Presented to the leadership of the State of Maine; this presentation describes the epidemiology of patients admitted with stroke in Maine from 2010-2014. It exams independent predictors of mortality.

1. |
A Closer look at Stroke In Maine 2010-
2014
Presented for Maine Stroke Alliance 2019
Aug 2019
EASTERN MAINE MEDICAL CENTER
Gillian Gordon Perue, MD1*, Keerthi Padooru, MD2, Samreen Fathima,
BDS, MPH1, Astra I. Chang Schwertschkow, PhD1, Barbara Sorondo,
MD, MBA1

2. |
Conflict of Interest
Nothing to disclose

3. |
What is known about stroke in Maine?
Maine also has the highest stroke prevalence in New England
ME 3.1%
VT 2.5%
NH 2.6%
MA 2.7%
CT 2.6%
RI 2.3%

4. |
What is known about stroke in Maine?
Maine has the highest stroke mortality rate of all the new England
states
Stroke Death Rate
ME 34.4
Vermont 29.2
NH 28
MA 27.9
CT 26.3
RI 26.8

5. |
What is known about stroke in Maine?
There is a known disparity in stroke mortality rate by stroke county
2005-2007 2008-2010 2010-2012 2011-2013
USA 312.1 275.1 258.5 251.4
Cumberland 219.3 220.5 219.2 219.3
Piscataquis 286.7 304.1 273.8 286.7
Penobscot 265.2 301.2 267.3 265.2
Kennebec 250.1 292.2 262.9 250.1
200
220
240
260
280
300
320Per100,000persons
Stroke Death Rate 65+

6. |
What is known about stroke in Maine?
Most data from the CDC and analysis of Stroke Capacity in Maine
done by Stein and Louder in 2010.
Overall prevalence of risk factors in population of Maine
Stroke Mortality rate
Stroke services at the hospital
But no published data about traditional and non-traditional risk
factors and hence the drivers of stroke in Maine
No new analysis of stroke epidemiology in Maine in 8 years

7. |
Hypothesis
The population of Maine is unique
Oldest state in the nation which may imply higher stroke risk factor prevalence
Relatively high rates of nontraditional risk factors for stroke such as poly substance abuse or cancer.
Data from Maine state wide cancer surveillance show that stroke occur more commonly in patients with cancer
survivors (18%) than hematology patients without cancer 8% (Huston (2005)ref).
We therefore hypothesized that the epidemiology of stroke in Maine has some
unique characteristics.
Describe the epidemiology of stroke in Maine
Exam traditional stroke risk factors and the contribution of non-traditional stroke risk factors
Exam stroke mortality by county
• Help us to better allocate resources as a state

8. |
Source of Data
Maine hospitals’ inpatient discharges were obtained from the Maine
Health Data Organization (MHDO).
Hospital inpatient stroke related discharges
2010 to 2014 including information on demographics, up to 9 diagnosis, and 6 procedure
codes were obtained.

9. |
Methods- how did we exam this data?
Statistical analysis with SPSS
t tests for means (age) and chi sq test of significance for proportions (gender).
Calculate stroke prevalence, mortality and traditional and non-
traditional diagnosis risk factors
calculate rates of risk factor occurrence of
Traditional risk factors Non-traditional risk factors
diabetes Polysubstance abuse
Hypertension ( LVH) Sleep apnea
Smoking Hypercoagulable states
hyperlipidemia depression
atrial fibrillation Neoplasm

10. |
Methods-
how did we examine this data?
Statistical analysis with SPSS
t tests for means (age) and chi sq test of significance for proportions (gender).
Calculate stroke prevalence, mortality and traditional and non-
traditional diagnosis risk factors
calculate rates of risk factor occurrence of
For those with stroke in the young (18-44 year old) look at polysubstance
abuse and stroke mortality.
Exam the trend for stroke mortality by county
Multiple linear regression analyses to identify the independent
predictors for stroke mortality.

11. Maine Stroke Demographics
Ischemic Stroke Hemorrhagic
stroke
Transient cerebral
ischemia
p
N (%)
(n=13857)
9174 (66%) 2033 (15%) 2651 (19%)
Age (Mean, SD)
(Min-Max)
73.19 (13.97)
(0-104)
72.59 (14.27)
(0-105)
73.68 (13.28)
(21-102)
0.03
Gender (% F) 51.3 50.9 56.4 0.00
There were 13857 hospital discharges with a primary diagnosis of stroke between 2010-2014;
app 2700 admissions per year
-Average age of stroke patients in state of Maine 73 years.
-there was a slight female predominance
-66% of all acute stroke were ischemic, 14% hemorrhagic and 20% TIA.
-no change in prevalence per year

12. |
Maine Stroke Demographics
Ischemic Stroke Hemorrhagic stroke Transient cerebral
ischemia
p
N (%)
(n=13857)
9174 (66%) 2033 (15%) 2651 (19%)
Age (Mean, SD) (Min-
Max)
73.19 (13.97)
(0-104)
72.59 (14.27)
(0-105)
73.68 (13.28)
(21-102)
0.03
Gender (% F) 51.3 50.9 56.4 0.00
There were 13857 hospital discharges with a primary diagnosis of stroke between 2010-2014; app 2700 admissions per year
-Average age of stroke patients in state of Maine 73 years.
-there was a slight female predominance
-66% of all acute stroke were ischemic, 14% hemorrhagic and 20% TIA.
-no change in prevalence per year

13. |
Maine Stroke Demographics
Ischemic Stroke Hemorrhagic stroke Transient cerebral ischemia p
Risk factors
HTN (n=7033; 50.8%) 4618 (50.3%) 969 (47.7%) 1446 (54.5%) 0.000
DM (n=3354; 24.2%) 2261 (24.6%) 385 (19%) 708 (26.7%) 0.000
Tobacco Use (n=1764; 12.7%) 1249 (13.6%) 184 (9.1%) 331 (12.5%) 0.000
Afib (3334; 24.1%) 2302 (25.1%) 473 (23.3%) 559 (21.1%) 0.000
LVH (n=114; 0.8%) 81 (0.9%) 8 (0.4%) 25 (0.9%) 0.065
Lipid Disorder (n= 5655; 40.8%) 3749 (40.9%) 548 (27%) 1358 (51.2%) 0.000
Prevalence of traditional stroke risk factors

14. |
Maine Stroke Demographics
Ischemic Stroke Hemorrhagic stroke Transient cerebral ischemia p
N (%) (n=13857) 9174 (66%) 2033 (15%) 2651 (19%)
Sleep Apnea (n=292; 2.1%) 184 (2%) 37 (1.8%) 71 (2.7%) 0.065
Polysubstance abuse
(n=1,460; 10.5%)
1066 (11.6%) 146 (7.2%) 248 (9.4%) 0.000
Alcohol Abuse (n=233; 1.7%) 157 (1.7%) 39 (1.9%) 37 (1.4%) 0.359
Neoplasm (n=788; 5.7%) 519 (5.7%) 149 (7.3%) 120 (4.5%) 0.000
Moyamoya (n=15; 0.1%) 12 (0.1%) 2 (0.1%) 1 (0%) 0.434
Mental Disorder (n=4,768;34%) 3112 (34%) 676 (33%) 980 (37%) 0.007
Depression (n=860; 6.2%) 527 (5.7%) 121 (6%) 215 (8.1%) 0.000
Prevalence of the non-traditional risk factors

15. |
Stroke Risk Factors By Stroke Type

16. |
AIS Maine Hospitals compared with GWTG
Ischemic Stroke in Maine GWTG
N 9174 274988
Age (Mean, SD) (Min-Max) 73.19 (13.97) (0-104) 71.6 (14.3)
Gender (% F) 51.3 53.4
In hospital mortality n (%) 536 (5.8%) 15143 (5.5%)
Risk factors:
HTN 50.3% 73.99%
DM 24.6% 29.92%
Tobacco Use 13.6% 17.11%
Afib 25.1% 18.15%
Lipid Disorder 40.9% 35.2%

17. |
AIS, 6.3%
ICH, 26.2%
TIA, 0.0%0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
2010 2011 2012 2013 2014
Percentageinhospital
deaths
Trend of Stroke Mortality rate in Maine by subtype
Stroke in hospital mortality rates are unchanged since 2010 6.1%AIS; 25%; TIA 0.1% -Stein Louder CDC
Validates our numbers for 2010

18. |
AIS, 6.3%
ICH, 26.2%
TIA, 0.0%0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
2010 2011 2012 2013 2014
Percentageinhospitaldeaths
Trend of Stroke Mortality rate in Maine by
subtype
Stroke Mortality Trend

19. |

20. |

21. |
Results
Potential Some other findings:
1. 36% of patients transferred to a different hospital,
how many patients are transferred more than once?
The stroke mortality rate is not declining in the state of Maine

22. |
Maine Certified Stroke Centers

23. |
Predictors of Stroke Mortality in Maine

24. |
Conclusion
Maine local determinants for in hospital stroke mortality
include:
limited access to a certified stroke center
an older population.
Other concomitants conditions for risk include atrial fibrillation and
neoplasm
Mental illness appears to be a significant stroke risk factor and State of
Maine.
More frequent review of stroke epidemiology in Maine needs to be
undertaken.

25. |
Future goals
Stroke In Maine
Stroke Registry for the state of Maine
Or at least have regular review of epidemiology
Data will be more robust when prospectively collected.

26. |
References
Stein, R., Louder, D. Stroke and Stroke care in Maine- Where we have been and might be headed. Retrieved on June 2018 from
http://www.mainecardiohealth.org/Stroke%20and%20Stroke%20Care%20in%20Maine%2011%2010%2011%20-%20Stein%20and%20Louder.pdf
Vital Signs: Recent trends in stroke death rates – United States, 2000-2015. MMWR 2017;66.
Karp DN, Wolff CS, Wiebe DJ, Branas CC, Carr BG, Mullen MT. Reassessing the Stroke Belt: Using Small area Spatial Statistics to Identify Clusters of High
Stroke Mortality in the United States. Stroke 2016. Jul;47(7):1939-42. doi: 10.1161/STROKEAHA.116.012997.
Louder, D., Keith, R., Meyer, K., Ghourie, F. (May 2010). Stroke Care in Maine: Analysis of All Payer claims data to measure quality of care.
He, W., Sengupta, M., Velkoff, V. A., & DeBarros, K. A. (2005). 65+ in the United States: 2005: Citeseer.
Bang, O. Y., Ovbiagele, B., & Kim, J. S. (2015). Nontraditional Risk Factors for Ischemic Stroke An Update. Stroke, 46(12), 3571-3578. Retrieved from
http://stroke.ahajournals.org/content/46/12/3571.short
Wolf PA, D'agostino RB, Belanger AJ, Kannel WB. Probability of stroke: a risk profile from the Framingham Study. Stroke. 1991 Mar 1;22(3):312-8.

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References Continued
Daggett, C. (2013). Closing the Rural Mortality Gap? An examination of 10-year cardiovascular mortality trends in Washington and Aroostook Counties, Maine. Retrieved from http://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1084&context=muskie_capstones
Diomede, T. (2014). Substance Abuse Trends in Maine: State Epidemiological Profile 2014. Retrieved from http://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1094&context=muskie_capstones&sei-
redir=1&referer=http%3A%2F%2Fscholar.google.com%2Fscholar%3Fq%3Dsubstance%2Babuse%2Btrends%2Bin%2Bmaine%253A%2Bstate%2Bepidemiological%2Bprofile%2B2014%26btnG%3D%26hl%3Den%26as_sdt%3D0%252C20#search=%22substance%20abuse%20trends%20
maine%3A%20state%20epidemiological%20profile%202014%22
Huston, S. L., Albert, P.M., Yob, D., Decker, K. (April 2015). Maine Cancer Surveillance Report 2014. Augusta, ME: MAine Center for Disease Control and Prevention; 2014.
Kini, N., Huston, S.L., Fullman, T., Richards, H., Kendall, S., Wigand, D., Parsons, A.G., Teach, F. (2012). The Burden of Cardiovascular disease in Maine, 2012. Augusta, ME: Cardiovascular Health Program, Maine Center for Disease control and Prevention; 2012.
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., . . . Stroke Statistics, S. (2015). Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation, 131(4), e29-322. doi:10.1161/CIR.0000000000000152
Romero, J. R. (2007). Prevention of ischemic stroke: overview of traditional risk factors. Curr Drug Targets, 8(7), 794-801. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/17630932
Schneider, A. T., Kissela, B., Woo, D., Kleindorfer, D., Alwell, K., Miller, R., Shukla, R. (2004). Ischemic stroke subtypes A population-based study of incidence rates among blacks and whites. Stroke, 35(7), 1552-1556. Retrieved from
http://stroke.ahajournals.org/content/35/7/1552.full
Sultan, S., & Elkind, M. S. (2013). The growing problem of stroke among young adults. Curr Cardiol Rep, 15(12), 421. doi:10.1007/s11886-013-0421-z

28. |
Thank you for being a vital part of the fight against stroke
Helping us get the right care, to the right patient at the right time.

29. |
Special Thanks
Dr. Barbara Sorondo and the research Team