Stroke adalah penyebab kematian kedua serta penyebab kecacatan ketiga di dunia. Penatalaksanaan yang menjadi standar baku emas pada stroke iskemik akut adalah trombolisis. Angka tindakan trombolisis masih rendah, bawah standar yang diharapkan sebesar 12% (Hoffmeister et al., 2016). Kondisi ini terjadi secara global, baik negara maju maupun negara berkembang. Oleh karena itu, perlu dilakukan penelitian mengenai penyebab rendahnya cakupan tindakan trombolisis pada penderita stroke di berbagai negara di dunia. Penelitian ini merupakan systematic review dengan melakukan analisis faktor konfirmatori. Penelusuran dilakukan pada basis data dari PubMed, EMBASE, SpringerLink, dan ScienceDirect dari tahun 2012 sampai dengan 2022. Dilakukan juga penelusuran pada Google Schoolar dan Pusinfokesmas FKM UI serta Universitas Indonesia Library. Pelaporan systematic review ini menggunakan panduan PRISMA. Pada hasil penelusuran berdasarkan kata kunci dan kriteria yang sudah ditetapkan didapatkan total 4971 jurnal didapatkan dari berbagai negara di dunia. Setelah dilakukan skrining terdapat 101 jurnal, kemudian setelah diteliti, terdapat 26 studi terpilih yang diekstraksi dan disintesis. Analisis faktor yang diteliti mengikuti kerangka kerja Donabedian yang mengevaluasi pelayanan kesehatan. Pada hasilnya didapatkan bahwa pada komponen struktur pelayanan trombolisis terdapat beberapa hal yang menjadi penyebab rendahnya trombolisis pada pasien stroke iskemik di berbagai negara yaitu kurangnya penggunaan telemedisin pada lokasi yang jauh dari pusat stroke, belum optimalnya pelayanan EMS sehingga meningkatkan door to needle time, tim stroke belum berkompeten dan berpengalaman, faktor pembiayaan dari mahalnya biaya pelayanan dan kurang mendukungnya penjaminan dari asuransi, tipe rumah sakit yang belum mendukung, SOP rumah sakit yang belum sempurna, kurangnya pelatihan, kultur organisasi rumah sakit yang belum mendukung, serta faktor dari pasien sendiri. Proses trombolisis dilakukan di beberapa tempat, antara lain di pusat stroke di rumah sakit besar, maupun di rumah sakit kecil dengan telestroke. output dari pelayanan trombolisis yaitu cakupan pemberian trombolisis pada pasien stroke akut di rumah sakit dimana pada penelitian ini ditemukan memiliki angka yang masih relatif kecil. Disarankan kepada manajemen rumah sakit dan otoritas kesehatan setempat untuk meningkatkan kesadaran masyarakat mengenai stroke dan langkah yang harus dilakukan saat terjadi stroke. Rumah sakit juga perlu untuk meningkatkan kapabilitas tim stroke dengan pelatihan dan simulasi, menyempurnakan prosedur pelayanan melalui hospital by law, meningkatkan kemampuan EMS sehingga door to needle time berkurang, dan mencoba menerapkan berbagai metode trombolisis seperti telestroke untuk pasien yang lokasinya jauh, metode Helsinki dan drip and ship yang terbukti menurunkan penundaan pemberiantrombolisis Kata kunci : cakupan trombolisis, utilisasi trombolisis, stroke iskemik

Stroke is the second leading cause of death and the third cause of disability in the world. The gold standard treatment for acute ischemic stroke is thrombolysis. The rate of thrombolysis is still low, below the expected standard of 12% (Hoffmeister et al., 2016). This condition occurs globally, both developed and developing countries. Therefore, it is necessary to conduct research on the causes of the low coverage of thrombolysis in stroke patients in various countries in the world. This is a systematic review research by conducting confirmatory factor analysis. Searches were conducted on databases from PubMed, EMBASE, SpringerLink, and ScienceDirect from 2012 to 2022. A search was also carried out on Google Schoolar and the FKM UI's Pusinfokesmas and the University of Indonesia Library. This systematic review report uses PRISMA guidelines. In the search results based on keywords and predetermined criteria, a total of 4971 journals were obtained from various countries in the world. After screening there were 101 journals, then after being researched, there were 26 selected studies that were extracted and synthesized. The factor analysis studied followed the Donabedian framework that evaluates health services. In the results, it was found that in the structural component of the thrombolysis service there are several things that cause low thrombolysis in ischemic stroke patients in various countries, namely the lack use of telemedicine at locations remote from the stroke center, not optimal EMS services that increasing door to needle time, the stroke team has not competent and experienced, the financing factor is the high cost of service and the lack of support for insurance coverage, the type of hospital that does not supported, the hospital SOP is not perfect, the lack of training, the organizational culture of the hospital is not supportive, as well as factors from the patients themselves. The thrombolysis process is carried out in several places, including in stroke centers in large hospitals, as well as in small hospitals with telestroke. The output of thrombolysis services is the coverage of thrombolysis in acute stroke patients in hospitals, which in this study were found to have relatively small numbers. It is recommended to the hospital management and local health authorities to increase public awareness about stroke and the action that must be taken when a stroke occurs. Hospitals also need to improve stroke team capabilities with training and simulations, improve service procedures through hospital by law, improve EMS capabilities so that door-to-needle time is reduced, and try to apply various thrombolysis methods such as telestroke for patients who are placed remotely, the Helsinki method and drip and ship which has been shown to reduce delays in thrombolysis. Keyword : Thrombolysis Rate, Ischemic Stroke, Thrombolysis systematic review

Pada Penelitian ini membahas implementasi penjaminan obat alteplase pada stroke iskemik di RS Tipe B pada tahun 2023, sesuai dengan PMK No. 3 Tahun 2023. Penelitian dilakukan di RS Tipe B di DKI Jakarta. Tujuan penelitian adalah mengetahui implementasi penjaminan obat alteplase Tahun 2023, menggunakan pendekatan kualitatif non-eksperimental Edward III. Hasil penelitian menunjukkan implementasi berjalan dengan baik, meskipun terdapat perbedaan dalam penentuan onsite stroke antara PNPK Stroke dan Fornas. Persiapan sarana, prasarana, dan tim code stroke menjadi krusial. Di RS S, tim code stroke tersedia sejak pertengahan 2023 dan trombolisis dimulai pada Oktober 2023. Di RS P, trombolisis dimulai pada Februari 2024 setelah persiapan intens mulai November 2023. Tantangan utama adalah kurang siapnya pelaksana (tim Code Stroke) sejak dimulainya penjaminan obat alteplase dan RS yang belum dilengkapi CT-Scan. Dari 2.218 RS, 82 RS mengajukan klaim obat alteplase (3,70%) dengan 774 kasus klaim (0,24%) dari 322.282 kasus stroke iskemik. Kesimpulannya, implementasi penjaminan obat alteplase di RS yang diteliti terbilang tidak ada kendala disisi penjaminan, namun masih diperlukan sosialisasi ke RS. Selain itu diperlukan persiapan dari sisi pelaksanaan tindakan trombolisis seperti SDM, sinkronisasi kebijakan, dan persiapan yang lebih baik di RS untuk optimalisasi trombolisis. Rekomendasi mencakup revisi kebijakan, penyusunan buku pedoman Tim Code Stroke, dan penggunaan aplikasi stroke registry serta program ECHO untuk sosialisasi dan pelatihan yang lebih baik.

This study discusses the implementation of alteplase drug assurance for ischemic stroke in Type B Hospitals in 2023, in accordance with PMK No. 3 of 2023. The research was conducted at a Type B Hospital in DKI Jakarta. The aim of the study is to understand the implementation of alteplase drug assurance in 2023, using a non-experimental qualitative approach by Edward III. The results indicate that the implementation is proceeding well, although there are differences in the determination of onsite stroke between PNPK Stroke and Fornas. The preparation of facilities, infrastructure, and the code stroke team is crucial. At RS S, the code stroke team has been available since mid-2023, and thrombolysis began in October 2023. At RS P, thrombolysis started in February 2024 after intensive preparation from November 2023. The main challenge is the unpreparedness of the implementing team (Code Stroke team) since the commencement of alteplase drug assurance and hospitals not yet equipped with CT-Scans. Out of 2,218 hospitals, 82 hospitals submitted claims for alteplase drugs (3.70%) with 774 claim cases (0.24%) out of 322,282 ischemic stroke cases. In conclusion, the implementation of alteplase drug assurance in the studied hospitals does not face any issues from the assurance side, but further socialization to hospitals is needed. Additionally, preparation is required in terms of thrombolysis actions such as human resources, policy synchronization, and better preparation at hospitals for optimal thrombolysis. Recommendations include policy revisions, preparation of a Code Stroke Team handbook, and the use of stroke registry applications and the ECHO program for better socialization and training.

Lama rawat inap diduga dipengaruhi oleh berbagai fakor kompleks diantaranya sosio-demografis, gizi, dan kondisi klinis. Penelitian ini bertujuan untuk mengetahui hubungan antara faktor sosio-demografi (usia, jenis kelamin, pendidikan terakhir, status pekerjaan, status pernikahan, kelas rawat inap), gizi (asupan energi, asupan protein, status gizi, dan risiko malnutrisi), dan kondisi klinis (tingkat keparahan, komorbiditas, riwayat rawat inap stroke) terhadap lama rawat inap pasien stroke iskemik. Desain penelitian ini adalah cross-sectional melibatkan 150 pasien stroke iskemik usia 18-59 tahun di RSPON Prof.Dr.dr. Mahar Mardjono melalui metode purposive sampling. Analisis statistik menggunakan chi-square pada bivariat dan regresi logistik pada multivariat. Hasil menunjukkan mayoritas pasien memiliki lama rawat inap pendek (78%). Tidak ada perbedaan proporsi antara usia, jenis kelamin, pendidikan terakhir, status pekerjaan, status pernikahan, kelas rawat inap, risiko malnutrisi, tingkat keparahan, komorbiditas, atau riwayat rawat inap stroke terhadap lama rawat inap bagi pasien stroke iskemik (p>0,05). Melalui analisis bivariat ada perbedan proporsi status gizi terhadap lama rawat inap (p=0,026), namun ketika dikontrol dengan variabel lain keduanya tidak signifikan (p=0,888). Ada perbedaan proporsi antara asupan energi (p=0,001) dan protein (p=0,001) terhadap lama rawat inap pasien stroke iskemik. Pada permodelan akhir asupan energi (OR=165,4; CI:4,27-6404,3) dan protein (OR=547,94; CI: 19,86-15116,4) defisit berhubungan signifikan dan berisiko meningkatkan lama rawat inap panjang pasien stroke iskemik. Asupan protein menjadi faktor dominan terhadap lama rawat inap.

Multifactorial aspects such as sociodemographic, nutrition, and clinical condition were related to length of stay among ischaemic stroke patients. The aim of the study was to explore the association between sociodemographic (age, gender, education, occupation, marital status, and type of class), nutrition (energy intake, protein intake, nutritional status, and risk of malnutrition) and clinical condition (severity, comorbidity, and previous history of stroke) with length of stay in ischaemic stroke patients. Design of the study was cross-sectional. The study recruited 150 ischaemic stroke patients aged from 18 to 59 years old at National Brain Center Hospital Prof.Dr.dr. Mahar Mardjono Jakarta. Data was analysed by using chi-square test for bivariate and logistic regression for multivariate. Most of of ischaemic stroke patients had shorted length-of-stay (78%). There was no difference proportion between age, gender, education, occupation, marital status, type of class, risk of malnutrition, severity, comorbidity, or previous history of stroke and length of stay in ischaemic stroke patients (all p>0.05). Based on bivariate analysis, there was a difference proportion between nutritional status and length of stay (p=0.026), but not significant when controlled with other variables (p=0.888). There was a difference proportion between energy intake (p=0.001) or protein intake (p=0.001) and length of stay. Patients who had inadequate energy intake (OR=165.4; CI:4,27-6404.3) and protein intake (OR=547.94; CI: 19.86-15116.4) significantly related and increased the risk of prolonged hospital length of stay in ischaemic stroke patients. Protein intake was dominant determinant factor of length of stay in ischaemic stroke patients.

Stroke adalah penyakit peringkat ketiga dengan biaya terbanyak dalam program Jaminan Kesehatan Nasional (JKN). Pelayanan medisnya dilaksanakan sesuai dengan alur klinis (clinical pathway), yang merupakan turunan dari Pedoman Nasional Pelayanan Kedokteran (PNPK). Tarif pelayanan penyakit stroke iskemik dalam skema Indonesia Case-Based Group (INA-CBG) ditetapkan sebelum pemberlakuan PNPK. Akibatnya, penyusunan tarif stroke iskemik belum sepenuhnya mempertimbangkan standar pelayanan nasional. Penelitian ini bertujuan untuk menunjukkan bahwa rumah sakit perlu mengelola biaya perawatan dan kualitas layanan agar tarif INA-CBG dapat mencukupi biaya satuan rawat inap stroke iskemik pada pasien JKN di Rumah Sakit Pusat Otak Nasional (RS PON) Prof. Dr. dr. Mahar Mardjono Jakarta. Desain penelitian yang digunakan adalah noneksperimental dengan data retrospektif Oktober—Desember 2019. Unit analisisnya adalah 96 pasien stroke iskemik yang dirawat di RS PON. Penelitian menunjukkan bahwa rata-rata biaya satuan untuk stroke iskemik di RS PON adalah sebesar Rp11.598.286 ± Rp5.799.088. Uji regresi multipel memperlihatkan bahwa lama hari rawat inap, sistolik dan skor National Institutes of Health Stroke Scale (NIHSS) saat admisi ke rumah sakit merupakan determinan signifikan terhadap rata-rata biaya satuan rawat inap stroke iskemik pasien JKN di RS PON. Perbedaan tidak signifikan terlihat antara tarif INA-CBG tahun 2016 regional 1 RS kelas A dan rata-rata biaya satuan rawat inap stroke iskemik pada pasien JKN di RS PON. Namun, temuan ini juga menjelaskan penerapan tarif INA-CBG tahun 2016 regional 1 RS kelas A bagi RS PON mengakibatkan defisit rata-rata sebesar -Rp214.049 ± Rp4.647.223 per kasus. Perbedaan biaya satuan dan tarif INA-CBG ini diperkirakan menyebabkan defisit sebesar -Rp1.262.304.927 bagi RS PON pada tahun 2019. Selain itu, diperkirakan defisit yang ditanggung oleh seluruh rumah sakit peserta JKN mencapai -Rp61.108.299.113, dengan asumsi prevalensi stroke iskemik adalah 1,1‰. Meskipun secara rata-rata biaya satuan lebih tinggi dari tarif, rumah sakit dapat melakukan pengelolaan keuangan yang baik agar operasional tidak terganggu. Hal ini tercermin dari rasio kas dan rasio lancar RS PON yang masing-masing sebesar 240,47% dan 1.695,31%. Dengan demikian, kewajiban jangka pendek dapat dipenuhi oleh RS PON, namun banyak aset lancar yang mengendap dan seharusnya bisa menjadi potensi pendapatan tambahan rumah sakit, atau banyak piutang yang belum terbayarkan. BPJS Kesehatan juga perlu mengelola keuangan dengan baik untuk menjaga keberlangsungan program JKN, yang ditunjukkan dengan rasio kas dan rasio lancar sebesar 152,91% dan 914,6%.

Stroke ranks as the third most costly disease in the National Health Insurance (Jaminan Kesehatan Nasional/JKN) program. Medical services are carried out in accordance with the clinical pathway, which is derived from the national guidelines for medical services (PNPK). The tariff for treating ischemic stroke in the Indonesia Case-Based Group (INA-CBG) was set before establishing of the PNPK, resulting in the tariff for ischemic stroke treatment being issued before calculating the real actual costs of delivering the national service standards of care. This research is necessary to demonstrate that hospitals need to manage care costs and service quality so that the INA-CBG rates can cover the unit costs of inpatient ischemic stroke care for JKN patients at the National Brain Center Hospital (RS PON) Prof. Dr. dr. Mahar Mardjono Jakarta. A retrospective nonexperimental research design was used, analyzing data from ischemic stroke patients hospitalized at RS PON between October—December 2019. The results showed that the average unit cost of inpatient ischemic stroke at RS PON was IDR11,598,286 ± IDR5,799,088, based on the 2019 data. Multiple regression tests indicated that the length of stay, sistolic and the national institutes of health stroke scale (NIHSS) scores upon admission were significant determinants of the variation of the average unit cost. Non-significant difference was found between the INA-CBG 2016 tariff for type A hospitals (region 1) and the average unit cost of inpatient ischemic stroke among JKN patients at RS PON. In conclusion, implementing the INA-CBG 2016 tariff for type A hospitals such as RS PON creates an average deficit of -IDR214,049 ± IDR4,647,223 per case. The discrepancy between unit costs and INA-CBG tariffs is estimated to have resulted in a deficit of -IDR1,262,304,927 for RS PON in 2019. Furthermore, assuming an ischemic stroke prevalence of 1.1‰, the deficit borne by all JKN-participating hospitals is estimated to have reached -IDR 61,108,299,113. Although the average unit cost is higher than the tariff, the hospital can manage its finances well to ensure that operations are not disrupted. This is reflected in RS PON's cash ratio and current ratio, which are 240.47% and 1,695.31%, respectively. Thus, RS PON can meet its short-term obligations, but many current assets are idle and should be potential additional hospital revenue or m any outstanding receivables. BPJS Kesehatan also needs to manage its finances well to maintain the continuity of the JKN program, as indicated by its cash ratio and current ratio of 152.91% and 914.6%.