Lessons From Flint, Mich. on Stroke Preparedness and Lytic Uptake

DALLAS -- Efforts to boost stroke treatment in Flint, Michigan had mixed results that nevertheless left the community with one of the highest thrombolytic usage rates in the state, even amid a public health crisis, according to the Stroke Ready investigators.

A concerted intervention combining community engagement and hospital emergency department (ED) optimization was not significantly associated with tissue plasminogen activator (tPA) use for stroke (adjusted OR 1.12, 95% CI 0.74-1.70), the study's primary outcome, reported Lesli Skolarus, MD, MS, of Northwestern University Feinberg School of Medicine in Chicago.

Looking at the separate components of the intervention suggested that the ED strategy corresponded to more thrombolysis (OR 1.64, 95% CI 1.04-2.58), while the ensuing community intervention, which comprised peer-led stroke preparedness education, did not (OR 0.99, 95% CI 0.96-1.01), according to Skolarus' presentation at the American Stroke Association's International Stroke Conference.

Skolarus said Flint is notable for showing the highest increase in thrombolysis treatment rates in comparison to other Michigan communities over the last decade, jumping from 4% in 2010 to 14% in 2020. "Flint started out as a very low-performing city, into 2020 and ended up being the highest utilizing thrombolysis city among our comparators," she said.

Racial disparities were also significantly impacted, as Black patients experiencing stroke saw greater increases in thrombolysis treatment rates when compared to white peers.

"We learned and hopefully we displayed that community interventions are pretty complicated to evaluate in the context of the real-world backdrop," Skolarus added. "Often cluster randomized trials of EDs or communities would be needed."

Flint is notable for a crisis of lead-contaminated water that started in 2014 and rose to national prominence in 2016. After better water sourcing and the replacement of pipes citywide, Flint's water has since been declared by officials to be safe again, but many locals still refuse to drink from it.

Stroke Ready's ED intervention component lasted from October 2017 to June 2018 and had hospitals improve their tPA implementation strategies.

Community education sessions, ranging from one-on-one 5-minute sessions to 60-minute group workshops, commenced afterward and lasted until March 2020. The program reached 5,970 participants -- nearly 10% of the total population of adults in Flint -- who attended a total of 234 in-person sessions with 28 peer educators regarding stroke preparedness. Social media, radio advertisements, mailers, and posters had been used to reach out to the Flint community.

Of the community participants, 46% identified as being of Black and white race, 36% identified as primarily Black, and 18% identified as primarily white. The majority of the workshops (71%) provided included both men and women among the participants.

Flint had 3,334 ischemic stroke and transient ischemic attack (TIA) patients analyzed in the study, 2,506 patients recorded during the pre-intervention period (July 2010 to September 2017), and 1,022 patients postintervention (October 2017 to March 2020).

Stroke patients were 52% Black, and their average age was 68 years old.

Among the limitations of the study was the underpowered analysis: the study had recruitment interrupted by the COVID-19 pandemic, shortening the community arm of the intervention program by 3 months, as well as the study's follow-up period. Skolarus also cautioned that the study was not designed to analyze the arms of the study separately, but rather the intervention program as a whole.

Despite the lack of association between the program and thrombolysis altogether, Skolarus noted that the impact of the intervention program will be felt long after the study's conclusion.

"It's really amazing. Amid a public health crisis, Flint became a community with one of the highest thrombolysis treatment rates," said Skolarus. "Flint also has 28 trained stroke peer educators who can maintain the level of stroke preparedness in the community."

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