Stroke Death Rate in Hawaii
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Stroke Death Rate in Hawaii State & County September 9, 2005 Sharon H. Vitousek, M.D. North Hawaii Outcomes Project. The Problem. Hawaii stroke death rate is relatively high State County Projected to increase Costly Geographic disparities Clear opportunities for improvement.

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Stroke Death Rate in Hawaii

State & County

September 9, 2005

Sharon H. Vitousek, M.D.

North Hawaii Outcomes Project


The problem
The Problem

  • Hawaii stroke death rate is relatively high

    • State

    • County

  • Projected to increase

  • Costly

  • Geographic disparities

  • Clear opportunities for improvement


  • State ranking 1 lowest death rate cerebrovascular death rate age adjusted 2001

    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


    Projected increase in us total ischemic stroke deaths per year

    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
    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


    Increasing diabetes hospital discharges 10 000 population
    Increasing Diabetes Hospital Discharges/10,000 Population

    Source: Hawaii Health Information Corporation, 1995-2002


    Geographic disparities in stroke death rates 1991 1998 age adjusted average annual
    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
    Hawaii Ethnic Disparities in Stroke Death Rates

    Source: Hawaii Outcomes Institute/OHSM



    What would help
    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


    Geographic disparities in stroke death rates
    Geographic Disparities in Stroke Death Rates

    Source National Stroke Association (NSA)


    Analyzing geographic disparities in stroke death rates
    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


    Adherence to Quality Indicators,

    According to Condition

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


    Adherence to Quality Indicators,

    According to Condition

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


    Income disparities in us counties associated with higher stroke death rates
    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


    Protective effect of access to primary care
    Protective Effect of Stroke Death RatesAccess 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


    Measuring access to primary care physicians
    Measuring Access to Stroke Death RatesPrimary 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


    Possible Causes of Excess Stroke Deaths in the Stroke Belt Stroke Death Rates

    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


    Enabling ring concept for stroke belt

    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.


     Article Options Stroke Belt Initiative

     •

    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.


    Evidence stroke can be prevented
    Evidence Stroke Stroke Belt InitiativeCan 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
    Franklin Cardiovascular Health Program Stroke Belt Initiative

    • 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 develop a state stroke system
    Driving Forces to Stroke Belt InitiativeDevelop a State Stroke System

    • Hawaii stroke death rate is relatively high

      • State

      • County

  • Projected to increase

  • Costly

  • Geographic Disparities

  • Opportunities for Improvement


  • Collaborate to address measurement challenges
    Collaborate to Address Measurement Challenges Stroke Belt Initiative

    • 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


    What would help1
    What would help? Stroke Belt Initiative

    • 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


    Acknowledgements
    Acknowledgements: Stroke Belt Initiative

    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


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