A systematic comparison of key features of ischemic stroke prevention guidelines in low- and middle-income vs. high-income countries.
OBJECTIVE
Implementation of contextually appropriate, evidence-based, expert-recommended stroke prevention guideline is particularly important in Low-Income Countries (LMICs), which bear disproportional larger burden of stroke while possessing fewer resources. However, key quality characteristics of guidelines issued in LMICs compared with those in High-Income Countries (HICs) have not been systematically studied. We aimed to compare important features of stroke prevention guidelines issued in these groups.


METHODS
We systematically searched PubMed, AJOL, SciELO, and LILACS databases for stroke prevention guidelines published between January 2005 and December 2015 by country. Primary search items included: "Stroke" and "Guidelines". We critically appraised the articles for evidence level, issuance frequency, translatability to clinical practice, and ethical considerations. We followed the PRISMA guidelines for the elaboration process.


RESULTS
Among 36 stroke prevention guidelines published, 22 (61%) met eligibility criteria: 8 from LMICs (36%) and 14 from HICs (64%). LMIC-issued guidelines were less likely to have articulation of recommendations (62% vs. 100%, p=0.03), involve high quality systematic reviews (21% vs. 79%, p=0.006), have a good dissemination channels (12% vs 71%, p=0.02) and have an external reviewer (12% vs 57%, p=0.07). The patient views and preferences were the most significant stakeholder considerations in HIC (57%, p=0.01) compared with LMICs. The most frequent evidence grading system was American Heart Association (AHA) used in 22% of the guidelines. The Class I/III and Level (A) recommendations were homogenous among LMICs.


CONCLUSIONS
The quality and quantity of stroke prevention guidelines in LMICs are less than those of HICs and need to be significantly improved upon.
Department of Neurology, Medical University of South Carolina, Charleston, USA; Department of Neurology, Fundación Santa Fe de Bogotá Hospital, Andes University, Bogota, Colombia.
Hernán
H
Bayona
Department of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria.
Mayowa
M
Owolabi
Department of Neurology, Medical University of South Carolina, Charleston, USA. Electronic address: feng@musc.edu.
Wuwei
W
Feng
Department of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria.
Paul
P
Olowoyo
Department of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria.
Joseph
J
Yaria
Department of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria.
Rufus
R
Akinyemi
Department of Neurology, Medical University of South Carolina, Charleston, USA.
James R
JR
Sawers
Department of Neurology, Medical University of South Carolina, Charleston, USA.
Bruce
B
Ovbiagele
D002545:Brain Ischemia / Q000150:complications / Q000453:epidemiology; D016206:Databases, Bibliographic / Q000706:statistics & numerical data; D019049:Developed Countries / Q000706:statistics & numerical data*; D003906:Developing Countries / Q000706:statistics & numerical data*; D017408:Guidelines as Topic / Q000592:standards*; D006801:Humans; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*
Developing countries; Guideline; Practice guideline; Primary prevention; Secondary prevention; Stroke