Stroke costs the Ontario economy almost a billion dollars a year and is a leading cause of death and adult neurological disability. Currently, at least 90,000 Ontarians are living with the effects of stroke, such as motor, sensory, cognitive or communication deficits. Stroke is believed to be one of the leading causes of transfer of the elderly to long-term care. As the population of Ontario ages, the number of strokes is expected to increase.

Stroke poses a number of challenges to not only the health care system but to the citizens of Ontario. In the past, it was assumed that little could be done to prevent or treat stroke. As a result, strokes were not generally treated as medical emergencies requiring urgent care, resources for expert stroke rehabilitation -- particularly home-based rehabilitation -- were limited, and minimal attention was paid to stroke prevention.

With the advent of new knowledge and therapies, there is the potential to dramatically improve stroke care in Ontario. There is now good scientific evidence that strokes can be prevented and acute care and rehabilitation appreciably enhanced. Such developments could significantly reduce the future human and economic burden of stroke. Those who are at risk of stroke -- or who have had a stroke -- and their families will benefit significantly from the developments being proposed in stroke care in Ontario.

To begin, we now know that stroke is highly preventable. The number of Ontarians at risk of stroke can be significantly reduced through lifestyle modifications such as smoking cessation and the promotion of increased physical activity and good nutrition. Among individuals at high risk, the number of strokes can be cut in half by such interventions as blood pressure lowering medications, antiplatelet or anticoagulant drugs ("blood thinners") or surgery (carotid endarterectomy).

More recently, developments have shown that -- contrary to what we thought in the past -- stroke can be effectively treated. Using evidence-based stroke protocols and interdisciplinary stroke teams can significantly reduce stroke mortality, morbidity, hospital costs and the need for long-term care. This approach (called "organized stroke care") does not depend upon large investments in new technologies but rather reorganization of existing resources. An even more exciting discovery has been that, under the right circumstances, the thrombolytic drug used to stop heart attacks (t-PA) can also stop "brain attacks" (strokes). And this is only the beginning. Other drugs for stroke (such as "neuroprotectives") are in development.

Of particular note should be two innovative and ground-breaking initiatives that are currently underway in Ontario. The Coordinated Stroke Strategy and the Canadian Stroke Network represent valuable opportunities for Ontario to build on the most advanced work in Canada on stroke care. This will allow Ontario to make more rapid progress in the development of organized stroke care and stroke research.

If we take advantage of these many new developments, we could improve the quality of life for Ontarians and avoid a significant proportion of future stroke costs and burden. To do so, we must organize stroke care across the entire continuum (i.e. from prevention, to acute care, rehabilitation and secondary prevention) on a province-wide basis.

A comprehensive, integrated, evidence-based province-wide stroke strategy would also make Ontario a world leader in stroke prevention, care, rehabilitation and research.

After careful consideration and review of both current stroke practices in Ontario and the international literature, the Joint Stroke Strategy Working Group came to a number of recommendations as to how stroke care can be improved. These recommendations are :

Stroke Prevention
1. The Ministry of Health and Long-Term Care should support health promotion efforts that contribute to the primary prevention of stroke.
2. Stroke Prevention Clinics should be developed to improve secondary stroke prevention and to provide support to ongoing prevention efforts in the primary care, acute care and rehabilitation sectors.
3. Stroke prevention by primary care providers should be supported.
4. Drugs needed for "best practices" in stroke prevention should be provided on the Ontario Drug Benefit program.
Emergency / Acute Care
5. As part of an integrated stroke plan for Ontario, stroke should be designated a priority of the Ministry of Health and Long-Term Care.
6. A system of Regional and District Stroke Centres and protocols should be established linking all acute care hospitals in Ontario.
7. To further the development of "telestroke", the Ministry of Health and Long-Term Care should move to address the legal and funding implications of using telecommunication linkages for remote diagnosis.
8. To support organized acute care of stroke and implementation of thrombolytic therapy for ischemic stroke, public education should be conducted on the warning signs of stroke.
Rehabilitation
9. The Ministry of Health and Long-Term Care and the Heart and Stroke Foundation of Ontario should promote the development of regional stroke rehabilitation systems.
Measuring and Monitoring
10. An information system should be developed to further data collection and monitoring across the continuum of stroke care.
Human Resources
11. The Ministry of Health and Long-Term Care should study future needs for human resources in stroke.
12. A committee responsible for stroke training should be established to administer a provincial stroke training fund.
Implementation and Development
13. To advance the evidence base for specific issues in stroke care, the Ministry of Health and Long-Term Care should support a number of pilot projects (e.g. on "telestroke" and stroke rehabilitation).
14. To ensure that all recommendations are realized in an orderly manner, an implementation structure should be developed to oversee a phased development of organized stroke care. The implementation structure should consists of a Stroke Implementation Steering Committee, Work Groups, Ministry of Health and Long-Term Care regional offices and a Forum of Regional Stroke Centres, with Ministry Management Team support. The phased implementation should cover a three-year period.
15. A coordinated and intensified approach to funding stroke research should be developed.

FULL REPORT Report of the Joint Stroke Strategy Working Group, June 2000 117 pages | 257 k | PDF format

APPENDICES Appendix 1 Terms of References for the Joint Stroke Strategy Working Group and Task Groups PDF format

Appendix 2 Prevalence of Stroke-Related Hospital Discharge Over Time - Emerging Trends in Ontario PDF format

Appendix 3 Prevalence of TIA-Related Hospital Discharge Over Time - Emerging Trends in Ontario

Appendix 4 Literature Review of Effectiveness of Health Promotion

Appendix 5 Emergency / Acute Stroke Task Group Economic Decision Analysis Model PDF format

Appendix 6 Measuring and Monitoring Working Group - Current Initiatives PDF format

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June 2000