Stroke Care in Brazil and France: National Policies and Healthcare Indicators Comparison

Figures & data

Table 1 Health National Actions Plans – Brazil and France

Country	Health Policies and Laws	Objective	Specific Objectives
Brazil	Cerebral Vascular Accident (CVA) Care Line in the Urgency and Emergency care network	Reduce stroke morbidity and mortality, through the Stroke Care Line in the Urgency and Emergency Care Network through the comprehensive care	- Disseminate the knowledge that stroke is a medical emergency; - Improve the population’s knowledge about stroke, its signs and symptoms, risk factors, and the need for adequate control of them; - Increase the control of risk factors for vascular diseases in primary healthcare network; - Qualify SAMU 192 for proper stroke care; - Enable Type I, Type II, and Type III Stroke Urgent Care Units, to perform general care and thrombolytic therapy; - Expand the supply of hospital beds for chronic care and rehabilitation; - Establish an adequate outpatient clinic care after hospital discharge - rehabilitation, specialized care, home care, and social and work reintegration of individuals
France	Action National Plan - Stroke 2010–2014	Develop prevention and information to prevent strokes and limit their sequelae; Improve the organization of stroke care; Improve the offer of re-education, rehabilitation, and reintegration; Implement a research policy in the stroke field; Develop ethical thinking; Facilitate the accompaniment of patients and the action of patient associations; Contribute to changing the social outlook on disability.	- Take care of patient victim or suspect of stroke in an organized and territorially defined sector; - Reduce the time between the first symptoms and care, based on a positive diagnosis; - Increase the rate of thrombolysis in eligible patients; - Better coordinate the intervention of professionals at the interfaces between healthcare establishments and city, home, or medical-social sector; - Define a specific organization for the management of children’s stroke; - Improve professional practices; - Improve information and training for professionals and carers people; - Increase research efforts on stroke due to its social burden;
Brazil	Ordinance No. 664, April 12, 2012	Approves the Clinical Protocol and Therapeutic Guidelines - Thrombolysis in Acute Ischemic Stroke	- The general concept of Acute Ischemic Stroke, diagnostic criteria, inclusion and exclusion criteria, treatment and regulation, control, and evaluation mechanisms. This protocol must be used by the Health Departments of the States, Federal District, and Municipalities. - Compliance with the Clinical Protocol and Therapeutic Guidelines - Thrombolysis in Acute Ischemic Stroke is mandatory in eligible patients. - It is mandatory to inform the patient or his legal guardian about the potential risks and side effects related to the use of recommended medication for the treatment of acute ischemic stroke; - State, district, and municipal managers of the Unified Health System (SUS) should structure the healthcare network, define referential services and establish flows for the care of patients described in the Annex to this Ordinance
Brazil	Ordinance No. 665, April 12, 2012	Provides the criteria for the qualification of hospital establishments such as the Urgent Care Center for Patients with Stroke, institutes the respective financial incentive, and approves the Stroke Care Line.	- The Stroke Care Line is approved, to be observed by all health services enabled, - The Urgent Care Centers for stroke patients are part of the Stroke Care Line and are components of the Urgency and Emergency Care Network (RUE). - Treatment stroke patients, Urgent Care Centers, will be classified as Type I, Type II, or Type III.
France	Circular N ° DHOS/SDO/01/DGS/SD5D/DGAS/PHAN/3B/200 4/280; June 18, 2004	Establishes the organizational principles of health care, medical-social and social, traumatic brain, and spinal cord injuries. Emphasizes these injuries’ characteristics and the need to provide speed, fluidity, relevance, and durability in their care also, physically, mentally, and socially. Recommends an organization in a network of experienced and identified actors for the reception, listening, information, and support for relatives of traumatized people.	- Give to the Regional Hospitalization Agencies (ARH), to regional directorates of health and social affairs (DRASS), to the departmental directorates of health business and social services (DDASS), and the organization of the care sector for traumatic brain injury and spinal cord injury which is a basis for the development of Regional Health Organization Schemes, in close collaboration with medical-social actors. - Specifies in its appendices the care of all traumatized craniocerebral types and spinal cord injury.
France	Circular DGOS/R4/R3/PF3 n 2012–106. March 6, 2012	Relating to the organization of supply chains services for patients suffering from cerebrovascular accident (stroke)	Presents the guide intended to provide methodological support to ARS in the organization of care for stroke victims. The purpose is to present the three major objectives of the plan: structuring the sectors, ensuring individualized and optimal care for all stroke victims, and developing telemedicine and information systems. It is supplemented by a methodological guide to help the regions in the implementation of these objectives.

Note: ^{8–10,13,14,25,26}.

Figure 1 Stroke Flow in a Comprehensive Health Care in Brazil.

Note: ^9,19.

Figure 2 Stroke Flow in a Comprehensive Health Care in France.

Note: ^13,22.

Table 2 Risk Factors Indicators Related to Stroke in Brazil and France, 2010 and 2016

Risk Factors	2010		2016
	Brazil	France	Brazil	France
Total alcohol per capita consumption, adults aged 15+ (liters of pure alcohol) (world average is 6.4 liters)	8.7	12.2	8	13
Physical inactivity - adults aged 18+ (%) (recommended 150 minutes of moderate-intensity physical activity per week)	48.6	33	47	32
Salt/Sodium intake - (g/day) (recommendation - 5 g/day salt or 2g/day sodium)	x	x	10g	10g
Tobacco use - Current tobacco smoking, adults aged 15+ (%) (worldwide prevalence 20%)	14.1	23.6	14	28
Raised blood pressure - adults aged 18+ (%)	40.0	42.7	23	29
Diabetes - adults aged 18+ (%)	9.7	6.8	8	8
Obesity - adolescents aged 10–19 (%)	x	x	9	7
Obesity - adults aged 18+ (%)	18.8	18.2	22	23

Note: ^27,28.

Table 3 Acute Stroke Hospitalizations, Average Stay, Hospital Deaths and Hospital Mortality Rate from Brazil and France, 2010–2017

Year	Acute Hospitalizations (Total Amount = Prevalence)		Average Stay (Days)		Hospital Deaths		Acute Hospitalizations Rate per 1.000 Inhabitants		Hospital Mortality Rate of 1.000 Inhabitants		Estimated Population (in Thousands)
	Brazil	France	Brazil	France	Brazil	France	Brazil	France	Brazil	France	Brazil	France
2010	116,633	101,982	7,5	12,74	20,018	28,559	0.59	1.62	0.102	0.454	195,714	62,880
2011	124,143	101,359	7,5	16,36	20,944	28,529	0.62	1.60	0.106	0.451	197,515	63,222
2012	127,512	105,269	7,6	10,71	21,082	28,141	0.63	1.65	0.105	0.442	199,287	63,564
2013	133,930	108,514	7,6	11,34	21,406	28,495	0.66	1.69	0.106	0.445	201,036	63,894
2014	142,403	110,439	7,7	13,35	22,134	28,550	0.70	1.72	0.109	0.444	202,764	64,194
2015	145,276	112,188	7,7	13,34	23,388	28,391	0.71	1.74	0.114	0.440	204,472	64,453
2016	149,333	115,460	7,7	10,63	24,154	28,301	0.72	1.78	0.117	0.437	206,163	64,668
Total	1,095,721	755,211	–	–	153,126	198,966	–	–	–	–	–	–

Note: ^29–31.

Table 4 Stroke’s Prevalence by Age Group in Brazil and France, 2010–2016 (Total Cases in a Year and Prevalence per 10.000 Inhabitants, by Age Group)

Year	Prevalence (Number of Cases)		Prevalence per 10,000 Inhab.		Prevalence (Number of Cases)		Prevalence per 10,000 Inhab.		Prevalence (Number of Cases)		Prevalence per 10,000 Inhab.		Prevalence (Number of Cases)		Prevalence per 10,000 Inhab.
	0–39 Years Old				40–59 Years Old				60–79 Years Old				80+ Years Old
	BR	FR	BR	FR	BR	FR	BR	FR	BR	FR	BR	FR	BR	FR	BR	FR
2010	6578	4919	0.05	0.15	35.147	19.522	0.78	1.14	75,184	46,658	6.07	4.18	34,337	48,495	13,89	14,44
2011	6801	4550	0.05	0.14	37.148	18.906	0.81	1.11	78,977	45,634	6.15	4.01	35,913	49,490	13,67	14,26
2012	7183	4798	0.05	0.15	37.706	19.855	0.79	1.16	79,877	47,450	6.00	4.10	36,731	51,848	13,28	14,51
2013	7357	4804	0.05	0.15	38.747	20.564	0.81	1.19	83,545	49,502	6.04	4.18	38,147	53,350	13,18	14,54
2014	7722	4676	0.05	0.14	40.665	20.872	0.84	1.21	87,870	50,723	6.11	4.20	39,198	54,492	12,96	14,51
2015	7752	4478	0.05	0.14	40.775	21.035	0.82	1.22	89,710	52,440	5.97	4.26	40,194	55,943	12,71	14,62
2016	7989	4778	0.06	0.15	41.697	21.926	0.83	1.27	92,391	55,983	5.91	4.47	41,386	59,154	12,25	15,16

Note: ^29,31,32.

Figure 3 Stroke Care in Comparation.

Note: ^{8,12,16–18,23,24}. made by the author.

CONITEC. Comissão Nacional de Incorporação de Tecnologias no Sistema Único de Saúde. Protocolos e Diretrizes. Linha de cuidados em Acidente Vascular Cerebral (AVC) na rede de atenção às urgências e emergências; 2020. Available from http://conitec.gov.br/protocolos-e-diretrizes. Accessed October 2019.

 Google Scholar

Brazil. Portaria nº. 665, de 12 de abril de 2012. Dispõe sobre os critérios de habilitação dos estabelecimentos hospitalares como Centro de Atendimento de Urgência aos Pacientes com Acidente Vascular Cerebral (AVC), no âmbito do Sistema Único de Saúde (SUS), institui o respectivo incentivo financeiro e aprova a Linha de Cuidados em AVC. Brasilia. 2012b. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/PRT0665_12_04_2012.html. Accessed October 2019.

 Google Scholar

Circulaire DGOS/R4/R3/PF3 n°2012-106 du 6 mars 2012 relative à l’organisation des filières régionales de la prise en charge des patients victimes d’accident vasculaire cérébral AVC. BO Sante, protection sociale, solidarité n°2012/4 du 15 mai 2012. Available from: https://solidarites-.gouv.fr/fichiers/bo/2012/12-04/ste_20120004_0100_0081.pdf. Accessed January 2020.

 Google Scholar

Loi n°2004–806 du 9 aout 2004 relative à la politique de sante publique (version consolide du 8 décembre 2011) JO. 2004. Available from: https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000000787078&categorieLien=id. Accessed January 2020.

 Google Scholar

Ministère de la Sante et des Sports - Ministère du Travail, de la Solidarité et de la Fonction Publique - Ministère de L’enseignement Supérieur et de la Recherche. Plan d’actions national “accidents vasculaires cérébraux” 2010–2014. 2010. Available from: https://www.cnsa.fr/documentation/plan_actions_avc_-_17avr2010.pdf. Accessed February 2020.

 Google Scholar

Ministry of Health of Brazil. Strategic action plan to confront Non-communicable Chronic Diseases (NCDs). 2013–2019. Available from: http://www.saude.gov.br/vigilancia-em-saude/vigilancia-de-doencas-cronicas-nao-transmissiveis-dcnt/plano-de-acoes-estrategicas-para-o-enfrentamento-das-doencas-cronicas-nao-transmissiveis-dcnt. Accessed February 2020.

 Google Scholar

Brazil. Portaria nº 664, de 12 de abril de 2012. Aprova o protocolo clínico e diretrizes terapêuticas - trombólise no acidente vascular cerebral isquêmico agudo. Brasilia. 2012a. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/PRT0664_12_04_2012.html. Accessed October 2019.

 Google Scholar

Borba SRC, Lamy M. Internação a longo prazo de portadores de sequelas neurológicas após acidentes vasculares cerebrais no Rio Grande do Sul: um problema de saúde pública. Long-term admission of neurological sequelae patients after stroke in Rio Grande do Sul: a public health problem. Unisanta Law Soc Sci. 7(3):97–119.

 Google Scholar

Haute Autorité de Santé. Service communication. Accident vasculaire cérébral: prise en charge précoce (alerte, phase préhospitalière, phase hospitalière initiale, indications de la thrombolyse). 2009. Available from: www.has-sante.fr. Accessed January 2020.

 Google Scholar

World Health Organization WHO. Global Report. Noncommunicable diseases country profiles. 2011. Available from: https://www.who.int/nmh/publications/ncd_profiles2011/en/. Accessed February 2020.

 Google Scholar

World Health Organization - Noncommunicable Diseases (NCD) Country Profiles. 2018. Available from: https://apps.who.int/iris/handle/10665/274512. Accessed February 2020.

 Google Scholar

DATASUS. Produção Hospitalar. 2019. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0202. Accessed February 2020.

 Google Scholar

PMSI. Fédération Hospitalière de France. 2020. Available from: https://www.fhf.fr/gestion-hospitaliere/pmsi.html. Accessed February 2020.

 Google Scholar

United Nations. World Population Prospects 2019. Available from: https://population.un.org/wpp/. Accessed February 2020.

 Google Scholar

Broussy-Boudeau S. Parcours Post-AVC, mesure des séquelles Post-AVC et lien entre parcours et séquelles à un an: enjeux conceptuels et méthodologiques résultats d’une cohorte rétrospective perspectives de recherche. Thèse de Doctorat De L’Université de Bordeaux. Ecole Doctorale de Sante Publique et Science Politique. Discipline: Epidémiologie. 2019. Available from:: http://www.theses.fr/2019BORD0414. Accessed January 2020.

 Google Scholar

Nugem RC, Bordin R, Schott-Pethelaz AM, Michel P, Piriou V. National Health Systems of Brazil and France: a comparative analysis. World J Advan Healthcare Res. 2019;3:50–61.

 Google Scholar

Ministry of Health of Brazil. The health of People with Disabilities: guidelines, policies, and actions. 2020. Available from: https://saude.gov.br/saude-de-a-z/saude-da-pessoa-com-deficiencia. Accessed January 2020.

 Google Scholar

Agence Nationale d’Accréditation et d’Évaluation en Santé (ANAES). Recommandations pour la pratique clinique. Prise en charge initiale des patients adultes atteints d’accident vasculaire cérébral - aspects paramédicaux – argumentaire. 2002a. Available from: https://www.has-sante.fr/jcms/c_451113/fr/avc-aspects-paramedicaux-recommandations. Accessed January 2020.

 Google Scholar

Agence Nationale d’Accréditation et d’Évaluation en Santé (ANAES). Prise en charge initiale des patients adultes atteints d’accident vasculaire cérébral - Aspects médicaux - Recommandations. 2002b. Available from: https://www.has-sante.fr/jcms/c_272249/fr/prise-en-charge-initiale-des-patients-adultes-atteints-d-accident-vasculaire-cerebral-aspects-medicaux. Accessed February 2020.

 Google Scholar