An approach to coordinate efforts to reduce the public health burden of stroke: the Delta States Stroke Consortium

Stroke is the third leading cause of death and a leading cause of disability in the United States, with a particularly high burden on the residents of the southeastern states, a region dubbed the "Stroke Belt." These five states — Alabama, Arkansas, Louisiana, Mississippi, and Tennessee — have formed the Delta States Stroke Consortium to direct efforts to reduce this burden. The consortium is proposing an approach to identify domains where interventions may be instituted and an array of activities that can be implemented in each of the domains. Specific domains include 1) risk factor prevention and control; 2) identification of stroke signs and symptoms and encouragement of appropriate responses; 3) transportation, Emergency Medical Services care, and acute care; 4) secondary prevention; and 5) recovery and rehabilitation management. The array of activities includes 1) education of lay public; 2) education of health professionals; 3) general advocacy and legislative actions; 4) modification of the general environment; and 5) modification of the health care environment. The Delta States Stroke Consortium members propose that together these domains and activities define a structure to guide interventions to reduce the public health burden of stroke in this region.     

Das Kompetenznetz Schlaganfall

In 1999 the German Ministry of Education and Research initiated a funding initiative for competence networks in health research in order to improve research and health care for major diseases with high morbidity and relevance to public health. All major players in a given field were invited to cooperate. The aims were to improve horizontal as well as vertical networking in order to improve research quality and the transfer of new results into general clinical practice. Another aim was to establish sustainable structures for lasting cooperation. After a highly competitive application round, the Competence Network Stroke was among the very first to be funded. The incidence of stroke in Germany is about 250,000 new patients per year, it is the leading cause of adult impairment and its societal impact is dramatic.     

亟待建立中国卒中中心网络

卒中是中国最常见、最严重的疾病,各国研究表明发展卒中中心能大大改善卒中医疗服务质量,文章系统回顾了欧美发达国家初级、高级卒中中心建设标准,并提出了中国卒中中心网络建设的相关建议。     

The quality and adequacy of care received at home in the last 3 months of life by people who died following a stroke: a retrospective survey of surviving family and friends using the Views of Informal Carers Evaluation of Services questionnaire

Stroke is the third leading cause of death in the UK. Despite this, little is known about the care needs of people who die from or following a stroke. In early 2003, a total of 183 questionnaires were returned from a survey of 493 people who had registered a stroke-related death in four Primary Care Trusts, giving a response rate of 37%. This paper reports on 53 deceased from the survey who had lived at home during their last 3 months and who had been ill for more than 1 month. The data were analysed to explore the role of informal carers and the provision of community-based care in the last 3 months of life. Family and friends helped 82% of deceased with household tasks, 68% with personal care, 66% with taking medication and 54% with night-time care. By contrast, health and social services helped 30% with household tasks, 54% with personal care, 20% with taking medication and 6% with night-time care. Two-fifths (43%) of informants had to give up work or make major life changes to care for the deceased, and 26% of informants found looking after them 'rewarding'. Half (51%) reported that help and support from health services were excellent or good compared to 38% for social services. Results from the Regional Study of Care for the Dying indicated that people who died from a stroke in 1990 and their informal carers would have benefited from increased levels of community-based care and enhanced communication with care professionals. Our data suggest that informal carers continue to provide the majority of care for those who die from stroke, despite government initiatives to improve care for stroke patients and frail elderly people. Further research is required to explore best practice and service provision in caring for this group.     

Prevalence of stroke--United States, 2005

Stroke is the third most common cause of death in the United States. Stroke also results in substantial health-care expenditures; the mean lifetime cost resulting from an ischemic stroke is estimated at $140,000 per patient. Nationwide, costs related to stroke are expected to reach an estimated $62.7 billion in 2007. Stroke death rates are higher in the southeastern United States, compared with other regions of the country; blacks, American Indians/Alaska Natives (AI/ANs), Asians/Pacific Islanders, and Hispanics die from stroke at younger ages than whites. Regional and national data on self-reported stroke prevalence have been published previously; however, state-specific prevalence data for persons with a history of stroke have not. To provide national-level stroke prevalence estimates by age group, sex, race/ethnicity, and education level and overall prevalence estimates for each of the 50 states, the U.S. Virgin Islands (USVI), the District of Columbia (DC), and Puerto Rico, CDC analyzed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of that analysis and provides the first state-based prevalence estimates of stroke. The results indicated that, in 2005, substantial differences existed in the prevalence of stroke by state/territory, race/ethnicity, age group, and education level. To lower the incidence of stroke and meet the Healthy People 2010 objective to reduce stroke deaths (objective no. 12-7) and the overall goal to eliminate health disparities, public health programs should augment stroke risk-factor prevention and educational measures in disproportionately affected regions and populations.     

Differences in disability among black and white stroke survivors--United States, 2000-2001

Stroke is a leading cause of serious, long-term disability in the United States and was responsible for an estimated 53.6 billion dollars in direct and indirect costs during 2004. Stroke survivors can experience residual physical, psychological, and social impairment; nearly 45% of all stroke survivors aged > or =65 years have moderate or severe disability. Furthermore, persons in certain racial/ethnic populations experience disparities in stroke-related disability. To assess the prevalence of functional limitations among U.S. adult stroke survivors and to examine potential racial/ethnic disparities in stroke-related disability, CDC analyzed National Health Interview Survey (NHIS) data from 2000-2001. The results of this analysis indicated that black stroke survivors had greater activity limitations than white stroke survivors. To increase the quality and length of life among stroke survivors and to eliminate disparities in stroke incidence, greater efforts are needed to implement stroke prevention and intervention activities among black populations, particularly young to middle-aged adults. Increasing public awareness of stroke-related warning signs and encouraging patients to seek immediate treatment might reduce stroke-related disabilities and costs.     

Public health and aging: hospitalizations for stroke among adults aged >/=65 years--United States, 2000

Stroke is the third leading cause of death in the United States and a major cause of serious, long-term disability among adults; the projected cost of stroke during 2003 is $51 billion, including $12 billion in nursing home costs. During 1988-1997, the rate of hospital admissions for stroke increased 18.6%, from approximately 560 per 100,000 population in 1988 to 664 in 1997. To assess the burden of stroke hospitalizations and discharge status after hospitalization among U.S. residents aged >/=65 years, CDC analyzed Medicare hospital claims for persons with stroke during 2000 for the 50 states and the District of Columbia (DC). This report summarizes the results of that analysis, which indicate that geographic variation exists in both rates of hospitalization for stroke and patient discharge status. Reducing the burden of stroke in the United States will require primary prevention and control of risk factors, public education, early evaluation and treatment of persons with acute stroke, and effective secondary prevention among persons living with stroke.     

Atrial fibrillation as a contributing cause of death and Medicare hospitalization--United States, 1999

Stroke is the leading cause in the United States of serious long-term disability and the third leading cause of death. One of the major risk factors for stroke is atrial fibrillation (AF), a common cardiac disorder characterized by cardiac arrhythmia and the absence of coordinated contractions, which increases the risk for blood stasis, clot formation, and embolic stroke. AF affects approximately 2.2 million adults in the United States and is the most common sustained heart rhythm disturbance observed in clinical practice. The rate of AF increases with age, from < 1% among persons aged < 60 years to approximately 10% among persons aged > or = 80 years. The frequency with which AF is reported on death certificates as a contributing cause of death has increased since 1980. To assess the burden of AF-related deaths and hospitalizations among U.S. residents, CDC analyzed national and state multiple-cause mortality statistics and Medicare hospital claims for persons with AF in 1999 (the latest year for which data were available) for the 50 states and the District of Columbia. The findings indicate that AF as a contributing cause of death and hospitalization affects primarily persons aged > or = 75 years and that death and hospitalization rates vary by state. Public and medical education are needed to prevent and reduce AF-related disability and death.     

Implementation of a surveillance system for stroke based on administrative and clinical data in the Lazio region (Italy): methodological aspects

Stroke is the third leading cause of death and the most important cause of long-term disability in Italy and other developed countries, heavily influencing quality of life and costs of health care. In spite of the widespread occurrence of the disease and its relevant impact in Italy, there is neither a national nor a regional surveillance system of cerebrovascular diseases. A regional surveillance system for stroke has two important aims: to help to interpret the geographical and temporal trends of the disease for health care planning and resource allocation and to allow close monitoring of the quality of stroke services. Age-standardized mortality rates for cerebrovascular diseases in the Lazio region (5,242,709 inhabitants) in the period 1998-99 were 69.4 for males and 59.4 for females per 100,000 inhabitants. In the year 2000, about 3% of all hospital discharges were for cerebrovascular diseases with a hospitalisation rate of 4.36 per 1000 inhabitants. The mean length of stay is 12 days (median of 9 days) and in-hospital death is 15.4%. The admission rate for cerebrovascular diseases to emergency departments is 3.40 per 1000 inhabitants. The goal of the Lazio Regional Health Authority is to implement a surveillance system for stroke based both on current data (mortality and discharge data) and on information collected in a registry for quality assessment of stroke care. The first step of the study is to develop a regional register of acute stroke using an 'ad hoc' data sheet integrated in the computer-based patient record system of clinical and administrative data (GIPSE) operating in all emergency departments in the region.     

Age-specific excess deaths associated with stroke among racial/ethnic minority populations--United States, 1997

Stroke was the third leading cause of death in the United States in 1997. During 1950-1996, age-standardized stroke death rates declined 70% for the entire U.S. population; however, the decline varied among racial/ethnic populations. The estimated number of stroke deaths by race/ethnicity and age illustrate the differences in stroke mortality that may be used to direct prevention efforts. This report presents an analysis of stroke mortality by age and racial/ethnic group; the findings indicate that for persons aged 35-64 years, excess stroke deaths and higher risk for stroke mortality occurred among members of U.S. racial/ethnic minority populations than among the non-Hispanic white population.     

Social work's partnership in community-based stroke prevention for older adults: a collaborative model

Stroke prevention includes public education and community- based screenings to identify stroke risks. Even though more than half of all strokes are preventable, the incidence has increased in recent years and remains the leading cause of adult disability. Age is highly associated with stroke and twice as likely to occur with each decade after age 55. Risks fall into one of two categories. One category, such as obesity and high blood pressure, are controllable through behavior change and/or preventive medical care. The other category of risks, such as age or race, are not controllable. Stroke risks tend to occur in multiples that interact to heighten individual effects, thus, interdisciplinary methods to identify and reduce risk may be required. Social workers can play a key role in these partnerships. Social work's skills base in gerontology, psychosocial interventions, and empowerment through community organization are ideal for early intervention and behavior change. This article describes a collaborative community-based model for screening older adults for stroke risk and lessons learned from a three-month risk reduction follow-up.     

Human health research and policy development: experience in the Great Lakes region

As a direct outgrowth of industrial and agricultural activities, the quality of the Great Lakes ecosystem has declined significantly because of toxic substances in the water, eutrophication, overfishing, and invasive species that have been introduced into the waterways. Although measures have been adopted to restore the health of the ecosystem, contamination of Great Lakes sport fish continues arising from conditions that still prevail, but on a more limited scale. As a consequence, the Great Lakes states have issued guidelines for the public in the form of health advisories for fish consumption to encourage practices that will minimize exposure to contaminants found in Great Lakes sport fish. Scientific research has strongly influenced many policy decisions, including the development of laws, rules, and guidelines applicable to public health not only in regard to fish advisories but also other issues impacting human health. This paper proposes to outline how policy has been influenced by scientific findings and the far-reaching effect that these decisions have had on the health status of the public in the Great Lakes area and its potential for influencing the nation as a whole and our global neighbors. Within the Great Lakes basin, polychlorinated biphenyls (PCB) and mercury are the subject of the greatest number of fish advisories. Great Lakes-based researchers have studied populations residing in the Great Lakes basin to determine their level of awareness concerning fish consumption health advisories. They found that almost 50% of the residents who consumed Great Lakes sport fish were aware of sport fish consumption advisories. Of those with awareness, almost 60% were males and only about 40% were females. The researchers attributed the greater awareness among males to the health advisory materials that males receive with their fishing licenses and to their contact with fishing-related groups. The lower level of awareness among women regarding fish consumption advisories subsequently prompted the researchers to recommend targeting risk communication programs for female consumers of Great Lakes sport fish, particularly women of reproductive age. The Wisconsin Department of Health and Family Services subsequently followed the recommendation and developed uniform outreach materials for women, minorities, and the general public to be used by the Great Lakes states. The policy change directing educational materials to at-risk groups (e.g., women of reproductive age and minorities) is a direct outgrowth of the finding of low awareness about fish advisories among women who were interviewed.     

Impact of systems of care and blood pressure management on stroke outcomes

Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.     

Social Work's Partnership in Community-Based Stroke Prevention for Older Adults

Abstract

Stroke prevention includes public education and community-based screenings to identify stroke risks. Even though more than half of all strokes are preventable, the incidence has increased in recent years and remains the leading cause of adult disability. Age is highly associated with stroke and twice as likely to occur with each decade after age 55. Risks fall into one of two categories. One category, such as obesity and high blood pressure, are controllable through behavior change and/or preventive medical care. The other category of risks, such as age or race, are not controllable. Stroke risks tend to occur in multiples that interact to heighten individual effects, thus, interdisciplinary methods to identify and reduce risk may be required. Social workers can play a key role in these partnerships. Social work's skills base in gerontology, psychosocial interventions, and empowerment through community organization are ideal for early intervention and behavior change. This article describes a collaborative community-based model for screening older adults for stroke risk and lessons learned from a three-month risk reduction follow-up.     

The Minnesota Heart Disease and Stroke Prevention Plan 2011-2020

Although Minnesota is known as a heart-healthy state, heart disease and stroke are still among the leading causes of death for people living here, especially those in certain racial and ethnic groups. To address this concern and reduce the overall incidence of heart disease and stroke, the Minnesota Department of Health's Heart Disease and Stroke Prevention Unit led an effortto create the Heart Disease and Stroke Prevention Plan 2011-2020. This article describes the plan's fundamentals and some of its recommendations.     

Implementing a community education program on stroke for health care providers and consumers

Stroke remains a leading killer and cause of disability in the United States. The incidence of stroke appears to be increasing while new advances in the management of stroke continue to emerge. These realities emphasize the need to communicate advances to health care providers and consumers. However, educating health care providers and consumers in rural states is often difficult due to dispersed geographic distribution and lack of resources. This project, utilizing teleconferencing technology, brought an educational program on stroke management for providers and consumers into rural communities. Community hospitals, with teleconferencing capability, were identified throughout Vermont. Community providers and consumers were invited to participate in educational sessions using a variety of marketing methodologies. A multidisciplinary team designed two curricula (one for providers and one for health care consumers) on the management of stroke. A total of 211 health care professionals and 122 consumers participated in the program. Education session evaluations suggested that the program either met or exceeded participants' expectations for the majority of programs. This project demonstrated that academic centers can provide quality continuing medical education for their rural communities using teleconferencing technology. Experience with this program suggests that there are three key elements for success: adequate planning time, communication on multiple levels, and strong marketing strategies.     

An Emergency Medical Services Toolkit for Improving Systems of Care for Stroke in North Carolina

The Centers for Disease Control and Prevention is partnering with the National Association of Chronic Disease Directors and the North Carolina Office of EMS to design, develop, and implement an emergency medical services (EMS) performance improvement toolkit to evaluate opportunities to improve the emergency identification and treatment of acute stroke. The EMS Acute Stroke Care Toolkit is being developed, tested, and implemented in all 100 counties in the state by the EMS Performance Improvement Center, the agency that provides technical assistance for EMS in North Carolina. The toolkit helps each EMS system in defining, measuring, and analyzing their system of care and promotes collaboration through public education, regional stroke planning with hospitals, EMS service configuration, EMS staffing patterns, EMS education, and timely care delivery. We outline the issues surrounding acute stroke care, the role of emergency medical systems in stroke care, and the components of the EMS Acute Stroke Care Toolkit designed to improve EMS systems and outcomes for stroke patients.     

Place of death after stroke--United States, 1999-2002

Stroke is the third leading cause of death in the United States. Successful acute stroke intervention depends on early recognition of symptoms, prompt emergency transport, and rapid in-hospital treatment. However, approximately half of stroke decedents die before admission to the hospital. During 1990-1998, the proportion of stroke deaths that occurred in hospitals declined, and the proportion occurring before transport to hospitals increased. This report summarizes trends in the place of death among all stroke decedents, the proportion of stroke deaths occurring before emergency assistance arrives, and characteristics associated with place of death. Among 162,672 persons who died of stroke in 2002, 49.2% died pre-transport, 0.4% were dead on arrival (DOA), 3.3% died in emergency departments (EDs), and 47.0% died after admission to a hospital. Early patient and bystander recognition of stroke symptoms and timely action in calling for emergency assistance might reduce the number and proportion of stroke deaths. In addition, improving timely arrival of emergency care and appropriate treatment of stroke patients can reduce the proportion of pre-transport deaths and serious sequelae that lead to severe disabilities.     

Outpatient rehabilitation among stroke survivors--21 States and the District of Columbia, 2005

Stroke is a leading cause of severe and long-term disability in the United States. Approximately 700,000 persons in the United States have a new or recurrent stroke each year; among those who survive, only 10% recover completely, and many of the remaining survivors need rehabilitation because of resulting impairments. Long-term disability not only affects functional status and social roles among stroke survivors but also results in substantial costs; the combined direct and indirect costs of stroke are projected to be $62.7 billion in the United States in 2007. Although studies have established that timely and intensive rehabilitation can substantially improve patients' functional outcomes and quality of life after an acute stroke, few studies have provided population-based estimates of the prevalence of acute stroke rehabilitation. To examine the prevalence of outpatient stroke rehabilitation among selected populations, CDC assessed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey on stroke survivors in 21 states and the District of Columbia (DC). This report summarizes the results of that assessment, which indicated that 30.7% of the stroke survivors received outpatient rehabilitation and a higher prevalence of outpatient stroke rehabilitation was reported among men, non-Hispanic blacks, unemployed or retired adults, and persons living in the center city of a metropolitan statistical area (MSA) than in comparison groups. The findings indicated that the prevalence of stroke survivors who were receiving outpatient stroke rehabilitation services was lower than would be expected if clinical practice guideline recommendations for all stroke patients had been followed. Increasing the number of stroke survivors who receive needed outpatient rehabilitation might lead to better functional status and quality of life in this population.     

Assessment of mercury emissions inventories for the Great Lakes states

Anthropogenic mercury (Hg) air emissions for the eight Great Lakes states in 1999-2000 were evaluated by analyzing three inventories. The US Environmental Protection Agency (EPA) National Emissions Inventory (NEI) had the most complete coverage for all states, and total Hg emissions ranged from 4226 lb in Minnesota to 15,828 lb in Pennsylvania. Coal-fired electric utilities accounted for 52.7% of the region's Hg emissions, varying from 20.2% of the total in New York to 67.5% in Ohio. Other important contributors to regional emissions included municipal waste combustion (5.6%), mercury-cell chlor-alkali plants and hazardous-waste incinerators (4% each), stationary internal combustion engines (ICEs) (3.5%), industrial, commercial, and institutional (ICI) boilers (3.3%), and lime manufacturing (3.0%). Although medical waste incineration accounted for just over 1% of regional emissions using the original classifications, the inclusion of health care facilities that may have been inappropriately identified with other sectors would increase the sector to 4.5% of regional emissions (and decrease the stationary ICE sector to 1.4% of the regional total). There were substantial differences for some sectors between the NEI and the Great Lakes Regional Air Toxics Emissions Inventory (GLEI), as well as unexplained differences within inventories between states (particularly for the cement, lime, and asphalt industries, and for lamp breakage). Toxics Release Inventory data for 2000 mainly covered electric utilities, and differences from the NEI were significant for several states. An independent assessment indicates the possibility of underestimated Hg emissions by about twofold for ICI boilers, although data for the sector (in particular concerning fuel oil emissions) are highly uncertain. Limited data indicate the likelihood of significant underestimates of electric arc furnace mercury emissions in the NEI and GLEI inventories. Several measures are here identified for improving the reliability of the inventories, both for modeling of atmospheric transport and deposition modeling and for tracking progress in Hg reduction initiatives.