Stroke is among the most serious public health challenges facing this Commonwealth. Sometimes referred to as a brain attack, stroke is the third leading cause of death and a leading cause of adult disability in both Pennsylvania and the United States. This devastating illness is a particularly severe problem in Pennsylvania, which has a population significantly older than most of the other states. As the population of the Commonwealth continues to age, the incidence of stroke and the number of deaths from stroke are likely to increase.

A variety of programs are already responding to the challenge of stroke with considerable success. These untiring efforts in both the private and public sectors—with much of the work performed by volunteers—deserve our admiration and support. However, more can and should be done because of the growing need for stroke prevention, treatment, and rehabilitative care.

In addition to its high incidence, two other factors have caused greater attention to be paid to stroke. Recent advances in treatment, including the emergence of thrombolytic therapy, have made it possible to limit the damage caused by some strokes. However, these therapies must be administered rapidly after the onset of symptoms to be effective. Consequently, the stroke care community must develop a new approach to the structure of stroke treatment and must educate the public about the need to treat stroke as a medical emergency.

A second factor is proposed federal legislation called the Stroke Treatment and Ongoing Prevention (STOP) Act that would provide block grant funding for stroke prevention and treatment. The legislation contemplates a phased in appropriation rising from $50 to $125 million, contingent in later years on matching state appropriations. If this legislation is enacted, Pennsylvania will need to have a stroke prevention, treatment and rehabilitation structure in place to qualify for federal funding.

Pursuant to 2000 Senate Resolution No. 130, the Commission assembled an advisory committee of 27 experts in various related fields to draw upon their knowledge and experience and recommend measures to the task force to improve the state's response to stroke. These recommendations are set forth in this report and are briefly summarized here.

The report includes a summary of data relating to stroke incidence and death rates, data on risk factors affecting stroke, and a description of current acute care and rehabilitative treatments. Among the items included in the data are the following:

• • The annual number of deaths from stroke in Pennsylvania has risen from its low point of 7,587 in 1991 to 8,919 in 2000.
  • While the age-adjusted death rate for stroke is lower for Pennsylvania than for the nation, the unadjusted death rate is higher.
  • Preventable causes include a higher incidence of smoking in Pennsylvania African Americans and persons aged 25-34, compared to national rates.
  • Hispanics are the only Pennsylvania race or ethnic group with an ageadjusted stroke death rate that is higher than the national average.
  • A crude estimate of the cost of stroke to the economy of Pennsylvania puts it at well in excess of two billion dollars per year.

Statistical tables from Pennsylvania Vital Statistics 2000 are included as appendices to the report. Also included are extensive tables of Pennsylvania data on each stage of stroke treatment, compiled with the assistance of the Emergency Medical Services Office and the Pennsylvania Health Care Cost Containment Council. The informational part of this report concludes with descriptions of public and private programs that deal with the study and treatment of stroke.

RECOMMENDATIONS
Because of the particular urgency of stroke as a public health problem in Pennsylvania, the advisory committee recommends that the Commonwealth establish a special stroke office within the Department of Health (PADOH) but with an independent advisory committee. Draft legislation to implement this recommendation is included as appendix 5. The purpose of this office would be to coordinate and assist stroke prevention, treatment, and rehabilitation programs, disseminate best practices and other information, and conduct research. An office with a similar mission has been established in Ohio, and offices dealing with cardiovascular disease and stroke have been established in Maryland and Mississippi. PADOH does not agree with this recommendation, as it believes such an office would duplicate its stroke programs and its effort to formulate a statewide cardiovascular disease implementation plan. (See pp. 52-53 and PADOH's statement at appendix 6 for a discussion of this issue.)

The advisory committee recommended to PADOH that it reorganize so as to create an administrative unit under the Bureau of Chronic Disease and Injury Prevention that would be responsible for vascular diseases; this unit would include a cardiovascular disease office and a stroke office, which could perform the functions recommended in this report.

The first maxim among professionals who face the challenge of stroke is this: The best way to treat a stroke is to prevent it. The stroke office can greatly assist in the implementation of preventive efforts that address the specific requirements of underserved urban and rural populations and are tailored to the cultural backgrounds and other characteristics of the public intended to be served. The next essential component of a comprehensive stroke treatment and prevention system is an acute care structure that takes the maximum realistic advantage of the new therapies and responds to the need to administer treatment within three hours of onset. Finally, the stroke program must address the needs of stroke survivors. Many survivors need extensive rehabilitation services, and the earlier the services are provided, the more likely the patient can preserve function and maintain independence.

Leading recommendations of the advisory committee are as follows:

• Stroke Office
  • Establish a stroke office under PADOH, guided by a representative multidisciplinary advisory committee. The office should be afforded adequate resources to enable it to lead the Commonwealth's response to stroke, following the more detailed suggestions made throughout this report, as well as its own strategies.

• Prevention
  • Establish educational programs to raise health care provider and public awareness about risk factors and warning signs of stroke, emphasizing early recognition of risk factors to increase the effectiveness of early preventive intervention.
  • Encourage educational programs that inform potential victims and their caregivers to treat stroke as an emergency and to obtain immediate EMS assistance.
  • Make available to health professionals the best practices for preventive care and establish a clearinghouse for stroke research and information.
  • Create a stroke registry to facilitate medical research into stroke prevention.
  • Study strategies for expanding the availability of insurance coverage for diagnostic services and preventive care for stroke.

• Acute Care
  • Formulate a statewide stroke care plan, starting with a comprehensive survey of the present capability of the Commonwealth's acute care providers.
  • Establish a long-term goal of improving acute care capacity such that no Pennsylvania resident lives more than one hour away from a hospital with capability of treating all acute strokes. Where this is not presently the case, public funds should be used (either alone or in conjunction with private funds) to close this gap.
  Establish as a professional practice that every hospital that is not capable of treating all acute strokes must have a transfer agreement under which the receiving hospital can quickly evaluate the patient and, if necessary, transfer the patient to a hospital with that capability.
  • Public health policy at this time should emphasize improving the stroke treatment capability of all hospitals. At the same time, it should leave open the possibility of using designated stroke centers within a well-planned stroke treatment system.

• Rehabilitation
  • Perform a comprehensive study of insurance coverage of rehabilitation to inform carriers of the types of coverage that can reduce overutilizaton of nursing homes.
  • Promote awareness of evidence-based rehabilitation guidelines and protocols established by professional organizations.
  • Expand the right to appeal denial of rehabilitation coverage for patients outside managed care, insure that all stages of utilization review are conducted by qualified medical specialists, and inform patients and caregivers of their right to challenge coverage decisions under present law.
  • Ensure that all stroke rehabilitation is performed in facilities that are licensed by PADOH or accredited by appropriate professional organizations.

Implementing these recommendations will obviously require a substantial commitment of financial resources. The STOP legislation, if enacted, may supply a portion of these. Money from the tobacco settlement can help, especially in funding medical research, but such funds would need to be reallocated. A possible avenue is reallocation of part of the recent increase in cigarette taxes. The stroke office could pursue funding from private sources, such as foundations and medical charities.

The advisory committee believes that directing funds and effort toward enhancing stroke prevention and care will pay off by helping more Pennsylvanians achieve a longer, healthier life, free of the tragic effects of stroke that too often darken the lives of the Commonwealth's citizens.