WSO October 2023 – Issue 1 - 966

966
International Journal of Stroke 18(8)
to multidisciplinary rehabilitation highlighting how improvements are needed to reduce morbidity and mortality from
stroke in India.
Keywords
Organized stroke care, stroke in India, post-stroke outcomes
Received: 2 January 2023; accepted: 16 March 2023
Introduction
Stroke is a major contributor to death and disability in
India, where incidence of stroke exceeds those in North
America and Europe.1,2 Recent reductions in age-standardized
stroke incidence and case-fatality reported in highincome
countries contrasts with increases reported in
low- and middle-income countries.3 To date, most large
registries describing patterns of stroke have been predominantly
conducted in high-income countries, with comparatively
fewer registries in low/middle-income countries.4
Individual components of stroke unit care vary significantly
across international comparisons highlighting the need to
examine hospital-level and individual-level factors in poststroke
care.5
Despite the burden of stroke in India, previous studies
exploring patterns and processes of care, with related stroke
outcomes, were small with limited geographical scope.6,7
There are reasons to suspect that patterns of stroke etiologies,
clinical practice patterns, and functional outcomes
may differ in India, compared to other regions, based on
studies reporting higher rates of intracerebral hemorrhage
(ICH), lower frequency of atrial fibrillation, and absence of
universal care model of healthcare delivery in India.8,9
Understanding the socioeconomic and financial implications
of stroke in India is important as limitations in access
to evidence-based stroke care may lead households to
poverty.10
Aims
In the INSPIRE (In Hospital Prospective Stroke Registry)
study, we aimed to describe etiological patterns of hospitalized
stroke, practice patterns in the management of acute
and subacute stroke, and clinical outcomes after acute
stroke.
Methods
INSPIRE is a prospective hospital-based registry of consecutive
patients presenting with acute stroke to 62 hospitals
in India, including an approximately equal number of
secondary and tertiary care hospitals with good distribution
across the country (North, West, East, South, and Central
India). In all, 10,329 patients were included between
International Journal of Stroke, 18(8)
February 2009 and March 2013. The INSPIRE registry
constituted (1) a prescribed registry (N = 10,329) which
represented consecutive patients admitted with acute
stroke, for which baseline characteristics were collected,
and (2) a consented registry (n = 8900), which constituted
the subgroup of patients (86.2%) who consented to clinical
follow-up after hospital discharge at 3 and 6 months
(Supplementary Figure 1).
For inclusion in the overall registry, admitted patients
were required to meet the clinical definition of stroke,
defined as " clinical signs and symptoms of focal neurological
deficit lasting 24 hours, " with symptom onset in the previous
14 days. Written informed consent was obtained from
participants or their proxy. The study was approved by the
ethics committee at St John's Research Institute, Bangalore,
India (reference 148/2008).
Standardized case report forms were used to collect data
on baseline demographics, lifestyle stroke risk factors, and
characteristics of acute stroke. Socioeconomic status was
classified subjectively by the attending physician (poor,
lower-middle class, upper-middle class, and rich). Physical
measurements of weight, height, waist and hip circumferences,
heart rate, and blood pressure (BP) were recorded in
a standardized manner. Hypertension was defined as a
composite of previous history of hypertension or a BP reading
of greater than 140/90 mm Hg at recruitment. Primary
stroke subtype was based on clinical assessment and results
of neuroimaging and local physician assessment, with
stroke cases classified as ischemic stroke, hemorrhagic
stroke, or undetermined (Supplementary Methodology).
Statistical analysis
Descriptive statistics were used to summarize patient characteristics,
prior medical history and medications, in-hospital
and discharge treatments, crude rates of mortality, and
other clinical outcomes (e.g. modified-Rankin score
(mRS)). Between-group comparisons of continuous variables
were completed utilizing independent-sample t-tests.
Categorical variables were analyzed using chi-square tests,
and Mann-Whitney tests were used to compare difference
in median times.
We employed a mixed-effects multivariable logistic
regression model to determine the association of baseline
patient-level factors with clinical outcomes, namely,
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