Sherman Lecture: Are We Aiming at the Correct Targets to Reduce Disparities in Stroke Mortality? Celebration, Reflection, and Redirection

We could probably vastly reduce disability and mortality post stroke if we stopped the 5 causes of the neuronal cascade of death in the first week. But no one in the stroke medical world seems to be working on that. And since there is NO leadership in stroke, there is no one to address this problem.

 

Sherman Lecture: Are We Aiming at the Correct Targets to Reduce Disparities in Stroke Mortality? Celebration, Reflection, and Redirection

George Howard

Originally published26 Mar 2024Journal of the American Heart Association. 2024;0:e031309

Abstract

Although deaths from stroke have been reduced by 75% in the past 54 years, there has been virtually no reduction in the relative magnitude of Black‐to‐White disparity in stroke deaths, or the heavier burden of stroke deaths in the Stroke Belt region of the United States. Furthermore, although the rural–urban disparity has decreased in the past decade, this reduction is largely attributable to an increased stroke mortality in the urban areas, rather than reduced stroke mortality in rural areas. We need to focus our search for interventions to reduce disparities on those that benefit the disadvantaged populations, and support this review using relatively recently developed statistical approaches to estimate the magnitude of the potential reduction in the disparities.

At the beginning of each decade since 1980, the US Department of Health and Human Services releases a Healthy People guidance document providing goals for the nation's health for the upcoming decade. The goals for Healthy People 2000 (released in 1990) included calls for both the reduction of the burden from major diseases and elimination of health disparities.¹ Over the years, the goal of reducing the burden of disease has shifted to the more positive view of improving health; however, the focus on eliminating health disparities remains a guiding principle of Healthy People 2030 (released in 2020).¹ Herein, we consider the multidecade progress to reduce the overall burden from stroke and improve cerebrovascular health (discussed in the Celebration section), reduce disparities in stroke (discussed in the Reflection section), and new approaches to potentially improve success in better selecting targets for intervention to reduce stroke disparities (discussed in the Redirection section). Although stroke disparities can be defined by innumerable characteristics, the focus of this report is on 3 stroke disparities: (1) race and ethnicity, (2) geographic region of the nation (ie, the Stroke Belt), and (3) rural or urban. These were selected as being the most studied of the potential stroke disparities, and because the Minority Health and Health Disparities Research and Education Act (US Public Law 106–525; 2000) specifically instructs the National Institutes of Health to have a focus of disparity investigations on minority health and rural health research.² The focus of this lecture is on disparities in the United States, because a more international discussion substantially complicates both the disparities to be considered and the breadth of the potential contributors to these disparities. In the Redirection section of this work, we encourage an approach where the impact of potential interventions specifically on the magnitude of disparities is considered. Relatively new analytic approaches can be employed to quantify the magnitude of the potential impact. In the section, we use different approaches to hypertension management to reduce racial disparities in stroke as an illustrative example. With the wide breadth of potential interventions (ie, structural racism, lifestyle management, environmental exposures, and traditional risk factors), we need to take approaches that proactively and explicitly seek interventions that will differentially benefit the disadvantaged populations. These approaches need to be analytically supported using methods that formally evaluate the potential impact on the disparities.

CELEBRATION

As we continue to work to reduce the burden of stroke, it is important to take time to reflect on progress and celebrate successes. Figure 1 shows the age‐adjusted stroke mortality rates (for those aged ≥45 years) over the 54‐year period from 1968 to 2021 (from the Centers for Disease Control and Prevention WONDER [Wide‐Ranging Online Data for Epidemiologic Research] study).³ To reduce redundancy for the reader, mortality rates in this report are expressed per 100 000 (ie, a reported mortality of 150 represents mortality of 150 per 100 000). Over this 54‐year period, stroke mortality decreased by a remarkable 75%, from 465.5 to 114.8 between 1968 and 2021. In 2021, there were 158 536 deaths from stroke among the population aged ≥45 years; however, had the 1968 stroke mortality rate persisted there would have been 643 966 deaths among those aged ≥45 years, an increase of 485 153 stroke deaths. This increase in stroke deaths is nearly identical to the entire 2021 population aged ≥45 years in Montana (485 431) and larger than the population aged ≥45 years in Delaware (461 971), South Dakota (366 907), Vermont (307 159), North Dakota (295 293), Alaska (271 202), Wyoming (243 700), or Washington DC (222 743).³ In 1999, the decrease in stroke (and heart disease) mortality was declared 1 of the 10 greatest public health achievements of the 21st century,⁴ and in 2011 was declared 1 of the 10 greatest public health achievement of the decade from 2000 to 2010.⁵

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Figure 1. Age‐adjusted stroke mortality for the population aged ≥45 years, 1968 through 2021.

Data are from 1968 through 1978 from ICD‐8 (codes 430–438), 1979 through 1998 from ICD‐9 (codes 430–438), and 1999 through 2021 from ICD‐10 (codes I60–I69). ICD‐8, ICD‐9, ICD‐10 indicate International Classification of Diseases, Eighth Revision, Ninth Revision, Tenth Revision, respectively.