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      Analysis of Time to the Hospital and Ambulance Use Following a Stroke Community Education Intervention in China


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          Key Points


          Is Stroke 1-2-0, a community education campaign on rapid assessment of an individual potentially having a stroke, associated with time to arrival at the hospital and the use of an ambulance?


          This population-based cross-sectional study evaluated 2857 Chinese individuals with ischemic stroke. Following implementation of the Stroke 1-2-0 program, the delay in hospital arrival time was significantly decreased and use of an ambulance was significantly increased.


          The findings of this study suggest a multifaceted campaign increasing the recognition of stroke and appropriate action may be useful in achieving timely hospital arrival.



          Prehospital delay (time from symptom onset of stroke to the door of a hospital) in patients with stroke is long in China. With the goal of improving public awareness and knowledge of stroke recognition, Stroke 1-2-0 was developed in China as an education program to prompt rapid response to the onset of stroke based on clinical practice in China, and examination of its outcomes is needed.


          To investigate the association of the Stroke 1-2-0 educational campaign with prehospital delay for patients with ischemic stroke.

          Design, Setting, and Participants

          In a population-based cross-sectional study, all patients with ischemic stroke events were admitted to the Minhang Hospital, which is the only tertiary care hospital with a stroke center that provides acute stroke care in Xinzhuang county, Shanghai, China. The study period was from January 1, 2016, to December 31, 2019, and data analysis was performed from January 1 to July 31, 2021.


          A multifaceted Stroke 1-2-0 educational campaign comprising slides, videos, brochures, and posters distributed in the community.

          Main Outcomes and Measures

          Proportion of patients with hospital arrival within 3 hours and use of an ambulance to seek medical care, as well as the odds of seeking medical attention within 3 hours after the stroke before vs after initiation of the multifaceted educational campaign.


          A total of 2857 patients (1774 men [62.1%]; mean [SD] age, 69.83 [12.66] years) with stroke were identified, including 503 in the precampaign period and 2354 in the postcampaign period. Following the multifaceted campaign, the median (IQR) prehospital delay time decreased from 18.72 (7.44-27.84) hours to 6.00 (2.00-16.35) hours ( P < .001). After the implementation of the Stroke 1-2-0 campaign, the proportion of patients with hospital arrival time within 3 hours increased from 5.8% to 33.4% ( P < .001) and use of an ambulance increased from 3.2% to 30.6% ( P < .001). In an interrupted time series analysis, the initiation of the Stroke 1-2-0 campaign was associated with significantly increased odds of arriving at the hospital within 3 hours (odds ratio, 8.01; 95% CI, 7.17-8.95; P < .001) and use of an ambulance (odds ratio, 9.41; 95% CI, 8.24-10.74; P < .001).

          Conclusions and Relevance

          The persistent multifaceted campaign using the Stroke 1-2-0 program was associated with reduced prehospital delay and improved timely arrival rate and ambulance arrival rate for patients with stroke. These findings suggest that Stroke 1-2-0 can be adopted in other regions of China to possibly improve health outcomes and reduce clinical burdens for all patients with stroke.


          This cross-sectional study examines hospital arrival time and use of ambulances following implementation of a community education program to increase recognition of stroke.

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          Most cited references34

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          Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

          Summary Background Public health is a priority for the Chinese Government. Evidence-based decision making for health at the province level in China, which is home to a fifth of the global population, is of paramount importance. This analysis uses data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to help inform decision making and monitor progress on health at the province level. Methods We used the methods in GBD 2017 to analyse health patterns in the 34 province-level administrative units in China from 1990 to 2017. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), summary exposure values (SEVs), and attributable risk. We compared the observed results with expected values estimated based on the Socio-demographic Index (SDI). Findings Stroke and ischaemic heart disease were the leading causes of death and DALYs at the national level in China in 2017. Age-standardised DALYs per 100 000 population decreased by 33·1% (95% uncertainty interval [UI] 29·8 to 37·4) for stroke and increased by 4·6% (–3·3 to 10·7) for ischaemic heart disease from 1990 to 2017. Age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs in 2017. Musculoskeletal disorders, mental health disorders, and sense organ diseases were the three leading causes of YLDs in 2017, and high systolic blood pressure, smoking, high-sodium diet, and ambient particulate matter pollution were among the leading four risk factors contributing to deaths and DALYs. All provinces had higher than expected DALYs per 100 000 population for liver cancer, with the observed to expected ratio ranging from 2·04 to 6·88. The all-cause age-standardised DALYs per 100 000 population were lower than expected in all provinces in 2017, and among the top 20 level 3 causes were lower than expected for ischaemic heart disease, Alzheimer's disease, headache disorder, and low back pain. The largest percentage change at the national level in age-standardised SEVs among the top ten leading risk factors was in high body-mass index (185%, 95% UI 113·1 to 247·7]), followed by ambient particulate matter pollution (88·5%, 66·4 to 116·4). Interpretation China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system. Funding China National Key Research and Development Program and Bill & Melinda Gates Foundation.
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            An Ecological Perspective on Health Promotion Programs

            During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health promotion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.
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              Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis

              Summary Background Recombinant tissue plasminogen activator (rt-PA, alteplase) improved functional outcome in patients treated soon after acute ischaemic stroke in randomised trials, but licensing is restrictive and use varies widely. The IST-3 trial adds substantial new data. We therefore assessed all the evidence from randomised trials for rt-PA in acute ischaemic stroke in an updated systematic review and meta-analysis. Methods We searched for randomised trials of intravenous rt-PA versus control given within 6 h of onset of acute ischaemic stroke up to March 30, 2012. We estimated summary odds ratios (ORs) and 95% CI in the primary analysis for prespecified outcomes within 7 days and at the final follow-up of all patients treated up to 6 h after stroke. Findings In up to 12 trials (7012 patients), rt-PA given within 6 h of stroke significantly increased the odds of being alive and independent (modified Rankin Scale, mRS 0–2) at final follow-up (1611/3483 [46·3%] vs 1434/3404 [42·1%], OR 1·17, 95% CI 1·06–1·29; p=0·001), absolute increase of 42 (19–66) per 1000 people treated, and favourable outcome (mRS 0–1) absolute increase of 55 (95% CI 33–77) per 1000. The benefit of rt-PA was greatest in patients treated within 3 h (mRS 0–2, 365/896 [40·7%] vs 280/883 [31·7%], 1·53, 1·26–1·86, p<0·0001), absolute benefit of 90 (46–135) per 1000 people treated, and mRS 0–1 (283/896 [31·6%] vs 202/883 [22·9%], 1·61, 1·30–1·90; p<0·0001), absolute benefit 87 (46–128) per 1000 treated. Numbers of deaths within 7 days were increased (250/2807 [8·9%] vs 174/2728 [6·4%], 1·44, 1·18–1·76; p=0·0003), but by final follow-up the excess was no longer significant (679/3548 [19·1%] vs 640/3464 [18·5%], 1·06, 0·94–1·20; p=0·33). Symptomatic intracranial haemorrhage (272/3548 [7·7%] vs 63/3463 [1·8%], 3·72, 2·98–4·64; p<0·0001) accounted for most of the early excess deaths. Patients older than 80 years achieved similar benefit to those aged 80 years or younger, particularly when treated early. Interpretation The evidence indicates that intravenous rt-PA increased the proportion of patients who were alive with favourable outcome and alive and independent at final follow-up. The data strengthen previous evidence to treat patients as early as possible after acute ischaemic stroke, although some patients might benefit up to 6 h after stroke. Funding UK Medical Research Council, Stroke Association, University of Edinburgh, National Health Service Health Technology Assessment Programme, Swedish Heart-Lung Fund, AFA Insurances Stockholm (Arbetsmarknadens Partners Forsakringsbolag), Karolinska Institute, Marianne and Marcus Wallenberg Foundation, Research Council of Norway, Oslo University Hospital.

                Author and article information

                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                17 May 2022
                May 2022
                17 May 2022
                : 5
                : 5
                : e2212674
                [1 ]Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, China
                [2 ]Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis
                [3 ]Department of Neurology, Minhang Hospital, Fudan University, Minhang District, Shanghai, China
                [4 ]Clinical Pharmacy and Outcomes Sciences Department, University of South Carolina, Columbia
                [5 ]Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
                [6 ]Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
                [7 ]Department of Cardiology, Minhang Hospital, Fudan University, Minhang District, Shanghai, China
                [8 ]Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
                [9 ]Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
                Author notes
                Article Information
                Accepted for Publication: March 29, 2022.
                Published: May 17, 2022. doi:10.1001/jamanetworkopen.2022.12674
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Yuan J et al. JAMA Network Open.
                Corresponding Authors: Jing Zhao, MD, PhD, Department of Neurology, Minhang Hospital, Fudan University, 170 Xinsong Rd, Minhang, Shanghai, 201100, China ( zhao_jing@ 123456fudan.edu.cn ); Renyu Liu, MD, PhD, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 336 John Morgan Bldg, 3620 Hamilton Walk, Philadelphia, PA 19104 ( renyu.liu@ 123456pennmedicine.upenn.edu ).
                Author Contributions: Drs Jing Zhao and Jing Yuan had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Yuan, Li, Yang Liu, and Lu contributed equally to the study.
                Concept and design: Yuan, Y. Liu, Hu, Lu, R. Liu, Zhao.
                Acquisition, analysis, or interpretation of data: Li, Y. Liu, Xiong, Zhu, F. Liu, Wang, R. Liu, Zhao.
                Drafting of the manuscript: Yuan, Y. Liu, Zhu, Hu, Lu, R. Liu.
                Critical revision of the manuscript for important intellectual content: Li, Y. Liu, Xiong, F. Liu, Wang, Hu, Lu, R. Liu, Zhao.
                Statistical analysis: Yuan, Li, Y. Liu, Zhu, Hu, R. Liu, Zhao.
                Obtained funding: R. Liu, Zhao.
                Administrative, technical, or material support: Y. Liu, Lu, R. Liu, Zhao.
                Supervision: R. Liu, Zhao.
                Conflict of Interest Disclosures: None reported.
                Funding/Support: This study was supported by the National Natural Science Foundation of China grants/awards 82173646 and 81973157 (Dr Zhao), Natural Science Foundation of Shanghai grant/award 17dz2308400 (Dr Zhao), and the University of Pennsylvania grant/award CREF-030 (Dr R. Liu).
                Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Additional Contributions: We acknowledge the community volunteers and the physicians in the community hospital for promoting the Stroke 1-2-0 educational program in the Minhang District.
                Copyright 2022 Yuan J et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                : 17 November 2021
                : 29 March 2022
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