Georgians’ high stroke rate combined with string of hospital closings hurts chances of survival

From the Georgia Recorder

Desric Seecheran felt strong. He exercised nearly every day after work, had a good job and generally took good care of himself.

One day, he was in his Douglasville home getting ready to go to the mall with a friend, but something didn’t feel right.

“I stood up, and then I fell,” he said. “And when I fell, I was like, oh my god, I guess my leg is asleep, so I asked her to pull me up, so she did, and I sat on the edge of the bed. And as soon as I sat down on the edge of the bed, the room started spinning. So all I told her was get my brother and tell him to call 911.”

At 32, Seecheran was experiencing a stroke. His fast thinking helped him get the treatment he needed to save his life, but after a month-and-a-half stay in the hospital, doctors thought he might never regain the ability to speak.

“Sometimes, like, I would speak, but the word that came out of my mouth was totally wrong. And it’s like, I knew it was wrong, and it frustrated me so much,” he said.

“My mom started going through cards with me. That helped me, and she got me coloring books, like, to literally start me over like I was a baby. When I got home, I just couldn’t speak, but eventually, I got to where I started to talk and stuff like that. Ended up just trying to make the best out of my life that I could.”

Today, at 41, Seecheran uses a cane to get around the house and a wheelchair when he’s out. He goes to the hospital for Botox injections to help relieve his pain, and he’s been trying to deal with his insurance to get a robotic arm brace he hopes will help him regain some of his mobility.

“It’s hard, doing everything with one arm,” he said. “Your arm gets tired as you’re doing everything that a regular person would do with two hands with just one. If I could get that, I’d be ecstatic, I’d be so happy. Yeah, I wouldn’t have full use of my body, but just to have two arms to move, even if it doesn’t even move the same way as my left, just the fact that I could move it, that would be great.”

Disparities in care

According to a Georgia Department of Public Health report, Georgia had the 12th-highest stroke death rate in the U.S. in 2020. With 4,821 deaths, it was the fourth-leading cause of death that year. And the disease does not only afflict the elderly. About 19% of Georgia stroke deaths in 2020 were classified as premature, or occurring in people under 65, and the age-adjusted death rate for Black Georgians was 52.2 per 100,000 people, about 30% higher than for white Georgians.

Dr. Dawn Aycock, director of Georgia State University’s doctoral program in nursing, has been following these trends.

“We have seen an increase in stroke among young adults in the past, I would say, two decades,” she said. “Hospitalizations for stroke have increased by about 40% in individuals less than 40 years of age, I would say 20 to 40, and what we’re seeing as far as research is that it’s the traditional cardiovascular risk factors that are contributing to that risk of stroke, so we’re seeing higher rates of hypertension, diabetes, and obesity in that population. So similar risk factors that we see in older adults that contribute to stroke, we’re also now seeing in the younger adults.”

Up to 80% of strokes can be prevented, Aycock said, and she’s working to prevent as many as she can through a Georgia State University program called Stroke Counseling for Risk Reduction, or SCORRE, where she serves as principal investigator. The goal is to educate young African-American adults about the risks of stroke and ways to lessen that risk.

“Many young adults don’t think that they’re at risk of stroke, because it’s typically a disease of older adults,” she said. “And if you don’t think that you’re at risk, you’re going to be less likely to take part in risk reduction behaviors, and so another goal is to promote healthy lifestyles to reduce stroke risk, so improving diet, physical activity, as well as smoking cessation.”

Dr. William Humphries, a neurosurgeon at WellStar Health System, has first-hand experience helping stroke patients, and he said inequalities that have been around for generations have been exacerbated by the pandemic.

“There’s been a lot of studies to show that even before COVID, there were disparities in health care, in terms of access to care, but also in terms of sometimes African Americans not wanting to present to the hospital right away, or in some instances not having rides to get there because of where they live. And so those things were present even before COVID. What we are starting to see is that, like most things, when you introduce a pandemic, or some large system shock to an ecosystem, it exacerbates what’s already there.”

Even when patients get to the hospital, there are often variations in care, Humphries said. A white patient may be more likely to be identified as having a stroke and may be more likely to be recommended for surgery.

“We have to do a better job of trying to figure out, OK, now that the people here, why is there variation? That’s the part I think the hospital system has to try and control,” he said. “I don’t have the answer, but I think the way you do that is you look at your process in how you move patients through your hospital system and all the areas for improvement along the entire workflow path.”

The state Department of Public Health tracks data on strokes through a 2008 law called the Coverdell-Murphy Act. Under it, 83 participating hospitals which receive 93% of acute stroke patients in the state report annual stroke care data, which can highlight hospitals which are suffering from discrepancies in care, said Dr. Alexander Millman, chief medical officer at the Georgia DPH.

“These disparities that happen in care are very important for us to be able to recognize, fortunately, by having Georgia Coverdell Acute Stroke Registry, we have the ability to be able to identify where some of these gaps in care happened, and it provides us with a way of being able to communicate both to the public and to providers about things to look out for for strokes,” he said. “It allows institutions, if there are disparities that are identified, to have the ability to look at what they might be able to do to address some of the care disparities that they may have, both within hospital care, as well as in post-hospital care.”

Racial disparities are not the only issue making Georgians more vulnerable to stroke. A glance at the map of hospitals participating in the stroke registry shows wide gaps across parts of the state that are distant from big cities.

“Another disparity that we know also happens in Georgia, too, is that there’s disparities in stroke care in rural areas compared to urban areas,” Millman said. “And I think the most important thing that we can really try to do, as a department, is really being able to help the public understand what are the signs and symptoms to look out for. It’s important that they call 911 as soon as they have this, because the sooner that they’re able to get to the hospital  and to the appropriate care, the better.”

Health department materials tell Georgians to remember the acronym FAST: if someone is experiencing Facial drooping, Arm weakness on one side or Speech difficulty, it is Time to call 911.

A stroke happens when blood is cut off to part of the brain, cutting off oxygen and killing brain cells. Strokes can occur in different parts of the brain and damage regions responsible for various functions like muscle control or speech.

As soon as a potential stroke patient arrives at the hospital a team of doctors will start a battery of tests to determine whether the problem is a stroke and if so, whether they are candidates for surgery or clot busting medication, Humphries said.

While time is not the only factor in a patient’s prognosis, it is a big one, he said, and the longer a patient goes without treatment, the more their brain tissue is likely to be damaged. That can present big problems in rural areas, but even in Atlanta, there are pockets where residents don’t have access to stroke centers, he said.

Just this month, Wellstar Atlanta Medical Center closed its doors, leaving fewer hospitals in the city to treat health emergencies like strokes.

The state’s role

The state could play a role in reducing Georgia’s rate of stroke death by going into areas without coverage and boosting hospitals’ ability to handle stroke patients, said Democratic state Sen. Michelle Au, a physician from Johns Creek who was elected to serve in the state House next year after GOP lawmakers reconfigured her Senate district.

“We need to look at how we allocate these resources and maybe shore up some of these hospitals that aren’t able to provide this level of acute care in a timely fashion, to provide them with the staffing and resources and equipment they need to be able to provide that care,” she said. “Because if the structure is there, then we need to use our resources in the best ways possible, especially given that we have had so many hospitals closed, like, let’s use what we have in a smart way now.”

That’s easier said than done, Au said, because turning a hospital into a stroke center comes with staffing and equipment requirements across multiple disciplines.

“We could change, really, the entire way our hospitals run, but we have to incentivize this and also provide resources for hospitals to be able to do this if our goal is to address this issue,” she said. “If we care about this issue and agree that it’s important, you can’t just look at it and be like, ‘Oh, too bad. That sucks.’ You have to actually invest.”

According to a United Health Foundation report, Georgia ranked No. 48 in the nation for health insurance coverage with 13.4% of Georgians not covered by private or public health insurance.

“I know that Democrats love to go back to Medicaid expansion as an answer for everything, but we do have to factor that in, that one of the reasons that we have one of the highest uninsurance rates in the nation and the reason it’s difficult for people to access health care is because we have not availed ourselves of the full complement of resources that we have to get people covered,” Au said.

Strokes are associated with chronic health conditions like high blood pressure, high cholesterol, obesity and diabetes, Au said, and people without insurance are more likely to put off going to the doctor about these conditions until they suffer a catastrophic issue like a stroke.

“I don’t think of it purely as a fiscal argument, but I think that it bears repeating how much that costs the system, to have to lifeflight a patient in for care that could have been prevented by a simple oral medication that they’re going to take every day,” Au said. “Not to mention the cost of the surgical care, the medications, the ICU stays.

Another major risk factor for stroke is tobacco use, and Au said she’s hoping to tackle this in next year’s session. The state cigarette tax in Georgia is 37 cents a pack, the second-lowest in the nation. The average state tax on a pack of smokes in the 50 states is $1.86, according to CDC data.

Au said she’s working on legislation to raise the tobacco tax at least to the national average, which she says will raise revenue and discourage people from smoking, thus lowering risk for strokes and other serious health problems.

“I think this is something that we are ready to talk about,” she said. “I think the last time this was brought up, there were some Republican folks who were willing to buy into this purely for logical reasons. And I think that having these statistics out that we are a sad leader in terms of our high stroke rates and just the general unhealthiness of our state is something that could lead to looking at this issue.”