May 1999 volume 15 number 5 Division of Public Health http://health.state.ga.us The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources Director Kathleen E. Toomey, M.D., M.P.H. Epidemiology and Prevention Branch Acting Director Kathleen E. Toomey, M.D.,M.P.H. Stroke in Georgia: Defining the Problem and Finding Solutions Introduction Acting State Epidemiologist Paul A. Blake, M.D.,M.P.H. Epidemiology Section Chief Paul A. Blake, M.D., M.P.H. Public Health Advisor Mel Ralston Notifiable Diseases Jeffrey D. Berschling, M.P.H., Carol A. Hoban, M.S., M.P.H. Katherine Gibbs McCombs, M.P.H. Jane E. Koehler, D.V.M., M.P.H. Laura Gilbert, M.P.H., Kathryn E. Arnold, M.D. Amanda Reichert, R.N., M.S. Susan E. Lance-Parker, D.V.M., Ph.D. Chronic Disease and Injury Ken Powell, M.D., M.P.H.- Program Manager Patricia M. Fox, M.P.H., Rana Bayakly, M.P.H., Mary P. Mathis, Ph.D., M.P.H., Alexander K. Rowe, M.D., M.P.H. Linda M. Martin, M.S. Tuberculosis Rose Marie Sales, M.D., M.P.H.- Program Manager Naomi Bock, M.D., M.S., Beverly DeVoe, M.S. HIV/AIDS/Sexually Transmitted Diseases John F. Beltrami, M.D., M.P.H.&T.M.- Program Manager Lyle McCormick, M.P.H., Ann Buckley, M.P.H. Perinatal Epidemiology James W. Buehler, M.D. - Program Manager Leslie E. Lipscomb, M.P.H., Hui Zhang, M.D., M.P.H. Mohamed Qayad, M.D., M.P.H. Corliss Heath, M.P.H. Preventive Medicine Residents Mark E. Anderson, M.D., M.P.H. Anthony Fiore, M.D., M.P.H. EIS Officers Julia Samuelson, R.N., M.P.H. & Keoki Williams, M.D. Graphics Dept. Jimmy Clanton Jr. Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Jeffrey D. Berschling, M.P.H. Paul A. Blake, M.D., M.P.H. Jane E. Koehler, D.V.M., M.P.H. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphics Stroke is the third leading cause of death in Georgia, accounting for 4,276 deaths in 1997 (Figure 1). Stroke is also a major cause of hospitalization and disability. In Georgia, there were nearly 25,000 hospitalizations for stroke in 1997. Nationally, stroke is the leading cause of serious, long-term disability. Despite this burden, the impact of stroke can be reduced by the actions of individuals and policies throughout the state. This report presents a brief overview of stroke death rates in the past two decades, the approximate cost of stroke for 1997 in terms of hospitalizations, and recommendations for reducing the impact of stroke in Georgia. Methods Stroke was defined by the International Classification of Diseases, Ninth Revision, codes 430-438. The source of the number of deaths in Georgia was the Georgia Division of Public Health. The source of stroke hospitalizations was the 1997 Georgia Hospital Inpatient Data System. The source of the population estimates was the United States (U.S.) Bureau of the Census. The source of national stroke death rates was the National Center for Health Statistics. Stroke death rates were age-adjusted using the direct method; the U.S. 1990 population was used as the standard. Trends in Stroke Mortality Georgias stroke death rate is the sixth highest in the country, and in 1996, Georgias rate was 24 percent higher than the U.S. rate. Throughout the 1980s and early 1990s, death rates from stroke declined dramatically in both Georgia and the U.S. (Figure 2). From 1981 to 1992, the average annual decrease of the Georgia stroke death rate was 4.4 percent per year. This decline is presumably due to improvements in medical care and healthier lifestyles. In the early 1990s, however, the trend began to reverse direction. From 1992 to 1997, the Georgia rate leveled off and the curve may be increasing. This disturbing trend occurred in all sex and race groups (Figure 3). Figure 3 also reveals striking differences between black and white stroke death rates. In 1997, the risk for dying from stroke was 32 percent higher for black females than white females and 54 percent higher for black males than white males. Furthermore, these differences have not changed much over the past two decades. The reasons for these differences are not well understood, but may be a result of a higher percentage of blacks with high blood pressure, or factors related to poverty, such as poor diet or decreased access to health care. Males have a higher risk than females for dying from a stroke. However, in terms of absolute numbers, there are actually 53 percent more deaths among females than males. In 1997, there were 1,688 deaths among males, but 2,588 deaths among females. This difference exists because women live to older ages when strokes are more common. Females also die in greater numbers than men each year from other cardiovascular diseases, such as heart disease. However, stroke is not just a disease of old age: One in five Georgians who died from stroke in 1997 was younger than 65 years of age. Georgia Department of Human Resources Division of Public Health Epidemiology & Prevention Branch, Epidemiology Section Two Peachtree St., N.W., Atlanta, GA 30303 - 3186 Phone: (404) 657-2588 Fax: (404) 657-2586 Hospitalizations for Stroke in Georgia Recognition of Stroke Warning Signs Each year there are more nonfatal than fatal strokes. Stroke survivors are often left with permanent, severe disabilities. We can estimate the burden of non-fatal strokes in Georgia by examining hospital admissions. In 1997, there were 24,553 hospitalizations for stroke among Georgia residents, or on average, a hospitalization for stroke every 21 minutes. Hospitalizations for stroke consume considerable health and financial resources. In 1997, Georgians spent 153,656 days in the hospital because of stroke, and charges for these admissions totaled more than $300 million. The average charge for a hospital stay was $12,253. 5) Support a statewide multi-media public awareness campaign to educate Georgians about stroke risk factors, stroke warning signs, and the need to call 911 when a stroke is suspected. Such a campaign should include direct mailings, television and radio announcements, and the creation of a stroke information hotline. 6) Officially recognize that stroke is a treatable disease that, like a heart attack, should be considered a medical emergency; and recognize May as Stroke Awareness Month in Georgia. Transport, Treatment, and Rehabilitation of Stroke Victims Reducing the Risk of Stroke The increase in stroke death rates should alert Georgians to the importance of modifying their personal lifestyles to reduce the rate of stroke. The following risk factors can be modified to reduce the risk of stroke: Hypertension is a leading risk factor for stroke. The National Institutes of Health have updated their guidelines for diagnosing and treating hypertension. According to these new guidelines, blood pressure should be maintained at less than 130/85. The following lifestyle modifications can help keep blood pressure under control and even prevent hypertension from developing in the first place: 1) Stay active; 2) Eat less fat; 3) Use less salt; and 4) Dont drink too much alcohol. Tobacco Use. Tobacco is a major preventable cause of stroke. The message is simple: if you use tobacco, stop; if you dont use tobacco, dont start. Diabetes. Having diabetes can seriously increase the risk of stroke and heart disease. Diabetics can prevent or delay heart and blood vessel disease by controlling their weight, cholesterol, and blood pressure. Elevated cholesterol. A person with a normal cholesterol level (less than 200 mg/dl), should get their level checked every five years. Eating foods that contain no cholesterol, such as fruits and vegetables, and staying physically active are two easy ways to keep cholesterol low. Policies for Reducing the Impact of Stroke in Georgia In March 1999, a state legislative committee chaired by Representative Barbara Mobley published The Final Report of the Joint Study Committee on the Impact of Stroke on Georgias Citizens. In this report, a comprehensive policy agenda is proposed for reducing the impact of stroke in Georgia. The report emphasizes: 1) Preventing strokes by reducing risk factors for stroke and heart disease; 2) Improving the ability of Georgians to recognize stroke warning signs and call 911 immediately when a stroke is suspected; 3) Improving the transport, treatment, and rehabilitation of stroke victims; and 4) Systematically evaluating the preceding three components to identify areas of strength and weakness, and to plan improvements. The report concluded with the following 12 recommendations. Prevention 1) Support the primary prevention efforts of the Georgia Division of Public Health. Primary prevention for stroke includes lowering rates of smoking and obesity and improving levels of physical activity. 2) Authorize an expert study committee to determine which policies and environmental features could be changed to make it easier for Georgians to be physically active and to eat healthy diets. 3) Support the use of all tobacco settlement funds for health. 4) Create a policy requiring annual renewal of the license to sell tobacco products and collect a fee for the license renewal to pay for the enforcement of laws prohibiting tobacco sales to minors. 7) Recommend that local Emergency Medical Services (EMS) directors amend their protocols to designate stroke calls as priority one. Such a recommendation will facilitate the swift transport of patients to hospitals where appropriate treatment can be delivered and underscore the importance of treating stroke as a medical emergency. 8) Authorize an expert committee to develop acute stroke treatment guidelines for Georgia. 9) Support an educational program to train health providers (emergency medical technicians, emergency department physicians and nurses, and others) on the appropriate care of patients having an acute stroke. 10) Acknowledge the leadership and work of the Collaborative Quality Improvement Partnership (a partnership of the Georgia Hospital Association, Georgia Medical Care Foundation, and the Medical Association of Georgia) and encourage collaboration with other organizations working to reduce the impact of stroke in Georgia, such as EMS. One potentially useful product of such a collaboration is a directory of hospitals capable of treating stroke with t-PA (tissue plasminogen activator) for local EMS directors and ambulance dispatchers. 11) Authorize an expert committee to develop guidelines for the rehabilitation of stroke victims in Georgia. Evaluation 12) Create a Georgia Center for Public Health Partnership on Stroke. The Center should help coordinate the efforts of other organizations throughout the state working to reduce the impact of stroke in Georgia and should be a resource for current scientific knowledge on stroke prevention, treatment, and rehabilitation. The purpose of the Center should be to evaluate the three preceding components of stroke reduction in Georgia, identify strengths and weaknesses, and make recommendations for improvements. Conclusions After years of steady decline, the death rate for stroke has leveled off and may be increasing. Black Georgians should be especially concerned because their risk for dying from stroke is particularly high. All Georgians should be concerned by the disparity between the death rates of stroke among blacks and whites. It is not possible to explain conclusively reasons for the change in stroke death rates, but two factors are probably important contributing causes. First there is either a leveling off or an increase in the percentage of Georgians with unhealthy behaviors that put them at risk for a stroke. Second, owing to advances in medical care, the population of Georgians who have already had a previous heart attack or stroke is growing. These cardiovascular disease survivors are at particularly high risk for dying from stroke, and thus contribute to a growing number of stroke deaths. The practical implications of these findings are clear. Because most strokes result from a process of arterial blockage that begins at an early age, a greater effort should be made to reduce the prevalence of risk factors among all Georgians. Reducing stroke risk factors involves not smoking, eating a healthy diet, engaging in regular physical - 2 - activity, controlling high blood pressure, and reducing blood cholesterol. Fig 3. Age-adjusted Stroke Death Rates in Georgia by race-sex groups, 1981 - 1997 Sustained behavioral changes are often difficult to make, even for highly motivated individuals. Therefore, it is crucial to engage entire communities in a process to encourage policy and environmental changes that make it easier for people to change their behavior. Physicians, community leaders, and parents can act as role models. Additionally, local environments, such as schools and workplaces, can be changed to facilitate healthy behaviors. Much of the death and disability from stroke in Georgia is preventable. If we focus attention on realistic ways of reducing risk, we can renew the decline in stroke death rates that Georgia has experienced in much of the past two decades. Georgians can work together to reduce the number of individuals who suffer and die from strokes. For More Information The latest comprehensive report on stroke in Georgia is the 1998 Georgia Stroke Report. This report is available from the Georgia Division of Public Health (404-657-2588) and the American Heart Association, Southeast Affiliate (770-952-1316). The report can also be accessed via the Internet at www.health.state.ga.us/manuals/stroke/. The final report of the Joint Study Committee on the Impact of Stroke on Georgias Citizens can be obtained from Representative Mobleys legislative office (404-656-0126). Contributor This article was contributed by Alex Rowe, M.D., M.P.H., Chronic Disease, Injury, and Environmental Epidemiology Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources. Fig 1. Leading Causes of Death in Georgia, 1997 Deaths per 100,000 population 200 Black males 150 Black females 100 White males White females 50 Death rates decreasing Death rates leveling off 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97