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Yeghiazaryan et al.
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awareness regarding stroke, and an enlarging segment of
the population is making more informed decisions.
However, more needs to be done in public education for
stroke symptoms and modifiable risk factor recognition.
Starting from primary schools, " healthy living messages "
should be taken to all segments of society.
In Armenia, the concept and practice of communitybased
health advocacy groups or societies communicating
with governmental bodies or local authorities are in their
infancy. These activities are mainly carried out by the members
of academic faculty members, stroke physicians, hospital
administrators, professional medical organizations,
SIATA, and ASC. However, increasingly, heightened public
awareness is bolstering stroke advocacy.
Prehospital care
Emergency medical systems (EMS) play a key but highly
varied role in stroke care globally, given differential stages
of EMS development in each country. Armenia adheres to
the Franco-German model of pre-hospital care with ambulances
staffed by a physician, a nurse, and a driver in the
capital city and the regions.12 Ambulance physicians have
not been consistently trained regarding rapid stroke rating
systems. There are no well delineated geographic zones and
guidelines in Yerevan to direct the transfer of patients to the
nearest stroke center. This uncertainty carries the risk of
" cherry-picking. " Although the MOH covers the cost of
ambulance calls, many patients still choose transport by private
car, further delaying diagnosis and care and accurate
referral to a designated stroke center. Outside of Yerevan,
suspected stroke cases are taken to the nearest regional hospital.
The patients are often transferred to the EMC by
ground or air transport if diagnosed with acute stroke.
The ambulance service is not under the direction of the
MOH but is administered by local authorities. Keeping it
outside of the governance of the MOH introduces a potential
disruption in the creation of a seamless operation of stroke
protocols from the patient's home to the hospital. The ASC
has voiced concerns regarding this arrangement. Thus, prehospital
emergency care remains a weak link in stroke care
in Armenia, and there are undoubtedly many opportunities
for improvement in pre-hospital patterns of practice.
It is important to note that currently, there is little hospitalbased
emergency room care. When patients arrive at the hospital
triage area, they are frequently seen by a non-emergency-trained
on-duty physician. Stroke training of triaging physicians
remains inadequate and inconsistent. Stroke team members are
frequently called for patients who have not been screened for
possible stroke by on-duty physicians.
Outcomes of the Armenian National Stroke
Program
The Armenia NSP was launched in February of 2019.
During the first 36 months of the program, 1230 patients
received treatment for acute ischemic stroke. Of those,
486/1230 (39.5%) received intravenous thrombolysis (IVT)
only, 546/1230 (44.4%) endovascular thrombectomy
(EVT) only, and 184/1230 (15%) had both IVT and EVT.
Data were missing for 1.1% (14/1230) of cases. Most
patients received treatment at the EMC (1029/1230;
83.7%). Among non-thrombolysed patients the most frequent
reasons for non-thrombolysis were admission delays,
stroke severity (mostly mild), and advanced age; frequently
non-thrombolysed patients had more than one exclusion
criteria. However, the percentage of acutely treated patients
was growing with every year (6.8% (377/5560) in 2019;
8.9% (372/4180) in 2020; and 8.7% (481/5554) in 2021)
and was not largely affected by COVID situation. Table 1
summarizes patient and treatment-related data.
Funding of acute stroke care in Armenia
Stroke care is an expensive proposition for low- and middle-income
countries.16,17 In Armenia, the median recombinant
tissue plasminogen activator (rtPA) cost for a 50 mg
vial is over seven times the allocated annual per capita
health expenditure.16
These economic realities have
imposed financial restraints on health care funding.
Approximately 5.7% of the Government's yearly budget
has been allocated to health care in recent years.18 As of
2020, nearly 12% of the country's gross domestic product
(GDP) was allotted to health care, while public health
expenditure constituted 2.4% of GDP.1 These figures are
much lower than in high-income countries, and they indicate
that a large portion of the health care expenses is
funded privately by patients and their families. Private
health insurance programs remain underdeveloped, and the
available programs are affordable only for a few.
To mitigate the financial burden of health-related
expenses on the families, a state-sponsored program, the
" co-payment, " was introduced in 2011. During subsequent
years, the state's contribution incrementally increased. The
program covered significant expenses accrued for the treatment
of subacute stroke, but it did not cover the costs of
acute stroke treatment. The introduction of the Armenia
National Stroke Program (NSP) by the MOH in 2019 was a
significant undertaking as it provided funding for thrombolytic
therapy and thrombectomy for acute stroke. Despite
economic strains, the collaboration between the scientific
advisory bodies, such as SIATA and ASC, and the MOH
have allowed estimates to secure sufficient funding for
acute stroke treatments in Armenia.
TeleStroke service and stroke care expansion
program
The NSP described in the preceding paragraphs is centered
mainly around resources in the capital city of Yerevan,
home to approximately one-third of the country's population.
The geographic disparity in access to acute stroke
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