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December 10, 2009 Volume VI, No. 29

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

According to the American Stroke Association, stroke is the number three cause of death in the United States, behind heart disease and cancer. In this week's issue of the DM Update, you will discover which U.S. residents may have a higher risk of dying from a stroke, how salt intake is linked to stroke risk and the medication patients are consuming to prevent repeat strokes.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Southern Americans Have Risk of Dying from Stroke
  2. Salt Intake Linked to Strokes & Cardiovascular Disease
  3. Improving Quality of DM
  4. Daily BNP Notifications
  5. Healthcare Trends: Healthcare Trends for 2010
  6. Preventing Repeat Strokes
  7. Healthcare Case Management

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Please send comments, questions and replies to jpapay@hin.com.

Melanie Matthews, mmatthews@hin.com

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Americans Born in the South May Have Higher Risk of Dying from Stroke as Adults

The “stroke belt” has a tight hold. People born in the Southern stroke belt have a higher risk of dying from stroke as adults, even if they later move away, compared to people who were born in other parts of the country. The research is published in the December 1, 2009, print issue of Neurology®, the medical journal of the American Academy of Neurology. People who live in the stroke belt in adulthood also had elevated risk of dying from stroke, even if they were not born there.

For the study, researchers examined information from the 1980, 1990 and 2000 U.S. national death records for people age 30 to 80 who were born and lived in 49 U.S. states. Stroke death rates were calculated by linking this information to U.S. census information. The stroke belt was defined as seven states: North Carolina, South Carolina, Georgia, Tennessee, Arkansas, Mississippi and Alabama. The study looked at four groups of people: those who were born and lived in the stroke belt as adults, people born in the stroke belt but who did not live there as adults, those born outside the stroke belt but who lived there as adults and those who were not born or lived in the stroke belt.

The study found that those who were born in the stroke belt and then moved away had a higher risk of death caused by stroke than those who were born outside the region and still lived outside the region as adults. The same was true with those who were born elsewhere but later moved to the stroke belt. At the highest risk were those who were both born in the stroke belt and lived there as adults. For example, both Caucasians and African-Americans who were born and lived in the stroke belt as adults had a 34 percent higher risk of dying from stroke in 2000 compared to people of the same gender, age and race who were born and lived outside of the stroke belt in the same year. The rate of death related to stroke was 74 per 100,000 for people who were born in the stroke belt and lived there in the year 2000, but only 47 per 100,000 for people who were neither born in the stroke belt nor lived there in the year 2000, although this inequality partially reflects differences in age and race.

“Our results cannot pinpoint a specific explanation, but they are consistent with other research suggesting that the roots of stroke risk begin in childhood or even infancy. Efforts to reduce the incidence of fatal stroke may need to consider how underlying physiologic changes accumulate from early life. It is possible that where one lives affects stroke risk through socioeconomic conditions, social stressors, environmental factors or access to preventive medical care,” said study author M. Maria Glymour, ScD, with Harvard School of Public Health in Boston. “Many important behaviors such as diet, physical activity and smoking are shaped by childhood social conditions. Future long-term national studies with detailed information on when people moved are needed to help show whether those who move may have different patterns of risk factors and also identify more precisely at what point in life stroke risk begins to build. This will help us understand how to reduce stroke for people living in every region of the country,” added Glymour.

To learn more about this research, please visit:

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High Salt Intake Linked to Strokes and Cardiovascular Disease

Eating high amounts of salt is linked to a significantly higher risk of strokes and cardiovascular disease, states a study published in the British Medical Journal. The study looked at the relationship between the level of habitual dietary salt intake and the occurrence of stroke and cardiovascular disease by reviewing 13 prospective studies from the UK, Japan, USA, the Netherlands, Finland and China, including more than 170,000 participants, followed up for 3.5 to 19 years, who experienced nearly 11,000 vascular events.

The study provides unequivocal evidence of the direct link between high dietary salt intake and increased risk of stroke and cardiovascular disease. A 5 gram lower daily salt intake would reduce stroke by 23 percent and total cardiovascular disease by 17 percent, thus averting 1.25 million fatal and non-fatal strokes, and almost 3 million vascular events worldwide each year. The effect is greater, the larger the difference in salt intake and increases with time.

“Habitual salt intake in most adult populations around the world exceeds 10 grams per day,” said a senior author, “and the World Health Organization recommends that daily intake should not exceed 5 grams. Our study supports current recommendations to reduce substantially salt intake worldwide to avoid unnecessary strokes and other cardiovascular events.”

To learn more about this research, please visit:

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Improving Quality of DM with Patient Activation

American Health Holding relies on the Patient Activation Measure™ to assess a patient’s level of engagement in their own overall DM, but it does more than just that. PAM scores are also used to gauge the success of the DM program and its coaches. Director of DM and wellness services Diane Bellard discusses PAM — who is using it, how to deal with a decrease in PAM levels, how it fits with a patient's readiness to change and with an organization's overall quality improvement effort.

To listen to this complimentary HIN podcast, please visit:

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Daily BNP Notifications

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Lenore Blank, M.S.N., N.P-C., administrative manager of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center.

Question: How are you notified about B-Type Natriuretic Peptide (BNP) levels each day?

Response: We get a BNP list generated to us daily through our printer, which was set up through the IT department. It’s a list of all BNPs that were done anywhere in the hospital the previous day. We use that list to identify all heart failure patients. It’s easy to identify those patients that come through the ER, but it’s more difficult if they are already in the hospital. If they’ve had a BNP, we’ll be notified through the listing. If not, the case management department will notify us. Using these methods, we’re capturing 100 percent of the heart failure patients. We have about 1,200 heart failure discharges per year.

For more information on managing heart failure patients in the hospital, please visit:

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Healthcare Trends for 2010 — Reform, Revenue & Resources Top of Mind

As 2009 draws to a close, which products and services served healthcare companies best this year? What were the greatest operational challenges they faced in 2009?

Looking ahead, are healthcare organizations more or less optimistic about the 12 months to come? Which aspect of healthcare reform will have the greatest impact on their business, and will there be a new healthcare bill by the new year? This executive summary of responses from 100 healthcare organizations to HIN's November 2009 Healthcare Trends for 2010 e-survey identifies reform priorities, top-of-mind concerns for the year ahead and best and worst business decisions in 2009.

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Preventing Repeat Strokes — Are Survivors Taking Their Medicine?

Since 1999, stroke survivors have been advised to use aspirin, prescription antiplatelet agents or prescription anticoagulants to help avoid another stroke. Many large surveys of the U.S. population have reported the use of aspirin for secondary prevention, but commonly combine people with stroke and coronary artery disease, and only rarely report the use of antithrombotic agents other than aspirin. In an article published in the American Journal of Preventive Medicine, researchers analyze survey data over a seven-year period to determine whether true usage of all preventive therapies, including aspirin, is increasing.

The annual Medical Expenditure Panel Survey (MEPS) contains data on use of both aspirin and prescription medications. Each year, a MEPS panel is drawn from respondents from the previous year’s National Health Interview Survey, a representative sample of the U.S. civilian non-institutionalized population with oversampling of minority populations and households with low family income. In the seven annual MEPS data sets from 2000–2006, there were 4168 people who reported a cerebrovascular event. Pooling results across the seven years, 57 percent were taking aspirin, 66 percent were using any antiplatelet agent and 75 percent were using any antithrombotic agent. After excluding people who said that they were not taking aspirin because it was unsafe, 81 percent were using any antithrombotic agent.

Lead author Eric M. Cheng, M.D., M.S., and co-authors state, “even though use of prescription antiplatelet medications is rising, aspirin remains the predominant antithrombotic agent used for secondary stroke prevention. There were no improvements in overall use of antithrombotic agents over the seven-year period. Use of aspirin, prescription antiplatelet agents, and use of any antiplatelet agent increased over the study period, but after dropping the first two years, no temporal trend was detected, indicating that temporal changes in usage of these agents had plateaued.” The authors also found that older non-Hispanic men were more likely to be taking antithrombotic agents. They conclude that “although the level of use of antithrombotic agents appears high, further research should investigate whether the remaining 20 percent truly have indications for antithrombotic therapy that outweigh any contraindications, and, if so, why they are not taking these medications, particularly among younger, female and Hispanic patients."

To learn more about this research, please visit:

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Healthcare Case Management

Case managers are playing a larger role in the coordination of all phases of patient care, from management of the chronically ill in primary care offices to monitoring hospitalized patients from admission through discharge to overseeing care of residents of long-term care facilities. Complete HIN's Survey of the Month on Healthcare Case Management by January 4, 2010 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

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