Reduce stroke death rate, reduce stroke rate, and reduce burden of stroke.

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• Stroke death rate age-adjusted per 100,000 population (Chart).
• Stroke hospital discharge rate per 10,000 population (Chart).
• Transient ischemic attack (TIA) or mini-stroke hospital discharge rate per 10,000 population.

• % “Told have high blood pressure” (Chart).
• %  On medication for high blood pressure (Chart).
• %  On medication for high blood pressure with blood pressure ≥ 130/90.
• %  Adults who smoke (Chart).
• %  Adults body mass index > 30 (Chart).
• %  Adults with sedentary lifestyle (Chart).
• %  Adults with diabetes (Chart).
• %  Who consumed alcohol > two drinks per day for men and more than one drink per day for women (Chart).
• Diabetes hospital discharge rate per 10,000 population (Chart).
• Ratio of primary care physicians to population (Chart).
• % Population with atrial fibrillation.

North Hawaii and Hawaii County have stroke death rates, except in 2004 and 2005, which are consistently higher than the other counties, State and the Healthy People 2010 goal.  It is unclear whether the dramatic drop in 2004 and 2005 is a variation associated with small numbers or a real trend.  Risk factors for stroke and stroke deaths can be conceptualized in three categories: (Hawaii County is relatively high in many of these risk factors).

Individual risk factors include high blood pressure, obesity, smoking, diabetes, sedentary lifestyle, heavy alcohol use and atrial fibrillation. 

Population risk factors include inadequate access to primary care, that is a low ratio of primary care providers to population, and  high income inequality (gap between highest and lowest income).

Health System risk factors include high uninsured rate, inadequate workforce, (primary care, EMS, acute care, and rehabilitation) fragmentation of care, long transportation times to ER, acute care and tertiary care, degree of commitment to and support for quality and systems improvement.

• Individual:

  • Decreasing high blood pressure has been clearly documented to have the highest impact in reducing strokes and stroke death rates (Source: “Prevention of First Stroke” Phillip B. Gorelick, M.D., MPH, Daniel F. Hanley, et al. JAMA 1999;28 1:1112-1120).
  • Lifestyle modification and medical management JNC to reduce high blood pressure and other risk factors (See www.nhlbi.nih.gov).
  • Increase appropriate self management of high blood pressure through home blood pressuring monitoring.
  • Appropriate use of anticoagulants for atrial fibrillation.

  Population:

  • Health and Human Services Stroke Belt Initiative.
  • Franklin Project, Community-wide approach.

• Hawaii Heart Brain Center at North Hawaii Community Hospital – Community Partnership for Prevention Committee working on increasing awareness of stroke and its risk factors, increasing blood pressure screening and stroke risk factor screening and training volunteers to perform stroke risk factor screening. 
• Hawaii County Fire department doing free blood pressure checks.
• North Hawaii Community Hospital – Participating in “Get with the Guidelines Stroke” Program.

Increase Awareness:

• Increase awareness of high stroke death rate and risk factors on Hawaii Island through partnerships with American Stroke Association, National Stroke Association, Providers, Employers and U.S. Department of Health and Human Services.
• Increase awareness of high blood pressure as key intervention and reducible risk factor.
• Increase awareness of Fire Department screening for high blood pressure.
• Increase awareness of stroke signs and symptoms, and need to call 911.
• Increase awareness of stroke warning signs and “time is brain.”
• Increase awareness of resources for stroke screening, prevention and treatment.
• Increase awareness of resources for life-style management.
• Transient ischemic attack as an opportunity to prevent larger stroke.

Obtain Additional Data:

• Comparison of transient Ischemic Attack (TIA) hospitalization rate by County and by hospital.
• Comparison of mortality rates by County and by hospital.
• Work with Department of Health to add annual monitoring of blood pressure to annual behavioral risk factor surveillance survey.
• Develop statewide stroke registry and Big Island Hospital Stroke Registry.
• Ratio of primary care physicians to population on annual basis.
• Rehabilitation data on number and percent of stroke patients receiving both in and out patient rehab and outcomes.
• Number of ER admissions for hypertension crisis and for TIA by County and by hospital.

Inventory and Build on Existing Resources:

• Inventory list of primary care providers in North Hawaii who will accept new patients.
• Inventory lifestyle support resources for: weight management, nutrition and exercise.
• Inventory culturally and linguistically appropriate stroke prevention patient information.
• Inventory stroke rehabilitation resources.

Increase Organizational Links:

• Improve health care provider links with effective lifestyle management programs for nutrition, exercise, smoking cessation, weight reduction, stress reduction, blood pressure self management and diabetes self management.
• Increase links between employers and community screening and lifestyle prevention resources.
• Develop State stroke strategic plan.
• Increase links with referral centers: Cleveland Clinic and University of California – San Francisco.
• Increase collaboration between Big Island hospitals, EMS, and Queen’s Medical Center on Stroke System of Care, as well as University of California-San Francisco and Cleveland Clinic.

Identify and Address Barriers:

• Inadequate primary care workforce.
• Inadequate reimbursement for primary care.
• Access to life style modification support.

Promote Effective Programs:

• Increase community wide screening for stroke risk factors. 
• Community-wide approaches to increase identification and effective management of high blood pressure, including lifestyle management (See www.nhlbi.nih.gov).
• Increase high blood pressure self management and access to home blood pressure monitoring.
• Partner to increase capacity for access to state-of-the-art stroke out patient rehabilitation.

Promote Effective Practices:

• Free Fire Department blood pressure screening.
• Partner to support employee wellness programs targeted to identifying and managing high blood pressure.

Promote Effective Policies:

• Independent review of provider reimbursement policies.

Improve Health Systems:

• Professional development on:  best practices in stroke prevention, acute stroke management, TIA management, and state-of-the-art stroke rehabilitation.
• Develop emergency consultation services and transfer protocols for patients requiring advanced stroke therapies not available in North Hawaii.

Acknowledge Champions and Progress:

• Hawaii Heart-Brain Center at the North Hawaii Community Hospital.
• Department of Health Stroke Data Committee.
• Department of Health and American Heart Association State Stroke Strategic Planning Group.
• Hawaii County Fire Department for blood pressure screening