ESO East Supplement 2023 - 36

36
European Stroke Journal 8(1S)
Bank, Estonia is currently among high-income countries.7
The life expectancy for men was 74 and for women 83 years
in 2020. As most of the European countries, the share of
persons at pension age has also increased over time. In
2021, 20% of the population were 65 years old and older.6
The Estonian health care system is based on the solidarity
principle of health insurance. All insured people have
access to medical care which is covered by the Estonian
Health Insurance Fund (EHIF).8 However, the ambulance
services and emergency assistance services in Estonia are
provided free of charge to all persons, including persons
without medical insurance. The management and supervision
of health care system and development of health policy
is under the scope of the Ministry of Social Affairs (MSA)
and its agencies.
According to the EHIF reimbursement database, there
are around 3500-3600 strokes annually. It is estimated that
more than 90% of stroke patients are treated in hospitals.
There are 18 acute care hospitals in Estonia. Intravenous
thrombolysis (IVT) is provided in six stroke-ready hospitals
and three of them are 24/7 ready for mechanical
thrombectomy (MT).
The first patient with ischemic stroke was treated with
IVT in 2003 in Tartu University Hospital which is the only
academic hospital in Estonia.9 During the following few
years only single patients were given IVT, even in largest
hospitals of Estonia. The possible reasons were short therapeutic
window of 3 h, low awareness of stroke as medical
emergency among medical personnel, and insufficient
knowledge of stroke symptoms and action at onset of stroke
among general population.
The Estonian Stroke Initiative (ESI) was founded as a
subsociety under the Estonian L. Puusepp Society of
Neurologists
and
Neurosurgeons (ENNS)
in 2008.
Increasing of stroke knowledge was set on the top of the
priorities of activities of the ESI. An observational study
over a 5 months period was designed to assess stroke awareness
of the Estonian population in 2008-2009. With an
original closed-ended questionnaire 355 randomly selected
subjects were interviewed in public places in two largest
cities. The overall knowledge about the stroke causes, risk
factors, symptoms and behavior at the onset of stroke was
better compared to many other studies but stressed the need
for future awareness campaigns for younger subjects with
lower education.10 Starting from 2008, stroke awareness
campaigns for general population were organized in three
larger cities of Estonia on World Stroke Day in October,
together with numerous media broadcasts, lectures in
schools and workplaces all over the year. In parallel, educational
events and lectures on modern management of stroke
introducing the " time is brain " principles and stressing the
importance of shortening the onset-to-door time (ODT) and
door-to-needle time (DNT) were held by the members of
the ESI to emergency medical services and hospitals.
The importance of quality of stroke care was also recognized
by the EHIF and MSA in early 2000s. Three clinical
audits were initiated by the EHIF and led by the ENNS in
2003, 2010, and 2013 with the aim to analyze acute care of
stroke in 18 Estonian hospitals. The audits concluded that
stroke management was better in large hospitals compared
to small general hospitals. It was recommended that all
stroke patients should be treated in stroke units and stroke
units should be organized in all large hospitals.11 Although
the auditors stressed the need for defining stroke pathways,
stroke-ready hospitals and the need for organizing stroke
units, no specific changes were implemented into clinical
practice.
However, after the publication of the results of the audits
the ESI started actively collaborating with the EHIF and
MSA of Estonia about the results of the audit and urgent
need for reorganizations of stroke service and implementation
of modern treatments into clinical practice. After years
of negotiations with the stakeholders, it was finally agreed
between the MSA, EHIF, Union of Estonian Medical
Emergency and all acute care hospitals that (1) all patients
from 1st of September 2019 with acute onset of stroke
should be admitted straight to stroke-ready hospitals containing
stroke units or stroke centers; (2) all stroke patients
should be managed in stroke units or stroke centers; (3)
access to post-stroke rehabilitation should be increased.
Estonia joined the Safe Implementation of Treatments in
Stroke (SITS) International Stroke Treatment Registry
(SITS-ISTR) in 2007 and since then several stroke-ready
hospitals of Estonia have been using this platform for monitoring
the trends and time logistics of IVT and MT.12
However, as during the years the platform has been changed
to more sophisticated one with several data not directly
related to monitoring of stroke quality care, the interest has
been lowered and currently three hospitals are participating.
Being aware of the importance of monitoring of the
quality of care as a part of a process of quality improvement,
a national health care quality indicators program was
launched in Estonia in 2015.13 This comprehensive project
was initiated by the EHIF in collaboration with the Medical
Faculty of the University of Tartu with the aim to improve
the quality of health care in Estonia by selecting appropriate
quality indicators which best assess the management of
diseases causing the highest burden. Stroke care quality
indicators were chosen among other indicators to be monitored
and are annually reported.
Almost in parallel with the national program, the ESOEAST
project was initiated to improve stroke care at both
hospital and national levels.2 Estonia joined it from the
very beginning in 2015. A national steering committee
containing the representatives of all stroke-ready hospitals
and members of the ESI was established. The Registry
of Stroke Care Quality (RES-Q) platform was introduced
to stroke-ready hospitals, and they were asked to join the
initiative.14
Herewith, the trends of stroke care in Estonia based on
national quality indicators of stroke care and RES-Q indicators
are presented.
ESO East Supplement 2023

Table of Contents for the Digital Edition of ESO East Supplement 2023
