Stroke

Chronic disease surveillance and disease control

Stroke Brain tissue death due to interruption of

blood supply to the brain

http://commons.wikimedia.org/wiki/File:MCA-Stroke-Brain-Human-2.JPG www.theuniversityhospital.com/.../inhospital.htm

Two stroke types: Ischemic stroke (~80%): Artery blockage

Thrombotic Embolic Hemorrhagic stroke (~20%): Artery rupture

Transient Ischemic Attack

Risk Factors for stroke• Genetic predisposition

– Familial aggregation– Sickle cell disease

• Perinatal factors • Age >55 years• Race AA>W• Gender M>F• Hypertension, diabetes, elevated cholesterol,

smoking• Atrial fibrillation

QJM 2006 99(2):117-122;

QJM 2006 99(2):117-122;

Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999

Men

Women

www.who.int/cardiovascular.../en/cvd_atlas_15_burden_stroke.pdf

Stroke Epidemiology: Geography

Stroke Mortality, Georgia, 2004• 4,050 deaths• 6% of all deaths• 3rd leading cause of death• Age-adjusted stroke death rate (per 100,000 population)

– Georgia 60– US Overall 50– Healthy People 2010 Target 48 (Healthy People 2010 objective number 12-7)

• Georgia has 8th highest stroke mortality rate among states (2003)*

• Several Georgia counties, particularly in the coastal plain, have substantially higher stroke death rates

*American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics—2007 Update. Circulation 2007, published online Dec 28, 2006. Downloaded from circ.ahajournals.org on 2/1/2007.

Stroke Mortality, Georgia, 2004• 766 (19%) of the stroke deaths among

Georgia residents in 2004 occurred in persons aged <65 years

• 2002 comparison of 50 states*– Georgia had 4th highest percentage of stroke

deaths that occurred among persons aged <65 years

– Georgia had 7th highest number of years of potential life lost due to stroke before age 75 years

*Harris C, Ayala C, Dai S, Croft JB. Disparities in deaths from stroke among persons aged <75 years—United States, 2002. MMWR 2005;54(19): 477-481.

Stroke Patient Outcomes- Ischemic Stroke

• 30-day case fatality rate*– Ages 45-64: 8-12%– Ages 65+: 8%

• Recurrent stroke occurs in approximately 8% within 1 year**

• Functional outcomes among stroke survivors*– 50% -70% regain functional independence– 15%-30% permanently disabled– 20% require institutional care at 3 months

*Rosamond W, Flegal K, Friday G, Furie K, GO, A, et. al. Heart Disease and Stroke Statistics—2007 Update: A report from the American Heart Association statistics committee and stroke statistics subcommittee. Circulation 2007;115;e69-e171. **Dhamoon MS, Sciacca RR, Rundek T, Sacco RL, Elkind MSV. Recurrent stroke and cardiac risks after first ischemic stroke: The Northern Manhattan Study. Neurology 2006;66:641-646.

Stroke Morbidity, Georgia, 2004• 23,451 acute care hospitalizations with

stroke as primary diagnosis (ICD-9-CM codes 430-438)

• Average length of hospital stay: 6 days• Costs:

– Average hospital charge: $22,700– Total hospital charges for Georgia admissions

with a primary diagnosis of stroke: $533 million

*Derived from AHA 2006 statistical update- based on US cost estimate and the number of stroke discharges in Georgia

Effectiveness of Stroke Therapies• Tissue Plasminogen Activator (tPA) (NINDS Part

II)*: – Patients treated within 180 minutes of stroke onset– OR for favorable outcome at 3 months: 1.7 (1.2-2.6) for t-PA group vs. placebo group

• DVT prophylaxis– Heparin can reduce the risk of DVT and PE by ~60%**– Intermittent compression devices also effective

*The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N. Engl. J. Med 1995;333:1581-1587

**Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest 2004 Suppl.;126; 438S-512S.

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Coverdell Acute Stroke Registry Prototypes

• Named for Senator Paul Coverdell of GA, who had a fatal stroke in 2000.

• Congressional funding to CDC.• Following a competitive process, 8 sites

funded to independently design and test prototypes (including Emory’s Dept. of Neurology).

• Includes adult patients hospitalized for stroke or TIA

Evidence of Sub-optimal Stroke Guideline Adherence

• Paul Coverdell National Acute Stroke Registry Prototypes– October 2001-November 2002– Four states (GA, MA, ,MI, OH)– Analysis weighted to account for hospital

sampling scheme in each state

Evidence of Sub-optimal Stroke Guideline Adherence

• Coverdell Pilot Data : sample of results* (Percentages of patients receiving recommended care)

Measure GA MA MI OH Summary

tPA (any route) 3.0 8.5 3.4 3.2 4.5

Dysphagia Screening 38.5 50.7 50.1 47.2 45.4

Smoking cessation 21.2 28.2 34.1 16.5 21.4

*Reeves MJ, Broderick JP, Frankel M, LaBresh KA, Schwamm L, et.al. The Paul Coverdell National Acute Stroke Registry: Initial findings from four prototypes. Am J Prev Med 2006;31(6S2):S202-S209.

HDS HP2020–22: Increase 30-day survival rates following first occurrence of heart disease and stroke.

HDS HP2020–23: (Developmental) Reduce the recurrence rates among survivors of heart disease and stroke.

Healthy People 2020 and Stroke care

http://www.healthypeople.gov/HP2020/

Public Health Surveillance and Chronic Disease

Public Health SurveillanceSystematic, ongoing• Collection• Analysis• Interpretation• Dissemination• Link to public health

practicehttp://www.cdc.gov/ncphi/disss/nndss/phs/overview.htm

Georgia Coverdell Acute Stroke Registry

• Responsibilities– Overall program oversight– Writing of reports and proposals– Management of budget– Coordination of activities of contractors– Data preparation– Data analysis– Web site maintenance– Assist contractors with hospital enrollment, site visits,

preparation of training events, newsletters, conference calls

– Coordination with other DPH programs

GA DPHGeorgia Coverdell Acute Stroke Registry

Goals of the Georgia Coverdell Acute Stroke Registry (GCASR)

• Monitor the quality of in-hospital acute stroke care in Georgia

• Use data to guide stroke care quality improvement interventions

• Design and implement interventions to improve the quality of in-hospital acute stroke care, as measured by increased compliance with recommendations

• Ultimately– reduce the impact of stroke in Georgia including– Complications of acute stroke– Case fatality– Prevalence and severity of disability due to stroke– Recurrent strokes

Strategies for Increasing Guideline Adherence

Generally Effective:Variably Effective:

Generally Ineffective:

-Reminders to healthcare providers-Academic detailing -Interactive educational interventions -Barrier oriented interventions tailored to specific identified barriers-Multifaceted interventions

-Audit and feedback-Local opinion leaders-Local consensus conferences-Consumer education

-Passive educational approaches- dissemination of guidelines and publication of research findings-Didactic educational interventions

Gross PA, Greenfield S, Cretin S, Ferguson J, Grimshaw J. et.al. Optimal methods for guideline implementation: Conclusions from Leeds Castle meeting. Medical Care 2001;39 (8, Suppl 2):II-85-II-92

• 2001-2007• 46 participating hospitals

– 34 randomly selected– 12 volunteer

• Chart abstraction done at Georgia Medical Care Foundation

Georgia Coverdell Acute Stroke Registry

• Quality improvement interventions during the Pilot Phase included– Annual feedback of data to hospitals– Annual workshops– Monthly calls– Some hospitals initiated “Get With The

Guidelines” participation

Pilot PhaseGeorgia Coverdell Acute Stroke Registry

• 26 hospitals participating in 2005-2006• 52 hospitals participating as of 10/1/2006

Hospital EnrollmentGeorgia Coverdell Acute Stroke Registry

MF

MEASURES OF IMPACT OF GCSAR

Success implementation of stroke surveillance infrastructure

• Hospital Participation– “Trust” and reputation– High % of randomly selected hospitals participating– Sustainability

• Information sharing amongst participating hospitals• High number of JCAHO primary stroke certified hospitals• Hiring of four QI consultants • High number of charts abstracted• Improvement in quality indicators• Maintaining partnerships• Interest in ASLS workshop and use of tools provided• High attendance rates at workshops and on teleconferences• Newsletter production and distribution• Website creation and maintenance

Percentage of ischemic stroke patients arriving at the ED within 120 minutes of onset of Stroke Symptoms who receive

IV t-PA within 180 minutes of onset of Stroke Symptoms—GA Coverdell Wave III hospitals

Percentage of ischemic stroke or TIA patients discharged on antithrombotics (e.g. warfarin, aspirin, other

antiplatelet drug)—GA Coverdell Wave III hospitals