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Stroke Death Rate in Hawaii State & County September 9, 2005 Sharon H. Vitousek, M.D. North Hawaii Outcomes Project PowerPoint Presentation
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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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slide1
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
slide17

Adherence to Quality Indicators,

According to Condition

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

slide18

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 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

measuring access to primary care physicians
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

slide27

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

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.

slide29

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Readers Reply

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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.

evidence stroke can be prevented
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
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 develop a state stroke system
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
collaborate to address measurement challenges
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
what would help1
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

acknowledgements
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