Georgia program and data summary. Cardiovascular disease

2009 Georgia Program and Data Summary:

CARDIOVASCULAR DISEASE

Cardiovascular disease is the leading cause of death in Georgia.
Cardiovascular disease (CVD) includes all diseases of the heart and blood vessels including ischemic
heart disease, stroke, congestive heart failure, hypertension, and atherosclerosis. Currently, Georgia is taking a comprehensive approach to reducing illness, premature death, and disability from heart disease and stroke through three distinctive interventions: the Cardiovascular Health Initiative; the Stroke and Heart Attack Prevention Program (SHAPP); and the Georgia Coverdell Acute Stroke Registry.
Funded by the Centers for Disease Control and Prevention (CDC), the Cardiovascular Health Initiative (CVHI) is part of a national effort to address heart disease and stroke prevention. The CVHI seeks to improve cardiovascular outcomes by employing strategies that result in system, policy, and/or environmental change in four areas: healthcare, worksites, communities, and schools.
The Initiative includes a focus on high blood pressure and cholesterol control, awareness of signs and symptoms of heart attack and stroke, improving emergency response, improving quality of care, and eliminating health disparities between population groups. Because heart disease and stroke are also related to poor nutrition, physical inactivity, tobacco use, diabetes, and obesity, the CVHI collaborates with other chronic disease prevention programs that address these issues.
Annually, the Georgia CVHI makes over 15 awards totaling approximately $200,000 available to public health districts1 to implement population-based interventions at the local level that result in sustainable environmental and system changes. Current efforts include the North Central Health Education Task Force, a faith-based network that improves health outcomes in minority communities by promoting healthy lifestyle changes. The task force includes over 20 churches that participate in

monthly conference calls to share ideas on programs, training, and other initiatives for their health ministries. Ten churches have adopted written health policies covering healthy eating, physical activity, and tobacco cessation. The task force supports two comprehensive wellness centers in Hancock and Houston Counties that offer health screenings and exercise classes, healthy eating and cooking classes, and health education classes. The Southwest Georgia Stroke Task Force conducts train-the-trainer courses in Acute Stroke Life Support for hospital and EMS personnel. Approximately 350 individuals have been trained.
Each year about 795,000 Americans suffer from a stroke, about 144,000 die from stroke, and 15-30% are permanently disabled. In response to this urgent public health need, Congress provided funding to implement state-based registries that measure, track, and improve the delivery and quality of stroke care. The project is called the Paul Coverdell National Acute Stroke Registry, in honor of the late U.S. Senator Paul Coverdell of Georgia, who suffered a fatal stroke in 2000. Georgia is currently one of six funded states. The mission of the Georgia Coverdell Acute Stroke Registry is to establish a statewide registry with a sample of acute care hospitals to monitor and improve the quality of acute stroke care. The stroke registry team works closely with hospitals to establish policies and procedures that will improve stroke care.
Funded partly by the Georgia General Assembly since 1974, the Stroke and Heart Attack Prevention Program (SHAPP) is an education, screening and treatment program for low-income, uninsured, or underinsured patients age 18 or older who are diagnosed with primary hypertension. The program goal is to reduce cardiovascular risk for heart attack and stroke by improving healthy behaviors and increasing access to education, screening, and treatment for high blood pressure. SHAPP uses a population-based, clinical approach that allows partnerships between public and private health care providers to coordinate medication and lifestyle modifications. SHAPP clinics are located in fourteen public health districts. An evaluation conducted by the Research Triangle Institute in 2005 concluded that SHAPP is a successful, cost-effective program targeting an unfulfilled need for the state of Georgia.2

1 For a full list of Georgia public health districts, see: http://health.state.ga.us/regional/index.asp 2 Rein DB, Constantine RT, Orenstein D, et al. A cost evaluation of the Georgia Stroke and Heart Attack Prevention Program. Prev Chronic Dis [Internet]. 2006 Jan; 3(1). Available from: http://www.cdc.gov/pcd/issues/2006/jan/05_0143.htm.
Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us

DEFINITIONS

CARDIOVASCULAR DISEASE (CVD) BURDEN

Atherosclerosis: the hardening and narrowing of the arteries caused by deposits of cholesterol and other substances.
Blood Pressure: the force of the blood against artery walls. A blood pressure consists of systolic pressure measurement and diastolic pressure measurement.
Cardiovascular Disease (CVD) includes all diseases of the heart and blood vessels, including ischemic heart disease, stroke, congestive heart failure, hypertensive disease, and atherosclerosis.
Diastolic Pressure: blood pressure measurement between contractions, when the heart chambers are filling with blood.
Hemorrhage: severe bleeding.
Hypertension: high blood pressure, which is defined as above the 140/90 threshold.
Infarct: an area of dead tissue resulting from insufficient blood flow.
Ischemic Heart Disease (IHD) also known as coronary heart disease, refers to narrowing of the coronary arteries, which reduces blood flow and oxygen to the heart. IHD includes myocardial infarction (MI) and complications from a previous MI.
Myocardial Infarction: also known as a heart attack, occurs when the heart muscle is damaged due to insufficient coronary blood supply.
Stroke (Cerebrovascular Disease): refers to an infarct or hemorrhage in the brain.

DEATHS

CVD accounted for one third (32%) of deaths in Georgia, with 21,389 CVD deaths in 2007

In 2006, Georgia's CVD death rate was 9% higher than the national rate

Causes

# GA Deaths (2007)

Heart Disease

16,074

Stroke

3,749

Hypertension

931

Atherosclerosis

151

Other

484

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Cardiovascular Disease Deaths (total) 21,389

HOSPITALIZATIONS
Approximately 144,000 hospitalizations occurred among Georgia residents due to CVD in 2007
The average hospitalization length of stay for CVD was 5 days in 2007, similar to the national average (2006 data)
ESTIMATED COSTS
The average charge per CVD hospitalization in Georgia was $32,800 in 2007
Total hospital charges for CVD increased by over $1.4 billion between 2003 and 2007, from $3.4 billion to $4.7 billion
The cost of CVD in Georgia in 2007 is estimated at $11.2 billion, which includes direct health care costs and lost productivity from morbidity and mortality (indirect costs)3

Systolic Pressure: blood pressure measurement during contraction of the heart, when blood is pushed through the arteries.

Thrombus: a clot that blocks blood flow in an artery or vein.
3 Derived from national estimates published by the American Heart Association. Heart Disease and Stroke Statistics -- 2007 Update. Dallas, TX: American Heart Association; 2007.

Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us

STROKE BURDEN

ISCHEMIC HEART DISEASE (IHD) BURDEN

DEATHS
Stroke was the third most frequent cause of death in Georgia, accounting for 6% of all deaths, with 3,749 stroke deaths in 2007
In 2007, strokes were responsible for 18% of all cardiovascular deaths in Georgia
In 2006, Georgia's stroke death rate was 16% higher than the national rate
In 2007: o 4% of Georgia's stroke deaths were due to ischemic stroke, or stroke caused by blockage or constriction of blood vessels supplying blood to the brain o 26% of Georgia's stroke deaths were due to hemorrhagic stroke, or stroke caused by a rupture in the blood vessels supplying blood to the brain
HOSPITALIZATIONS
Approximately 19,900 hospitalizations occurred among Georgia residents due to stroke in 2007
76% of stroke hospitalizations were due to ischemic stroke, while 17% were due to hemorrhagic stroke
The average hospitalization length of stay for stroke was 6 days in 2007, compared to a national average of 5 days (2006 data)
ESTIMATED COSTS
The average charge per stroke hospitalization in Georgia was $32,000 in 2007
Total hospital charges for stroke in Georgia were $635 million in 2007, accounting for 14% of all CVD hospital charges
The cost of stroke in Georgia in 2007 is estimated at $1.7 billion, which includes direct health care costs and lost productivity from morbidity and mortality (indirect costs)3

DEATHS
Heart disease was the leading cause of death in Georgia, accounting for 24% of all deaths, with 16,074 heart disease deaths in 2007. Of the deaths due to heart disease, 7,791 were attributable specifically to ischemic heart disease (IHD)
In 2007, IHD was responsible for 49% of all heart disease deaths in Georgia
In 2006, Georgia's IHD death rate was 21% lower than the national rate

Heart Disease Type

# GA Deaths (2007)

Ischemic Heart Disease

7,791

Hypertensive Heart Disease

1,181

Other Heart Disease

7,102

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Heart Disease Deaths (total)

16,074

HOSPITALIZATIONS
Approximately 45,600 hospitalizations occurred among Georgia residents due to IHD in 2007
The average hospitalization length of stay for IHD was 4 days in 2007, similar to the national average (2006 data)
ESTIMATED COSTS
The average charge per IHD hospitalization in Georgia was $40,500 in 2007
Total hospital charges for IHD in Georgia were $1.8 billion in 2007, accounting for 39% of all CVD hospital charges
The cost of IHD in Georgia in 2007 is estimated at $2.7 billion, which includes direct health care costs and lost productivity from morbidity and mortality (indirect costs)3

Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us

CARDIOVASCULAR DISEASE DISPARITIES

SEX
CVD death rates were 1.4 times higher for men than women in 2007

GEOGRAPHIC
Age-Adjusted CVD Death Rates by County, Georgia, 2003-2007

Stroke death rates were similar for men and women in 2007

IHD death rates were 1.9 times higher for men than women in 2007
RACE
CVD death rates were 1.3 times higher for blacks than whites in 2007
Stroke death rates were 1.5 times higher for blacks than whites in 2007

Age-Adjusted Stroke Death Rates by County, Georgia, 2003-2007

IHD death rates were similar for blacks and whites in 2007

AGE
CVD death rate increases with age but 1 in 4 persons who died from CVD in 2007 was less than 65 years of age
Black males are at particularly high risk for premature death from CVD. Almost 1 in 2 black males who died from CVD in 2007 was less than 65 years of age
23% of persons dying from stroke in Georgia in 2007 were less than 65 years old
27% of persons dying from IHD in Georgia in 2007 were less than 65 years old

Age-Adjusted IHD Death Rates by County, Georgia, 2003-2007

Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us

CARDIOVASCULAR DISEASE RISK FACTORS
Over 2.3 million Georgia adults (33%) do not know the modifiable risk factors for cardiovascular disease.4

SMOKING
2,949 deaths due to CVD were attributable to smoking among adults ages 35 or older in 2007
Quitting smoking greatly reduces the risk for heart disease and stroke
In Georgia, 18% of adults ages 35 or older reported smoking cigarettes in 2008
LACK OF PHYSICAL ACTIVITY
Lack of physical activity increases the risk for heart disease and stroke
Regular physical activity helps to maintain proper body weight and improves health
In 2008, 23% of adults in Georgia had no leisure time physical activity in the last 30 days
POOR EATING HABITS
Poor eating habits such as a high-fat diet can lead to obesity, ischemic heart disease, stroke, and other chronic diseases
Eating five or more servings of fruits and vegetables a day can help prevent heart disease, cancer, and other chronic conditions
The majority (75%) of adults in Georgia did not consume the recommended five or more daily servings of fruits and vegetables in 2007

OBESITY
Obesity, which is present in 27% of adults in Georgia, increases the risk for cardiovascular disease
HIGH BLOOD PRESSURE
High blood pressure can be controlled through lifestyle changes such as physical activity and healthy diet and, if necessary, medications
The percentage of adults in Georgia who have been told that they have high blood pressure increased from 21% in 1997 to 30% in 2007
HIGH CHOLESTEROL
Many people can control high cholesterol by modifying their diet. For those who cannot, medication can lower blood cholesterol levels
The percentage of adults in Georgia who have been told that they have high cholesterol increased from 24% in 1997 to 37% in 2007
DIABETES
Diabetes can cause atherosclerosis, also known as hardening of the arteries
Diabetes increases the risk for CVD death
The percentage of adults who report having diabetes increased from 6% in 1998 to 10% in 2008

Percent

Prevalence of risk factors for cardiovascular disease among adults,

Georgia, 2007 and 2008
100 75
80

60

40

20

23

20

27

30

37

0

Current smoker No leisure time physical activity

<5 fruits and vegetables per
day

Obese

Ever had high blood pressure
(1)

Ever had high cholesterol (2)

10
Diabetes

(1) The percentage of Georgians who reported having been told they had high blood pressure (2) Of persons who had their blood cholesterol level checked, the percentage told that they have high cholesterol Data Source: Georgia Behavioral Risk Factor Surveillance System 2007 and 2008
4 Data Source: 2006 Georgia Stroke and Heart Attack Awareness Survey

Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us

Stroke and Heart Attack Prevention Program (SHAPP)
SHAPP is an education, screening and treatment control program designed to reduce morbidity and mortality from cardiovascular disease associated with hypertension.

OVERVIEW
Funded by the Georgia General Assembly since 1974
An education, screening, and treatment program that targets low-income, uninsured, or underinsured patients over the age of 18 who have high blood pressure
The program seeks to identify people at risk and to teach them how to manage their lifestyle to prevent complications and avoid further illness
An in-depth evaluation conducted by the Research Triangle Institute for the Centers for Disease Control and Prevention concluded that SHAPP is a successful, cost-effective program targeting an unfulfilled need for the state of Georgia2
THE ROLE OF HIGH BLOOD PRESSURE MANAGEMENT IN STROKE AND HEART ATTACK PREVENTION
Blood pressure is defined as "controlled" if the systolic and diastolic readings are below 140 and 90 mm Hg, respectively
Some people can control their high blood pressure with lifestyle changes such as diet modification, increasing physical activity, and smoking cessation
For those who are unable to decrease their blood pressure by lifestyle modification alone, medications prescribed by a physician can often control high blood pressure successfully
Adults with increased blood pressure have reduced life expectancy as well as more time spent living with cardiovascular disease. Life expectancy for those with controlled blood pressure is 5.1 years longer for men and 4.9 years longer for women compared to those with uncontrolled blood pressure6

SHAPP CLINICS

SHAPP services are available in 14 of the 18 Georgia health districts

SHAPP PATIENTS
SHAPP service
High blood pressure screening High blood pressure treatment Cardiovascular disease education Counseling on:
Blood pressure medications Low sodium diet Physical activity Weight management Tobacco cessation

# patients served (2008 fiscal year)
17,668 8,816 2,088
6,645 5,414 5,458 4,373 1,734

58% of the patients were African American 85% of patients were less than 65 years old

SHAPP CONTROL RATES
SHAPP clinics have varying blood pressure control rates, ranging from 52% to 83% with a median control rate for all clinics of 66%

Private health plans in Georgia had a range of
control rates from 47% to 68% with a median
control rate of 60% for patients treated in a private setting7

Nationally, 53% of patients undergoing
treatment for high blood pressure are controlled8

6 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. 7 Based on performance indicators on the Health Plan Employer Data and Information Set (HEDIS), implemented by the National Committee for Quality Assurance. 8 Hajjer, I, Kotchen TA. Trends in Prevalence, Awareness, Treatment, and Control of Hypertension in the United States, 1988-2000. JAMA 2003;290:199-206.
Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us

Georgia Coverdell Acute Stroke Registry

PROGRAM OVERVIEW
Funded by the Centers for Disease Control and Prevention (CDC) as part of the Paul Coverdell National Acute Stroke Registry
Named in honor of the late Senator Paul Coverdell of Georgia who died of a massive stroke in 2000
Partnership between Georgia Department of Community Health's Division of Public Health, Emory University, American Heart Association/American Stroke Association, Georgia Medical Care Foundation, Georgia Hospital Association, CDC and participating hospitals

HOSPITAL PARTICIPATION
Hospitals actively recruited in three stages: - Cohort 1 started in November 2005 - Cohort 2 started in October 2006 - Cohort 3 started in March 2008
Other hospitals continued to join the registry, and the next recruitment is planned for late 2009
52 currently participating hospitals, representing over half of stroke admissions in Georgia

GOALS
Reduce fatalities and disability due to stroke and the incidence of recurrent stroke in Georgia by o monitoring and improving the quality of acute stroke care in hospitals; and o encouraging collaboration between hospitals and between hospitals and other institutions in Georgia concerned with stroke care quality improvement.

QUALITY IMPROVEMENT ACTIVITIES
Individualized stroke care quality improvement consultation for participating hospitals
Monthly registry-wide telephone conference calls and bimonthly newsletters sharing best practices between hospitals
Annual meetings to exchange best practices in conjunction with the American Heart Association/American Stroke Association
Acute Stroke Life Support training using curriculum from the University of Miami
Focus of participating hospitals' quality improvement efforts during first two years was on deep vein thrombosis (DVT) prophylaxis, and is now on dysphagia screening
DATA COLLECTION
Data on stroke patient characteristics and care received during the hospital stay are collected by participating hospitals for patients admitted with an acute stroke or transient ischemic attack
The purpose of data collection is to monitor the quality of stroke care delivered at hospitals in the state and to guide quality improvement efforts

Note: Dots represent location and may represent more than one facility
REGISTRY STROKE CASE DATA
Analysis included data from 22,737 patients admitted from November 2005 to October 2008
The majority (58%) had a discharge diagnosis of ischemic stroke, followed by hemorrhagic stroke and transient ischemic attack, at 19% each
For ischemic stroke, prompt treatment (thrombolysis) is critical for good recovery
o Of patients admitted with a presumptive diagnosis of ischemic stroke, 19% arrived at the emergency department within 2 hours from the last time they were known to be well
o Among these, only 52% of eligible patients received thrombolytic treatment within 3 hours after symptom onset

Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us

KNOW THE SIGNS AND SYMPTOMS OF HEART ATTACK AND STROKE

Over 1.3 million Georgia adults (19%) do not know the signs of heart attack, and nearly 2.8 million (39%) do not know the signs of stroke.4 Heart attack and stroke are life-threatening emergencies.
Call 9-1-1 if you experience these symptoms.

Heart Attack

Stroke

Cardiac arrest

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.

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.

Sudden loss of responsiveness. No response to gentle shaking.
No normal breathing. The victim does not take a normal breath when you check for several seconds.
No signs of circulation. No movement or coughing.
If cardiac arrest occurs, call 911 and begin CPR immediately. If an automated external defibrillator (AED) is available and someone trained to use it is nearby, involve him or her.
Source: The American Heart Association

REDUCE YOUR RISK OF HEART DISEASE AND STROKE
Small lifestyle changes can reduce your risk.
Eat healthy. A healthy eating plan is one that emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products; includes lean meats, poultry, fish, beans, eggs, and nuts; and is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars.

Be active. Participating in regular physical activity can help to reduce many risk factors associated with chronic diseases including obesity and high blood pressure.

Be smoke free. Quitting smoking lowers the chance of having a heart attack or stroke and improves overall health and well-being, regardless how long a person has been smoking.
Get checked. Undergoing routine physical check-ups and screenings can prevent some chronic diseases and detect other chronic diseases earlier when treatment may be more effective.

Be positive. A positive attitude contributes to your overall well being.
Following these guidelines can greatly reduce the chances of developing a chronic disease, leading to an improved quality of life and reduced healthcare costs.

Date updated: July 2009 Publication number: Visit http://www.health.state.ga.us/epi/cdiee/cardio.asp for more information about cardiovascular disease in Georgia.
Georgia Department of Community Health, Division of Public Health 2 Peachtree Street, NW Atlanta, GA 30303 (404) 657-3103 ga-cvh@dhr.state.ga.us http://health.state.ga.us