StrokeinHawaii200510.10.05_000.ppt

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  • Us rate 2000=60.2 2002 =56.3
  • Logrythi increase in number of strokes over next 30 years
  • Unfortunately there is a second equally worrisome, economic indicator in North Hawaii which is also associated with poorer health status. And it’s a “tricky one in the sense that it could represent an opportunity as well as a challenge. This second measure is not an individual measure, but rather a population or “ecological variable” ( it does not make sense at the individual level as income or somoking do.) This economic measure –Income distribution is unfortunately highly correlated with poorer healthstatistics. income distribution which can be measured by several different methods. The challenging news is that no matter how you mesure income distribution, the wider th gap between those in the lowest and highest brackets the pooreer the population health In particulars the lower the average life expectancy, and the higher the overall mortality, stroke mortality and infant mortality.
  • Increasing access to primary care mitigated the negative effect of wide income disparity even when controlling for risk factors
  • Calcuatiosn by NHOP?
  • StrokeinHawaii200510.10.05_000.ppt

    1. 1. <ul><li>Reducing the High Stroke Death Rate in Hawaii County </li></ul><ul><li>October 10, 2005 </li></ul><ul><li>Sharon H. Vitousek, M.D. </li></ul><ul><li>North Hawaii Outcomes Project </li></ul>
    2. 2. Driving Forces to Increase Screening for Stroke in Hawaii county <ul><li>Hawaii County stroke death rate is relatively high </li></ul><ul><li>Geographic disparities </li></ul><ul><li>Stroke deaths projected to increase </li></ul><ul><li>Costly: disability & $ </li></ul><ul><li>Prevention works </li></ul>
    3. 4. State Ranking (1=lowest death rate) Cerebrovascular Death Rate Age-Adjusted - 2001 <ul><li>1 = New York </li></ul><ul><li>2 = New Jersey </li></ul><ul><li>3 = Rohde Island </li></ul><ul><li>4 = Florida </li></ul><ul><li>5 = Arizona </li></ul><ul><li>6 = Massachusetts </li></ul><ul><li>7 = Delaware </li></ul><ul><li>8 = New Mexico </li></ul><ul><li>9 = Connecticut </li></ul><ul><li>10 = Vermont </li></ul><ul><li>11 = New Hampshire </li></ul><ul><li>12 = South Dakota </li></ul><ul><li>13 = Minnesota </li></ul><ul><li>14 = Colorado </li></ul><ul><li>15 = Maine </li></ul><ul><li>16 = Nevada </li></ul>Chart: North Hawaii Outcomes Project – August 2005 Source : Health Care State Rankings 2004 <ul><li>17 = Pennsylvania </li></ul><ul><li>18 = Wyoming </li></ul><ul><li>19 = Utah </li></ul><ul><li>20 = Nebraska </li></ul><ul><li>21 = Ohio </li></ul><ul><li>22 = Alaska </li></ul><ul><li>23 = Montana </li></ul><ul><li>24 = Michigan </li></ul><ul><li>25 = Illinois </li></ul><ul><li>26 = Iowa </li></ul><ul><li>27 = West Virginia </li></ul><ul><li>28 = Maryland </li></ul><ul><li>29 = Hawaii </li></ul>
    4. 5. Projected Increase in US Total Ischemic Stroke Deaths Per Year Source: Elkins, JS, “Thirty Year Projections for Deaths for Ischemic Stroke in US”, ( Stroke .2003:34:2109-2113)
    5. 6. 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
    6. 7. Increasing Diabetes Hospital Discharges/10,000 Population Source: Hawaii Health Information Corporation, 1995-2002
    7. 8. Geographic Disparities in Stroke Death Rates 1991-1998 Age - Adjusted Average Annual Source: CDC Stroke Atlas of Stroke Mortality 2003
    8. 9. Hawaii Ethnic Disparities in Stroke Death Rates Source: Hawaii Outcomes Institute/OHSM
    9. 10. Geographic Disparities in Stroke Death Rates Source: National Stroke Association (NSA)
    10. 11. <ul><li>“ Stroke is ideally suited for prevention. It has a high prevalence, burden of illness, and economic cost, and safe and effective prevention measures.” </li></ul><ul><li>Source: Stroke prevention April “95; P. B. Gorelick Department of Neurological Sciences, Rush-Presbyterian-St Luke's Medical Center, Chicago, Ill, USA. </li></ul>  Article Options  • Send to a Friend  • Readers Reply    • Submit a reply  • Similar articles in this journal   E-mail Alerts  •    Featured Link
    11. 12. Why is the stroke death rate in Hawaii County high? What would help? <ul><li>Risk factors </li></ul><ul><ul><li>Individual: nonmodifiable & modifiable </li></ul></ul><ul><ul><li>Environmental </li></ul></ul><ul><li>Access to Primary Care </li></ul><ul><li>Quality of Care </li></ul><ul><ul><li>Pre-hospital </li></ul></ul><ul><ul><li>Acute hospital </li></ul></ul><ul><ul><li>Rehabilitation </li></ul></ul>
    12. 16. “ Modifiable Risk Factors”-% BRFSS 2001 ( Hawaii County v Hawaii State ) <ul><li>HTN “ever told by MD” ( 24.1 v 24.8) </li></ul><ul><li>HTN “currently treated” ( 30 v 25.2) </li></ul><ul><li>Diabetes % ( 6.3 v 5.2) </li></ul><ul><li>High cholesterol ( 26.3 v 25.1) </li></ul><ul><li>Obesity ( 15.2 v 15.7) </li></ul><ul><li>Smoking ( 23.1 v 19.7) </li></ul><ul><li>Alcohol (>5drinks/day) ( 17.3 v 14.0) </li></ul><ul><li>Physical inactivity ( 25.4 v 23.2) </li></ul><ul><li>Atrial Fibrillation ?? </li></ul>Source: North Hawaii Outcomes Project - BRFSS
    13. 18. 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 <ul><ul><li>Overall mortality </li></ul></ul><ul><ul><li>Stroke mortality </li></ul></ul><ul><ul><li>Infant mortality </li></ul></ul>Health Measures <ul><li>Economic Measures </li></ul><ul><ul><ul><li>Gap between haves & have nots </li></ul></ul></ul><ul><ul><ul><li>“ Robin Hood Index” </li></ul></ul></ul><ul><ul><ul><li>(Gini coefficient) </li></ul></ul></ul>
    14. 19. Population Health Measures <ul><li>Protective Factors </li></ul><ul><li>“ Ratio of Primary Care Physicians </li></ul><ul><li>Risk Factors </li></ul><ul><li>Income Distribution </li></ul><ul><ul><li>Gini coefficient </li></ul></ul><ul><ul><li>(Robin Hood Index) </li></ul></ul>Source: Leiyu Shi, Ichiro Kawachi, Ph.D. Income Inequality, Primary Care, and Health Indicators J Fam Prac 1999 48: 275-284
    15. 20. Access to Physicians - 2003 <ul><li>Number licensed physicians per population* </li></ul><ul><ul><li>State 2.8 per 1,000 people </li></ul></ul><ul><ul><li>Hawaii County 2.1 per 1,000 people </li></ul></ul><ul><ul><li>City & County of Honolulu 3.1 per 1,000 people </li></ul></ul><ul><ul><li>Maui County 2.1 per 1,000 people </li></ul></ul><ul><ul><li>Kauai County 2.2 per 1,000 people </li></ul></ul><ul><ul><li>Source: Numerator from Department of Commerce and Consumer Affairs - 2005* Uniform Crime Report 2003 population estimate </li></ul></ul>
    16. 21. National Adherence to Quality Indicators, According to Condition Source: The New England Journal of Medicine, June 26, 2003 (62.6 – 66.7) 64.7 27 Hypertension (64.2 – 71.8) 68.0 37 Coronary artery disease (69.5 – 76.6) 73.0 39 Prenatal care (69.9 – 81.4) 75.7 9 Breast cancer (73.3 – 84.2) 78.7 10 Senile cataract (95% CI) Percentage of Recommended Care Received No. of Indicators Condition
    17. 22. National Adherence to Quality Indicators, According to Condition Source: The New England Journal of Medicine, June 26, 2003 (6.8 – 14.6) 10.5 5 Alcohol Dependence (18.4 – 30.9) 24.7 10 Atrial Fibrillation (42.7 – 48.3) 45.4 13 Diabetes Mellitus (44.1 – 53.2) 48.6 7 Hyperlipidemia (49.7 – 68.4) 59.1 10 Cerebrovascular Disease (95% CI) Percentage of Recommended Care Received No. of Indicators Condition
    18. 26. Focus on Hypertension ( High Blood Pressure) <ul><li>“Hypertension is the most prevalent and modifiable risk factor for stroke, and its treatment substantially reduces the risk of stroke.” </li></ul>Source: “Prevention of a First Stroke” Philip B. Gorelick, MD, MPH; Daniel F. Hanley, MD; et al JAMA. 1999;281:1112-1120 .
    19. 27. Focus on Hypertension <ul><li>“ 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%.” </li></ul><ul><li>[Example: Diastolic BP from 95-90, reduces stoke risk by nearly half] </li></ul><ul><li>“ 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%.” </li></ul>Source: JAMA. 1999;281:1112-1120
    20. 28. Focus on Hypertension <ul><li>“ Less than 30% of those being treated (nationally) have blood pressure lower than 140/90 mm Hg.” </li></ul><ul><li>Source: JAMA. 1999;281:1112-1120 </li></ul>
    21. 31. Evidence Stroke Can be Prevented <ul><li>Oxford Study </li></ul><ul><li>“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.” </li></ul>Source: Lancet 2004: 1925-33
    22. 32. Franklin Cardiovascular Health Program <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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). </li></ul>
    23. 33. Driving Forces to Increase Screening for Stroke in Hawaii County <ul><li>Hawaii County stroke death rate is relatively high </li></ul><ul><li>Geographic disparities </li></ul><ul><li>Projected to increase </li></ul><ul><li>Costly –Disability & $ </li></ul><ul><li>Prevention works </li></ul>
    24. 34. “ Enabling Ring” Concept for Stroke Belt National (federal/ non-federal) Regional Sub-regional/ state Enabling Activites Enabling Activites Enabling Activites Enabling Activites HSA COMMUNITY Priority Condition: STROKE Priority Risk Factor: HYPERTENSION The US Department of Health and Human Services Secretary’s Stroke Belt Initiative public policy, ecological strategies, quality of care, etc .
    25. 35. North Hawaii Initiatives <ul><li>2002 NHOP Noted Disparities in Stroke Death Rates </li></ul><ul><li>2003 NHOP Stroke leadership Think Tank </li></ul><ul><ul><ul><li>Public education Chamber of Commerce </li></ul></ul></ul><ul><ul><ul><li>AHA Community Screenings in North Hawaii </li></ul></ul></ul><ul><ul><ul><li>Tutus’ House public education: CVA, smoking , walking, senior exercise classes </li></ul></ul></ul><ul><li>2004 NHCH Stroke clinical path & link with Queen’s Medical Ctr. </li></ul><ul><li>2005 NHCH Heart Brain Center & GWTG </li></ul><ul><li>Participate with AHA & DOH in State Stroke Strategic Plan </li></ul><ul><li>AHA Training for Community Screenings </li></ul><ul><li>2006 Increase screenings & detection and ideal management of HTN (High Blood Pressure) </li></ul><ul><li>2010 Decreased admissions & deaths for stroke </li></ul>
    26. 36. Acknowledgements: <ul><li>The Earl & Doris Bakken Foundation </li></ul><ul><li>North Hawaii Outcomes Project, Consultant Andy Ten Have, M.D.,MPH </li></ul><ul><li>Office of Health Status Monitoring, Alvin Onaka, Ph.D., Brian Horiuchi, MPH, Tina Salvail, M.S. and Ann Pobutsky </li></ul><ul><li>Hawaii Outcomes Institute </li></ul><ul><li>Hawaii Health Information Corporation </li></ul><ul><li>National Stroke Association </li></ul><ul><li>Health and Human Services, Larry Fields, M.D. </li></ul><ul><li>North Hawaii Outcomes Project, Staff Makani Stevens, Lehua Ka ' ae </li></ul><ul><li>Presentation available at www.nhop.org/progress_stroke.php </li></ul><ul><li>Contact info Sharon Vitousek (808) 887-1945, vitousek@nhop.org </li></ul>

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