New Delhi: Kerala accounted for more than 40 per cent of all insurance claims made for treatment of strokes under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) between August 2019 and March 2021, according to an analysis by the National Health Authority (NHA).
Kerala-based doctors say this figure could be attributed to the state’s higher life expectancy — the prevalence of strokes goes up with advancing age — and access to healthcare, as well as greater awareness about strokes and acceptance of modern medicine among the people.
As many as 16,179 patients from nine states and two Union territories (UTs) were treated for strokes in 536 private and 299 public health facilities from August 2019 to March 2021, the NHA analysis shows.
Kerala reported the maximum number of claims for stroke packages (42 per cent) followed by Madhya Pradesh (13 per cent), Chhattisgarh and Punjab (11 per cent each), Uttarakhand (10 per cent) and Uttar Pradesh (6 per cent).
The analysis is a collaboration between the NHA, which governs the PM-JAY, the National Centre for Disease Informatics and Research (NCDIR), and the Indian Council of Medical Research (ICMR).
When a person suffers a stroke, blood and oxygen supply to a part of the brain is cut off. This happens if there is a blockage in one of the blood-supplying vessels (ischemic stroke), or when a vessel bursts in the brain (haemorrhagic stroke).
Dr Rajeev Jayadevan, vice-chairman of the research cell of the Indian Medical Association’s (IMA’s) Kerala chapter, said that the prevalence of strokes goes up with advancing years. Given that life expectancy is higher in Kerala, he added, cases are on a relatively higher side in the state.
Diabetes and hypertension — two known risk factors for stroke — have been known to have a higher incidence in Kerala.
According to data from National Family Health Survey-5, 30.9 per cent of women and 32.8 per cent of men above the age of 15 either have blood pressure or are on hypertension medication.
For diabetes, the corresponding figures are 24.8 per cent and 27 per cent, respectively. The all-India averages for women and men are 21.3 per cent and 24 per cent for hypertension, and 13.5 per cent and 15.6 per cent for diabetes.
The NHA analysis found that the “highest proportion of beneficiaries were in the age group of 60-74 (38 per cent), followed by 45-59 (29.8 per cent), similar to the age pattern distribution in the PBSRs (population-based stroke registries) in India”.
“Mean age for stroke ranged from 58-67 years in different population-based studies in India. In the 11 states/UTs, the mean age ranged from 44 years in Chhattisgarh to 64 years in Kerala. Young stroke (proportion of stroke in < or less than 45 years) was 18.9 per cent, as compared to studies in India with range of 4 to 20 per cent. Population-based registry data in India have shown that 11 per cent of stroke registrations were in the age group of 18 to 44 years.” However, given that PM-JAY beneficiaries are limited to particular socio-economic strata (in accordance with deficiencies listed in the Socio-Economic and Caste Census), and because claims made will also be a function of availability of medical services, the data in itself cannot be extrapolated to assess the incidence of stroke in India. Under the PM-JAY, which is the tertiary healthcare arm of Ayushman Bharat, an annual health cover of Rs 5 lakh is provided to eligible families. Longevity, awareness & access to healthcare Dr Rajeev Jayadevan of IMA’s Kerala chapter said the data on strokes is in line with the fact that life expectancy in Kerala is higher than the national average. “Kerala does have higher longevity and, perhaps as a function of that, a greater number of people living with non-communicable diseases. Strokes are more common with every passing decade of life. It’s also a fact that access to healthcare in Kerala is better right from the grassroots, so it’s a well-oiled machine,” he said, adding that public health infrastructure was very good, and so were private hospitals. “There is a very high level of awareness. Multiple drives have ensured that both common people and grassroots healthcare workers are familiar with the basic concepts of stroke care and the importance of getting medical help during the golden hour,” he said. Dr Vivek Nambiar, neurologist at Amrita Hospital, Ernakulam, said that claim numbers from Kerala are high because it has a large number of neurologists and stroke-care centres, and modern medicine is highly accepted. “Kerala is one large city with 8-10 very good stroke-care centres. There are about 300-350 neurologists. Also, people have faith in modern medicine,” he said. “Strokes in many parts of the country are mired in superstition. There are some parts where people believe rubbing pigeon’s blood on the patient cures strokes. Stroke patients often go to traditional healers. But in Kerala, people go to modern centres and get treatment.” Stroke incidence in India A “disability-adjusted life year” (DALY), as defined by the World Health Organization, represents the loss of the equivalent of one year of full health. Strokes are among the top 10 leading causes of DALY, according to the study. Its rate is highest in eastern (West Bengal, Odisha) and northeastern (Assam, Tripura) and central (Chhattisgarh) states. “The data from the National Stroke Registry Programme showed that crude incidence for stroke in India ranged from 96.6-187.6 per lakh population in the areas of Cachar, Kota, Varanasi, Tirunelveli and Cachar population-based registries. These population-level data on stroke burden highlight the need for stroke services to reduce the disability and mortality due to stroke,” reads the report. It also mentions that there’s a lack of updated data on the availability of stroke services. In 2012, there were 100 centres providing clot-busting services and 35 stroke units with resources for the comprehensive management of strokes. Data from 2018-19 shows that the use of stroke imaging in registered cases ranged from 72 per cent in Assam’s Cachar district to greater than 80 per cent in Cuttack, Tirunelveli, Kota and Varanasi. “Structured data on the diagnosis of stroke by imaging with CT or MRI details from imaging and confirmation on type of stroke was not available,” the report adds. Public hospitals at the forefront Public hospitals took almost the entire burden of stroke care in Kerala (81 per cent), Chhattisgarh (91 per cent), Jammu and Kashmir (94 per cent), Bihar (85.4 per cent) and Dadra (100 per cent). Empanelled private hospitals provided the majority of services in Punjab (75 per cent), Uttarakhand (82 per cent), and Haryana (74 per cent), the analysis shows. Of the beneficiaries, 61 per cent were men and 39 per cent women. “With the increase in age, the proportion of beneficiaries increased, and the maximum proportion was seen in the 60-74 age group in both men and women. Proportion of women in 60-74 and 75+ was higher than the men in these age groups,” the analysis found. The mean age ranged from 42 (Chhattisgarh) to 63.2 (J&K) among men, and 49 (Chhattisgarh) to 66.3 (Kerala) among women.