health & science

Stroke: New Zealand’s preventable $3 billion problem

Stroke is the most common cause of permanent disability, costing the country an estimated $3 billion each year. This week, a nationwide campaign to raise awareness around the condition kicks off. Teuila Fuatai reports.

Auckland University of Technology (AUT) Professor Valery Feigin has dedicated his entire academic career to working in the field of neurological disorders. Stroke, which occurs in about 9000 New Zealanders each year and is more prevalent in Pacific and Māori people, is his priority research project.

“Direct costs of stroke in New Zealand, which is the cost of acute stroke treatment in the hospital is $700 million per year,” the head of AUT’s National Institute for Stroke & Applied Neurosciences, says.

“Indirect costs are usually three times of direct costs, so in total it comes to about $3 billion lost for the country. The whole budget of the health system is about $15 billion - it’s comparable.”

Conventional risk factors for stroke include high blood pressure, diabetes, smoking, having a high-salt diet and being overweight. Since 1981, four community-based studies have been undertaken in Auckland examining stroke rates and outcomes.

In that time, the treatment of stroke, and rehabilitation of stroke patients has improved, however prevention measures have not succeeded at the same pace - resulting in an increase in the “burden” of stroke on families, the health system, and country overall.

Dr Geoff Green, a Middlemore Hospital physician specialising in stroke treatment and rehabilitation, says the impact of stroke on families is significant.

According to the Auckland regional stroke studies, stroke incidence - which is the number of new cases of stroke each year, adjusted for population - decreased in Pākehā, but not in Pacific and Māori people over the 30 years to 2012. A 15-year age gap in the mean age of Pākehā stroke patients, and Pacific Island and Māori stroke patients also persisted over the period. The latest 2011/12 study showed for Pākehā, the mean age of stroke onset was 76, in Māori it was 60, and 61 in Pacific.

“It’s the most common cause of permanent disability, especially in younger Māori and Pacific Island patients,” Green says.

“Sometimes, they’re working, they could be the breadwinner for the family, they suddenly get admitted to hospital, are disabled and there is threat of income and threat of job loss.”

“I’ve seen circumstances where kids get pulled out of school to look after mum or dad, or grandmum or grandad, and then their education is threatened. There’s also complications of stroke, sometimes seizures. Depression is also very common - as many as 60 percent of patients who have a stroke have a period of depression following it,” Green says.

Overall, the survival rate for stroke at six months is about 80 percent. About 25 percent of people suffer a permanent disability after a stroke, and the remaining proportion end up making a good recovery, and living reasonably independently. However, survival, and path to recovery, is dependent on treatment effectiveness and timeliness.

Both Green and Feigin emphasise a preventative approach to stroke management - in line with international research and experts.

According to an article published in the academic journal Nature Reviews Neurology last year, because stroke had so many modifiable risk factors - such as smoking, high blood pressure, and excessive alcohol consumption - targeting these behaviours and habits could reduce individual risk of stroke by 80 percent, and the total number of strokes by 50 percent.

“Everyone is at risk for stroke, it’s just the level of risk that differs,” Feigin says.

“What we are trying to develop and advocate is that the emphasis in primary stroke prevention should be at people at any level of risk because most strokes - and it is the same for heart-attacks - are happening to people deemed low-risk.”

Feigin pointed to research showing the low efficacy of primary prevention strategies for cardiovascular disease heavily focused at those deemed to be “high-risk”.

Theoretical models showed, at best, a reduction in cardiovascular disease incidents by 11 percent using that approach. “In the clinical trial, it was shown that it didn’t reduce incidence or mortality at all.”

"Indirect costs are usually three times of direct costs, so in total it comes to about $3 billion lost for the country. The whole budget of health system is about $15 billion - it’s comparable."

While prevention strategies targeted at individuals who were at high risk of having a stroke are useful for determining treatment pathways, they do little to address the real problem, Feigin points out. “There have been breakthroughs in the treatment of stroke - clot retrieval and thrombolysis. Those are very good treatments and are effective - but quite few people benefit from those treatments in the big scheme of things.”

“Those treatments are not going to solve the causes of stroke. We need to act at the root, ground-level, not when the problem already happens,” he says.

“The trend is so threatening in terms of the number of people affected by stroke, it’s tripled over the last 30 years. It will continue, and in another 20 years, we’ll have 100,000 stroke survivors, then it will threaten the whole health system sustainability.”

Programmes targeted at addressing the behavioural and modifiable risk factors for stroke at primary health and community level are the most effective way to reduce the burgeoning impact of the stroke in New Zealand, Feigin believes. In addition to this, the large range of risk factors for stroke indicates primary intervention programmes would likely assist in managing and reducing other health problems, like cardiovascular disease and diabetes. It is imperative that they be considered and implemented, Feigin says.

Meanwhile, the national FAST campaign, which runs for three months, is focused on raising awareness around the importance of getting to hospital quickly when someone has a stroke. Available stroke therapies, while not applicable to everyone and every type of stroke, lose effectiveness as time lapses. Some therapies, if the patient arrives quickly enough, can even reverse a stroke.

Stroke recognition:

Face: Is their face drooping on one side? Can they smile?

Arm: Is one arm weak? Can they raise both arms?

Speech: Is their speech jumbled or slurred? Can they speak at all?

Time: Time is critical. Call 111.

Stroke Foundation

*Graphs supplied from AUT

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