Report on stroke in Georgia 2021, as required by the Coverdell-Murphy Act, Georgia SB549, amended by Georgia HB853.

Report on Stroke in Georgia 2021, as Required by the Coverdell-Murphy Act, Georgia SB549, Amended by Georgia HB853 Compiled by the Georgia Coverdell Acute Stroke Registry Georgia Department of Public Health December 2021
Background
Why should we care about stroke in Georgia?
Georgia's age-standardized stroke death rate in 2020 was 10.8 percent higher than the national average1
In 2020, Georgia had the 12thhighest stroke death rate in the U.S.1
Stroke is the fourth-leading cause of death in Georgia (4,821 stroke deaths in 2020)1
In 2020, about 19 percent of Georgia stroke deaths were premature, i.e. among persons under the age of 65 years.1
In 2020, the age-adjusted stroke death rate for Blacks in Georgia was 52.2 per 100,000 population, which was 30 percent higher than the rates for Whites.1
Stroke is a leading cause of disability.2 Treatment of eligible stroke patients with the drug Alteplase (a tissue plasminogen activator) can reduce disability by 30 percent, but the drug needs to be administered in the first three hours after symptom onset.3
In 2020, Georgians had more than 20,800 stroke hospitalizations
o The median charge per hospitalization was around $46,002
o The total stroke-related hospitalization charges were over $1.7 billion in Georgia
Georgia is in the "Stroke Belt," an area in the southeastern U.S. with stroke death rates that are approximately 30 percent higher than the rest of the U.S. The coastal plains of Georgia are in the "buckle" of the Stroke Belt, an area with stroke death rates about 40 percent higher than the rest of the nation.4
o The higher death rates seen in the Stroke Belt can be collectively explained, in large part, by demographic and socioeconomic factors and the prevalence of stroke risk factors and chronic diseases like diabetes and hypertension.5

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In 2020, only 64 percent of adult Georgians knew all three signs of stroke facial droop, arm weakness, and slurred speech and the importance of calling 911 immediately.
Georgia stroke patients have higher prevalence rates for stroke-related risk factors versus adult Georgians. The 2019 2020 Georgia Behavioral Risk Factor Surveillance System (GA-BRFSS) and 2020 GCASR data showed:6

Risk Factor

Acute Stroke Patients (%)a

Adult Georgians
(%)b

Hypertension Dyslipidemia Diabetes Mellitus Coronary Artery Disease/Prior Myocardial Infarction Atrial Fibrillation/Flutter Smoking
a: GCASR 2020 b: 2019/2020 BRFSS data

78.4 45.3 35.5 19.6 13.7 21.3

34.8 32.4 11.6 7.0
-15.8

Coverdell-Murphy Act Required Reporting
To assure that patients are receiving the appropriate level of care and treatment at each level of stroke center, Georgia's Coverdell-Murphy Act (GA-CMA), Senate Bill 549, enacted in 2008 and amended in 2016 (House Bill 853), requires the reporting of stroke care related data to the Georgia Department of Public Health (DPH) as part of the Georgia Coverdell Acute Stroke Registry (GCASR).7,8 The required data elements are used to generate performance measures that help to monitor the quality of stroke care among the designated stroke centers. GCASR currently has 83 participating acute care hospitals, of which 6 are designated as comprehensive, 44 as primary, and 21 as remote treatment stroke centers (Map 1). In 2020, the designated hospitals received 93 percent of Georgians admitted with acute stroke across the state.
Summary of Data Findings
Based on 2008-2019 hospital discharge data from 19 designated Remote Treatment Stroke Centers, acute ischemic stroke patients treated after the hospitals were designated had 48 percent lower odds of in-hospital death compared to patients admitted when the hospitals were not participating in the Georgia Coverdell Acute Stroke Registry, which aims to improve the quality of stroke care.

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From 2018 to 2020, Georgians received high quality stroke care consistently.
Nine out of ten eligible ischemic stroke patients received the clot-busting drug Alteplase intravenously.
The median time from hospital arrival to intravenous administration of Alteplase was shortened from 47 minutes in 2018 to 43 minutes in 2020.
About 51 percent of the patients received alteplase in the first 45 minutes of hospital arrival in 2020 compared to 43 percent in 2018.
Numbers for other quality indicators, such as venous thromboembolism prophylaxis, antithrombotic medication, stroke education and discharge on appropriate medication, remained consistently high (above 90 percent) from 2018 to 2020.
However, less than 60 percent of stroke patients were transported to hospitals by EMS and the proportion of patients who arrived at hospital in the first two hours of symptom onset remained persistently below 40 percent, indicating the need to raise public awareness to identify stroke in the community, call 911, and transport patients to designated centers rapidly.
Discussion
The Centers for Disease Control and Prevention (CDC) funds the Georgia Coverdell Acute Stroke Registry (GCASR) to improve stroke systems of care in Georgia. Participating EMS agencies and hospitals are working to strengthen the existing relationships and developing new approaches to deliver the best stroke care possible at all levels of the patient care continuum. Currently, 46 EMS agencies and 83 acute care facilities in Georgia, of which 21 hospitals were designated as Remote Treatment Stroke Centers, participate in the GCASR, and they already have a major impact on the lives of Georgians by reducing mortality and limiting disability from stroke.9,10
Shortening the time between symptom onset and hospital arrival is crucial for better patient outcomes. Currently, 66 percent of patients arrived at hospitals two hours or later after symptom onset and 31 percent transport themselves to a hospital; therefore, it is critical that all stakeholders exert a concerted effort to increase public awareness about the signs of acute stroke and the importance of calling 911 for a swift transfer of patients to one of the designated and appropriate level stroke centers.
Moreover, we must continue to improve stroke prevention and treatment across the state by reducing the prevalence of stroke risk factors in Georgia. Adults 55 years and older have a higher risk for stroke.11 Based on the National Center for Health Statistics projection, 16 percent of Georgia residents are expected to be 65 years and older by the 2030.12 Thus, the number of Georgians affected by stroke is expected to rise over the next few years.
Stroke is a major cause of disability, and adequate post-hospital care contributes significantly to reducing late complications of the acute incident. It is imperative, therefore, to monitor the quality of post-hospital stroke care. To this end, the GCASR collaborates with EMS agencies to strengthen community paramedicine program.

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Table 1. Performance Measures for Designated Stroke Centers, GCASR, 2018-2020

Performance Measure

2018 2019 2020

Reach

% of state acute stroke admissions in designated GCASR hospitals

89

90

93

Public Awareness

% of patients presenting to ED with acute stroke or TIA that arrive by EMS

56

55

59

% of patients with acute stroke or TIA who arrive at ED in less than 2 hours from time last known to be well (LKW)

37

36

34

Quality of In-hospital Stroke Care

Early phase

% of stroke patients who have brain imaging performed within 25 minutes of hospital arrival

70

72

77

% of ischemic stroke patients whose disease severity was assessed and documented using NIH stroke scale score

89

91

93

% of acute stroke patients who had dysphagia screening

85

87

87

% of acute stroke patients who received venous thromboembolism prophylaxis the day of or the day after admission

93

94

92

% of acute ischemic stroke patients who arrived at the hospital within 2 hours from time LKW and received IV alteplase within 3 hours of time LKW

91

93

94

% of eligible of acute ischemic stroke patients who received IV alteplase within 60 minutes of hospital arrival

84

85

89

% of ischemic stroke patients who received antithrombotic medication by the end of hospital day two

97

98

97

Later and at discharge

% of ischemic stroke patients with medical history of smoking who received smoking cessation advice or counseling

98

98

99

% of ischemic stroke patients who were prescribed antithrombotic at discharge

99

99

99

% of ischemic stroke patients with atrial fibrillation who received anticoagulation therapy

96

98

97

% of eligible ischemic stroke patients who were discharged on statin medication

98

99

99

% of stroke patients who were assessed for rehabilitation services

99

99

99

Patient Education

% of patients and/or caregiver that received educational materials during the hospital stay addressing all stroke education areas1

96

95

97

Aggregate

% of patients with defect-free2 in-hospital care

76

79

78

Total number of patients

21,823 22,966 21,437

Abbreviation: ED Emergency Department; EMS Emergency Medical Service; GCASR Georgia Coverdell Acute Stroke Registry; LKW Last Known Well; NIH National Institute of Health; TIA Transient Ischemic Attack

1Stroke education areas include activation of EMS, follow-up after discharge, medication adherence, risk factors, and sign and symptoms of stroke.

2Defect-free care is defined as the delivery of care meeting all quality indicators for which a patient is eligible.

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References
1. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/ucd-icd10.html on Jan 4, 2022.
2. Centers for Disease Control and Prevention (CDC). Prevalence and most common causes of disability among adults: United States, 2005. MMWR Morb Mortal Wkly Rep. 2009;58:421426. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5816a2.htm
3. 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; 333:1581-1588. Available at: http://www.nejm.org/doi/full/10.1056/NEJM199512143332401#t=article doi: 10.1056/NEJM199512143332401
4. Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, et al; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2021 update: a report from the American Heart Association. Circulation. 2021; 143(8):e254-e743. doi: 10.1161/CIR. 0000000000000950.
5. Liao Y, Greenlund KJ, Croft JB, et al. Factors Explaining Excess Stroke Prevalence in the US Stroke Belt. Stroke. 2009,40:3336-3341. Available at: http://stroke.ahajournals.org/content/40/10/3336.full (https://doi.org/10.1161/STROKEAHA.109.561688)
6. Georgia Behavioral Risk Factor Surveillance System Data 2020. Chronic Disease, Healthy Behaviors, and Injury Epidemiology, Georgia Department of Public Health. For more information: http://dph.georgia.gov/georgia-behavioral-risk-factor-surveillance-system-brfss
7. Georgia Coverdell-Murphy Act. SB 549, Section 31-11-116. 14 May 2008, Official Code of Georgia Annotated, 2008. Available at: http://www.legis.ga.gov/Legislation/20072008/85749.pdf
8. Amendment to Georgia Coverdell-Murphy Act. House Bill 853, 26 April 2016. Accessed on Dec 15, 2017 at: http://www.legis.ga.gov/Legislation/en-US/display/20152016/HB/853
9. Ido MS, Bayakly R, Frankel M, Lyn R, Okosun IS. Administrative data linkage to evaluate a quality improvement program in acute stroke care, Georgia, 2006-2009. Prev Chronic Dis. 2015;12:E05. doi: 10.5888/pcd12.140238.
10. Ido MS, Okosun IS, Bayakly R, Clarkson L, Lugtu J, Floyd S, et al. Door to intravenous tissue plasminogen activator time and hospital length of stay in acute ischemic stroke patients, Georgia, 2007-2013. J Stroke Cerebrovasc Dis. 2016;25(4):866-71. doi: 10.1016/j.jstrokecerebrovasdis.2015.12.025.
11. Ralph L. Sacco R, Emelia J. Benjamin EJ, Joseph P. Broderick JP, Mark Dyken M, J. Donald Easton JD, William M. Feinberg WM, et. Al. Risk Factors. Stroke. 1997;28:1507-1517. Available at http://stroke.ahajournals.org/content/28/7/1507.full (https://doi.org/10.1161/01.STR.28.7.1507)
12. Population Projections, United States, 20042030, by state, age and sex, on CDC WONDER Online Database, September 2005. Accessed at http://wonder.cdc.gov/populationprojections.html on Dec 15, 2021.

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Definitions:
Alteplase: FDA-approved clot-busting drug for stroke. This drug can reduce disability by 30 percent in stroke sufferers if given to eligible patients within 3 hours of symptom onset.
Anticoagulation and Antithrombotic Medications: Medications that reduce blood clotting.
Atrial fibrillation: A disorder resulting in an irregular and often rapid heart rate. It predisposes to blood clotting and increases the risk of stroke, coronary heart disease and other heart-related complications.
Door-to-Needle Time: Time elapsed from when an eligible stroke patient arrives at the hospital to when Alteplase is administered. Eligible patients must receive Alteplase within 3 hours of symptom onset.
Dysphagia Screening: Screening for difficulty in swallowing. This identifies patients who need targeted treatment to improve their ability to swallow, so they do not aspirate or take fluid into the lungs. Aspiration of fluid can lead to pneumonia.
Hemorrhagic Stroke: A stroke caused by a blood vessel rupturing and bleeding in the brain. Hemorrhagic strokes are often fatal.
Ischemic Stroke: A stroke caused by a clot or blockage in a blood vessel supplying blood to the brain. The majority of strokes in Georgia are ischemic.
Statin medications: High cholesterol is a risk factor for stroke and statins lower blood cholesterol level.
Stroke ICD-10 Codes: GCASR uses the following ICD-10 codes to define stroke and TIA I60, I61, I63, I64, G45, and G46.
Venous Thrombosis: When a blood clot forms in a vein, usually in the leg. If the clot breaks off, it can cause serious complications and even death.

Know the Signs and Symptoms of Heart Attack and Stroke

Heart attack and stroke are life-threatening emergencies. Call 911 if you experience these symptoms.

Signs of Heart Attack Chest discomfort. Most heart attacks
involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness, or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath. This feeling often accompanies chest discomfort, but it can occur before the chest discomfort. Other symptoms may include nausea, lightheadedness, or breaking out in a cold sweat.

Signs of Stroke Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination. Sudden, severe headache with no known cause.