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Nathan R. James, American Heart Association

This summer, Gov. Phil Bredesen signed the Tennessee Stroke Registry Act of 2008 into law. The legislation represents a culmination of work by the American Heart Association's (AHA) Stroke Systems of Care task force, numerous providers, public health officials and legislators from both sides of the aisle.

The volunteer registry has widely been hailed as a significant step in an attempt to turn the tide on stroke … the number three killer in Tennessee and the state's leading cause of disability.

Beginning in January 2009, Tim Aldrich, PhD, a professor and epidemiologist with East Tennessee State University's College of Public and Allied Health, will collect data from participating hospitals. The information will range from the number of patients evaluated for stroke to the medication prescribed upon discharge (see box). ETSU, in collaboration with the AHA, is charged with maintaining the new databank and submitting an annual report on aggregate data to the public health community to ultimately improve standards of care and outcomes.

Nathan R. James, Tennessee Advocacy Director for the American Heart Association said the stroke task force had originally applied for a federal grant to participate in the Paul Coverdale National Stroke Care Registry. Although accepted, the necessary funding fell through.

"We're pretty proactive in this state," said James. "The other members of the stroke task force and myself talked a lot about it and decided to go forward with this (statewide effort)."

The task force members found willing ears among legislators who were also concerned about the toll of stroke on the state's population.

Bipartisan legislation submitted by Senators Diane Black, RN, (R-Gallatin) and Rusty Crowe (R-Johnson City) and Representative Craig Fitzhugh (D-Ripley) called for a database "that compiles information and statistics on stroke care involving prevalence, mortality and performance metrics that align with the stroke consensus metrics developed and approved by the American Heart Association, Centers for Disease Control and Prevention and The Joint Commission."

Just as with the Paul Coverdale National Stroke Care Registry, it looked as if funding would once again prove to be a stumbling block. James explained that the original legislation came with a price tag of $520,800 in the first year and approximately $350,000 in subsequent years.

That, he said, is when ETSU's College of Public Health stepped up. The university's offer to collect and disseminate data came with a much more manageable fiscal note of $30,000 … more than half a million in savings to the state in the first year alone.

"They said they wanted to do this as a public service for the state," noted James with evident appreciation. "It represents a significant partnership between East Tennessee State University and public health at large."

Patti Vanhook, PhD, RN, an assistant professor in the College of Nursing at ETSU, has been a very visible and vocal advocate for improved outcomes both as the chair of the statewide Stroke Systems of Care task force and as a clinician with a neuroscience background.

Not only has she seen firsthand the devastating effects of stroke as a caregiver but has felt the impact personally. Her father and brother have both had a stroke … her brother was only 38 at the time.

As she worked with other health officials, it became apparent that the only statistics Tennessee was collecting regarding stroke was mortality data.

"We could tell you how many died but not how many had a stroke," she said. "What's the true outcome of stroke? We didn't really know that."

However, the hope is that will soon change. Although the registry is voluntary, Vanhook said the response has already been positive. Requests for participation have been sent to all hospitals in Tennessee. She said the "yes" responses that have already been received are representative of the state with hospitals signing on from East, Middle and West Tennessee.

For hospitals currently taking part in AHA's "Get with the Guidelines" program for stroke, participation is as easy as signing an agreement that allows the state to access data that is already being reported. If a hospital is not currently part of the AHA program, Aldrich will help them set up the collection system. Vanhook stressed that the setup is simple and doesn't require expensive software or other major financial outlays to participate.

She said that the much broader data collection would help the state create a baseline of care in 2009 and figure out where improvements are needed. She and James both stressed the registry is in no way a punitive program, but rather it should be viewed as a quality improvement project.

"It truly is an outcomes-based and evidence-based mechanism of looking at care," she said. "We're not out to point fingers at hospitals but to give them the opportunity to raise up to the level where expert stroke care is delivered."

Ultimately, Vanhook, continued, the goal would be to analyze the collected data to get a better picture of stroke across the entire spectrum and continuum of care and to use that information to create new programming or initiatives where needed. She noted effective measures would take a multi-prong approach including prevention –– not only for adults, but Vanhook stressed it would also be important to "look at our children so that they won't have to go through the process."

Marian Levy, DrPH, associate professor and director of the Master of Public Health program at the University of Memphis, is equally excited about the promise such a registry holds for the future.

"It's a huge public health problem in West Tennessee, particularly among African-Americans," she stated. "Nationwide, African-Americans have twice the mortality from stroke as compared to whites."

Her hope is that the data would allow public health officials to track behaviors and efforts to reduce the impact of stroke, which is costly both in terms of hard dollars and lingering disability.

"In Tennessee in 2002, there was $395 million spent in stroke inpatient hospital charges," she noted. "This represents a 73 percent increase over the five years previously."

Levy added the cost for inpatient care was $168 million more in constant dollars than in 1997, when the figure came in at $227 million. She believes that a significant portion of the expenditures and human toll are directly linked to factors that have the potential for change such as prevalence rates for diabetes, hypertension and obesity.

"If you have the proper health behaviors, then it reduces your risk of getting a stroke and therefore reduces morbidity and mortality across the state," Levy pointed out. "Data can be used to drive education," she continued.

Levy also noted that education covers the spectrum from the general public knowing the warning signs … to first responders and emergency personnel initiating accepted protocols and rapidly transferring patients … to hospitals following evidence-based guidelines.

"We want to make sure the standards of care are state-of-the-art so we can reduce disability and restore function," she concluded.

Stroke Registry Requested Data

The new law establishing the voluntary Tennessee Stroke Registry outlines specific information and measures the state hopes to collect from participating hospitals. These include:
The number of patients evaluated.
The number of patients receiving acute interventional therapy.
The amount of time from patient presentation to delivery of acute interventional therapy.
Patient length of stay, functional outcome and morbidity.
The number of deep vein thrombosis prophylaxes given; the number of patients discharged on antiplatelet, antithrombotics or both; the number of patients with atrial fibrillation receiving anticoagulation therapy; and the number of tissue plasminogen activators (tPA) administered.
The number of times antithrombotic medication was administered within 48 hours of hospitalization.
The number of lipid profiles ordered during hospitalization; and the number of screens for dysphagia performed.
The number of times stroke education was provided; the number of times a smoking cessation program was provided or discussed; and the number of patients assessed for rehabilitation and whether or not a plan for rehabilitation was considered.
The number of EMS stroke patients transported to the facility and how many EMS stroke patients were admitted to the hospital.
The number of strokes by type –– including ischemic, hemorrhagic, transient ischemic attack or stroke of uncertain type.
The number of patients discharged on cholesterol reducing medications.

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