Bhutan's Response Against Increasing Number of Stroke (BRAINS): A Hybrid Type II Effectiveness-Implementation Study.

Area of Science:

• Global Health
• Neurology
• Implementation Science

Background:

• Bhutan faces a rising stroke burden, ranking as the third leading cause of death.
• Existing challenges include delayed hospital arrivals, fragmented care, and limited thrombolysis due to systemic gaps.
• A lack of trained healthcare professionals and standardized protocols further exacerbates the stroke care crisis.

Purpose of the Study:

• To evaluate a physician-led stroke care model in Bhutan's referral hospitals using the RE-AIM framework.
• To assess the impact of capacity-building for non-neurologists, protocol standardization, and stroke unit establishment.
• To determine the effectiveness, adoption, implementation, and maintenance of organized stroke care in a low-resource setting.

Main Methods:

• A hybrid type II implementation study conducted from 2020 to 2023.
• Utilized the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.
• Employed an uncontrolled pre-post design comparing baseline data (Jan-Jun 2020) with post-intervention data (Oct 2022-Mar 2023).

Main Results:

• Adherence to stroke care quality indicators significantly improved, nearly doubling from 30% to 57%.
• Unadjusted in-hospital mortality decreased substantially from 29% to 9% post-intervention (aOR, 0.65; 95% CI, 0.50-0.85).
• High staff attrition (55%) presented challenges to protocol fidelity and long-term sustainability.

Conclusions:

• Organized stroke care elements can be successfully adapted to low-resource settings like Bhutan.
• The physician-led model shows promise for replication in similar low- and middle-income countries (LMICs).
• Addressing systemic constraints, such as workforce retention and training non-neurologists, is crucial for long-term maintenance.