- Email: [email protected]
The stroke belt consortium
Special Report The Stroke Belt Consortium Mark J. Alberts, MD, for the Stroke Belt Consortium
The "Stroke Belt" describes a region of the southeastern United States with a high incidence of stroke and mortality due to stroke. In an effort to address the problem of stroke in this region, we have formed the Stroke Belt Consortium (SBC). This report describes the formation and functions of the SBC. The SBC is a unique organization with representatives from many areas, including health care, government, nonprofit organizations, the pharmaceutical industry, minority groups, educational groups, and managed care. The goals of the consortium are to advance public and professional education about stroke in the Stroke Belt, with a special emphasis on the populations in that region. The first meeting of the consortium was held in November 1994. Many helpful and innovative ideas and initiatives were generated at the first SBC meeting. These included improved techniques for professional education, the development of a mass media campaign for public education, screening of college students for stroke risk factors, and using fast-food restaurants and sporting events as venues to promote stroke education. This type of organized effort may produce cost-effective programs and initiatives, particularly for largescale educational efforts, that will enhance the prevention and treatment of stroke patients. If successful in the Stroke Belt, similar organizations can be formed in other regions of the nation to address specific issues related to stroke prevention, education, and treatment. Key Words: Cerebrovascutar disease--Epidemiology-Treatment--Education.
The incidence and mortality of stroke is not evenly distributed within the United States. Numerous studies have shown that the southeastern states have the highest stroke incidence and mortality in the country. 1,2 To organize a comprehensive and wide-ranging effort to address the problem of stroke in the Southeast, we have formed the Stroke Belt Consortium (SBC). The SBC represents a unique joining of people and resources from m a n y different venues. This report reviews the formation of the SBC, along with its short-term and long-term goals. It is hoped that if successful, the SBC will serve as a model for cooperative efforts in other regions of the nation.
From the Duke University Medical Center, Durham, NC. Received September 7,1995; accepted October 3, 1995. Address reprint requests to Mark J. Alberts, MD, Division of Neurology, PO Box 3392, Duke University Medical Center, Durham, NC 27710. Copyright © 1996by National Stroke Association 1052-3057/96/0601-0003503.00/0
54
What is the Stroke Belt? The southeastern states have the highest incidence and mortality of stroke in the United States (Table 1). Although it is unclear w h y this is the case, several factors have been cited as possible contributors, including (1) a high prevalence of cerebrovascular risk factors? (2) diet, 4.s (3) racial make-up of the population, 6,7 (4) socioeconomic factors, 2,8and perhaps (5) poor access to health care. Other as yet unidentified factors also m a y be important in explaining the higher incidence and mortality of stroke in the Southeast. 2,9 Recent studies have documented a relative decline in stroke mortality in the southeastern states that constitute the "Stroke Belt.'l°,n Despite these changes, there is still an excess of stroke-related deaths in the Stroke Belt region. Based on these factors, it is apparent that programs designed to prevent or treat stroke could be focused on the Stroke Belt in the hopes of having a more significant and ongoing impact on reducing stroke mortality and morbidity. As was emphasized in a recent edito-
Journal of Stroke and Cerebrovascular Diseases, Vol. 6, No. 1, 1996: pp 54-59
55
STROKE BELT CONSORTIUM
Table 1. 1990 Age-adjusted Stroke Death Rates (Per 100,000 Population) in Stroke Belt States
State
Stroke death rate
National ranking
Washington, DC
36.9 37.4 37.4 33.8 32.5 34.3 36.6 36.4 43.6 36.3 33.5 35.4
3 2 2 9 11 8 4 5 1 6 10 7
Total US average
27.7
Alabama Arkansas Georgia Indiana Kentucky Louisiana Mississippi North Carolina South Carolina Tennessee
Virginia
Data from the American Heart Association.16 rial, there may be various types of Stroke Belts related to specific stroke types and demographic groups, u Therefore, the concept of a Stroke Belt also may be applicable to other regions of the country, at least with respect to one or more stroke types and at-risk groups.
What is the Stroke Belt Consortium? The SBC is an expansion of the Stroke Belt Coalition formed by the American Heart Association (AHA). Groups represented within the SBC include AHA affiliates in the Stroke Belt Coalition, Stroke Council Liaisons in the Coalition, government representatives (state, federal, and local), pharmaceutical industry and pharmacists, managed care, peer review organizations, minority groups, area health education centers, and academicians and practitioners, state medical societies, and the National Stroke Association. A complete listing of the attendees and their organizations is available on request. The goals of the SBC are as follows: 1. To implement programs to increase and improve public and professional education about stroke in the stroke belt. These efforts also include groups not previously targeted, such as legislators and journalists. 2. To execute plans to optimize cost-effective stroke care via stroke prevention, early stroke recognition, and aggressive treatment. 3. To place special emphasis on initiatives designed to reach minorities in the stroke belt, since they are significantly affected.
Why form the Stroke Belt Consortium? A large and diverse group of professionals is likely to include quite different viewpoints and approaches to any
problem. Yet, in the case of the Stroke Belt, it became clear that members of all these groups had a vested interest in attaining the goals of the SBC. In fact, several of these groups had ongoing initiatives meant to address one or more of the SBC goals. However, in almost every case there was a lack of awareness of the programs of the other groups, no coordination of efforts, and no attempt at achieving any type of economies of scale in some common areas. In addition, few of the ongoing programs had any outcomes measures incorporated as part of the program. Because the problem of stroke, particularly in the Stroke Belt, will likely require a concerted and coordinated effort to solve, it became clear that a more comprehensive and coordinated effort would be necessary. The ideas and concepts behind the SBC were formulated in May 1994. We had a pilot organizational and planning meeting with 25 attendees on June 24, 1994, in Atlanta, GA. The response from this meeting was very positive and we were encouraged to proceed with a larger meeting. With the help and cooperation of the AHA and the financial support of several pharmaceutical companies, we held the inaugural meeting of the SBC in November 1994 in Orlando, FL. Following this meeting, many of the attendees and participants felt strongly that the ideas and initiatives generated were so important that they should be disseminated.
Meeting Format Because we were bringing together such a diverse group of professionals, most of whom had never met with each other (even though they shared a common interest), we devised a meeting format that would maximize the productive interchange of ideas, while at the same time allowing for all attendees to share a common knowledge base with respect to the Stroke Belt and the SBC. The meeting began with a keynote address by Michael Walker, MD, Director of the Division of Stroke and Trauma at the National Institute of Neurologic Diseases and Stroke (NINDS). His address, entitled "Stroke Yesterday, Stroke Today," focused on the past history and future prospects for stroke research. One telling slide was a breakdown of research dollars by death per disease. While the research expenditure for the acquired immunodeficiency syndrome was approximately $25,000 per death, research spending per stroke death was approximately 90% lower. The first 2 days of the meeting had plenary sessions. For day 1, the plenary session was a series of brief research update presentations (see below). For day 2, the plenary session focused on minority issues related to the Stroke Belt. Following the plenary sessions, we conducted a number of break-out sessions to stimulate discussions
56
M A R K J. ALBERTS
among participants with similar interests. The first breakout session was organized by state, meaning that all residents of a particular state would meet together regardless of their group affil afion. This was quite illuminating, since on occasion we observed that members of the same state government had not met with each other prior to this meeting. The initial goal of this state break-out was to review what programs were already active in a state, their effectiveness, and the need for new programs. The other type of break-out was by affil afion. Members of a given group would meet, regardless of their state of residence. For example, all government officials met together, all AHA members, all health care providers, all members of the participating pharmaceutical companies, etc. This format was very useful for the sharing of information across lines of authority not usually crossed. During day 1 there were two presentations by mass media firms (The Alexis Group, FL; and Bozell Worldwide, Inc, Chicago, IL). These presentations focused on various approaches for conducting a mass media educational campaign in the Stroke Belt. The attendees then evaluated each presentation for content and applicability for the goals of the SBC. At the end of day 2, all participants were invited to submit a grant for a pilot project to further the goals of the SBC. These grants were reviewed by the SBC Executive Committee that evening, and the grants were awarded the next morning (perhaps the most rapid study section and grant award process in history!).
Research Update There were four research presentations that focused on various problems to be solved by the SBC. Dr Kenneth Gaines (University of Tennessee) discussed why minority groups in the Southeast have a higher incidence and mortality of stroke compared with other groups. Although an increased prevalence of risk factors may partially explain this phenomena, other as yet unidentified factors appear to be important. Dr William Golden (Arkansas Medical Foundation) presented data on how aspirin or warfarin are used in Arkansas to prevent stroke in patients with atrial fibrillation. He found that smaller hospitals are less likely than larger hospitals to use warfarin for stroke prophylaxis. Dr Thomas Brott (University of Cincinnati) presented the results of a study that showed how stroke patients could be referred to local emergency rooms more efficiently and quickly. A coordinated approach among health care providers and the use of 911 was successful in dramatically reducing the time delay between stroke onset and hospital presentation in the Cincinnati area. 13 Dr Mark Alberts (Duke University) discussed a study performed at Duke Hospital and Yale Hospital, examining time delays in the evaluation of patients having an
in-hospital stroke. This study found that such patients are not rapidly evaluated by physicians, with a number of factors contributing to a median delay of over 2 hours. 14
M i n o r i t y Issues There were three presentations focusing on minority issues and the Stroke Belt. These were given by Paul L. Douglass, MD (Association of Black Cardiologists), Johnie G. Hamilton, Jr, PhD (East Carolina University), and Rose Snipes, MD (Burroughs-Wellcome Co and the University of North Carolina). All the speakers discussed areas of special concern in understanding the cause of increased stroke among minorities and ways to better educate the minority community in this area. A common theme was the cultural and lifestyle differences between minority and nonminority populations, both in terms of educational approaches and interfacing with the medical system. Several of the excellent ideas are summarized below.
Meeting Results The state break-out sessions produced many excellent ideas for improving public and professional education about stroke. Listed below are some of the more unique or original ideas from these sessions: Increased training of nurses and other health care professionals Stroke victors' picnic Increased support of stroke clubs Minority outreach via black churches and historically black colleges Diet modification programs Screening for risk factors through black fraternities/ sororities Identify at-risk patients through prescription review Use fast-food restaurants to promote stroke education Use sporting events to promote stroke education The breakout session on academia/patient care reviewed several aspects of professional stroke education. One topic was undergraduate and postgraduate medical education. Many of the attendees thought that medical students receive little if any formal training about cerebrovascular disease. At Duke University Medical School, students rotating on the neurology service participate in stroke rounds twice per week (1 hour each time). This provides them with at least 7 formal hours of patientbased stroke teaching per rotation, plus an additional hour of didactic teaching on cerebrovascular disease. Stroke rounds is the highest-rated formal teaching experience. This is in addition to whatever stroke teaching they might receive during attending and work rounds. However, it was unclear how common such an educational experience was at other medical schools.
57
STROKE BELT CONSORTIUM
There was a strong feeling among the clinicians that improved medical student education about cerebrovascular disease was of paramount importance in reversing the nihilistic attitudes about stroke, as well as providing future physicians with a better fiand of knowledge about stroke etiology, diagnosis, treatment, and prevention. Another issue was quality control and credentialing. Several attendees noted that state medical societies or licensing boards had the power to mandate continuing medical education (CME) hours for specific diseases. The idea was advanced that medical societies in Stroke Belt states should have yearly requirements for stroke education via CME programs. It was suggested that other credentialing bodies be approached, such as the Joint Commission on the Accreditation of Healthcare Organizations. We also learned that there is a similar organization, the National Council on Quality Assurance (NCQA), that is involved in credentialing managed care groups. Another suggestion was that all physicians be required to be certified in brain resuscitation for stroke, similar to cardiopulmonary resuscitation for cardiac arrest. A recently published position paper supports this concept. ~5 Other ideas included setting up statewide hotlines for physicians to have rapid access to stroke experts, care-mapping for inpatients with strokes, and regular CME conferences about stroke for physicians. The government affairs session produced several ideas for new initiatives. These included (1) organizing statewide task forces to discuss stroke programs and goals, (2) draft a resolution for each state legislature to support CME requirements for stroke, (3) reductions in malpractice premiums for practitioners in the Stroke Belt that meet certain educational criteria, (4) identifying sources of funding within state government to be used for a mass media educational campaign, and (5) incorporate stroke screening and prevention guidelines into quality assurance standards. The pharmaceutical breakout session dealt with the issue of cooperation among various companies, funding mechanisms, and competing priorities between research, sales, and marketing. Given the current health care funding climate, these issues were of major concern for the pharmaceutical representatives. In terms of funding the SBC, this group decided that they were willing to be a source of pilot funding for some projects, but were not in a financial position to fund the entire effort, either individually or collectively. However, they were very supportive of these efforts, and were willing to provide low-level monetary and resource assistance in select areas.
Grants All attendees were told that funds were available for demonstration projects with very modest budgets ($500 to $2,000). These projects must be completed by June 30,
1995. Grant application forms were provided, and the submitted grants were reviewed by the Executive Committee during the meeting. We had expected 10 to 15 grant submissions; however, 60 grant applications were received. Each was given a priority score, and the nine grants with the best score were funded (Table 2).
Future Directions At the conclusion of the meeting, there was tremendous enthusiasm and momentum to proceed with many of the ideas and initiatives that were discussed. As a practical problem, it was unclear how the SBC should move forward in terms of organization, funding, and future priorities. After some discussion at the state level and by the Executive Committee, we decided that the success of the SBC will be largely determined by its ability to raise funds to support its programs. The state legislatures were the most obvious (and perhaps receptive) sources of funding for the SBC, although other organizations (ie, endowments, foundations) were also identified as potential funding mechanisms. Since the states are the most likely sources of future funds, we felt that each state should form its own consortium (ie, the Alabama Stroke Consortium) while continuing to be part of the overall SBC. This was necessary since a given state is unlikely to fund programs Table 2. Pilot grants funded at the first stroke belt consortium meeting
Grant title Church-based blood pressure/ nutrition awareness program Brain attack alert for the black community Planning grant for stroke prevention education/George SBC Objective structured clinical examination: a tool for medical student stroke education High blood pressure screening in churches Implementing quality improvement programs focused on stroke prevention and treatment through state-based peer review organizations African-American male blood pressure screening at high school athletic events Eating for a healthy tomorrow South Carolina Stroke First Alert
Principal investigator Vinay Sood (AHA) Sylvia Robinson (AHA) Robert J. Adams, MD E. Eugene Marsh, MD
Quincy Neal (AHA) Allison Hardy (AMRRC)
Dean Cleghorn, EdD (AHEC) David Markiewicz (AHA) E Joseph Hodge, RPh
Abbreviations: AMRRC, American Medical Review Research Center; AHEC, Area Health Education Center.
58
MARK J. ALBERTS
for a neighboring state. Although this could fragment the SBC, it also empowers each state (and the SBC members in that state) to move forward with the knowledge that their efforts will directly benefit local residents and programs. In addition, since the political environment of each state is unique, local leaders can mold a program that has the best chance for success. We discussed the formation of an SBC newsletter to keep members of the SBC informed of new developments and to keep a positive momentum. It was also suggested that the SBC contact other medical, health care, and political organizations to share ideas, explore funding opportunities, and identify areas for cooperative efforts. The SBC still acts as the umbrella organization for each state effort, providing advice, support, group meetings to discuss progress, and some degree of coordination. This may become important when planning a mass media educational campaign, since the production costs for various advertisements and commercials could be amortized over several states.
Conclusion The SBC is a new, unique organization that brings together many diverse professionals and groups with common goals: reducing stroke death and disability by improving education about stroke and improving care of stroke patients. Its structure as a freestanding organization allows it to have the flexibility to address the needs of the Stroke Belt in a rapid fashion without excessive bureaucratic hindrance. The rapidity with which the SBC meetings were organized and held, along with the very efficient grant award process at this meeting, demonstrate the advantages of this type of organization. The future success of the SBC will depend on its ability, via individual statewide efforts, to raise funds for new programs, especially a mass media campaign focusing on stroke ,education for the public. The SBC may serve as a model for similar programs in other regions of the United States and perhaps other countries.
Acknowledgment: The author acknowledges the contributions of all members of the SBC, but space does not permit l i s ~ g of all the participants. Below is a list of members of the Executive Committee and their affiliations and states: Mark J. Alberts, MD (Duke University, Durham, NC); Robert Adams, MD (Medical College of Georgia, Athens, GA); Bob Kirkpartick (AHA, Nashville, TN), Bill Golden, MD (University of Arkansas, Little Rock, AK); David Markiewicz (AHA, Chapel Hill, NC); Kaye Shipley (Dupont Pharma, Raleigh, NC); Michael Walker, MD (NINDS, Bethesda, MD); Jerry Gaylord (Dupont Pharma, Charlotte, NC); Rose Snipes, MD (Burroughs Wellcome, Research Triangle Park, NC); Senator Nadine Thomas (GA); Gary Ravetto (area health education
center, Lafayette, LA); David Gordon, MD (University of Mississippi Medical Center, Jackson, MS); Paul Douglas, MD (Association of Black Cardiologists, Atlanta, GA); Andrew Brugger, MD (Lorex Pharmaceuticals, Chicago, IL); Ken Williams (Upjohn, Arnold, MD); Renee Twombly (Medical Communications, Duke University, Durham, NC). The author also acknowledges the generous support for the SBC by the following pharmaceutical companies: Dupont Pharma, Burroughs Wellcome, Upjohn, and Lorex.
References 1. Lanska DJ. Geographic distribution of stroke mortality in the United States: 1939-1941 to 1979-1981. Neurology 1993;43:1839-51. 2. Lanska DJ, Kryscio R. Geographic distribution of hospitalization rates, case fatality, and mortality from stroke in the United States. Neurology 1994;44:1541-50. 3. KuUer L, Reisler D. An explanation for variations in distributions of stroke and arteriosclerotic heart disease among populations and racial groups. Am J Epidemiol 1971;93:1-9. 4. Reed D. The paradox of high risk of stroke in populations with low risk of coronary artery disease. Am J Epidemiol 1990;131:579-88. 5. US Department of Agriculture. Food consumption: households in the South, Spring 1977. Nationwide Food Consumption Survey 1977-78. Washington, DC: US Department of Agriculture, 1983. 6. Howard G, Anderson R, Sorlie P, Andrews V, Backlund E, Burke GL. Ethnic differences in stroke mortality between non-Hispanic whites, Hispanic whites, and blacks. The National Longitudinal Mortality Study. Stroke 1994;25: 2120-5. 7. Carter LR, Walton SE, Knowles MK, Wing S, Tyroler HA. Social inequality of stroke mortality among US black populations, 1968 to 1987. Ethn Dis 1992;2:343-51. 8. Biggar J. The sunning of America: migration to the sunbelt. Popul Bull 1979;34:1-44. 9. Nefzger M, Heyman A, Acheson R. Stroke, geography and blood pressure. J Chron Dis 1973;26:389-91. 10. Lanska D, Peterson R Geographic variation in the decline of stroke mortality in the United States. Stroke 1995;26: 1159-65. 11. Howard G, Evans G, Pearce K, et al. Is the Stroke Belt disappearing? Stroke 1995;26:1153-58. 12. Lanska D, Kuller L. The geography of stroke mortality in the United States and the concept of a Stroke Belt [editorial]. Stroke 1995;26:1145-9. 13. Barsan W, Brott T, Broderick J, Haley E, Levy D, Marler J. Urgent therapy for acute stroke. Effects of a stroke trial on untreated patients. Stroke 1994;25:2132-7. 14. Alberts MJ, Brass LM, Perry A, Webb D, Dawson DV. Evaluation times for patients with in-hospital stroke. Stroke 1993;24:1817-22. 15. A Working Group on Emergency Brain Resuscitation. Emergency brain resuscitation. Ann Intern Med 1995;122: 622-7. 16. American Heart Association. 1994Heart and Stroke Facts and Statistics. Dallas, TX: American Heart Association, 1993.
The "Stroke Belt" describes a region of the southeastern United States with a high incidence of stroke and mortality due to stroke. In an effort to address the problem of stroke in this region, we have formed the Stroke Belt Consortium (SBC). This report describes the formation and functions of the SBC. The SBC is a unique organization with representatives from many areas, including health care, government, nonprofit organizations, the pharmaceutical industry, minority groups, educational groups, and managed care. The goals of the consortium are to advance public and professional education about stroke in the Stroke Belt, with a special emphasis on the populations in that region. The first meeting of the consortium was held in November 1994. Many helpful and innovative ideas and initiatives were generated at the first SBC meeting. These included improved techniques for professional education, the development of a mass media campaign for public education, screening of college students for stroke risk factors, and using fast-food restaurants and sporting events as venues to promote stroke education. This type of organized effort may produce cost-effective programs and initiatives, particularly for largescale educational efforts, that will enhance the prevention and treatment of stroke patients. If successful in the Stroke Belt, similar organizations can be formed in other regions of the nation to address specific issues related to stroke prevention, education, and treatment. Key Words: Cerebrovascutar disease--Epidemiology-Treatment--Education.
The incidence and mortality of stroke is not evenly distributed within the United States. Numerous studies have shown that the southeastern states have the highest stroke incidence and mortality in the country. 1,2 To organize a comprehensive and wide-ranging effort to address the problem of stroke in the Southeast, we have formed the Stroke Belt Consortium (SBC). The SBC represents a unique joining of people and resources from m a n y different venues. This report reviews the formation of the SBC, along with its short-term and long-term goals. It is hoped that if successful, the SBC will serve as a model for cooperative efforts in other regions of the nation.
From the Duke University Medical Center, Durham, NC. Received September 7,1995; accepted October 3, 1995. Address reprint requests to Mark J. Alberts, MD, Division of Neurology, PO Box 3392, Duke University Medical Center, Durham, NC 27710. Copyright © 1996by National Stroke Association 1052-3057/96/0601-0003503.00/0
54
What is the Stroke Belt? The southeastern states have the highest incidence and mortality of stroke in the United States (Table 1). Although it is unclear w h y this is the case, several factors have been cited as possible contributors, including (1) a high prevalence of cerebrovascular risk factors? (2) diet, 4.s (3) racial make-up of the population, 6,7 (4) socioeconomic factors, 2,8and perhaps (5) poor access to health care. Other as yet unidentified factors also m a y be important in explaining the higher incidence and mortality of stroke in the Southeast. 2,9 Recent studies have documented a relative decline in stroke mortality in the southeastern states that constitute the "Stroke Belt.'l°,n Despite these changes, there is still an excess of stroke-related deaths in the Stroke Belt region. Based on these factors, it is apparent that programs designed to prevent or treat stroke could be focused on the Stroke Belt in the hopes of having a more significant and ongoing impact on reducing stroke mortality and morbidity. As was emphasized in a recent edito-
Journal of Stroke and Cerebrovascular Diseases, Vol. 6, No. 1, 1996: pp 54-59
55
STROKE BELT CONSORTIUM
Table 1. 1990 Age-adjusted Stroke Death Rates (Per 100,000 Population) in Stroke Belt States
State
Stroke death rate
National ranking
Washington, DC
36.9 37.4 37.4 33.8 32.5 34.3 36.6 36.4 43.6 36.3 33.5 35.4
3 2 2 9 11 8 4 5 1 6 10 7
Total US average
27.7
Alabama Arkansas Georgia Indiana Kentucky Louisiana Mississippi North Carolina South Carolina Tennessee
Virginia
Data from the American Heart Association.16 rial, there may be various types of Stroke Belts related to specific stroke types and demographic groups, u Therefore, the concept of a Stroke Belt also may be applicable to other regions of the country, at least with respect to one or more stroke types and at-risk groups.
What is the Stroke Belt Consortium? The SBC is an expansion of the Stroke Belt Coalition formed by the American Heart Association (AHA). Groups represented within the SBC include AHA affiliates in the Stroke Belt Coalition, Stroke Council Liaisons in the Coalition, government representatives (state, federal, and local), pharmaceutical industry and pharmacists, managed care, peer review organizations, minority groups, area health education centers, and academicians and practitioners, state medical societies, and the National Stroke Association. A complete listing of the attendees and their organizations is available on request. The goals of the SBC are as follows: 1. To implement programs to increase and improve public and professional education about stroke in the stroke belt. These efforts also include groups not previously targeted, such as legislators and journalists. 2. To execute plans to optimize cost-effective stroke care via stroke prevention, early stroke recognition, and aggressive treatment. 3. To place special emphasis on initiatives designed to reach minorities in the stroke belt, since they are significantly affected.
Why form the Stroke Belt Consortium? A large and diverse group of professionals is likely to include quite different viewpoints and approaches to any
problem. Yet, in the case of the Stroke Belt, it became clear that members of all these groups had a vested interest in attaining the goals of the SBC. In fact, several of these groups had ongoing initiatives meant to address one or more of the SBC goals. However, in almost every case there was a lack of awareness of the programs of the other groups, no coordination of efforts, and no attempt at achieving any type of economies of scale in some common areas. In addition, few of the ongoing programs had any outcomes measures incorporated as part of the program. Because the problem of stroke, particularly in the Stroke Belt, will likely require a concerted and coordinated effort to solve, it became clear that a more comprehensive and coordinated effort would be necessary. The ideas and concepts behind the SBC were formulated in May 1994. We had a pilot organizational and planning meeting with 25 attendees on June 24, 1994, in Atlanta, GA. The response from this meeting was very positive and we were encouraged to proceed with a larger meeting. With the help and cooperation of the AHA and the financial support of several pharmaceutical companies, we held the inaugural meeting of the SBC in November 1994 in Orlando, FL. Following this meeting, many of the attendees and participants felt strongly that the ideas and initiatives generated were so important that they should be disseminated.
Meeting Format Because we were bringing together such a diverse group of professionals, most of whom had never met with each other (even though they shared a common interest), we devised a meeting format that would maximize the productive interchange of ideas, while at the same time allowing for all attendees to share a common knowledge base with respect to the Stroke Belt and the SBC. The meeting began with a keynote address by Michael Walker, MD, Director of the Division of Stroke and Trauma at the National Institute of Neurologic Diseases and Stroke (NINDS). His address, entitled "Stroke Yesterday, Stroke Today," focused on the past history and future prospects for stroke research. One telling slide was a breakdown of research dollars by death per disease. While the research expenditure for the acquired immunodeficiency syndrome was approximately $25,000 per death, research spending per stroke death was approximately 90% lower. The first 2 days of the meeting had plenary sessions. For day 1, the plenary session was a series of brief research update presentations (see below). For day 2, the plenary session focused on minority issues related to the Stroke Belt. Following the plenary sessions, we conducted a number of break-out sessions to stimulate discussions
56
M A R K J. ALBERTS
among participants with similar interests. The first breakout session was organized by state, meaning that all residents of a particular state would meet together regardless of their group affil afion. This was quite illuminating, since on occasion we observed that members of the same state government had not met with each other prior to this meeting. The initial goal of this state break-out was to review what programs were already active in a state, their effectiveness, and the need for new programs. The other type of break-out was by affil afion. Members of a given group would meet, regardless of their state of residence. For example, all government officials met together, all AHA members, all health care providers, all members of the participating pharmaceutical companies, etc. This format was very useful for the sharing of information across lines of authority not usually crossed. During day 1 there were two presentations by mass media firms (The Alexis Group, FL; and Bozell Worldwide, Inc, Chicago, IL). These presentations focused on various approaches for conducting a mass media educational campaign in the Stroke Belt. The attendees then evaluated each presentation for content and applicability for the goals of the SBC. At the end of day 2, all participants were invited to submit a grant for a pilot project to further the goals of the SBC. These grants were reviewed by the SBC Executive Committee that evening, and the grants were awarded the next morning (perhaps the most rapid study section and grant award process in history!).
Research Update There were four research presentations that focused on various problems to be solved by the SBC. Dr Kenneth Gaines (University of Tennessee) discussed why minority groups in the Southeast have a higher incidence and mortality of stroke compared with other groups. Although an increased prevalence of risk factors may partially explain this phenomena, other as yet unidentified factors appear to be important. Dr William Golden (Arkansas Medical Foundation) presented data on how aspirin or warfarin are used in Arkansas to prevent stroke in patients with atrial fibrillation. He found that smaller hospitals are less likely than larger hospitals to use warfarin for stroke prophylaxis. Dr Thomas Brott (University of Cincinnati) presented the results of a study that showed how stroke patients could be referred to local emergency rooms more efficiently and quickly. A coordinated approach among health care providers and the use of 911 was successful in dramatically reducing the time delay between stroke onset and hospital presentation in the Cincinnati area. 13 Dr Mark Alberts (Duke University) discussed a study performed at Duke Hospital and Yale Hospital, examining time delays in the evaluation of patients having an
in-hospital stroke. This study found that such patients are not rapidly evaluated by physicians, with a number of factors contributing to a median delay of over 2 hours. 14
M i n o r i t y Issues There were three presentations focusing on minority issues and the Stroke Belt. These were given by Paul L. Douglass, MD (Association of Black Cardiologists), Johnie G. Hamilton, Jr, PhD (East Carolina University), and Rose Snipes, MD (Burroughs-Wellcome Co and the University of North Carolina). All the speakers discussed areas of special concern in understanding the cause of increased stroke among minorities and ways to better educate the minority community in this area. A common theme was the cultural and lifestyle differences between minority and nonminority populations, both in terms of educational approaches and interfacing with the medical system. Several of the excellent ideas are summarized below.
Meeting Results The state break-out sessions produced many excellent ideas for improving public and professional education about stroke. Listed below are some of the more unique or original ideas from these sessions: Increased training of nurses and other health care professionals Stroke victors' picnic Increased support of stroke clubs Minority outreach via black churches and historically black colleges Diet modification programs Screening for risk factors through black fraternities/ sororities Identify at-risk patients through prescription review Use fast-food restaurants to promote stroke education Use sporting events to promote stroke education The breakout session on academia/patient care reviewed several aspects of professional stroke education. One topic was undergraduate and postgraduate medical education. Many of the attendees thought that medical students receive little if any formal training about cerebrovascular disease. At Duke University Medical School, students rotating on the neurology service participate in stroke rounds twice per week (1 hour each time). This provides them with at least 7 formal hours of patientbased stroke teaching per rotation, plus an additional hour of didactic teaching on cerebrovascular disease. Stroke rounds is the highest-rated formal teaching experience. This is in addition to whatever stroke teaching they might receive during attending and work rounds. However, it was unclear how common such an educational experience was at other medical schools.
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STROKE BELT CONSORTIUM
There was a strong feeling among the clinicians that improved medical student education about cerebrovascular disease was of paramount importance in reversing the nihilistic attitudes about stroke, as well as providing future physicians with a better fiand of knowledge about stroke etiology, diagnosis, treatment, and prevention. Another issue was quality control and credentialing. Several attendees noted that state medical societies or licensing boards had the power to mandate continuing medical education (CME) hours for specific diseases. The idea was advanced that medical societies in Stroke Belt states should have yearly requirements for stroke education via CME programs. It was suggested that other credentialing bodies be approached, such as the Joint Commission on the Accreditation of Healthcare Organizations. We also learned that there is a similar organization, the National Council on Quality Assurance (NCQA), that is involved in credentialing managed care groups. Another suggestion was that all physicians be required to be certified in brain resuscitation for stroke, similar to cardiopulmonary resuscitation for cardiac arrest. A recently published position paper supports this concept. ~5 Other ideas included setting up statewide hotlines for physicians to have rapid access to stroke experts, care-mapping for inpatients with strokes, and regular CME conferences about stroke for physicians. The government affairs session produced several ideas for new initiatives. These included (1) organizing statewide task forces to discuss stroke programs and goals, (2) draft a resolution for each state legislature to support CME requirements for stroke, (3) reductions in malpractice premiums for practitioners in the Stroke Belt that meet certain educational criteria, (4) identifying sources of funding within state government to be used for a mass media educational campaign, and (5) incorporate stroke screening and prevention guidelines into quality assurance standards. The pharmaceutical breakout session dealt with the issue of cooperation among various companies, funding mechanisms, and competing priorities between research, sales, and marketing. Given the current health care funding climate, these issues were of major concern for the pharmaceutical representatives. In terms of funding the SBC, this group decided that they were willing to be a source of pilot funding for some projects, but were not in a financial position to fund the entire effort, either individually or collectively. However, they were very supportive of these efforts, and were willing to provide low-level monetary and resource assistance in select areas.
Grants All attendees were told that funds were available for demonstration projects with very modest budgets ($500 to $2,000). These projects must be completed by June 30,
1995. Grant application forms were provided, and the submitted grants were reviewed by the Executive Committee during the meeting. We had expected 10 to 15 grant submissions; however, 60 grant applications were received. Each was given a priority score, and the nine grants with the best score were funded (Table 2).
Future Directions At the conclusion of the meeting, there was tremendous enthusiasm and momentum to proceed with many of the ideas and initiatives that were discussed. As a practical problem, it was unclear how the SBC should move forward in terms of organization, funding, and future priorities. After some discussion at the state level and by the Executive Committee, we decided that the success of the SBC will be largely determined by its ability to raise funds to support its programs. The state legislatures were the most obvious (and perhaps receptive) sources of funding for the SBC, although other organizations (ie, endowments, foundations) were also identified as potential funding mechanisms. Since the states are the most likely sources of future funds, we felt that each state should form its own consortium (ie, the Alabama Stroke Consortium) while continuing to be part of the overall SBC. This was necessary since a given state is unlikely to fund programs Table 2. Pilot grants funded at the first stroke belt consortium meeting
Grant title Church-based blood pressure/ nutrition awareness program Brain attack alert for the black community Planning grant for stroke prevention education/George SBC Objective structured clinical examination: a tool for medical student stroke education High blood pressure screening in churches Implementing quality improvement programs focused on stroke prevention and treatment through state-based peer review organizations African-American male blood pressure screening at high school athletic events Eating for a healthy tomorrow South Carolina Stroke First Alert
Principal investigator Vinay Sood (AHA) Sylvia Robinson (AHA) Robert J. Adams, MD E. Eugene Marsh, MD
Quincy Neal (AHA) Allison Hardy (AMRRC)
Dean Cleghorn, EdD (AHEC) David Markiewicz (AHA) E Joseph Hodge, RPh
Abbreviations: AMRRC, American Medical Review Research Center; AHEC, Area Health Education Center.
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MARK J. ALBERTS
for a neighboring state. Although this could fragment the SBC, it also empowers each state (and the SBC members in that state) to move forward with the knowledge that their efforts will directly benefit local residents and programs. In addition, since the political environment of each state is unique, local leaders can mold a program that has the best chance for success. We discussed the formation of an SBC newsletter to keep members of the SBC informed of new developments and to keep a positive momentum. It was also suggested that the SBC contact other medical, health care, and political organizations to share ideas, explore funding opportunities, and identify areas for cooperative efforts. The SBC still acts as the umbrella organization for each state effort, providing advice, support, group meetings to discuss progress, and some degree of coordination. This may become important when planning a mass media educational campaign, since the production costs for various advertisements and commercials could be amortized over several states.
Conclusion The SBC is a new, unique organization that brings together many diverse professionals and groups with common goals: reducing stroke death and disability by improving education about stroke and improving care of stroke patients. Its structure as a freestanding organization allows it to have the flexibility to address the needs of the Stroke Belt in a rapid fashion without excessive bureaucratic hindrance. The rapidity with which the SBC meetings were organized and held, along with the very efficient grant award process at this meeting, demonstrate the advantages of this type of organization. The future success of the SBC will depend on its ability, via individual statewide efforts, to raise funds for new programs, especially a mass media campaign focusing on stroke ,education for the public. The SBC may serve as a model for similar programs in other regions of the United States and perhaps other countries.
Acknowledgment: The author acknowledges the contributions of all members of the SBC, but space does not permit l i s ~ g of all the participants. Below is a list of members of the Executive Committee and their affiliations and states: Mark J. Alberts, MD (Duke University, Durham, NC); Robert Adams, MD (Medical College of Georgia, Athens, GA); Bob Kirkpartick (AHA, Nashville, TN), Bill Golden, MD (University of Arkansas, Little Rock, AK); David Markiewicz (AHA, Chapel Hill, NC); Kaye Shipley (Dupont Pharma, Raleigh, NC); Michael Walker, MD (NINDS, Bethesda, MD); Jerry Gaylord (Dupont Pharma, Charlotte, NC); Rose Snipes, MD (Burroughs Wellcome, Research Triangle Park, NC); Senator Nadine Thomas (GA); Gary Ravetto (area health education
center, Lafayette, LA); David Gordon, MD (University of Mississippi Medical Center, Jackson, MS); Paul Douglas, MD (Association of Black Cardiologists, Atlanta, GA); Andrew Brugger, MD (Lorex Pharmaceuticals, Chicago, IL); Ken Williams (Upjohn, Arnold, MD); Renee Twombly (Medical Communications, Duke University, Durham, NC). The author also acknowledges the generous support for the SBC by the following pharmaceutical companies: Dupont Pharma, Burroughs Wellcome, Upjohn, and Lorex.
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