May 4, 2022
Stroke prevention was the topic of the 21st Annual Rural Health Conference hosted by the College of Community Health Sciences and its Institute for Rural Health Research.
The conference, “Tightening the Stroke Belt: Prevention, Emergency Management, and Rehabilitation of Stroke in the Nation’s Most Affected Region,” was held April 14-15 at the Bryant Conference Center on The University of Alabama campus.
Highlights from keynote speaker presentations:
Dr. Richard Benson, director of the Office of Global Health and Health Disparities in the National Institute of Neurological Disorders and Stroke/Division of Clinical Research –
The National Institute of Neurological Disorders and Stroke is committed to reducing the disproportionate burden of neurological disease borne by underserved populations by increasing diversity in clinical trials, Benson said. According to NINDS data, 40% of black-white stroke incidence disparity is attributable to traditional risk factors (high blood pressure, diabetes, heart disease), while some part of the remaining 60% might be related to structural racism. “Clinical recruitment of diverse populations is important – race, ethnicity, gender, age and socioeconomic. We need to have diverse people in clinical trials. Community engagement is key, it’s so important. We have to listen to the community.”
Dr. Toby Gropen, chief of the Division of Cerebrovascular Disease and director of the Comprehensive Neurovascular and Stroke Center at the University of Alabama at Birmingham –
Stroke is the fifth leading cause of death and the leading cause of disability in the United States. On average, every 40 seconds in the U.S. someone has a stroke, and every four minutes someone dies of a stroke, Gropen said. “Studies show earlier treatment is better.” He described a severity-based stroke triage project in Alabama that is two years into its five-year timeline. The goal of the project, modeled after and coordinated by the Alabama Trauma Communications Center, is to improve timely access to treatment for stroke patients. “Severity-based stroke triage separates severe stroke from less severe stroke,” Gropen said. “When a person is suspected of having a stroke, EMS calls the center and is directed to a hospital that can help. The center is a unique resource.”
Dr. Suzanne Judd, director of the Lister Hill Center for Health Policy and professor with the School of Public Health at the University of Alabama at Birmingham –
“We see more risk of stroke in more rural areas,” Judd said. Why? There are the traditional contributing risk factors, such as high blood pressure, diabetes and heart disease, which are higher in rural areas. “If more people are having strokes (stroke incidence), we need to focus on diabetes and hypertension. If people are more likely to die after stroke (case fatality) we need to look at what’s happening in hospitals. Urban and rural disparities are higher with stroke incidence than case fatality.” Still, we have to drill deeper, Judd said. “What else is going on in rural areas?” She highlighted other factors that can contribute to a higher incidence of stroke in rural communities: socioeconomic risk factors, including lower income levels and poorer education systems; psychosocial risk factors, including depression, poor water systems and other environmental impacts, as well as a lack of social support systems, health insurance and access to primary care. “Hypertension and access to care in your 30s and 40s really matters,” Judd said.
Dr. Chen Lin, assistant professor and director of the Stroke Recovery Clinic for the Division of Cerebrovascular Disease/Department of Neurology at the University of Alabama at Birmingham –
The National Institute of Neurological Disorders and Stroke estimates there are seven million stroke survivors in the United States, and about 40% have been disabled by their stroke. “Brain tissue dies with stroke. If you get to the hospital ASAP, you have a better outcome and a better after quality of life,” Lin said. He said for stroke patients, rehabilitation is important, contributing to a 28% decrease in mortality at four months, and a 21% decrease at one year. He said post-stroke interprofessional care is vital, and cited the UAB Stroke Recovery Clinic, which provides care from neurologists, neuro psychologists, and physical, occupational and speech therapists. “Stroke mortality is improving. People are living longer with decreasing risk of future stroke.” Lin said future directions in stroke care and rehabilitation include: treating co-morbidities like pain, post-stroke depression, cognition and poor sleep to improve stroke outcomes; focusing on rural regions; and integrating telehealth. “Telerehabilitation after stroke really hasn’t caught on, but when implemented correctly, many patients did significantly better than standard of care.”
Dr. Michael Lyerly, associate professor and director of Birmingham Veteran’s Affairs Medical Center Stroke Center –
“Alabama is a neurologist desert, and most hospitals don’t have immediate access to a neurologist,” requiring them to rely on consults when caring for stroke patients, Lyerly said. “These are telephone consultants, which they’ve been doing for decades, but there are limitations. They are essentially a chart review and not good for acute care.” There has been a rapid expansion in recent years of telemedicine – video and audio connection to a patient – and with that tele stroke systems that connect stroke providers to patients. “It’s better treatment than phone consultations, and the outcomes are similar as if I treated the patient in the ER. With telemedicine, I can ask the patient questions and do an exam with the help of a nurse there. Telemedicine can help tell us the specific neurological needs of patients and the best place for care based on the type of stroke they’ve had.” Emergency room doctors in hospitals located in under-resourced areas are more comfortable treating stroke patients with the help of telemedicine, and upward of 85% of patients are satisfied with the care they receive through telemedicine, Lyerly said. Tele stroke systems can potentially help improve outcomes among African Americans who experience higher incidences of stroke and “have reduced access to stroke care and longer ER waits.”
Dr. Janet Wright, a director in the Division for Heart Disease and Stroke Prevention for the U.S. Centers for Disease Control and Prevention –
While hypertension is relatively common, control of it is not, Wright said. In the United States, 116 million adults have high blood pressure. Uncontrolled hypertension is a leading cause of stroke. She said control of hypertension is possible through a balance of public health, health care, and employer and individual actions. She encouraged health-care professionals to “make self-monitoring blood pressure your secret weapon against stroke.” Self-measured blood pressure monitoring is the measurement of blood pressure by a patient outside of a clinic setting, including at home. The benefits are that self-monitoring is convenient, improves accuracy of diagnosis and facilitates timely treatment changes, Wright said. But there are challenges, including access to blood-pressure monitors, education and training for patients and clinical teams, and bi-directional data flow and analysis. “We need to propose hypertension as a national priority. Public health professionals can inform local action with local data. Health-care practices can make hypertension control a priority. Wide-spread implementation of these actions can save lives and prevent unnecessary suffering.”
Dr. Shadi Yaghi, director of Neurovascular Research and co-director of the Comprehensive Stroke Center at Rhode Island Hospital –
A stroke is defined as a sudden disabling attack or loss of consciousness caused by an interruption in the flow of blood to the brain, Yaghi said. The vast majority of strokes, 85%, are ischemic strokes caused by a blocked artery in the brain or neck that reduces blood flow to an area of the brain. These are the most serious strokes and “for every minute without blood, the brain ages three weeks. Ischemic strokes are treatable, but you have to act quickly.” Yaghi described the various treatments for ischemic strokes: clot busters; mechanical embolectomy, a new tool that focuses on removing the clot rather than dissolving it; direct aspiration of the clot; and stent-retrievers, a device that aims to grasp the clot and remove it. “We are witnessing a revolution in acute stroke treatment,” Yaghi said, adding that the stent-retrievers treatment is “very powerful. The faster you open the artery, the more brain you save and the better the patient will do.” And there’s another revolution happening – mobile stroke units. “A mobile stroke unit can bring stroke expertise to the patient and initiate treatment at the scene. Patients can be triaged in the field. The future of acute stroke is administering treatments in the field.”
Breakout sessions on issues related to the conference topic were also offered:
Dr. Elwin Crawford, medical director of Emergency Medicine Services for Region IV in the state of Alabama –
Strokes cost the United States billions in health-care costs and missed days of work each year. The Alabama Stroke Acute Care System is working to change that and to improve people’s lives. Crawford provided a history and explanation of the system, which developed from the state’s 26-year-old Trauma Center. “The Trauma Center needed to route patients to hospitals with real-time capabilities to take care of them. There is a decrease in mortality by routing the most critically ill patients to the best hospital for care,” he said. In 2000, the Alabama Stroke Acute Care System started following the same concept used by the Trauma Center, and by 2017 the system was statewide. Hospitals, meanwhile, are categorized by the stroke care they can provide: Level 3 are smaller, community hospitals that are considered stroke-ready; Level 2 are primary stroke centers, such as DCH Regional Medical Center in Tuscaloosa; and Level 1 are comprehensive stroke centers, such as Vanderbilt University Medical Center in Nashville, Grady Memorial Hospital in Atlanta, and UAB Hospital in Birmingham.
Dr. Louanne Friend, associate professor of community medicine and population health at The University of Alabama College of Community Health Sciences, and Suzanne Henson, RD, LD, assistant professor family, internal, and rural medicine at UA’s CCHS –
Management of high blood pressure is not easy, requiring lifestyle modifications, long-term medication adherence and lifetime management. “This can be challenging for patients,” Friend said. As the recipient of a grant awarded several years ago by the Alabama Department of Public Health, Friend has been working to improve high blood pressure control for patients of University Medical Center, which CCHS operates. As part of these efforts, a hypertension template was embedded into the UMC electronic health record. The template was piloted at UMC’s Northport clinic to identify patients with undiagnosed hypertension, those “hiding in plain sight,” Friend said. During the first year of the grant, 11 UMC-Northport patients were enrolled in the self-managed blood pressure program and were provided with automatic blood pressure cuffs, hypertension lifestyle education books and they received weekly phone calls from a nurse for lifestyle coaching. “The diagnosis of hypertension became a provider priority,” Friend said. Work on the grant was interrupted by the COVID-19 pandemic but will soon resume. Henson, also a part of the project, provided hypertension classes for patients beginning in fall 2019. The classes were suspended during COVID-19 but have recently restarted. She said hypertension education is important because “low adherence to antihypertensive medication is common and is a major contributing factor to uncontrolled blood pressure.” The class encourages participants to also use non-pharmacological approaches to lower their blood pressure.
The annual Rural Health Conference is attended by health-care providers, researchers, community leaders, government officials and policymakers who hear from prominent speakers in the field and share information and knowledge about rural health issues.