Reducing the High Stroke Death Rate in Hawaii County

October 10, 2005

Sharon H. Vitousek, M.D.North Hawaii Outcomes Project

Driving Forces to Increase Screening for Stroke

in Hawaii county

• Hawaii County stroke death rate is relatively high

• Geographic disparities• Stroke deaths projected to increase• Costly: disability & $• Prevention works

Stroke Death Rates - Age Adjusted

North Hawai'i(3 yr. moving average)

Hawai'i County

Hawaii State

HP 2010

0

10

20

30

40

50

60

70

80

90

100

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Death

s p

er

100,0

00 a

ge-a

dju

ste

d p

op

ula

tio

n

Source: Office of Health Status Monitoring/ HHIC/OHSMChart: NHOP - August 2005

State Ranking (1=lowest death rate)

Cerebrovascular Death Rate Age-Adjusted - 2001

1 = New York2 = New Jersey3 = Rohde Island4 = Florida5 = Arizona6 = Massachusetts7 = Delaware8 = New Mexico9 = Connecticut10 = Vermont11 = New Hampshire12 = South Dakota13 = Minnesota14 = Colorado•15 = Maine•16 = Nevada

Chart: North Hawaii Outcomes Project – August 2005

Source: Health Care State Rankings 2004

17 = Pennsylvania18 = Wyoming19 = Utah20 = Nebraska21 = Ohio22 = Alaska23 = Montana24 = Michigan25 = Illinois26 = Iowa27 = West Virginia28 = Maryland29 = Hawaii

Projected Increase inUS Total Ischemic Stroke Deaths Per Year

Source: Elkins, JS, “Thirty Year Projections for Deaths for Ischemic Stroke in US”, (Stroke.2003:34:2109-2113)

Increasing Obesity(Body mass index > 30)

Source: HHIC from Department of Health - Behavioral Risk Factors Surveillance System, 2000-2001 Department of Health - Hawaii Health Survey, 1994-1999

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

1994 1995 1996 1997 1998 1999 2000 2001

North Hawai'i Hawai'i State

Increasing Diabetes Hospital Discharges/10,000 Population

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

1995 1996 1997 1998 1999 2000 2001 2002

Dis

ch

arg

es

pe

r 1

0,0

00

po

pu

lati

on

North Hawai'i Hawai'I County State

: , 1995-2002Source Hawaii Health Information Corporation

Geographic Disparities in Stroke Death Rates 1991-1998 Age - Adjusted Average Annual

Source: CDC Stroke Atlas of Stroke Mortality 2003

Hawaii Ethnic Disparities in Stroke Death Rates

STROKE DEATHS Number of deaths due to stroke per 100,000 age-adjusted population, by race/ethnicity

02 04 06 08 0

10 0

2 0 0 0 4 7.6 6 9 .3 56 .9 75.1 51.3 4 6 .6 57.2 6 0 .92 0 0 1 50 .6 6 9 .3 6 8 .2 75.8 52 .9 50 .0 6 1.5 57.92 0 0 2 55.1 72 .0 6 6 .8 8 8 .8 57.5 70 .4 6 4 .7 56 .3

2 0 10HP 4 8 .0 4 8 .0 4 8 .0 4 8 .0 4 8 .0 4 8 .0 4 8 .0 4 8 .0

C F J H W O HI U S

Source: Hawaii Outcomes Institute/OHSM

Geographic Disparities in Stroke Death Rates

Source: National Stroke Association (NSA)

“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.

Why is the stroke death rate in Hawaii County high?

What would help?

• Risk factors– Individual: nonmodifiable & modifiable– Environmental

• Access to Primary Care• Quality of Care

– Pre-hospital– Acute hospital– Rehabilitation

“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 (>5drinks/day) (17.3 v 14.0)• Physical inactivity (25.4 v 23.2)• Atrial Fibrillation ??

Source: North Hawaii Outcomes Project - BRFSS

Income Disparities in US Counties Associated with Higher Stroke Death Rates

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

Overall mortalityStroke mortalityInfant mortality

Health Measures

Economic Measures

Gap between haves & have nots

“Robin Hood Index”

(Gini coefficient)

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

Access to Physicians - 2003

Number licensed physicians per population*

State 2.8 per 1,000 peopleHawaii County 2.1 per 1,000 peopleCity & County of Honolulu 3.1 per 1,000 peopleMaui County 2.1 per 1,000 peopleKauai County 2.2 per 1,000 people

Source: Numerator from Department of Commerce and Consumer Affairs - 2005* Uniform Crime Report 2003 population estimate

National Adherence to Quality Indicators, According to Condition

(62.6 – 66.7)64.7 27Hypertension

(64.2 – 71.8)68.0 37Coronary artery disease

(69.5 – 76.6)73.0 39Prenatal care

(69.9 – 81.4)75.7 9Breast cancer

(73.3 – 84.2)78.7 10Senile cataract

(95% CI)Percentage of Recommended Care

Received

No. of Indicators

Condition

Source: The New England Journal of Medicine, June 26, 2003

National Adherence to Quality Indicators, According to Condition

(6.8 – 14.6)10.55Alcohol Dependence

(18.4 – 30.9)24.710Atrial Fibrillation

(42.7 – 48.3)45.413Diabetes Mellitus

(44.1 – 53.2)48.67Hyperlipidemia

(49.7 – 68.4)59.110Cerebrovascular

Disease

(95% CI)Percentage of Recommended Care Received

No. of Indicators

Condition

Source: The New England Journal of Medicine, June 26, 2003

Focus on Hypertension( High Blood Pressure)

“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. 1999;281:1112-1120.

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%.”

• [Example: Diastolic BP from 95-90, reduces stoke risk by nearly half]

• “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. 1999;281:1112-1120

Focus on Hypertension

“Less than 30% of those being treated (nationally) have blood pressure lower than 140/90 mm Hg.”

Source: JAMA. 1999;281:1112-1120

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

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 40:579-651, 2002).

Driving Forces to Increase Screening for Stroke

in Hawaii County

• Hawaii County stroke death rate is relatively high

• Geographic disparities• Projected to increase• Costly –Disability & $• Prevention works

National (federal/ non-National (federal/ non-federal)federal)

RegionalRegional

Sub-Sub-regional/ regional/

state state

HSAHSA COMMUNITYCOMMUNITY

““Enabling Ring” Concept for Stroke BeltEnabling Ring” Concept for Stroke Belt

Priority Condition:Priority Condition:

STROKESTROKE

Priority Risk Factor:Priority Risk Factor:HYPERTENSIONHYPERTENSION

The US Department of Health and Human Services Secretary’s Stroke Belt Initiative

public policy, ecological strategies, quality of care, etc.

North Hawaii Initiatives2002 NHOP Noted Disparities in Stroke Death Rates

2003 NHOP Stroke leadership Think TankPublic education Chamber of CommerceAHA Community Screenings in North HawaiiTutus’ House public education: CVA, smoking , walking, senior

exercise classes

2004 NHCH Stroke clinical path & link with Queen’s Medical Ctr.

2005 NHCH Heart Brain Center & GWTGParticipate with AHA & DOH in State Stroke Strategic PlanAHA Training for Community Screenings

2006 Increase screenings & detection and ideal management of HTN (High Blood Pressure)

2010 Decreased admissions & deaths for stroke

Acknowledgements:

The Earl & Doris Bakken FoundationNorth Hawaii Outcomes Project, Consultant Andy Ten Have, M.D.,MPHOffice of Health Status Monitoring, Alvin Onaka, Ph.D., Brian Horiuchi, MPH, Tina Salvail, M.S. and Ann PobutskyHawaii Outcomes InstituteHawaii Health Information CorporationNational Stroke AssociationHealth and Human Services, Larry Fields, M.D.North Hawaii Outcomes Project, Staff Makani Stevens, Lehua Ka'ae

Presentation available at www.nhop.org/progress_stroke.phpContact info Sharon Vitousek (808) 887-1945, vitousek@nhop.org