Prevalence of Stroke — United States, 2005
Stroke is the third most common cause of death in the United States 1
Stroke also results in substantial health-care expenditures; the mean
lifetime cost resulting from an ischemic stroke is estimated at 140,000
per patient 1 Nationwide, costs related to stroke are expected to reach
an estimated 627 billion in 2007 1 Stroke death rates are higher in
the southeastern United States, compared with other regions of the country;
blacks, American Indians/Alaska Natives AI/ANs, Asians/Pacific Islanders,
and Hispanics die from stroke at younger ages than whites 1–3 Regional
and national data on self-reported stroke prevalence have been published
previously 1,4; however, state-specific prevalence data for persons with
a history of stroke have not To provide national-level stroke prevalence
estimates by age group, sex, race/ethnicity, and education level and
overall prevalence estimates for each of the 50 states, the US Virgin
Islands USVI, the District of Columbia DC, and Puerto Rico, CDC
analyzed data from the 2005 Behavioral Risk Factor Surveillance System
BRFSS survey This report summarizes the results of that analysis and
provides the
first state-based prevalence estimates of stroke The results
indicated that, in 2005, substantial differences existed in the prevalence
of stroke by state/territory, race/ethnicity, age group, and education
level To lower the incidence of stroke and meet the Healthy People 2010
objective to reduce stroke deaths objective no 12-7 and the overall
goal to eliminate health disparities, public health programs should augment
stroke risk-factor prevention and educational measures in
disproportionately affected regions and populations
BRFSS is a state-based, random-digit_dialed telephone survey of the
noninstitutionalized, US civilian population aged 18 years and is
administered by state health departments in collaboration with CDC In
2005, the median response rate among states, based on Council of American
Survey and Research Organizations guidelines, was 511 range: 346–
674 This rate accounts for the efficiency of the telephone sampling
method used and participation rates among eligible respondents who were
contacted A total of 356,112 respondents from all 50 states, DC, Puerto
Rico, and USVI participated in the survey State including DC and
territory sample sizes ranged from 2,422 USVI
to 23,302 Washington The
racial/ethnic national sample sizes ranged from 5,535 AI/ANs to 279,419
whites All prevalence estimates in this report have a numerator 50 and
a relative standard error 30 to ensure that estimates are stable
Survey respondents answered the question, Has a doctor or other health
professional ever told you that you had a stroke? Differences in
prevalence were assessed by age group, sex, race/ethnicity, education
level, and state or territory of residence Data were weighted to reflect
the population aged 18 years in each state and territory and were age
adjusted to the 2000 US standard population to allow for more meaningful
comparisons between states and between demographic groups The weighted
state prevalence values were used to estimate the number of persons with a
history of stroke in various demographic groups and in each state or
territory Respondents provided racial/ethnic identification; those who
identified themselves as multiracial were included in a separate category
In 2005, 26 95 confidence interval [CI] 25–27 of
noninstitutionalized US adults approximately 5,839,000 persons had a
history of stroke Table 1 The prevalence of stroke increased with
age:
81 of respondents aged 65 years reported a history of stroke, compared
with 08 of persons aged 18–44 years The prevalence of stroke among men
27 and women 25 was similar Among persons with less than 12 years
of education, 44 reported a history of stroke, approximately twice the
proportion among college graduates 18
The overall prevalences of stroke among AI/ANs 60, multiracial persons
46, and blacks 40 were higher than the prevalence among whites
23 The prevalences of stroke among Asians/Pacific Islanders 16 and
Hispanics 26 were similar to the prevalence among whites
The prevalence of stroke ranged from 15 in Connecticut to 43 in
Mississippi Table 2 States and territories with the highest prevalence
of stroke had approximately twice the prevalence of those with the lowest
Figure Wyoming, with an estimated state population of 509,000 in 2005,
had the lowest estimated number of persons reporting a history of stroke
10,000; California, with an estimated population of approximately 36
million in 2005, had the highest 641,000
Reported by: JR Neyer, KJ Greenlund, PhD, CH Denny, PhD, NL Keenan, PhD, M
Casper, PhD, DR Labarthe, MD, PhD, JB Croft, PhD, Div for Heart Disease
and
Stroke Prevention, National Center for Chronic Disease Prevention and
Health Promotion, CDC
Editorial Note:
This report provides the first state-based estimates of the prevalence of
persons with a history of stroke in the United States The results indicate
that, in 2005, substantial differences existed in the prevalence of stroke
by race/ethnicity, education level, and state/area of residence The
results also exhibit variation among states, with an approximately twofold
difference between states with the highest and lowest prevalence estimates
The overall prevalence estimate of 26 and race/ethnicity-specific
estimates in this report are comparable to previously published national
stroke prevalence data 1 In addition, the finding that many states with
high prevalence estimates are concentrated in the southeast corresponds to
the high rates of stroke mortality observed in this region, which has been
traditionally called the stroke belt 2 However, certain states
Illinois, Michigan, Missouri, Nevada, Texas, and West Virginia in other
US regions also had prevalence estimates 30, among the highest in the
country
Two factors contribute to stroke prevalence: stroke incidence ie,
new
cases and survival rates after cerebrovascular events Data on stroke
incidence and long-term survival are limited 5; thus, assessing the
relative contribution of these two factors is difficult Improved
surveillance for stroke, including data to determine incidence, survival,
and type of stroke, would be useful to better understand the causes of the
disparities described in this report 5
Several studies have hypothesized that the geographic and racial/ethnic
variation in stroke prevalence and mortality might be attributed to
variation in the amounts of trace elements in the environment,
inconsistencies in the accuracy of stroke vital statistics data, migration
patterns, and differences in the prevalence of stroke risk factors 2,6,7
A simple explanation for the observed variations remains elusive; however,
one likely explanation for the geographic variation in stroke prevalence
described in this report is variation in the proportion of the population
with risk factors for stroke and heart disease In a 2003 BRFSS analysis,
the prevalence of having two or more of the major, modifiable risk factors
for stroke and heart disease eg, high blood pressure, high blood
cholesterol levels,
diabetes, current smoking, physical inactivity, or
obesity was above the median value of 360 in 18 of the 19 states/areas
with the highest stroke prevalence estimates in this 2005 analysis 6
Reasons for the geographic variation in the prevalence of risk factors for
stroke are complex and might be attributed to a combination of factors
eg, cultural norms for diet and exercise, poverty and lack of economic
opportunity, social isolation, and regional differences in access to health
care and preventive services 2 The geographic distribution of
racial/ethnic groups alone does not account for the geographic variation in
stroke mortality 2 To further define and explain the underlying causes
of these differences, additional studies are needed, including small-area
analyses, in-depth interviews, more precise prevalence estimates by
race/ethnicity, quality-of-care assessments, and recorded health outcomes
One such study that is under way is the Reasons for Geographic and Racial
Differences in Stroke Study REGARDS, a national population-based,
longitudinal study designed to determine the causes of excess mortality in
the southeast United States and among blacks 7
As with the geographic
variations in stroke prevalence, the disparities
observed among racial/ethnic groups are likely attributed, in part, to
differences in the proportion of these population groups with risk factors
for stroke For example, in a recent analysis, AI/AN men had a higher
prevalence of hypertension and hypercholesterolemia than any other
racial/ethnic group, and AI/AN men and women had the highest prevalence of
obesity, current smoking, and diabetes 8 However, the AI/AN group is
diverse, and national-level data on stroke incidence, prevalence, and
mortality for AI/ANs are limited 3 Similarly, blacks have a much higher
prevalence of hypertension and diabetes and are less likely to have blood
pressure controlled or diabetes treated than whites 1 Risk factor
information for the multiracial group is limited because the multiracial
category has only recently been included in large, population-based
analyses
The findings in this report are subject to at least four limitations
First, BRFSS data are based on self-reported information and are subject to
recall bias and misinterpretation of the term stroke Differential recall
of stroke or ability to report a history of stroke by telephone
interview
could affect the disease prevalence estimates Despite this limitation,
self-reported disease history is used routinely to provide stroke
prevalence estimates 1,3,4 Second, BRFSS does not include persons living
in nursing homes, prisons, military bases, or other institutions,
populations whose inclusion might alter stroke prevalence estimates for the
entire population Third, BRFSS is limited to households with land-line
telephones and does not include persons who do not have telephones or who
use cellular telephones exclusively Finally, the BRFSS response rate was
low; however, the prevalence estimates are accurate when compared with
other surveys and other modes of survey administration eg, in-person
interviews 9
CDC has formed local, state, national, and international partnerships to
help control risk factors in susceptible populations, reduce the incidence
of stroke, and achieve the nations Healthy People 2010 health objectives
For example, the National Forum for Heart Disease and Stroke Prevention,
which comprises nearly 80 organizations, is working toward implementing A
Public Health Action Plan to Prevent Heart Disease and Stroke In
addition, the CDC State Heart
Disease and Stroke Prevention Program funds
health departments in 32 states and DC to support stroke prevention through
education, strategies to change physical and social environments, and
programs to help eliminate racial/ethnic disparities in stroke risk CDC
also funds 15 WISEWOMAN projects, which aim to prevent heart disease and
stroke by providing low-income, underinsured, and uninsured women aged 40–
64 years with opportunities for lifestyle interventions, referral services,
and screening for chronic disease risk factors; approximately 12,000 women
have received services through WISEWOMAN during the past 4 years Since
2000, WISEWOMAN has identified approximately 5,783 cases of previously
undiagnosed hypertension, 6,286 cases of undiagnosed high cholesterol, and
800 cases of undiagnosed diabetes
Since 1999, REACH 2010, a program funded by the US Department of Health
and Human Services, has supported several community-based projects that
target racial/ethnic groups disproportionately affected by certain
diseases For example, the Choctaw Nation Project in Oklahoma and the
Chugachmiut Native Organization in Alaska were both developed to address
the burden of heart disease and
stroke among AI/ANs In Louisiana, the
Black Womens Health Imperative has provided access to clinical preventive
services for nearly 4,000 persons and improved the recognition of risk
factors for heart disease and stroke in the communities it serves
The findings in this report indicate that, in 2005, the prevalence of
stroke varied by education level, race/ethnicity, and state/territory
These data can help health planners eg, policy makers and public health
officials better target prevention resources to groups with
disproportionately high stroke prevalence The importance of preventing and
controlling risk factors eg, high blood pressure, heart disease, atrial
fibrillation, high blood cholesterol levels, diabetes, tobacco use, alcohol
use, physical inactivity, and obesity to reduce the risk for stroke is
well-established 10 In communities, policies that reduce tobacco
exposure and promote healthy living eg, better access to healthy foods,
school and worksite health education, and environments that are safe for
and conducive to physical activity can contribute to the prevention of
stroke and other cardiovascular diseases Finally, measures that improve
recognition of the early signs
of stroke and timely access to emergency
stroke care can minimize the effects of strokes
Acknowledgment
The findings in this report are based on data provided by BRFSS state
coordinators
References
1 Rosamond W, Flegal K, Friday G, et al Heart disease and stroke
statistics — 2007 update: a report from the American Heart
Association Statistics Committee and Stroke Statistics Subcommittee
Circulation 2007;115:e69–e171
2 Casper ML, Barnett E, Williams GI Jr, Braham VE, Greenlund KJ Atlas
of stroke mortality: racial, ethnic, and geographic disparities in the
United States Atlanta, GA: US Department of Health and Human
Services, CDC; January 2003 Available at
http://wwwcdcgov/dhdsp/library/maps/strokeatlas/indexhtm
3 Stansbury JP, Jia H, Williams LS, Vogel WB, Duncan PW Ethnic
disparities in stroke: epidemiology, acute care, and postacute
outcomes Stroke 2005;36:374–87
4 CDC Regional and racial differences in the prevalence of stroke —
23 states and District of Columbia, 2003 MMWR 2005;54:481–4
5 Goff DC, Brass L, Braun LT, et al Essential features of a
surveillance system to support the prevention
and management of heart
disease and stroke: a scientific statement from the American Heart
Association Councils on Epidemiology and Prevention, Stroke, and
Cardiovascular Nursing and the Interdisciplinary Working Groups on
Quality of Care and Outcomes Research and Atherosclerotic Peripheral
Vascular Disease Circulation 2007;115:127–55
6 CDC Racial/ethnic and socioeconomic disparities in multiple risk
factors for heart disease and stroke MMWR 2005;54:113–7
7 Howard VJ, Cushman M, Pulley L, et al The reasons for geographic and
racial differences in stroke study: objectives and design
Neuroepidemiology 2005;25:135–43
8 CDC Health status of American Indians compared with other
racial/ethnic minority populations — selected states, 2001_2002 MMWR
2003;52:1148–52
9 Nelson DE, Holtzman DJ, Bolen JC, Stanwyck CA, Mack KA Reliability
and validity of measures from the Behavioral Risk Factor Surveillance
System BRFSS Soz Praventivmed 2001;46Suppl l:S3–S42
10 Goldstein LB, Adams R, Alberts MJ, et al Primary prevention of
ischemic stroke Stroke 2006;37:1583–634
Additional information available
at
http://wwwcdcgov/dhdsp/library/hp2010/indexhtm
Information regarding BRFSS data and methods available at
http://wwwcdcgov/brfss/technical_infodata/surveydata/2005htm
Additional information available at
http://wwwcdcgov/dhdsp/library/action_plan/indexhtm
Additional information available at
http://wwwcdcgov/dhdsp/wisewomanhtm
Additional information about these and other programs available at
http://wwwcdcgov/reach2010 and http://wwwcdcgov/dhdsp
Table 1
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Table 2
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Figure
Source:brentpct.nhs.uk
