LAUSR

Dear editor, Based on recently published studies, the age-standardised incidence of stroke in Europe at the beginning of the twentyfirst century ranged from 95 to 290/100,000 per year [1]. An East-West and North-South gradient was observedwith higher incidence rates in eastern countries and lower rates in southern countries. Within Europe, there are two ongoing realities. Specifically, while an overall decline in stroke incidence was noted in the last two decades, several Central Eastern European countries are still experiencing increasing rates in stroke incidence and stroke-related mortality [1]. The organisational models adopted at local and national levels may be influencing these differing stroke care performances [1]; however, there are considerable variations in the quality of care for stroke patients in Europe, both between and within countries. To this regard, in 2016, the ESO (European Stroke Organisation), European Society of Minimally Invasive Neurological Therapy (ESMINT), European Academy of Neurology (EAN), and the patient organisation Stroke Alliance for Europe (SAFE) formed the European Alliance for Endovascular Stroke Treatment. One of the first goals set by the group was to evaluate the access of patients with ischemic stroke in Europe to the three main pillars of acute treatment, particularly stroke unit care, thrombolysis and thrombectomy. To do so, this working group performed a survey of scientific societies and stroke experts, in which the best available information on access to and delivery rates of these treatments was collected from 44 out of 51 European countries [2]. The estimated mean number of stroke units was 2.9 per million inhabitants (95% CI 2.3–3.6) and 1.5 per 1000 annual incident strokes (95% CI 1.1–1.9) 9.2 and 5.8, respectively. Intravenous thrombolysis was provided in 42/44 countries. The average treatment rate was 7.3% of incident ischaemic stroke patients for intravenous thrombolysis (95% CI 5.4– 9.1), and 1.9% for endovascular treatment (95% CI 1.3–2.5); however, countries with the highest rates reached a proportion of 20% and 6% of treated patients, respectively, for intravenous thrombolysis and endovascular treatment. Despite scientific evidence and clinical guideline recommendations, this data shows too many patients are not treated in stroke units and centres that can offer the best evidencebased treatment in the acute phase. If we assume the highest national rates could be feasible in the remaining countries that participated in this European survey, which is still a somewhat conservative estimate, 226,662 more patients could have been treated with IVT and 67,347 with EVT in 2016. This would mean that only one-third of patients that would potentially be eligible for IVT and one-quarter of candidates for EVT received these treatments in Europe, in this recent period. These disparities in access and delivery of acute stroke treatment rates within Europe claim for a quality improvement program, with a focus on data and quality outcomes. Unfortunately, only a few countries have established a continuous quality improvement system with a predefined set of criteria that are regularly measured and compared with benchmarks [3]. A structured framework for health service–related researchers, practitioners and policy-makers are needed to improve the understanding of the determinants that underlie these differences and ultimately designing interventions that reduce and eliminate these disparities [4]. The survey addressed the first phase, but because several countries are still lacking prospective stroke registries, coordinators and experts often had to use multiple sources of regional and local information to extrapolate national figures. A further step to improve data quality will be a network of an * Valeria Caso [email protected]