Report on stroke data as required by the Coverdell-Murphy Act, Georgia SB549 [Dec. 2012]

Report on Stroke Data as Required by the Coverdell-Murphy Act, GA SB549 Compiled by the Georgia Department of Public Health December 2012

Background
Why should we care about stroke in Georgia?
Stroke is the fourth leading cause of death in Georgia (3,591 stroke deaths in 2010)1
Georgia's stroke death rate is 17% higher than the national average1,2 Georgia has the 9th worst stroke death rate compared to other U.S. states2 Stroke is a leading cause of disability.2 Treatment of eligible stroke patients with the
drug tissue plasminogen activator (tPA) can reduce disability by 30%, but many do not receive the drug because they arrive at the hospital too late.3 Georgians had approximately 20,625 stroke hospitalizations in 2010
o The average cost per hospitalization was $38,322 o The total Georgia stroke hospitalization charges were $790 million Georgia is in the "Stroke Belt," an area in the southeastern U.S. with stroke death rates that are approximately 20% 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% higher than the rest of the nation.2 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 hypertension4 31% of Georgia stroke deaths occur before the patient reaches the hospital.1 This suggests that stroke sufferers and witnesses are not recognizing stroke events or calling emergency services quickly enough. Georgia survey data support this suggestion, showing that 3.2 million Georgians (46% of Georgia adults) would not be able to recognize and properly respond to a stroke event.5 Nearly one-quarter (23%) of Georgia stroke deaths are premature, i.e. in persons under the age of 65 (2010 data) The stroke death rate for blacks in Georgia is 1.6 times higher than the rate for whites (2010 data) Georgians have high rates for stroke risk factors. 2011 data showed that:6 o 32% of Georgians had hypertension o 37% had high cholesterol o 10% were diabetic o 28% were obese o 27% were physically inactive o 76% did not consume the recommended five-a-day fruit and vegetable servings (2009 data) o 20% of Georgia adults smoked

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Coverdell-Murphy Act Required Reporting
Georgia's Coverdell-Murphy Act (CMA), or Senate Bill 549, requires the reporting of specific types of stroke data to the Georgia Department of Public Health (GDPH).7 The required elements are in Table 1 in bold, exactly as specified in the law. All data in this report comes from the Georgia Coverdell Acute Stroke Registry (GCASR), with exceptions noted for data coming from Georgia Emergency Medical Services (EMS). Georgia hospitals report certain data elements to GDPH through GCASR. Georgia EMS collects additional data. This is the second of the required CMA reports and covers the years 2009 through 2011. Some elements specified in the law are not available through GCASR or EMS (see Table 1) and thus are not reported here.

Summary of Data Findings
According to available data, the quality of stroke care for Georgians has improved from 2009 to 2011. In particular, delivery of the clot-busting drug tPA to ischemic stroke patients improved by 84% from 2009 to 2011. Numbers for many other quality indicators, such as stroke education and discharge on appropriate medication, also improved from 2009 to 2011:

The number of patients delivered to hospitals by EMS with presumptive stroke diagnoses based on provider impression increased by 45% from 2009 to 2011.A
The number of Georgians receiving acute interventional therapy for stroke, defined as tPA administration, increased by 84% from 2009 to 2011.
The median door-to-needle time for tPA administration improved by 3%, decreasing from 75 minutes to 73 minutes. Door-to-needle time refers to the number of minutes elapsed from when the patient arrives at the hospital to the administration of tPA. The drug must be administered to ischemic stroke patients within 3 hours of symptom onset.
The median length of stay in hospital for stroke did not change from 2009 to 2011. The percentage of eligible Georgia stroke patients who received deep vein thrombosis
prophylaxis increased from 93% to 96%. The percentage of eligible Georgia stroke patients discharged on antiplatelet or
antithrombotic medications remained consistently high at 98% from 2009 to 2011. The percentage of eligible atrial fibrillation patients who received anticoagulation therapy
decreased slightly from 94% to 93%. The percentage of eligible patients who had antithrombotic medication administered
within 48 hours of hospitalization increased slightly from 96% to 97%. The number of lipid profiles ordered increased by 33%. The percentage of eligible patients receiving dysphagia screenings increased from 83%
to 85%. The percentage of patients who received all five components of the recommended
stroke education increased from 77% to 87%. The percentage of eligible patients receiving smoking cessation programs or with whom
smoking cessation was discussed remained consistently high at 98% from 2009 to 2011. The percentage of eligible patients who were assessed for rehabilitation and for whom a plan for rehabilitation was considered remained consistently high at 97% from 2009 to 2011.

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The number of EMS patients actually admitted to a hospital for stroke increased by 29% from 2009 to 2011.
The percentage of eligible stroke patients treated with intravenous or intra-arterial tPA increased statistically significantly from 56% to 77%.
The percentage of eligible stroke patients who were discharged on cholesterol-reducing medication increased from 82% to 89%.

Table 1. Coverdell-Murphy Act Required Data Elements as available via GCASR or Georgia EMS, 2009-2011

Indicator
1. The number of patients evaluated
Defined as number of patients delivered to hospital by EMS with presumptive stroke diagnosis based on provider impression Data source: Georgia EMS data
2. The number of patients receiving acute interventional therapy Defined as number of stroke patients receiving tPA administration

2009

2010

2011

3,766*

4,309

5,469

399

533

736

3. The amount of time from patient presentation to delivery of acute interventional therapy Median door-to-needle time in minutes Range (high, low)
4. Patient length of stay Median length of stay in days Range (high, low)
5. Patient functional outcome Not collected; see Table 2 for alternative data
6. Patient morbidity Not collected; see Note Page 5
7. Deep vein thrombosis prophylaxis given Percent among eligible patients

75 (59, 98)

73

73

(56, 96) (54, 103)

4 (2, 7)
--
--
4,080 93%

4 (2, 6)
--

4 (2, 6)
--

--
4,496 96%

--
4,704 96%

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8. Number of patients discharged on antiplatelet or antithrombotic medication Percent among eligible patients
9. Number of patients with atrial fibrillation receiving anticoagulation therapy Percent among eligible patients
10. Patients on which the administration of tissue plasminogen activator was considered Not collected; see Note Page 5
11. Antithrombotic medication administered within 48 hours of hospitalization Percent among eligible patients
12. Number of lipid profiles ordered during hospitalization
13. Number of screens for dysphagia performed Percent among eligible patients
14. Stroke education provided Number of patients who received all five components of stroke education Percent among eligible patients
15. Number of smoking cessation programs provided or discussed Percent among eligible patients
16. The number of patients assessed for rehabilitation and whether a plan for rehabilitation was considered Percent among eligible patients

4,987 98%
559 94%
--

6,179 98%

6,854 98%

695 93%
--

771 93%
--

4,614 96%
7,356 5,641
83%
3,142 77%
1,506 98%
6,510 97%

5,672 97%
8,519
6,418 82%

6,298 97%
9,753
7,541 85%

4,000 84%

4,452 87%

1,875 98%

1,928 98%

7,397 97%

8,273 97%

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17. The number of emergency medical services stroke patients who were transported to the facility Defined as number of patients delivered to hospital by EMS with presumptive stroke diagnosis based on provider impression Data source: Georgia EMS data
18. The number of emergency medical services stroke patients who were admitted to the facility
19. The number and percentage of stroke cases treated with intravenous or intra-arterial tissue plasminogen activator Percent among eligible patients
20. The number of patients discharged on cholesterolreducing medication Percent among eligible patients
Total Patients

3,766*

4,309

5,469

4,654

5,321

5,989

285 56%

392 81%

401 77%

3,487 82%
9,881

4,464 85%
11,014

4,978 89%
12,472

* Data for 2009 may not be comparable to 2010-2011 data due to changes made in data collected by EMS reports between 2009 and 2010.
Eligibility for specific care varies and is based on criteria set by the Paul Coverdell National Acute Stroke Registry for measuring the performance of hospitals in stroke patient care.
The five stroke education components are: modifiable risk factors, warning signs and symptoms, activating EMS for stroke, prescribed medication, and follow-up after discharge.

Note: Some data elements listed in the Coverdell-Murphy Act are not available via GCASR or Georgia EMS (noted in Table 1) and thus are not reported here. Modification or clarification of the missing elements in the CMA may allow for future reporting on these elements. We are able to report alternative data for "patient functional outcome" in Table 2. While this data is not exactly what the CMA stipulates, it is an indicator of patient outcome and thus we include it here.

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Table 2. Additional Data from the Georgia Coverdell Acute Stroke Registry

Data Element
Ambulatory status of patient at discharge, if documented Able to ambulate independently with or without device Percent among eligible patients
Able to ambulate with assistance by another person Percent among eligible patients
Unable to ambulate Percent among eligible patients

2009

2010

4,888 56%
2,248 26%
1,603 18%

5,328 55%
2,715 28%
1,738 18%

2011
5,783 53%
3,200 30%
1,842 17%

Conclusions
Georgians are disproportionately affected by death and disability from stroke, compared to residents in other states. Those who survive, along with their families, must endure the lifelong burden of disability, which is often severe. Controlling stroke risk factors and providing timely treatment of acute stroke are effective ways to limit death and disability from stroke. Fortunately, hospitals participating in the GCASR have had a major impact on the lives of thousands across the state by limiting the damage and disability from stroke. GCASR accounts for 78% of all Georgia stroke admissions and its facilities emphasize high-quality acute stroke care. Recent analyses indicated that ischemic stroke patients treated at GCASR facilities were 1.38 times more likely to receive tPA and significantly less likely to die one year post-discharge than patients treated at non-GCASR facilities. With an aging Georgia population8 entering the strokeprone years, however, the number of Georgians affected by stroke is expected to rise over the next decade, increasing costs, both financially and in productive years of life lost. While our EMS and hospitals are working to improve outcomes for stroke patients, thousands of Georgians are still having strokes annually. We must continue to improve stroke prevention and treatment across the state by reducing the prevalence of stroke risk factors in Georgia, and increasing public awareness of stroke signs and symptoms and knowledge to call 911 immediately for stroke. We must also continue to enhance hospital-based treatments of acute stroke to limit the damage to the brain that stroke causes. Additionally, ongoing research on new stroke treatments could benefit those who are not eligible for currently-available therapies. Although we've made great progress, there's a great deal more to do to address this major public health problem in Georgia.

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Notes
A. The data elements collected by Georgia EMS changed from 2009 to 2010, therefore Georgia EMS data may not be entirely comparable from year to year.
References
1. Georgia Death Data 2010. Georgia Vital Records, Georgia Department of Public Health. For more information: http://health.state.ga.us/programs/vitalrecords/index.asp
2. Roger VL, Go AS, Lloyd-Jones DM, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2012;125:e2e220. Available at: http://circ.ahajournals.org/content/125/1/e2.full.pdf+html
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; 333:15811588. Available at: http://www.nejm.org/doi/full/10.1056/NEJM199512143332401#t=article
4. 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
5. Clarkson, LS. 2006 Georgia Stroke and Heart Attack Awareness Survey. Georgia Department of Human Resources, Division of Public Health, October 2008. Publication Number: DPH08/335. Available at: http://health.state.ga.us/pdfs/epi/cdiee/2008SHAAwarenessSurveyReport.pdf
6. Georgia Behavioral Risk Factor Surveillance System Data 2009 and 2011. Chronic Disease, Healthy Behaviors, and Injury Epidemiology, Georgia Department of Public Health. For more information: http://health.state.ga.us/epi/brfss/index.asp
7. Georgia Coverdell-Murphy Act. SB 549, Section 31-11-116. 14 May 2008, Official Code of Georgia Annotated, 2008. Available at: http://www1.legis.ga.gov/legis/2007_08/pdf/sb549.pdf
8. US Administration on Aging, Department of Health and Human Services. State Projections of Population Aged 65 and over: July 1, 2005 to 2030. Available at: http://aoa.gov/AoARoot/Aging_Statistics/future_growth/docs/State-Percent_65+yr-ageprojections-2005-2030.xls

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Definitions
Anticoagulation, Antiplatelet, and Antithrombotic Medications: Medications that reduce blood clotting.
Deep Vein Thrombosis: When a blood clot forms in a vein deep in the body, usually in the leg. If the clot breaks off, it can cause serious complications and even death.
Door-to-Needle Time: Time elapsed in minutes from when an eligible stroke patient arrives at the hospital to when tPA is administered. Eligible patients must receive tPA 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.
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.
Hemorrhagic Stroke: A stroke caused by a blood vessel rupturing and bleeding in the brain. Hemorrhagic strokes are often fatal.
Lipid Profile: Panel of tests to measure cholesterol and triglyceride levels. High cholesterol is a risk factor for stroke.
Tissue Plasminogen Activator (tPA): FDA-approved clot-busting drug for stroke. This drug can reduce disability by 30% in stroke sufferers if given to eligible patients within 3 hours of symptom onset.

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

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