Reducing the High Stroke Death Rate in Hawaii County

1

• Reducing the High Stroke Death Rate in Hawaii
  County
• October 10, 2005
• Sharon H. Vitousek, M.D.
• North Hawaii Outcomes Project

2
Driving Forces to Increase Screening for Stroke

• Hawaii County stroke death rate is relatively
  high
• Geographic disparities
• Stroke deaths projected to increase
• Costly disability
• Prevention works

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State Ranking (1lowest death rate)
Cerebrovascular Death Rate Age-Adjusted - 2001

• 1 New York
• 2 New Jersey
• 3 Rohde Island
• 4 Florida
• 5 Arizona
• 6 Massachusetts
• 7 Delaware
• 8 New Mexico
• 9 Connecticut
• 10 Vermont
• 11 New Hampshire
• 12 South Dakota
• 13 Minnesota
• 14 Colorado
• 15 Maine
• 16 Nevada

• 17 Pennsylvania
• 18 Wyoming
• 19 Utah
• 20 Nebraska
• 21 Ohio
• 22 Alaska
• 23 Montana
• 24 Michigan
• 25 Illinois
• 26 Iowa
• 27 West Virginia
• 28 Maryland
• 29 Hawaii

Source Health Care State Rankings 2004
Chart North Hawaii Outcomes Project August
2005
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Projected Increase inUS Total Ischemic Stroke
Deaths Per Year
Source Elkins, JS, Thirty Year Projections for
Deaths for Ischemic Stroke in US,
(Stroke.2003342109-2113)
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Increasing Obesity(Body mass index gt 30)
Source HHIC from Department of Health -
Behavioral Risk Factors Surveillance System,
2000-2001 Department of Health - Hawaii Health
Survey, 1994-1999
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Increasing Diabetes Hospital Discharges/10,000
Population
Source Hawaii Health Information Corporation,
1995-2002
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Geographic Disparities in Stroke Death Rates
1991-1998 Age - Adjusted Average Annual
Source CDC Stroke Atlas of Stroke Mortality 2003
9
Hawaii Ethnic Disparities in Stroke Death Rates
Source Hawaii Outcomes Institute/OHSM
10
Geographic Disparities in Stroke Death Rates
Source National Stroke Association (NSA)
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• Stroke is ideally suited for prevention. It
  has a high prevalence, burden of illness, and
  economic cost, and safe and effective prevention
  measures.
• Source Stroke prevention April 95 P. B.
  Gorelick Department of Neurological Sciences,
  Rush-Presbyterian-St Luke's Medical Center,
  Chicago, Ill, USA.

12
Why is the Stroke Death Rate in Hawaii County
high?

• Risk factors
• Individual
• Environmental
• Access to Primary Care
• Quality of Care
• Pre-hospital
• Acute hospital
• Rehabilitation

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Modifiable Risk Factors- BRFSS 2001 (Hawaii
County v Hawaii State)

• HTN ever told by MD (24.1 v 24.8)
• HTN currently treated (30 v 25.2)
• Diabetes (6.3 v 5.2)
• High cholesterol (26.3 v 25.1)
• Obesity (15.2 v 15.7)
• Smoking (23.1 v 19.7)
• Alcohol (gt5drinks/day) (17.3 v 14.0)
• Physical inactivity (25.4 v 23.2)
• Atrial Fibrillation ??

Source North Hawaii Outcomes Project - BRFSS
17
Income Disparities in US Counties Associated with
Higher Stroke Death Rates
Economic Measures Gap between haves
have nots Robin Hood Index (Gini coefficient)
Health Measures

• Overall mortality
• Stroke mortality
• Infant mortality

Source Leiyu Shi, Ichiro Kawachi, Ph.D. Income
Inequality, Primary Care, and Health Indicators J
Fam Prac 1999 48 275-284
18
Population Health Measures

• Protective Factors
• Ratio of Primary Care Physicians

• Risk Factors
• Income Distribution
• Gini coefficient
• (Robin Hood Index)

Source Leiyu Shi, Ichiro Kawachi, Ph.D. Income
Inequality, Primary Care, and Health Indicators J
Fam Prac 1999 48 275-284
19
Access to Physicians - 2003
Number licensed physicians per population State
2.8 per 1,000 people Hawaii County 2.1
per 1,000 people City County of Honolulu 3.1
per 1,000 people Maui County 2.1 per 1,000
people Kauai County 2.2 per 1,000 people
Source Numerator from Department of Commerce
and Consumer Affairs - 2005 Uniform Crime Report
2003 population estimate
20
Adherence to Quality Indicators, According to
Condition
Source The New England Journal of Medicine, June
26, 2003
21
Adherence to Quality Indicators, According to
Condition
Source The New England Journal of Medicine, June
26, 2003
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Focus on Hypertension

• Hypertension is the most prevalent and
  modifiable risk factor for stroke, and its
  treatment substantially reduces the risk of
  stroke.

Source Prevention of a First Stroke Philip B.
Gorelick, MD, MPH Daniel F. Hanley, MD et al
JAMA. 19992811112-1120.
27
Focus on Hypertension

• A systematic overview of 14 prospective
  randomized controlled trials indicates that a
  decrease in diastolic blood pressure of 5 to 6 mm
  Hg reduces the risk for stroke by 42.
• The Systolic Hypertension in the Elderly Program
  (SHEP) study shows that treatment of isolated
  systolic hypertension in the elderly decreases
  the risk for stroke by 36.
• Source JAMA. 19992811112-1120

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Focus on Hypertension

• Less than 30 of those being treated
  (nationally) have blood pressure lower than
  140/90 mm Hg.
• Source JAMA. 19992811112-1120

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Enabling Ring Concept for Stroke Belt
The US Department of Health and Human Services
Secretarys Stroke Belt Initiative
National (federal/ non-federal)
Enabling Activites
Enabling Activites
Priority Condition STROKE
COMMUNITY
Regional
HSA
Priority Risk Factor HYPERTENSION
Enabling Activites
Enabling Activites
Sub-regional/ state
public policy, ecological strategies, quality of
care, etc.
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Evidence Stroke Can be Prevented

• Oxford Study
• The age specific incidence of major stroke in
  Oxfordshire has fallen by 40 over the past 20
  years in association with increased use of
  preventive treatment and major reductions in
  premorbid risk factors

Source Lancet 2004 1925-33
32
Franklin Cardiovascular Health Program

• Dr. Burgess Record, wanted to do more than help
  people when they became ill. He and his wife,
  Sandy, a nurse, decided to take their
  blood-pressure cuffs and other equipment to
  grocery stores, businesses, and fairs to screen
  for problems and talk about prevention measures.
• Thus the Franklin Cardiovascular Health Program
  has served the region continuously for 29 years.
  The high blood pressure program was implemented
  in 1974 cholesterol was added in 1986, smoking
  in 1988, and Center for Heart Health in 1998.
• The mortality impact of this integrated community
  program has been reported in the American Journal
  of Preventive Medicine (Record, N.B. et al.
  American Journal of Preventive Medicine
  19(1)30-38, 2000) and Journal of the American
  College of Cardiology 40579-651, 2002).

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Driving Forces to Increase Stroke Screening

• Hawaii County stroke death rate is relatively
  high
• Geographic disparities
• Projected to increase
• Costly Disability
• Prevention works

34
North Hawaii Initiatives

• 2002 NHOP Noted Disparities in Stroke Death Rates
• 2003 NHOP Stroke leadership Think Tank
• Public education Chamber of Commerce
• AHA Community Screenings
• Tutus House public education CVA, smoking ,
  walking, senior exercise classes
• 2004 NHCH Stroke clinical path link with
  Queens Medical Ctr.
• 2005 NHCH Heart Brain Center GWTG
• Participate with AHA DOH in State Stroke
  Strategic Plan
• AHA Training for Community Screening

35
Acknowledgements

• The Earl Doris Bakken Foundation
• North Hawaii Outcomes Project, Consultant Andy
  Ten Have, M.D.,MPH
• Office of Health Status Monitoring, Alvin Onaka,
  Ph.D., Brian Horiuchi, MPH, Tina Salvail, M.S.
  and Ann Pobutsky
• Hawaii Outcomes Institute
• Hawaii Health Information Corporation
• National Stroke Association
• Health and Human Services, Larry Fields, M.D.
• North Hawaii Outcomes Project, Staff Makani
  Stevens, Lehua Ka'ae
• Presentation available at www.nhop.org/progress_st
  roke.php
• Contact info Sharon Vitousek [phone],
  vitousek_at_nhop.org

36
References

• Toward a Healthy Hawaii 2010 Checking the health
  of Hawaii County, Hawaii outcomes
  Institutewww.hawaiioutcomes.org
• National Center for Health Statistics. Deaths
  Preliminary data for 2000. National Vital
  Statistics Reports, Oct 2001
• Hawaii Department of Health, Office of Health
  Status Monitoring. As reported in Toward a
  Healthy Hawaii 2010 Checking the Health of
  Hawaii County in 2000.
• Brownson, RC, RL Remington, and JR Davis, eds.
  Chronic Disease Epidemiology and Control.
  American Public Health Association, 1998.
• National Center for Health Statistics. Fastats
  Stroke. Available at www.cdc.gov/nchs/fastats/stro
  ke.htm
• JAMA Sept 18,2002 Straus, New Evidence for Stroke
  Prevention
• 7. Hawaii Department of Health, Office of
  Health Status Monitoring. 2001 Behavioral Risk
  Factor Surveillance Survey. Available at
  www.state.hi.us/doh/stats/surveys/brfss01t.html
• 8. U.S. Census Bureau. Census 2000 Hawaii State
  and County Quick Facts.
• 9. Hawaii Department of Health, Family Health
  Services Division. 2001 Primary Care Needs
  Assessment Databook. Dec 2001.
• 10. Hawaii Health Information Corporation,
  Stroke Discharge Data for Hawaii State and County
  2000-2001.
• 11. www.howsyourhealth.com

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Types of Stroke Hawaii County Compared to State
2001
Source HHIC
Source Hawaii Health Information Corporation
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Possible Causes of Excess Stroke Deaths in the
Stroke Belt
The US Department of Health and Human Services
Presence of detected and undetected
non-modifiable stroke risk factors
Under-detection/ under-control of modifiable
stroke risk factors
Excess Stroke Incidence
Excess Stroke Mortality