Stroke Death Rate in Hawaii State & County September 9, 2005 Sharon H. Vitousek, M.D. North Hawaii Outcomes Project

1. Stroke Death Rate in Hawaii State & County September 9, 2005 Sharon H. Vitousek, M.D. North Hawaii Outcomes Project

2. The Problem • Hawaii stroke death rate is relatively high • State • County • Projected to increase • Costly • Geographic disparities • Clear opportunities for improvement

4. State Ranking(1=lowest death rate)Cerebrovascular Death Rate Age-Adjusted - 2001 • 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 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 Source: Health Care State Rankings 2004 Chart: North Hawaii Outcomes Project – August 2005

5. 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)

6. Increasing Obesity(Body mass index > 30) Source: HHIC from Department of Health - Behavioral Risk Factors Surveillance System, 2000-2001 Department of Health - Hawai'i Health Survey, 1994-1999

7. Increasing Diabetes Hospital Discharges/10,000 Population Source: Hawaii Health Information Corporation, 1995-2002

8. 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. Source CDC Stroke Atlas of Stroke Mortality 2003

11. What would help? • Develop a State Strategic plan and State-wide Stoke Systems of Care • Start with Assessment • Target Primary & Secondary Prevention • Dual approach • Medical Model • Use CQI Tools • Focus on Hypertension • Population Health model • Address underlying issues: Access to primary care, Socioeconomic & Environmental barriers to lifestyle changes

12. Geographic Disparities in Stroke Death Rates Source National Stroke Association (NSA)

13. Analyzing Geographic Disparities in Stroke Death Rates • Variations in life style factors associated with variations in medical factors • Access to quality care • Socioeconomic • Income disparity • Stress

17. Adherence to Quality Indicators, According to Condition Source: The New England Journal of Medicine, June 26, 2003

18. Adherence to Quality Indicators, According to Condition Source: The New England Journal of Medicine, June 26, 2003

21. Income Disparities in US Counties Associated with Higher Stroke Death Rates Economic Measures (Gini coefficient) Gap between haves & have nots (“Robin Hood Index”) Health Measures • Higher overall mortality • Stroke mortality • Infant mortality Source: Leiyu Shi, Ichiro Kawachi, Ph.D. Income Inequality, Primary Care, and HealthIndicatorsJ Fam Prac 1999 48: 275-284

22. Protective Effect of Access to Primary Care Increasing access to primary care mitigated the negative effect of wide income disparity even when controlling for risk factors Source: Leiyu Shi, Ichiro Kawachi, Ph.D. Income Inequality, Primary Care, and HealthIndicatorsJ Fam Prac 1999 48: 275-284

23. Measuring Access to Primary Care Physicians Number licensed physicians per population National: 2.8 per 1,000 people State: 2.7 per 1,000 County: 2.1 per 1,000 **“Have a PCP?” 70 % yes (N=533) **“Travel out of North Hawaii for Primary Care?”30% yes Source: HOI/Healthy People 2010 ** Source: www.howsyourhealth.com

27. Possible Causes of Excess Stroke Deaths in the Stroke Belt Age, Genetic, other risk factor awareness Early risk factor detection Risk factor prevention, reduction, avoidance (protective factor detection/ enhancement) Early stroke recognition *** Access to care *** Quality of care *** Health behavior changes Excess Stroke Recurrence 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

28. The US Department of Health and Human Services Secretary’s Stroke Belt Initiative “Enabling Ring” Concept for Stroke Belt 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.

29.  Article Options  • Send to a Friend  • Readers Reply  •Submit a reply  • Similar articles in this journal “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.

31. 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 40:579-651, 2002).

33. Driving Forces to Develop a State Stroke System • Hawaii stroke death rate is relatively high • State • County • Projected to increase • Costly • Geographic Disparities • Opportunities for Improvement

34. Collaborate to Address Measurement Challenges • Stroke is heterogeneous • Incidence is difficult to measure because of frequent under-detection via hospital discharge data • Risk factors are interrelated & influenced by age adjustment • Active primary care ratio not currently measured

35. What would help? • Develop a State Strategic plan and State-wide Stoke Systems of Care • Start with Assessment • Target Primary & Secondary Prevention • Dual approach • Medical Model • Use CQI Tools • Focus on Hypertension • Population Health model • Address underlying issues: Access to primary care, Socioeconomic & Environmental barriers to lifestyle changes

36. Acknowledgements: Bakken Foundation NHOP Consultant Andy Ten Have M.D.,MPH OHSM: Alvin Onaka, Brian Horuich, Tina Savail Ann Pobutsky Hawaii Outcomes Institute HHIC National Stroke Association HHS: Larry Fields MD NHOP Staff: Makani Stevens, Lehua Kaae Presentation at www.nhop Contact info Sharon Vitousek 808 887-1945, vitouske@nhop.org