Georgia epidemiology report, Vol. 21, no. 11 (Nov. 2005)

November 2005

volume 21 number 11

Stroke and Heart Attack Prevention Program (SHAPP) in Georgia

Introduction Cardiovascular disease (CVD), which includes stroke and heart disease, is the leading cause of death in Georgia. The Stroke and Heart Attack Prevention Program (SHAPP) is an education, detection, and treatment program for persons with hypertension aimed at reducing illness and premature death from stroke and heart disease. SHAPP provides hypertension medication and lifestyle counseling to uninsured and underinsured Georgians with limited or no access to hypertension management and treatment services. This report presents the burden of stroke and heart attacks, a summary of hypertension as a risk factor for CVD, an overview of the SHAPP program, and SHAPP results based on clinic reporting.
Methods Vital records death certificate data were analyzed for underlying causes of death by CVD. Both ICD-9 (1980-1998) and ICD-10 (1999-present) codes were used in the analysis. The following ICD-9 codes were used: CVD, 390-448; ischemic heart disease, 410-414; stroke, 430-438. The following ICD-10 codes were used: CVD, I00-78; ischemic heart disease, I20-25; stroke, I60-69. Mortality rates were calculated using the direct method from the 2000 standard population and estimated Georgia and US population from the US Bureau of Census.
Data on hospitalization at non-federal, acute care hospitals in Georgia were obtained from the Georgia Hospital Association and restricted to Georgia residents. ICD-9-CM codes (390-448) were used to identify the principal diagnosis of CVD during hospitalization.
Data on behaviors, health history, and health knowledge among adults were obtained from the Georgia Behavioral Risk Factor Surveillance System, a random-digit telephone survey conducted annually with a sample of persons aged 18 years and older. The sample is weighted so that it reflects the total adult population of the state.
Prevalence of hypertension control, patient demographics, and treatment costs for SHAPP were calculated based on quarterly and annual reports submitted by SHAPP clinics. Data on private health plan hypertension control were obtained from performance indicators on the Health Plan Employer Data and Information Set (HEDIS), implemented by The National Committee for Quality Assurance.
CVD in Georgia During 2003, CVD caused 23,295 deaths in Georgia; 35% of all deaths that year. Heart disease (all forms) and stroke are the first and third most common causes of death in Georgia, respectively. Ischemic heart disease the most common form of heart disease - and stroke account for about 20% of deaths in Georgia. During 2003, hospitalization charges were $1.4 billion for ischemic heart disease and $490 million for stroke.

heart. Ischemic heart disease includes acute myocardial infarctions ("heart attacks") and complications resulting from previous myocardial infarctions. Of the 23,295 cardiovascular deaths in Georgia during 2003, 9,579 (41%) were from ischemic heart disease. The death rate from ischemic heart disease in Georgia and in the US has decreased during the past 23 years at an average decline of 3.5% per year (Figure 1). Unlike total cardiovascular disease, Georgia's death rate from ischemic heart disease is below the national rate, ranging from 5% to 14% below the US rate each year.
In Georgia, the age-adjusted death rate from ischemic heart disease was 1.8 times higher for men (192 per 100,000) than for women (105 per 100,000) in 2003. The age-adjusted death rate from ischemic heart disease was similar for blacks (147 per 100,000) and whites (141 per 100,000) during 2003. The death rate from ischemic heart disease increases with age, but 26% of deaths during 2003 occurred in persons less than 65 years.
Figure 1: Ischemic heart disease death rates in Georgia and the United States, 1980-2003

Age-adjusted death rate per 100,000 population

400

350

300

US

250

GA

200

150

100

50

0
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04

NOTE. The dotted line indicates a change in coding systems used for cause of death. ICD-9 codes were used for 1980-1998 deaths; ICD-10 codes were used for 1999-2003 deaths.

Stroke in Georgia
Stroke, sometimes called cerebrovascular disease, refers to an infarct (loss of blood supply due to a blocked artery) or hemorrhage in the brain. Of the 23,295 CVD deaths in Georgia during 2003, 4,285 (18%) were due to stroke. Age-adjusted death rates from stroke have decreased during the past 23 years in both Georgia and the US (Figure 2); however, since 1992, the rate of decline has slowed. In Georgia, the stroke death rate decreased an average of 4.4% per year from 1980 to 1992 but decreased only 1.2% per year from 1992 to 2003. Age-adjusted stroke death rates in Georgia are consistently above the US rate, although the gap is narrowing; Georgia's rate is 32% above the US rate in 1980 but only 20% above the US rate in 2003.

Ischemic heart disease in Georgia
Ischemic heart disease, also known as coronary heart disease, refers to narrowing of the coronary arteries which reduces blood flow and oxygen to the

Unlike ischemic heart disease deaths, for which sex differences are more striking than racial differences, age-adjusted stroke deaths are much higher for blacks than whites. In Georgia, the age-adjusted death rates from

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Figure 2: Stroke death rates in Georgia and the United States, 1980-2003

Age-adjusted death rate per 100,000 population

140

120
GA
100

80

US

60

40

20

0
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04
NOTE. The dotted line indicates a change in coding systems used for cause of death. ICD-9 codes were used for 1980-1998 deaths; ICD-10 codes were used for 1999-2003 deaths.
stroke were similar for men (65 per 100,000) and women (63 per 100,000) during 2003. The age-adjusted death rate from stroke was 1.5 times higher for blacks (88 per 100,000) than for whites (58 per 100,000) during 2003. Reasons for the racial disparity are not well understood but may include the higher prevalence of high blood pressure and decreased access to health care among blacks.

As for most other types of cardiovascular disease, the stroke mortality rate increases with age. Nonetheless, 19% of persons dying from stroke in Georgia during 2003 were less than 65 years of age.

SHAPP serves as a safety net for people with hypertension who lack health insurance and/or prescription drug coverage. Medically indigent adults are eligible for high blood pressure medications at low or no cost; the annual medication cost average is approximately $29.68 per patient. Clinic visit costs range between $24 and $64 per visit and clients are generally seen on a quarterly basis once blood pressure control is established. Of the more than 13,776 patients served by SHAPP, the largest race and age demographic populations are African-Americans (54%) and those less than 65 years old (74%).
Case management is conducted via two different methods, joint management and public health management. Patients that are joint managed usually see a private doctor for the initial diagnosis and prescription, then, for economic reasons, come to the local health department's SHAPP Clinic for continued blood pressure checks, nutrition, counseling, medications and other services. Public health nurses work with the patient's private physician in managing the patient. Alternatively, for patients unable to obtain private care, certain health departments offer an initial history, a physical examination, and laboratory tests. After a diagnosis of hypertension is made, a public health nurse accesses and orders therapy according to nurse protocol. Patients return to the clinic for nurse follow-up, and physician referrals are available for complications or problems.
SHAPP takes a community-based, statewide clinical approach that allows for partnerships between public and private health care providers. SHAPP treatment clinics are not established in every county in Georgia, but its services are usually available in a nearby county within the same public health district. Currently SHAPP serves 16 of the 18 public health districts throughout Georgia.

Hypertension and CVD

SHAPP Results

High blood pressure is a major modifiable risk factor for both heart disease SHAPP clinics have varying blood pressure control rates, ranging from 34%

and stroke. Blood pressure is defined as "controlled" if the systolic and diastolic to 93% with a median control rate for all clinics of 61%. Private health

readings are below 140 and 90 mm Hg, respectively. Some people can control plans in Georgia had a range of control rates from 47% to 68% with a

their high blood pressure by losing weight and engaging in regular physical median control rate of 60% for patients treated in their private setting.

activity. For those who are unable to decrease their blood pressure by lifestyle National hypertension control is 53% based on NHANES data (1). The

modification alone, medications prescribed by a physician can often control SHAPP median control rate is slightly higher than both the national average

high blood pressure successfully.

and Georgia private sector median. Advocates of SHAPP have cited nu-

merous reasons for their high control rate, including using evidence-based

The percentage of Georgians who reported having been told they had high protocols, lower utilization of costly medications (that are not necessarily

blood pressure was 28% during 2003. The percentage of Georgians with more effective), and use of nurse practitioners for the treatment of patients.

previous high blood pressure whose blood pressure is under control is not

known. Nationally, about 69% of people with high blood pressure know they Considerations

have hypertension and 53% of those taking medications are controlled (1). SHAPP plays an important role in providing necessary hypertension treat-

The benefits of controlled blood pressure are clear. Adults with increased blood pressure have reduced life expectancy as well as more time spent living with CVD. Life expectancy for those with normal blood pressure levels is 5.1 years longer for men and 4.9 years longer for women (2).

ment to those Georgians who are unable to obtain it otherwise. The program achieves high control rates at a low cost per patient. Ultimately, lack of funding for SHAPP would result in increased costs to the state in other forms, such as hospitalizations in public hospitals for adverse health outcomes, costs to the Medicaid program, and increased usage of federally

Stroke and Heart Attack Prevention Program Overview

funded indigent care money. Without this program, the state would eventually face higher costs attributable to the complications of hypertension, as

The Stroke and Heart Attack Prevention Program (SHAPP) is a hyperten- well as an increased in hypertension related morbidity and mortality.

sion detection, treatment, and control program, created with the goal to

reduce morbidity and mortality from cardiovascular disease associated with This article was written by Kevin Gregory, M.P.H., Manxia Wu,

hypertension. The program has been partially funded by the Georgia Gen- M.D.,M.P.H., Dafna Kanny, Ph.D, Shonta Chambers M.S.W., Patricia Jones,

eral Assembly since 1974. Currently the Georgia General Assembly allo- R.N., C.D.E.

cates approximately $985,000 annually with additional annual Preventive

Block funds of approximately 1.2 million dollars. SHAPP seeks to identify References

people at risk for cardiovascular disease and to reduce their risk for heart 1. attack and stroke by managing those with hypertension. SHAPP is an

education and care program that provides services for screening, diagnosis,

treatment, and management of hypertension. Laboratory tests are available 2. to screen for cardiovascular risk factors and to monitor treatment. Treat-

ment protocols are based on the seventh report of the Joint National Com-

mittee on Prevention Detection, Evaluation, and Treatment of High Blood 3. Pressure (JNC-7) recommendations (3). The program also provides patient,

professional, and public education.

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Hajjer, I, Kotchen TA. Trends in Prevalence, Awareness, Treatment, and Control of Hypertension in the United States, 1988-2000. JAMA 2003;290:199-206. Franco et al. Blood Pressure in Adulthood and Life Expectancy With Cardiovascular Disease in Men and Women. Life Course Analysis. Hypertension.2005; 46: 280-286. Chobanian et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003;289:2560-2571.

SIDS Deaths in Georgia, 1994-2003
Introduction
SIDS, sudden infant death syndrome, is the leading cause of death for infants between one and twelve months. This syndrome is defined as "the sudden death of an infant less than one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of clinical history"1. The causes of SIDS are unknown. Some risk factors associated with SIDS include younger maternal age or low education, lack of prenatal care, premature birth, male gender, seasonality (fall and winter months) and being a second or later born infant. However, the most notable risk factors for SIDS are co-sleeping and prone (on the stomach) sleeping position.
The national SIDS rates have declined since 1992, due in part, to the National Back to Sleep Campaign initiated in 1994, which promotes the supine (on the back) sleeping position. From 1994-2002, SIDS remained the third leading cause of infant mortality and the leading cause of postneonatal death. However, during this time period, SIDS postneonatal mortality rates decreased by 55%2.
Although the numbers and rates of SIDS deaths have decreased nationally in the past decade, SIDS remains a public health concern. In an effort to address SIDS in Georgia, this report will discuss documented SIDS deaths from 1994-2003.
Methods
Vital records death certificate data from 1994-2003 were analyzed2. For analysis purposes, a SIDS death was defined as a documented death with codes 798.0 (ICD-9) or R95 (ICD-10) as the underlying cause. It should be noted that the change in coding from ICD-9 to ICD10 in 1999 also resulted in a change in the definition of SIDS. Currently, the specific ICD10 code, R95, can be included along with well-defined causes to identify SIDS as the cause of death. However, to present comparable data over the time period, the analysis was limited to only those deaths with R95 as the underlying cause of death for the years 19992003.
Results
In the ten-year time period, a total of 1198 SIDS deaths occurred among Georgia infants, an average of 120 SIDS deaths per year. The overall SIDS death rate peaked at 1.5 per 1,000 live births in 1994 but has remained consistently between 0.8 and 1.1 since 1996 (Figure 1). The average age at time of death was 94 days (median 92 days, range 3-345 days); the majority of deaths occurred between one and three months of age (Figure 2). Fifty-eight percent of SIDS deaths were among male infants, and the rate of SIDS deaths for male infants was 1.4 times the rate of SIDS deaths for female infants. The SIDS mortality rate among infants of African-American mothers was double the rate among infants of Caucasian mothers (Figure 3). During this time period, there were 32 SIDS deaths to infants of Hispanic mothers (rate of 0.3 per 1,000 live births). SIDS continued to be the leading cause of post-neonatal mortality in Georgia. The SIDS death rate varied by public health district from 0.7 per 1,000 live births in the Cobb-Douglas and East Metro districts to 1.5 per 1,000 live births in the West Central district (Figure 4).
Conclusion
SIDS remains a persistent public health concern in Georgia. An average of 120 SIDS deaths occurred each year among Georgia infants. Targeted educational campaigns focusing on at-risk populations and risk factors should continue.
Resources for SIDS
The Georgia Division of Public Health, Family Health Branch: http://health.state.ga.us/ programs/sids/index.asp
The Georgia SIDS Project
http://www.sidsga.org/ This article was written by Nicole Alexander, M.P.H. and Emily Kahn, Ph.D., M.P.H.

Number of Deaths

Rate/1000 Live Births

Figure 1: SIDS Deaths and Rate per 1,000 Live Births, Georgia, 1994-2003

Number of SIDS deaths

180

2.4

2.2

163

2.0

130 1.5 131

141

1.8 1.6

80

1.2

110.09

115 1.0

100.82

108 0.9

113 0.9

112 0.8

1.1

104 0.8

1.4 1.2 1.0

0.8

30

0.6

0.4

0.2

-20 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 0.0

Year

SIDS Deaths

SIDS Rate/1000 Live Births

Figure 2: SIDS Deaths by Age of Infant at Death, Georgia, 1994-2003

600

551

500
404
400

Number of Deaths

300

200
127
100

116

0
0-30

31-90

91-180

Age at Death (Days)

181-364

Figure 3: SIDS Mortality Rate by Mother's Race, Georgia, 1994-2003

2.00 1.80

1.87

Rate per 1000 live births

1.60 1.40 1.20

1.36

1.42

1.4

1.28

1.3

1.17

1.18

1.19

1.2

1.00

0.85

0.83

0.85

0.9

0.78

0.80

0.65

0.63

0.7

0.56

0.6

0.60

0.40

0.20

0.00

1994

1995

1996

1997

1998

1999

Year

2000

2001

2002

2003

B lack

W hite

Figure 4: SIDS deaths and Rate per 1,000 Live Births by Public Health District, Georgia, 1994-2003

160

140

120

100

80

60

40

20

0 01- 01- 02- 03- 03- 03- 03- 03- 04- 05- 05- 06- 07- 08- 08- 09- 09- 09120123450120012123

Number of Deaths

87 54 57 76 143 45 81 88 79 17 62 63 80 33 62 54 68 49

SIDS Rate/1000 Live Births 1.2 1 0.8 0.7 1.2 1.1 0.7 0.8 0.9 0.9 0.9 1 1.5 1 1.2 1.2 0.9 1

Health District

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Susan Lance, D.V.M., Ph.D. Director
State Epidemiologist

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D.
Cherie Drenzek, D.V.M., M.S. Susan Lance, D.V.M., Ph.D.
Stuart T. Brown, M.D. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
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Two Peachtree St., N.W. Atlanta, GA 30303-3186
Phone: (404) 657-2588 Fax: (404) 657-7517

Georgia Department of Human Resources
Division of Public Health

Please send comments to: Gaepinfo@dhr.state.ga.us

The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

November 2005

Volume 21 Number 11

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for June 2005

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for June 2005
2005
70 3037
24 8 62 1470 8 14 13 4 1 0 0 5 0 266 55 1 6 4 15 0 38

Previous 3 Months Total

Ending in June

2003

2004 2005

257

197

231

9237

9411

8297

40

63

42

14

2

12

248

284

154

4691

4471

4016

17

23

20

148

78

43

214

126

33

12

16

9

2

5

3

5

1

5

1

0

0

8

5

13

0

0

0

809

827

718

285

165

139

34

20

12

114

128

48

182

73

33

205

212

120

3

1

0

138

122

123

Previous 12 Months Total

Ending in June

2003 2004

2005

700

552

618

36162

35025

32625

116

160

144

31

21

28

869

891

730

18343

16363

15376

78

121

107

548

632

161

610

548

268

35

44

28

11

12

4

33

22

21

2

1

3

32

28

42

0

1

0

1991

2086

1858

1879

715

545

120

130

86

431

494

367

793

482

246

851

826

759

12

5

3

523

532

474

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

AIDS Profile Update

Report Period
Latest 12 Months: 11/04-10/05 Five Years Ago: 11/00-10/01 Cumulative: 07/81-10/05

Total Cases Reported* <13yrs >=13yrs Total

4

1,727 1,731

4

1,280 1,284

224

29,076 29,300

Percent Female
25.2
26.6
19.4

Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood

32.0

5.8

2.0

10.1

1.5

32.1

9.9

2.2

17.6

1.6

45.3

15.7

4.9

14.3

1.9

Unknown
48.6 36.6 18.0

Race Distribution (%) White Black Other

22.9 74.9

2.1

19.9 75.5

4.7

31.8 65.6

2.5

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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