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For decades, medical research has shown that Mississippi and states in 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,” said 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.

The good news for Mississippi is that the state has been consistent when it comes to the stroke mortality rankings, Howard said. The bad news is that the state has always ranked poorly.

“Everything that’s bad about the South strokewise, Mississippi is a powerful participant and collaborator in,” Howard said. “Basically, it’s been really, really high.”

How high? In 2004, 1,632 Mississippi residents died of stroke, according to a report by the Mississippi Department of Health. That was 5.9 percent of all deaths in the state.

The state’s stroke death rate is nearly 24 percent higher than the national average. The difference is even greater among blacks in Mississippi and the rest of the country.

Between the ages of 45 and 65, blacks are at a 300 percent increased risk of stroke, Howard said.

The increased risk is even greater than what would result if every black citizen were both hypertensive and diabetic, and no white people were, Howard said.
Howard is the principal investigator on an NIH-funded study, REGARDS or reasons for racial and geographic differences in stroke.

The study will look at 30,201 people nationwide, 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.

Either way, the economic impact of strokes is staggering. Each stroke costs around $140,000. In Mississippi, the lost productivity and medical costs from stroke in one year would be close to $231.3 million.

Mississippi and other members of the Delta States Stroke Consortium are fighting to reduce the number and deaths from stroke. Arkansas is heading the effort. The other members of the consortium are Alabama, Louisiana and Tennessee.

The consortium is assessing the problem of stroke in the region, the strengths of the health care systems, and the systems’ needs in preventing and treating stroke, said Dr. Namvar Zohoori, chronic disease director at the Arkansas Department of Health and Human Services.

One possible solution is to encourage hospitals to obtain their Joint Commission certification as primary stroke centers, he said.

For now, Mississippi has only one Joint Commission-certified center, Memorial Hospital in Gulfport.

Teresa Romano, clinical nurse specialist and program development coordinator, Neurosciences and Rehabilitation Services at Memorial, said taking the steps necessary for certification have improved length of stay and outcomes for stroke patients.

In order to be Joint Commission-certified, a hospital must perform a number of tasks within a designated time period, Romano said. For example, a CT scan of the patient must be done and read within 45 minutes. The patient must also be assessed and lab work done in the same amount of time.

There is only a three-hour window for giving the patient IV tPA, or intravenous tissue plasminogen activator, to unclog the arteries causing the stroke, Romano said.

“Time is of the essence. We have to be able to give that drug within three hours of last known normal. So the history that that patient comes in with is paramount,” Romano said. “If we cannot ascertain for certain what the time of the onset was -- the last known normal -- we can’t give the drug.”

Memorial is trying to educate consumers about the signs of stroke and what to do when the signs are spotted, such as calling 911, Romano said. The hospital’s campaign includes television and print advertising.

Delta consortium members have also discussed having rural hospitals connect with stroke treatment centers via the Internet.

Zohoori said telemedicine would allow doctors in rural hospital emergency departments to consult with a neurologist at a larger hospital.

This type of program has been used successfully by Medical College of Georgia and nine rural hospitals.

Romano said Memorial Hospital is also looking at telemedicine sometime in the future.

For now, Memorial is focusing on its internal procedures, Romano said. The next phase will be networking with other hospitals.



May 2008

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