Access, Risk Factors Inflate Arkansas’ Stroke Mortality Rates
Access, Risk Factors Inflate Arkansas’ Stroke Mortality Rates
Medical researchers have known for decades that Arkansas and other members of the Stroke Belt have higher-than-average mortality rates. The question is, why?
“It’s a great mystery, and we really don’t know what’s causing it,” admitted Dr. George Howard, chair of the University of Alabama at Birmingham School of Health’s Department of Biostatics. “I’m fond of saying, ‘We all know what causes it. We just all disagree with each other.’”

There are probably 10 published theories on why the Stroke Belt exists, Howard said. The potential causes include regional risk factors, such as hypertension and diabetes; lifestyle choices and diet; infection and inflammation; differences in the genetic pool; a lack of micronutrients in the drinking water; and regional differences in the quality of healthcare.

“All of these have some data that supports them, but it’s pretty clear that none of them are the magic bullet,” Howard said.

Howard is the principal investigator on an NIH-funded study, REGARDS (Reasons for Geographic and Racial Differences in Stroke).

The study will look at 30,201 people nationwide, with around 1,000 of them in Arkansas, Howard said. He hopes the study will fill in some of the gaps in the current research.

There is good data on mortality rates, Howard said, but there’s not good data that talks about regional variations in stroke incidence.

“In other words, is it southerners having more strokes or is it that strokes are more fatal in the south? Is it because they’re more severe or is it because the quality of care is worse?” Howard said.

The Stroke Belt was first documented in 1964, and may have been around for 100 years or more, Howard said. In the 1960s, the belt centered around Atlanta; Arkansas wasn’t even part of it.

“Over time, what has happened is the Stroke Belt has sort of broken into two pieces, and a part of it has sort of floated out to Arkansas … it’s really strange,” Howard explained.

Researchers who are trying to figure out what’s causing the Stroke Belt also need to think about what could allow the belt to migrate, Howard said.

The people who believe the Stroke Belt is related to a lack of micronutrients in the drinking water argue that Arkansas’s aquifer has changed, Howard said. But that is difficult to believe.

It’s possible that Arkansas’ contributing factors—hypertension, diabetes, lifestyle, and so on—have changed over four decades, Howard said.

It’s also possible that Atlanta’s stroke mortality rate is declining because people from other parts of the country are moving there more rapidly than to Arkansas or Birmingham, he said.

Researchers face a number of fascinating questions, Howard said. It’s not known if a person who moves to a new region takes their stroke risk with them or if they acquire the stroke risk of the new region. If it’s the latter, how long does it take to acquire that new profile?

Arkansas Leading the Nation
Whatever the reason the Stroke Belt moved to Arkansas, it did so in a big way.
Arkansas now has the highest stroke mortality rate in the country. In 2002, strokes killed 2,232 Arkansas residents, according to the Centers for Disease Control. Strokes accounted for roughly 8 percent of the state’s deaths.

In 2005, strokes accounted for 65.1 deaths per 100,000 residents of Arkansas, according to the American Heart Association. The national average was 51.1 deaths per 100,000 people.

Dr. Namvar Zohoori, chronic disease director at the Arkansas Department of Health and Human Services, said the state’s major risk factors for stroke, like other members of the Stroke Belt, involve smoking, hypertension, obesity, and a lack of physical activity.

In addition, Arkansas residents lack access to stroke treatment centers, Zohoori said.

Before this year, Arkansas had only one Joint Commission-certified stroke treatment center. But in January, the Fort Smith center was joined by Baptist Hospital in Little Rock.

The rural nature of the state contributes to the access issues, Zohoori added. Every area is not covered by 911 and emergency services. Even if there is coverage, most rural hospitals are not equipped to deal with stroke patients.
State lawmakers have created a Stroke Task Force to assess the situation, he said. The Health Department staffs the task force, helping examine the scientific research to determine the best ways to address strokes from a public health perspective.

When its research is completed, the task force will make recommendations for the best methods to reduce stroke mortality, Zohoori said.

In addition, Arkansas is leading the five-state Delta States Stroke Consortium, an effort to reduce the number and deaths from stroke. Other members of the consortium are Mississippi, Louisiana, Alabama and Tennessee.

The consortium is assessing the problem of stroke in the region, the strengths of the healthcare systems, and the systems’ needs in preventing and treating stroke.

The Health Department also has a CDC-funded heart disease and stroke prevention program, Zohoori said. The department’s mandate is to work on systems and policy changes.

The Health Department is also involved with public and professional education efforts. Zohoori said the department is working with some clinics to help them put in place the patient management structure that will allow the providers to track patients better, and improve the management of patients’ high blood pressure, high cholesterol and obesity.

Both the Stroke Task Force and the Delta State Strokes Consortium have discussed encouraging hospitals to obtain their Joint Commission certification, Zohoori said.

The Tele-answer?
Another possibility for improving access to healthcare and stroke centers is to use telemedicine, equipping rural hospitals so they can link via the Internet with Joint Commission-certified hospitals, Zohoori said. That way the rural hospitals’ physicians could consult a neurologist without having to hire one of their own.

The telemedicine equipment would allow the ER doctor in the rural hospital to share information and test results directly with the neurologist at a major hospital. The neurologist could then recommend a course of treatment, enabling the rural ER doctor to treat the stroke victim in time.

Then, if necessary, the rural hospital could ship the patient to the major facility.

With telemedicine, the smaller, rural hospitals could avoid the financial and bureaucratic burden required for Joint Commission certification, Zohoori said.
A telestroke system is now being used successfully by the Medical College of Georgia and nine rural hospitals, according to the Joint Commission.

Dr. David Hess, chairman of neurology at Medical College of Georgia (MCG), and other MCG neurologists have been credited with the idea. The neurologists noticed that Georgia’s rural hospitals could not provide stroke care quickly enough because their staffs did not include a neurologist.

A 2005 study published in Stroke showed that of 194 stroke patients in eight rural Georgia hospitals seen via the REACH (Remote Examination of Acute Ischemic stroke) system, most patients got tPA in less than two hours.

Arkansas may get some help from the REGARDS study, but Howard said he does not expect the study to provide the definitive answer to why the stroke belt exists.
He hopes to provide information that can guide interventions that can eventually reduce stroke, Howard said.

High Stroke Rate = High Costs
The Stroke Belt has around 20,000 extra stroke events a year, Howard said. Those are strokes that wouldn’t occur if Stroke Belt residents had strokes the way that people do in the rest of the country.

The cost is staggering. Each stroke costs an estimated $140,000, Howard said. The extra 20,000 strokes in the Stroke Belt cost $3 billion; the costs include care in hospitals and nursing homes and in lost wages.

If the REGARDS study can reduce strokes by 10 percent in the next few years, Howard said he would consider it a major win.

A 10 percent reduction would prevent 2,000 people from having a stroke and reduce costs by $300 million, he said.

“Having people aware of the existence of the Stroke Belt is actually one of the best ways to reduce it,” Howard said.

It’s important for residents in those areas to be more aware of their risk factors, for example hypertension, and to have them treated, Howard said. It’s also important for people who develop stroke symptoms to respond to them.

Caption: Reasons for Geographic And Racial Differences in Stroke (REGARDS) aims to determine why the “stroke belt” — the eight-state region comprising North Carolina, South Carolina, Georgia, Tennessee, Alabama, Mississippi, Arkansas and Louisiana (red) — has a stroke death rate one-and-a-half times the national average. Researchers will also study the “stroke buckle” (orange) — a defined area along the costal plains of North Carolina, South Carolina and Georgia — which has a stroke death rate twice the national average.

April 2008

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