The National Health Policy on stroke

in France

Pr Maurice GIROUDStroke Registry of Dijon ( 1985)

President of the Council of National Institute of Health Survey (2005)

Member of the Council of the National Stroke Projet(2009)

MG 05.11.10

Stroke and Health Policy in France

International recommendations on :• Stroke Unit• Fibrinolysis with rt-pa ( 2003)

1st national recommendations for :• Stroke Unit• Use of rt-pa• November 2003

2nd : March 2007

Evaluation

Slow development

National Plan on Stroke Care. March 2010

Objectives

142 Stroke Units for 60 millions of inhabitants

Fibrinolysis for 5 % of cerebral infarcts

Financial aid :

- 6 500 Euros per stroke / 15 days

- 450 Euros per stroke

per day

in SU

5

90 UNV Début 2010

AntillesFort de France 1Pointe à Pitre 1

Réunion St Denis 1 Bayonne

Bordeaux

Clermont F

Caen

Cherbourg

Saint Lô

Chalon

Dijon

St Brieuc St Malo

Rennes

Brest

LorientVannes Orléans

Bourges

Tours

Dreux

Reims

Besançon

Belfort

RouenLe Havre

Limoges

Perpignan

ToulouseAuch

MontaubanAlbi

Montpellier

Nîmes

Carcassonne

Toulon

Nice

Marseille

Freyming

Nancy

l

Nantes

Angers

Amiens St Quentin

Beauvais

Creil

Compiègne

Soissons

La Rochelle

Poitiers

Bourg

Lyon

Grenoble

Chambéry

AnnecyVillefranche

Haguenau

Strasbourg

Colmar

Mulhouse

DunkerqueLille

Roubaix

Tourcoing

CalaisBoulogne

ValenciennesBéthune Lens

Valence

ESCHU

PrivéArmées

Rodez

F Woimant

Results

6

UNV prévues142 UNV en 2011

AntillesFort de France 1Pointe à Pitre 1

Réunion St Denis 1St Pierre prévue

PauBayonne

PérigueuxBordeaux

AgenLibourne

Dax

Aurillac

Clermont F

Montluçon

Vichy

Caen

Cherbourg

Saint Lô

Avranches

Chalon

Macon

Dijon

St Brieuc St Malo

Rennes

Brest

Quimper LorientVannes

Pontivy

Orléans

Bourges

Chartres

Châteauroux

Tours

Dreux

Charleville

Reims

Troyes

Besançon

Belfort

RouenLe Havre

Limoges

Brive

Perpignan

Toulouse

Rodez

Tarbes

Auch

Cahors

MontaubanAlbi

Montpellier

Nîmes

CarcassonneBéziers

Lons le Saunier

Toulon

Nice

Marseille

Aix

Avignon

FreymingThionville

Metz

Nancy

Epinal

Nantes

La Roche sur Yon

AngersLaval Le Mans

Amiens St Quentin

Beauvais

Creil

Compiègne

Soissons

AngoulêmeLa Rochelle

Poitiers

Niort Bourg

Lyon

St Etienne Grenoble

ChambéryAnnecy

Villefranche

VienneRomans

Haguenau

Strasbourg

Colmar

Mulhouse

DunkerqueLille

Roubaix

CalaisBoulogne

ValenciennesMaubeuge

Béthune Lens

Valence

Montélimar

Dole

Metz

Verdun

UNV reconnues

UNV prévues

Vesoul

F Woimant

Number of fibrinolysis (2009) :the Top 4

- 155 per year = Lyon

- 127 per year = Toulouse

- 124 per year = Marseille

- 102 per year = Dijon

- 87 per year = Bordeaux

- 83 per year = Montpellier

Distribution of stroke management

Public hospital = 92 % (80 % in 1985)

Private Hospital = 5 % (13%)

Home = 3 %.(7%)

Dijon (1985-2004) : 20 years

Trends of incidence rates

Large artery infarct

lacunes

Cardio-embolic

Cerebral hemorrhage

SAH

0

50

100

150

200

250

300

1985 1990 1995 2000 2004

Auckland (p < 0.05)

Oxford (p < 0.05)

Dijon (NS)

Auckland. Stroke. 2005Oxford. Lancet. 2004Dijon. Stroke. 2006

International trends on incidence rates

Increase of hope of life without any stroke

Oxford : + 1 year NS

Soderham : + 3 years p < 0.01

Auckland : + 3 years p < 0.001

Dijon : + 5 years men p < 0.001

+ 8 years women p < 0.001

Stroke and cardiac - Infarct in Dijon (2001-2007) (A. Gentil. CVD 2009)

Case-fatality rates at 1 year in Dijon for 25 years(Béjot et al. CVD 2010)

1985 1990 2000 2010

26 % 24 % 21 % 16 %

Vascular risk factors

- stable VRF :

65% 64%

48%52%

22% 23%25%

22%

12% 10%

0%

10%

20%

30%

40%

50%

60%

70%

HTA TAS >= 180 FA TIA MI

1985

2004

- moving VRF

11%

28%

10%

17%

37%

25%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Cholestérol Diabetes Tobacco

1985

2004

Trends of preventive treatments for 20 years

47% 49%

5%

27%

3%

8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Anti-HTA Anti-agrégants Anti-coagulants

1985

2004

Perspectives

To allow to the non-neurologists (emergency doctors) to practice fibrinolysis

With a specific training for fibrinolysis (Licence for Fibrinolysis)

And control with Tele-Stroke-Medecine from the regional SU (order of October 2010)

Conclusion

A Stroke National Health Policy is able to improve the management of patients with stroke

The efficacy of this policy :

- of mortality rate

- rt-pa use

- SU

Ref. : Y.Béjot et al. Cerebrovascular Disease.2010