Thursday, May 7, 2020

Organization of stroke care in Japan

Takafumi Kubota1,2, Arsalan Anwar3, and Sidra Saleem3
1.     Department of Neurology, Teine Keijinkai Hospital, Sapporo, Japan
2.     Department of Neurology, University Hospitals of Cleveland Medical Center/Case Western Reserve University, OH, U.S.A.
Department of Internal Medicine, Dr. Ruth Pfau Hospital, Karachi, Pakistan.

In Japan, stroke is one of the major health problems. In particular, stroke has become a major factor in disability-adjusted life-years as the population ages, and is a significant burden on medical expenses. Therefore, Japan makes many efforts to lower age-adjusted mortality from stroke and extend a healthy life expectancy.
Stroke is the second most common cause of mortality and disability-adjusted life-years (DALYs), worldwide [1]. In Japan, the mortality rate of stroke has declined from 180 per 10000 in 1970 to 87 per 10000 in 2018, however, it still remains the fourth most common cause of death after cancer, cardiovascular disease, and senility [2]. The DALYs impact produced by this disease is 30% of the Japanese population. Therefore, the economic health care burden produced by stroke is 1.56 trillion dollars in health costs and 1.74 trillion dollars in nursing care costs [3]. The subtypes of ischemic stroke have also been changing. In the last four decades, as a result of changes in the salty traditional diet to the western fatty diet as well as the prevention of hypertension, the incidence of lacunar infarction in ischemic stroke steadily declined by 59% for men and by 28% for women [4]. On the other hand, the percentage of cardio-embolic and atherothrombotic stroke in ischemic stroke increased from 44.9% in 1984-1998 to 60.7% in 1998-2000 [5]. 
  The decline in stroke incidence is due to the contribution of Japan Stroke Society (JSS), which was established in 1975. It has provided a wide range of initiatives such as acute care, prevention, education, and rehabilitation. Currently, the JSS works with the Japanese Circulation Society (JCS) on two main goals to improve individual lives and reduce the economic burden. The first goal is to lower age-adjusted mortality from stroke and cardiovascular disease by 5% in 5 years and by 10% in 10 years.  The second goal is extending a healthy life expectancy. To achieve these two goals, the JSS has five strategies as follows; (1) Human resource development, (2) Enhancement of the medical system, (3) Promotion of registration business, (4) Prevention, and (5) Strengthening of clinical and basic research [6].   
  In Japan, there are 1,369 certified training institutions of the Japan Neurosurgical Society, the Japanese Society of Neurology, and/or the JSS. The institutions are divided into two types of the center. First, the primary stroke center (PSS) can perform standard evaluations such as MRI or CT and treatment including recombinant tissue plasminogen activator (rtPA) at any time in twenty-hour seven.  The necessary requirements for PSS were published in 2017, and the application of the primary stroke center was started in July 2019. Second, the comprehensive stroke center (CSC) is capable of advanced neurosurgery, endovascular surgery, stroke care unit and/or intensive care unit in addition to PSS requirements. The distribution, number, and mutual relationship of each other will be organized within a few years [3,7-9].
  For functional recovery after acute stroke care, rehabilitation medicine for stroke in Japan has improved since the beginning of the convalescent rehabilitation ward in 2000.  The patients can be hospitalized for rehabilitation up to 180 days with national health insurance, 3 hours per day including weekends of rehabilitation.  The convalescent rehabilitation hospitals have increased up to 1,348 hospitals and 76,631 beds (60 beds per 100,000) in 2015 which can cover the demand of 25 beds per 100,000 [10].  After being discharged from the convalescent rehabilitation hospitals, the patients are treated by the regional comprehensive care system such as outpatient clinics, visiting nursing stations, and home rehabilitation [7].
  The JSS also actively works to prevent stroke through lifestyle modifications and educating people about prevention. The prevention is primarily divided into four stages based on the severity as follows; (1) Improvement of lifestyle through public education, (2) Intervention for lifestyle-related diseases through primary care, (3) Early detection and intervention of stroke, and (4) Decrease in the mortality associated with stroke.  The JSS sets each goal in four stages and monitors the results [7].
  In conclusion, Japan is aware of the impact of stroke on individual life and economic burden. In the last 40 years, Japan makes many efforts to lower age-adjusted mortality from stroke and improve the outcomes.



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