Mechanical thrombectomy

The situation in Romania is significantly worse for mechanical thrombectomy. In 2017 a total number of 56 thrombectomies were performed throughout the country. The number increased five times in 2021, reaching 285 MTs but this means only 0.5% of all ischemic strokes. There are three main centers which regularly perform EVT (University Emergency Hospital Bucharest, Tg. Mures County Hospital and County Hospital “Pius Brinzeu” Timisoara) and two other centers with reduced activity. There are several problems leading to this situation. First, mechanical thrombectomy can be performed only by interventional radiologists, who are also performing all kinds of procedures like embolization of uterine fibromas, angioplasty and stenting for peripheral arteries, guided biopsies, and others. A reduced number of radiologists choose to be trained in interventional radiology and even fewer in interventional neuroradiology. The solution is to create a program of training dedicated to interventional neuroradiology and to increase the recruitment area by accepting other specialties for training, at least neurologists and neurosurgeons. Second, we need to increase the funding for the existing centers in order to reach a sufficiently large number of procedures per center to allow the concomitant training of several specialist, in accordance with ESMINT criteria. ³ Third, we need to increase the number of centers able to perform MT and to establish the exact catchment area for each center, to avoid the waste of time and resources generated by the lack of established drip-and-ship protocols. Fourth, we can increase the number of eligible patients by routinely performing CT angiography (CTA) in every primary stroke center and by extending the time window outside 6 h by utilizing perfusion CT (CTP). The number of centers performing routinely CTA and CTP are shown in Figure 4(a) and (b) (results from a questionnaire run by Razvan Radu, Elena Terecoasa, and Cristina Tiu in October 2020, results communicated in the 18th Congress of the Romanian Society of Neurology). CTA is available only in 42.5% of the stroke centers. Tg. Mures County Hospital is the only center with a CTP software available, although it is not used routinely.

Figure 4.

(a) CTA availability for acute stroke patients. In Bucharest there are seven stroke centers and only one, Fundeni Clinical Institute (FCI) does not perform CTA. (b) CTP availability: only one center: Tg. Mures County Hospital.

Despite the reduced number of procedures/centers, the door to groin time interval has constantly improved. We notice a paradoxical situation in RES-Q registry, where DTN time for Romania in the first quarter of 2022 is 60 min and DTG is 48.5, the reason being that many patients were transferred from other primary centers to the comprehensive stroke centers, so that the medical staff involved was practically pre-notified and things moved much faster. If we look at the national data obtained from the National Registry for Interventional Treatment in Acute Ischemic Stroke and from direct interviews with the stroke centers coordinators, the results are less optimistic, the median DTG for the interval January to March 2022 being 80 min.

Admittance into stroke units

There are 14 stroke units in Romania defined according to OMS No. 1408/2015, published in the Official Monitor Part I nr 870, November 20th, 2015 (Table 3). Obviously, given the large number of strokes, only a small percentage of patients are admitted to a stroke unit. There is an increasing number of patients admitted to a monitored bed. In Romania stroke is treated only by neurologists, but certain cases are admitted in other departments (either initially unrecognized minor strokes, or the opposite, very severe strokes who need to be taken care of in Intensive care Units).

Table 3.

Criteria for stroke units in Romania as defined by OMS No. 1408/2015.

Minimum required infrastructure
Number of beds: 4–20
Vital signs monitoring for 4–10 beds
Permanent oxygen supply for all beds
Tracheal aspiration systems for all beds
2–4 Portable mechanical ventilators
1 Defibrillator
At least two orotracheal intubation kits
1 Portable ECG device
Automated syringe pumps for all beds
1 Portable ultrasound Doppler echography device (including probe for TCD monitoring)
24/7 access to in-hospital CT
Rapid automated hematologic and biochemical analyzer and/or 24/7 access to the hospital’s central/emergency laboratory
Minimum required personnel
1 Neurologist for every 4 beds
1–2 Physiotherapists (with university degree)
1 Speech therapist and/or 1 psychologist
1 Nurse for every 1–4 bed per shift
1 Nurse assistant for every 1–4 beds per shift
1 Porter per stroke unit per shift
1 Housekeeper for every 200 m2 per shift

We need to increase the number of stroke units, but this is limited by bureaucratic inertia, as any change in the administrative structure of a hospital should be centrally approved by the Ministry of Health and by the shortage of medical personnel.

Other quality indicators

Some of the quality indicators of stroke care have improved since 2017 (Table 4). Centers were motivated by ESO Awards and by the constant feedback given by the national coordinator of the stroke network (Figure 2). In 2017 only County Hospital Oradea (Bihor County) has qualified for Gold Status, while in 2021 we had three Diamond Hospitals (Emergency Clinical Hospital Bucharest, County Emergency Clinical Hospital Brasov, Emergency Clinical County Cluj Napoca).

Table 4.

Quality indicators for acute stroke care with a good performance.

	NIHSS assessment at admission (%)	Cerebral imaging CT/MRI (%)	Anticoagulant treatment (%)	Antiplatelet treatment (%)	Antihypertensive treatment (%)	Statin treatment (%)
2017	54.05	97.94	95.27	92.64	86.34	79.36
2018	80.10	98.15	97.42	94.26	88.64	76.5
2019	73.55	98.42	98.47	95.33	89.15	78.92
2020	70.40	97.30	97.07	94.96	88.13	78.68
2021	63.40	98.03	97.06	91.41	87.51	91.63
2022	86.00	97.00	88.01	94.03	81.00	70.00

Data from RES-Q registry.

Figure 2.

Educational workshop for IVT organized by Angels Initiative and Romanian Society of Neurology in Galati, in 2018.

In 2017, when RES-Q Registry was implemented, slightly more than 50% of stroke patients were evaluated with the NIHSS scale, while in 2022 the percentage has increased to 86. Although the results in Table 4 look homogeneous over the 6 years, we can comment that there was a significant improvement over time because in 2017 there were only 10 experienced centers that included patients in the registry, while in 2021, there were 36 centers registering patients and more than half of them were initially not habituated with the standardized management of stroke patients but improved their activity after analyzing the RES-Q quality indicators. Brain imaging is performed for all patients (the missing percentages are due to very severe cases who decease immediately after admittance).

Evaluation of dysphagia using the GUSS scale has been implemented in Romania due to RES-Q Registry. Several training workshops for nurses were organized during the annual National Congress of Neurology and the National Stroke Conferences and the local stroke coordinators were advised to repeat the GUSS training at the hospital level. As a result, the percentage of standardized dysphagia screening at admission using the GUSS scale increased from 0.1% in 2017 to 45.07% in 2021, but further improvement is certainly needed.

Table 5 lists the most stringent things to be improved. Of utmost importance is the increasing mortality rate. It is true that the results for 2021 are influenced by the pandemic and that mortality is calculated for both ischemic and hemorrhagic stroke, but in-hospital mortality is unacceptably high and the situation is probably worse at 90 days. Beside the low number of patients admitted to stroke units, many other causes contribute to this reality, but the final link is the chronic low funding of the entire health system. Romania Country Health Profile for 2019 ⁴ mentions that health spending in Romania is the lowest in the European Union, both on a per capita basis (EUR 1029, EU average EUR 2884) and as a proportion of GDP (5%, EU 9.8%). Directly associated with the low funding, we have the highest mortality rate from treatable causes (208 per 100,000 population, EU average 100/100,000).

Table 5.

Quality indicators for acute stroke care that need to be improved.

	Carotid imaging (%)	>50% carotid stenosis (%)	Revascularization of symptomatic carotid stenosis (%)	Newly diagnosed AF (%)	Hemi-craniectomy (%)	Mortality (%)	Transfer to rehabilitation (%)	Dysphagia screening (Guss scale) (%)
2017	58.62	6.49	22.95	5.96	0.11	14.96	5.76	0.1
2018	67.23	5.21	28.7	11.11	0.27	13.31	8.42	39.12
2019	59.89	5.02	31.62	8.95	0.16	16.02	6.46	34.82
2020	50.12	7.77	17.14	10.95	0.01	15.08	6.36	54.04
2021	45.44	7.33	18.32	12.76	0.47	19.30	6.96	42.39
2022	60.10	4.21	22.20	10.90	0.37	15.80	9.00	45.07

Data from RES-Q registry.

On average, 40% of the patients admitted for acute ischemic stroke are discharged without any carotid imaging and less than one-third of the symptomatic carotid stenoses are revascularized. The percentage of newly diagnosed atrial fibrillation has increased since 2017, although monitoring for cardiac arrhythmias for (24-48 h), or longer is not broadly available. A seriously weak point is the low percentage of the decompressive craniectomy (<0.3% on average for all 6 years).

The transfer to neurorehabilitation varies between 5.76% and 9%. The access is usually limited to one or two intervals of 14 days and younger people (median age 65 years) with modified Rankin scores 3–5 are more likely to be eligible. ⁵ The insufficient number of neurorehabilitation facilities and the absence of palliative care institutions lead to an increased proportion of disability among stroke survivors, a high in-hospital mortality and a chronic lack of beds for emergencies, as patients with modified Rankin scores of 5 remain in neurology departments for weeks and sometimes even months.

Awareness campaign and stroke support organization

In 2021, the first Stroke Support Organization in Romania, called ALIA (Asociatia de Lupta Impotriva Accidentului vascular cerebral) was established (https://alia.org.ro/). The organization provides information about clinical signs and stroke prevention, about the network of hospitals providing revascularization treatment for acute ischemic stroke and was actively involved, together with the Romanian Society of Neurology and the Ministry of Health in the development of the first public awareness campaign in stroke, which will be released on May 17th, 2022 (Figure 5). We have succeeded to match the cardinal signs from the FAST scale with the acronym that designates stroke in Romanian language (AVC = Accident Vascular Cerebral). The slogan “AVC 112 – timpul înseamnă viaţă” (“Stroke 112 – time means life”) will be distributed as radio and TV spots on the main media channels.

Figure 5.

The poster of the media awareness campaign “AVC 112 – timpul înseamnă viață” (“Stroke 112 – time means life”).

Despite the difficulties induced by the economic situation and the pandemic, Romania has developed in a relatively short period of time a strong network for intravenous thrombolysis. There are still many quality indicators of acute stroke care to be improved, but the most important thing is that the voice of stroke physicians and stroke survivors is coming up.