Raising the Standard for Stroke Care and Education: Cleveland Clinic’s Minority Stroke Program

Gwendolyn Lynch, MD, FAAN

It’s no secret that racial and ethnic disparities in stroke prevalence and risk factors have been well documented throughout research studies. According to the Centers for Disease Control and Prevention (CDC), African American adults are 50% more likely to have a stroke in comparison with their White adult counterparts, and Black men are 70% more likely to die from a stroke compared with non-Hispanic White men.¹

Although there was a decline in stroke mortality for all races and ethnic groups across the United States during the mid-1990s, the rates remained higher for Black individuals compared with White individuals in terms of the decline.² There are a number of reasons that factor into the racial disparities that have been observed, including family history, as well as genetic, environmental, and cultural risk factors, diet, and rates of unfavorable social determinants of health.

"Stroke impacts individual quality of life, the ability to take care of yourself, your family and your community, as well as the local economy and other population-related factors," Gwendolyn Lynch, MD, FAAN, a stroke expert from Cleveland Clinic, told NeurologyLive^®. "These are reasons that justify our need to focus on these risk factors, address stroke prevention and awareness, as well as stroke treatment."

In addition to being an assistant professor of neurology, Lynch serves as the director of the Minority Stroke Program at Cleveland Clinic. This recently created program was launched in 2019 and comprises a team of physician volunteers who are interested in providing minority ethic patients the best possible stroke care. A majority of the patients that make up the program are enrolled after they have been admitted to the hospital with an acute stroke, where they receive education about stroke and their stroke type, in particular.

"We address their questions and concerns and will arrange for an outpatient follow-up, ideally within 14 days after they’re discharged from the hospital," Lynch added. "We discuss risk factors and what should be done to optimize their modifiable risk factors, as well as any concerns they have about any needs surrounding social determinants of health."

Greater Focus on Modifiable Risk Factors

The program maintains a big emphasis on addressing and educating minority patients on modifiable stroke risk factors, of which there are several. High blood pressure, occurring in nearly half of American adults, is the leading cause of stroke and the most significant controllable risk factor. Lifestyle changes such as improved diet, exercise, sleep, alcohol intake, weight maintenance, and lower stress, have all been proven to have an impact on lowering or maintaining healthy blood pressure.³

Smoking and nicotine intake can also damage heart and blood vessels, making one more susceptible to a stroke. In addition, people who live in rural areas are more likely to smoke than those in urban areas. A recent study found that Hispanic and Black adults in rural communities have a 38% increased rate of smoking, ultimately leading to greater stroke risk.⁴ There is also an even greater risk among women, as the use of birth control pills combined with cigarette smoking has been shown to raise stroke vulnerability.

Other factors such as diabetes, physical inactivity, obesity, high cholesterol, atrial fibrillation, sleep apnea, carotid artery disease, peripheral artery disease, and other heart diseases, are also considered risk factors that are modifiable through lifestyle changes. In particular, diet can have a major impact on the risk of stroke in minority populations. A study reported in the Journal of Hypertension showed that even just reducing salt intake from 10 mg to 5 mg per day attenuated blood pressure and urine protein excretion in Black patients who were hypertensive.⁵

"These are significant factors in terms of stroke risk, but knowing that, it’s also important for us to realize that addressing those modifiable risk factors can make a difference,” Lynch told NeurologyLive. "That’s why we emphasize that in our program."

G. Abbas Kharal, MD

From 1995 to 2012, changes in cardiovascular risk factors accounted for a 57% decrease in ischemic stroke incidence throughout that time. Compiled of 367,636 person-years of follow-up, the most important contributors were decreasing mean systolic blood pressure and smoking prevalence, which accounted for 26% and 17% of the observed decline, respectively. Conversely, increasing diabetes mellitus prevalence contributed negatively to the declining ischemic stroke incidence.⁶

"Throughout the day, when serving in outpatient clinics, we see patients who present with cerebrovascular issues, including patients with and without stroke. My role is to help them identify and manage key risk factors responsible for their stroke risk and help them become more aware of the things they need to do to help reduce their stroke risk," G. Abbas Kharal, MD, told NeurologyLive.

Kharal, a stroke/vascular neurologist who works within Cleveland Clinic’s Cerebrovascular Center and the Minority Stroke Program, feels that patient awareness and education are among the most observable racial/ethnic disparities within stroke care.

"Education is perhaps the most important aspect when it comes to minority stroke patients," he said. "Being aware of stroke risk factors and the importance of healthy lifestyle habits, being aware of stroke signs and when to seek help, and being educated about the importance of maintaining stroke follow up and medication compliance are all aspects of health education that hold more value especially for minority ethnic patients as they often lack these aspects compared with nonminority ethnic patients."

Tailoring the Approach to Minority Care

While the Minority Stroke Program is comprised of clinicians who specialize in stroke management, this group of experts are also highly educated and trained to address the specific, unique challenges of stroke in minorities, including educating about the historical racial disparities and providing updated statistics regarding minority stroke risk and risk factors.

"We also address the patient-physician relationship, as well as cultural sensitivity and awareness during that training," Lynch said. "We’ve done this from the very beginning of the program. We’ve also expanded to provide this education to the Cleveland Clinic community. In 2021, we held a national conference, Health Disparities 2021, to provide some of this education to others who were interesting in learning more about minority stroke and minority stroke prevention."

"Education is perhaps the most important aspect when it comes to minority stroke patients. Being aware of stroke risk factors and the importance of healthy lifestyle habits, being aware of stroke signs and when to seek help, and being educated about the importance of maintaining stroke follow up and medication compliance are all aspects of health education that hold more value."
—G. Abbas Kharal, MD

With regard to education, there is a steering committee made up of clinicians that works with a community advisory board comprised of stroke survivors, family members of those impacted, and key stakeholders, to implement changes and suggestions where needed. Some of those learnings have been quite useful in how the program is designed.

"For example, they’ve recommended that we emphasize the importance of maintaining optimal eye contact during visits with the patient and to avoid looking at the computer. This gives the patient a greater sense of your awareness of them being present and also a higher level of respect," Lynch added. "They also recommended that we emphasize the importance of being mindful to refer to the patient by their last name until the patient gives permission to use their first time."

Lynch went on to add that minority patient populations appear more engaged when they see materials that include more pictures of minorities involved in stroke care. In addition, they emphasize the importance of including young people in these materials, alluding to the disparities in stroke prevalence among African American patients at younger ages. Over time, the program has been tweaked to include these recommendations, ultimately better connecting with the presenting patient population.

As previously mentioned, social determinants of health like economic stability, neighborhood, access to food, education, and healthcare all can have impacts on stroke risks and outcomes. Within the stroke program, clinicians survey patients to identify what their needs are and help provide them with access to resources through a platform called Unite Us.

Unite Us is a service that helps clinicians connect patients with local resource agencies and programs based on their needs. "Once they inform us of their need, we pull up the option related to their need, we click an option, which then starts the process of that connection. Then, the agency sees it on their end and they contact the patient by phone to establish the relationship so that they can meet the need," Lynch said.

The Minority Stroke Program team also provides referrals to other medical providers who manage diabetes, heart disease, hypertension, and vascular disease; or who can help with weight loss, physical fitness, and smoking cessation. Additionally, the program provides information on transportation assistance for in-person appointments, prescription assistance, stroke support groups, and community education events.

Looking Ahead

In the coming years, the health center is looking to include collaborate with doctors of pharmacy from Cleveland Clinic during the outpatient visit setting to provide education about stroke prevention medication and other medications they may be taking. Another near-term goal is to incorporate additional diet education and a cooking demonstration program to show that healthy cooking is feasible and fun.

Regarding ways to continue to expand the program, Kharal stated, “improving access to this program and growing its resources [are key]. Being able to provide access to all patients from minority ethic backgrounds in Northeast Ohio, being able to provide more affordable options for medications, transportation, and medication discounts. [We want to] foster research on issues pertinent to minority ethnic populations in stroke care, and grow facilities and infrastructure for this clinic as we transition to our new Neurological Institute building."

REFERENCES
1. Stroke and African Americans. US Department of Health and Human Services Office of Minority Health. Updated, 2022; Accessed June 5, 2024. https://minorityhealth.hhs.gov/stroke-and-african-americans
2. Kleindorfer D, Broderick J, Khoury J, et al. The unchanging incidence and case-fatality of stroke in the 1990s. Stroke. 2006;37:2473-2478. Doi:10.1161/01.STR.0000242766.65550.92
3. Risk Factors Under Your Control. American Stroke Association. October 8, 2023. Accessed June 5, 2024. https://www.stroke.org/en/about-stroke/stroke-risk-factors/risk-factors-under-your-control
4. Cornelius ME, Loretta CG, Wang WT, Jamal A, Homa DM. Tobacco product use among adults – United States, 2020. CDC MMWR Morb Mortal Wkly Rep. 2022;71(11);397-405. doi:10.15585/mmwr.mm7111a1
5. Swift PA, Markandu ND, Sagnella GA, He FJ, MacGregor G. Modest salt reduction reduces blood pressure and urine protein excretion in black hypertensives: a randomized controlled trial. J Hypertension. 2005;46(2):308-12. Doi:10.1161/01.HYP.0000172662.12480.7f
6. Vangen-Lonne AM, Wilsgaard T, Johnsen SH, Lochen M, Njolstad I, Mathiesen EB. Declining incidence of ischemic stroke: What is the impact of changing risk factors? The Tromso study 1995 to 2012. Stroke. 2017;48:544-550. doi:10.1161/STROKEAHA.116.014377