Factors associated with prehospital and in-hospital delays in acute ischaemic stroke care in Indonesia: a systematic review.

Objectives: This systematic review examines prehospital and in-hospital delays in acute stroke care in Indonesia.

Design: Systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Data Sources: We conducted a thorough search across 11 databases, ClinicalTrials.gov registries and three preprint repositories up until October 2024.

Eligibility Criteria: Studies that examined risk variables associated with hospital delays in the treatment of acute stroke in Indonesian individuals were included.

Data Extraction And Synthesis: Two reviewers each carried out the data extraction and risk-of-bias evaluation separately. The quality of the study was evaluated using the Risk of Bias in Non-randomised Studies of Exposures tool. The 'combining p values' approach and albatross plots were used to synthesise the findings.

Results: A total of 27 studies with 3610 patients were included. Key factors contributing to prehospital delays included low educational level (p=0.014, 6 studies), low socioeconomic status (p=0.003, 5 studies), cultural beliefs affecting decision-making (p<0.001, 3 studies), significant clinical manifestations such as a low Glasgow Coma Scale score (<8) (p<0.001, 2 studies) and a high National Institutes of Health Stroke Scale score (>16) (p=0.002, 5 studies) and transportation challenges, such as extended travel distance (>15 km) (p=0.009, 5 studies) and lack of ambulance use (p=0.005, 9 studies). In-hospital delays were prominent, with male sex (p=0.046), dyslipidaemia (p=0.045) and arrival time (p=0.007) linked to thrombolysis delays, while CT location affected door-to-CT time (p<0.05).

Conclusion: Socioeconomic, cultural, clinical severity and logistical factors were significantly associated with hospital delays in acute ischaemic stroke care in Indonesia. Targeted interventions can mitigate these challenges and improve stroke management and results.

Prospero Registration Number: CRD42024494954.