A systematic review of cost-effectiveness research of stroke evaluation and treatment

BACKGROUND AND PURPOSE

This work was undertaken to review research addressing the cost-effectiveness of stroke-related diagnostic, preventive, or therapeutic interventions.

METHODS

We performed searches of MEDLINE, Excerpta Medica online, HealthSTAR, and Sciences Citation Index Expanded and examined the reference lists of the studies and reviews obtained. From these, we selected studies that reported an incremental analysis of cost per effect, in which the effect measure was life-years or quality-adjusted life-years. We abstracted data from each study using a standardized reporting form. Twenty-six articles met the eligibility criteria and were included in the review.

RESULTS

The methodological quality of the articles reviewed has improved compared with previously reported. Many stroke evaluation and treatment policies may result in benefits to health that are considered worth their cost. Some interventions were considered cost-ineffective (anticoagulation in low-risk nonvalvular atrial fibrillation and surveillance with duplex ultrasound after endarterectomy). Different studies addressing the cost-effectiveness of screening asymptomatic carotid stenosis resulted in strikingly divergent conclusions, from being cost-effective to being detrimental. Other studies omitted important costs that, if included, would likely have had profound impact on their cost-effectiveness estimates.

CONCLUSIONS

Given the divergent conclusions drawn from studies addressing similar questions, it may be premature to use the results of cost-effectiveness research in developing stroke policy and practice guidelines. Successful implementation of such evaluations in the care of patients with stroke will depend on further standardization of methodology and critical appraisal of reported findings.

[Direct cost of cerebrovascular disease during the first year of follow-up]

INTRODUCTION AND OBJECTIVE

There are not sufficient studies analyzing the health costs of ictus in Spain. We carried out a prospective study to evaluate the health costs incurred by a person with a stroke during the first postictal year.

PATIENTS AND METHODS

We included 118 patients from the Stroke Unit of the Hospital Universitario San Carlos in Madrid, admitted between 1 July and 31 December 1996. We studied 90 survivors, of an average age of 68 years, one year after having an stroke and specifically calculated the cost of an average period in hospital, neuroimaging tests, rehabilitation treatment, medical follow-up in the Outpatient Clinic, transport costs and the cost of medicines.

RESULTS

The average cost patient/year was: hospital admission (418,203 ptas.), health transport (108,209 ptas.), cost of medicines (74,647 ptas.), follow-up visits (64,496 ptas.), neuroimaging (61,203 ptas.), rehabilitation (58,643 ptas.). The total cost was 79,930,719 ptas. and the average cost patient/year 888,119 ptas. during the first year following the ictus. The use of health resources depended on the variables: handicap (increased in patients with a score < 60 on the Barthel scale), average neurological deficit on the Scandinavian neurological scale and sex (cost greater in women). The clinical follow-up of total infarcts of the territory of the anterior circulation cost twice as much as follow-up in cases of lacunar infarcts.

CONCLUSIONS

Cerebrovascular disease is expensive in terms of health-care. Fifty four percent of the health-care expenses are incurred during the acute phase of the ictus and the other 46% during the first year of follow-up.

Stroke: how large a public health problem, and how can the neurologist help?

Stroke is an enormous public health problem, the magnitude of which can be reduced mainly by effective stroke prevention and less so by effective treatment of acute stroke. The greatest effect is likely to be achieved by a mass approach to prevention, which consists of modification of lifestyle behaviors (eg, less smoking and less intake of salt, alcohol, and fat) among the general population through public education and, more importantly, government legislation. The appropriate identification and treatment of high-risk individuals by neurologists is likely to have a smaller but complimentary impact on the population burden of stroke and a substantial impact on the burden of stroke among individuals. The most cost-effective interventions for patients with transient ischemic attack and ischemic stroke are organized multidisciplinary acute care and rehabilitation in a stroke unit and early secondary prevention with aspirin, blood pressure control, smoking cessation, and, in the appropriate patient, oral anticoagulant therapy and carotid endarterectomy. The cost-effectiveness of carotid endarterectomy for asymptomatic carotid stenosis is highly questionable until data from ongoing trials (eg, Asymptomatic Carotid Surgery Trial) become available. Screening for asymptomatic carotid stenosis is more likely to be harmful than helpful, except perhaps among populations with a very high prevalence (pretest probability) of severe carotid stenosis. It is essential that the impact of these strategies on the incidence, outcome, and cost of stroke is measured and monitored. Currently, this is done simply, but unreliably, by examining changes in statistics that are already being measured, such as mortality (eg, among those younger than 70 years old, for greater accuracy). A growing priority in many countries is the development and implementation of valid, reliable, practical, and inexpensive methods of routinely collecting and evaluating data on stroke incidence, outcome, and cost.

Costs and outcomes of hip fracture and stroke, 1984 to 1994

OBJECTIVES

This study quantified changes in Medicare payments and outcomes for hip fracture and stroke from 1984 to 1994.

METHODS

We studied National Long Term Care Survey respondents who were hospitalized for hip fracture (n = 887) or stroke (n = 878) occurring between 1984 and 1994. Changes in Medicare payment and survival were primary outcomes. We also assessed changes in functional and cognitive status.

RESULTS

Medicare payments within 6 months increased following hip fracture (103%) or stroke (51%). Survival improved for stroke (P < .001) and to a lesser extent for hip fracture (P = .16). Condition-specific improvements were found in functional and cognitive status.

CONCLUSIONS

During the period 1984 to 1994, Medicare payments for hip fracture and stroke rose and there were some improvements in survival and other outcomes.

Stroke rehabilitation. 4. Stroke outcome and psychosocial consequences

This self-directed learning module highlights recent research in assessment of stroke outcomes and management of the psychosocial consequences of stroke. It is a part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses predictive factors for mortality and functional recovery; proposed case mix adjustment and prospective payment systems for stroke rehabilitation; continuum of care and utilization of acute, nursing home, outpatient and home health rehabilitation programs; reintegration and socialization after stroke; vocational rehabilitation of stroke patients; and management of the psychosocial effects of stroke on patients and families.

Estimation of costs due to hospitalization for first-ever stroke patients in northern Taiwan

BACKGROUND

The need for healthcare services and the related costs for stroke patients may rise steadily in the future. Even with the predictable and substantial burden of stroke, little effort has been devoted to measuring the population-based direct medical and nonmedical costs in Taiwan.

METHODS

Data from the study "Epidemiological Study of Stroke, Diabetes, and Cardiovascular Disease," which included 8,705 people older than 35 years of age, and the study "Costs of Stroke," which included 660 first-ever stroke patients, were used for the cost calculations. The cost of hospital care for stroke patients was obtained in two steps. First, the incidence of stroke and readmissions within one year were tallied; the sum was then multiplied by the average length of stay. Second, the total medical and nonmedical costs were divided by the sum obtained from step 1. The resulting quotient obtained was the cost of hospital care for stroke patients per day.

RESULTS

There were 6,691 incidents of stroke and stroke-related readmissions in 1995 (4,041 men and 2,650 women). The total person-days of hospital stay were 233,569 days (144,264 for men and 89,305 days for women). The average medical and nonmedical costs of hospital care per person-day was US $251.4 (NT $6,788 at an exchange rate of US $1 = NT $27). Cost for men (US $287, NT $7,749) was more than for women (US $208, NT $5,616). The total direct costs of hospital care were US $58,710,000 (NT $1,585,000,000) in 1995.

CONCLUSIONS

An average of US $1,682,000 (NT $45,410,000) in hospital care costs for stroke could have been saved in 1995 if the person-day stay had been decreased by only one day.

Predictors of acute hospital costs for treatment of ischemic stroke in an academic center

BACKGROUND AND PURPOSE

We sought to determine predictors of acute hospital costs in patients presenting with acute ischemic stroke to an academic center using a stroke management team to coordinate care.

METHODS

Demographic and clinical data were prospectively collected on 191 patients consecutively admitted with acute ischemic stroke. Patients were classified by insurance status, premorbid modified Rankin scale, stroke location, stroke severity (National Institutes of Health Stroke Scale score), and presence of comorbidities. Detailed hospital charge data were converted to cost by application of department-specific cost-to-charge ratios. Physician's fees were not included. A stepwise multiple regression analysis was computed to determine the predictors of total hospital cost.

RESULTS

Median length of stay was 6 days (range, 1 to 63 days), and mortality was 3%. Median hospital cost per discharge was $4408 (range, $1199 to $59 799). Fifty percent of costs were for room charges, 19% for stroke evaluation, 21% for medical management, and 7% for acute rehabilitation therapies. Sixteen percent were admitted to an intensive care unit. Length of stay accounted for 43% of the variance in total cost. Other independent predictors of cost included stroke severity, heparin treatment, atrial fibrillation, male sex, ischemic cardiac disease, and premorbid functional status.

CONCLUSIONS

We conclude that the major predictors of acute hospital costs of stroke in this environment are length of stay, stroke severity, cardiac disease, male sex, and use of heparin. Room charges accounted for the majority of costs, and attempts to reduce the cost of stroke evaluation would be of marginal value. Efforts to reduce acute costs should be monitored for potential cost shifting or a negative impact on quality of care.

Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital

BACKGROUND AND PURPOSE

In an inner-London teaching hospital, a randomized trial of "conventional" care versus early discharge to community-based therapy found no significant differences in clinical outcomes between patient groups. This report examines the economic consequences of the alternative strategies.

METHODS

One hundred sixty-seven patients received the early discharge package, and 164 received conventional care. Patient utilization of health and social services was recorded over a 12-month period, and cost was determined using data from provider departments and other published sources.

RESULTS

Inpatient stay after randomization was 12 days (intervention group) versus 18 days (controls) (P=0.0001). Average units of therapy per patient were as follows: physiotherapy, 22.4 (early discharge) versus 15.0 (conventional) (P=0.0006); occupational therapy, 29.0 versus 23.8 (P=0.002); speech therapy, 13. 7 versus 5.8 (P=0.0001). The early discharge group had more annual hospital physician contacts (P=0.015) and general practitioner clinic visits (P=0.019) but fewer incidences of day hospital attendance (P=0.04). Other differences in utilization were nonsignificant. Average annual costs per patient were pound sterling 6800 (early discharge) and pound sterling 7432 (conventional). The early discharge group had lower inpatient costs per patient (pound sterling 4862 [71% of total cost] versus pound sterling 6343 [85%] for controls) but higher non-inpatient costs (pound sterling 1938 [29%] versus pound sterling 1089 [15%]). Further analysis demonstrated that early discharge is unlikely to lead to financial savings; its main benefit is to release capacity for an expansion in stroke caseload.

CONCLUSIONS

Overall results of this trial indicate that early discharge to community rehabilitation for stroke is cost-effective. It may provide a means of addressing the predicted increase in need for stroke care within existing hospital capacity.

Cost-effectiveness of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors in the secondary prevention of cardiovascular disease: forecasting the incremental benefits of preventing coronary and cerebrovascular events

OBJECTIVE

To forecast the long-term benefits and cost-effectiveness of lipid modification in the secondary prevention of cardiovascular disease.

METHODS

A validated model based on data from the Lipid Research Clinics cohort was used to estimate the benefits and cost-effectiveness of lipid modification with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) based on results from the Scandinavian Simvastatin Survival Study (4S), including a 35% decrease in low-density-lipoprotein (LDL)-cholesterol levels and an 8% increase in high-density-lipoprotein (HDL)-cholesterol levels. After comparing the short-term outcomes predicted for the 4S with the results actually observed, we forecast the long-term risk of recurrent myocardial infarction, congestive heart failure, transient ischemic attacks, arrhythmias, and strokes and the need for surgical procedures such as coronary artery bypass grafting, catheterization, angioplasty, and pacemaker insertions. Outpatient follow-up care costs were estimated, as were the costs of hospital care and drug therapy. All costs were expressed in 1996 US dollars.

RESULTS

The short-term outcomes predicted for the 4S were consistent with the observed results. The long-term benefits of lipid modification among low-risk subjects (normotensive nonsmokers) with a baseline LDL/ HDL ratio of 5 but no other risk factors ranged from $5424 to $9548 per year of life saved for men and $8389 to $13747 per year of life saved for women. In high-risk subjects (hypertensive smokers) with an LDL/HDL ratio of 5, the estimated costs ranged from $4487 to $8532 per year of life saved in men and $5138 to $8389 per year of life saved in women. Assuming that lipid modification has no effect on the risk of stroke, cost-effectiveness increased by as much as 100%.

CONCLUSIONS

These long-term cost estimates are consistent with the short-term economic analyses of the published 4S results. The long-term treatment of hyperlipidemia in secondary prevention is forecasted to be cost-effective across a broad range of patients between 40 and 70 years of age. Recognizing the additional effects of lipid changes on cerebrovascular events can substantially improve the cost-effectiveness of treating hyperlipidemia.

The willingness of families caring for victims of stroke to pay for in-home respite care--results of a pilot study in Taiwan

This contingent survey was designed to investigate the willingness of family caregivers of stroke victims to pay for in-home respite care. Between September 1996 and December 1996, a designated family member from each family of 174 vascular accident patients hospitalized in the Taipei Metropolitan Area, including two medical centers, received the first interview during preparation and planning for discharge of the patient from the hospital, and follow up interview in their own homes at the end of the second month after the patient was discharged from the hospital. A willingness to pay for in-home respite care was measured as the percentage of monthly family income which would be sacrificed to receive the respite care. Logistic regressions were used to perform multivariate analysis. The willingness to pay for respite care ranged from US$ 363 to 2182, and 42.5% of the family caregivers interviewed indicated a willingness to pay at least 50% of monthly family income for respite care. Family income was strongly associated with the amount of money that family caregivers were willing to pay for respite care. After results were adjusted for the effect of variance in income level, the degree of dependence of patients on the caregiver was significantly associated with the percentage of monthly family income for respite care. The more severe the physical dysfunction of patient, the higher the willingness to pay for in-home respite care utilization. Initially, respite care could be provided to families caring for patients with severe dysfunction, and then the scope enlarged to include caregivers taking care of patients with mild dysfunction.

Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries

BACKGROUND AND METHODS

We studied the effects of admission to a teaching hospital on the cost and quality of care for patients covered by Medicare (age, 65 years old or older). We used data from the National Long Term Care Survey and merged them with Medicare claims data. We selected the first hospitalization for hip fracture (802 patients), stroke (793), coronary heart disease (1007), or congestive heart failure (604) occurring between January 1, 1984 and December 31, 1994, and calculated all Medicare payments for inpatient and outpatient care during the six-month period after admission. Survival was assessed through 1995. Hospitals were classified as major or minor teaching hospitals (with minor hospitals defined as those in which the number of residents per bed was less than the median number for all teaching hospitals) or as private nonprofit, government (i.e., public), or private for-profit hospitals.

RESULTS

Medicare payments for the six-month period after hospitalization were highest for patients initially admitted to teaching hospitals for the treatment of hip fracture, stroke, or coronary heart disease and for patients initially admitted to for-profit hospitals for the treatment of congestive heart failure. As compared with payments to for-profit hospitals, payments to major teaching hospitals for hip fracture were significantly higher, payments to government hospitals for coronary heart disease were lower, and payments to government and nonprofit hospitals for congestive heart failure were lower. After adjustment for patients' characteristics and social subsidies, major teaching hospitals had the lowest mortality rates (hazard ratio for death, 0.75, as compared with for-profit hospitals; 95 percent confidence interval, 0.62 to 0.91). For individual conditions, the only significant survival advantage associated with admission to major teaching hospitals was for hip fractures (hazard ratio, 0.54, as compared with for-profit hospitals; 95 percent confidence interval, 0.37 to 0.79).

CONCLUSIONS

Although admission to a major teaching hospital may be associated with increased costs to the Medicare program, overall survival for patients with the common conditions we studied was better at these hospitals, especially for patients with hip fractures.

Effects of stroke on medical resource use and costs in acute myocardial infarction. GUSTO I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries Study

BACKGROUND

Stroke occurs concurrently with myocardial infarction (MI) in approximately 30 000 US patients each year. This number is expected to rise with the increasing use of thrombolytic therapy for MI. However, no data exist for the economic effect of stroke in the setting of acute MI (AMI). The purpose of this prospective study was to assess the effect of stroke on medical resource use and costs in AMI patients in the United States.

METHODS AND RESULTS

Medical resource use and cost data were prospectively collected for 2566 randomly selected US GUSTO I patients (from 23 105 patients) and for the 321 US GUSTO I patients who developed non-bypass surgery-related stroke during the baseline hospitalization. Follow-up was for 1 year. All costs are expressed in 1993 US dollars. During the baseline hospitalization, stroke was associated with a reduction in cardiac procedure rates and an increase in length of stay, despite a hospital mortality rate of 37%. Together with stroke-related procedural costs of $2220 per patient, the baseline medical costs increased by 44% ($29 242 versus $20 301, P<0.0001). Follow-up medical costs were substantially higher for stroke survivors ($22 400 versus $5282, P<0.0001), dominated by the cost of institutional care. The main determinant for institutional care was discharge disability status. The cumulative 1-year medical costs for stroke patients were $15 092 higher than for no-stroke patients. Hemorrhagic stroke patients had a much higher hospital mortality rate than non-hemorrhagic stroke patients (53% versus 15%, P<0.001), which was associated with approximately $7200 lower mean baseline hospitalization cost. At discharge, hemorrhagic stroke patients were more likely to be disabled (68% versus 46%, P=0.002).

CONCLUSIONS

In this first large prospective economic study of stroke in AMI patients, we found that strokes were associated with a 60% ($15 092) increase in cumulative 1-year medical costs. Baseline hospitalization costs were 44% higher because of longer mean lengths of stay. Stroke type was a key determinant of baseline cost. Follow-up costs were more than quadrupled for stroke survivors because of the need for institutional care. Disability level was the main determinant of institutional care and thus of follow-up costs.

Functional outcomes of posthospital care for stroke and hip fracture patients under medicare

BACKGROUND

Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge.

METHODS

Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA).

RESULTS

In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement.

CONCLUSIONS

The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

A new accurate, rapid and cost-effective protocol for stroke-prevention screening

The three immediate causes of stroke are cervical carotid artery disease, atrial fibrillation and hypertension. Recognition and appropriate management of these causes can prevent the majority of strokes they would have caused. The purpose of this study was to develop a new protocol for screening for these causes that is more accurate, rapid and cost effective than existing protocols. In this protocol, rather than relying on auscultation with a stethoscope, the carotid artery was screened with a newly developed and more accurate quick color image scan ultrasound technique and a lead 2 EKG rhythm strip was used to find atrial fibrillation. The focus in this protocol was on the rapid detection of the three immediate causes of stroke and did not include a lengthy questionnaire or long counseling. A cholesterol determination was not included and there was little or no cost to the participants. In stroke screening trials of the new protocol at two institutions, 176 participants were screened at a rate of one every 2.7 minutes. There were 26 with > 50% carotid stenosis, 16 with previously unknown cardiac arrhythmias and 104 had hypertension. It was concluded that this protocol provides an accurate, rapid and cost-effective means of screening for the three immediate causes of stroke and can on broad application result in significant stroke reduction.

Thrombolysis, stroke units and other strategies for reducing acute stroke costs

Stroke is the leading cause of long term disability and the third leading cause of death in the US. Nearly $US40.9 billion (1997 values) are spent each year on direct and indirect stroke-related costs in the US alone. Length of hospital stay, hospital overheads and nursing-related and rehabilitation costs account for the majority of stroke-related expenditures. Intravenous recombinant tissue plasminogen activator (rt-PA) therapy for patients presenting within 3 hours from onset of ischaemic stroke was shown to improve outcome at 3 months by the National Institute of Neurological Disease and Stroke (NINDS) investigators using a dosage of 0.9 mg/kg. When the NINDS rt-PA Stroke Study results were examined using a Markov model, savings of $US4 to $US5 million (1996 values) per 1000 patients treated with rt-PA were projected. These savings were predicted to result from decreases in length of hospital stay, inpatient rehabilitation and nursing home costs, increases in the number of patients discharged directly to home and improvements in quality-adjusted life-years. Furthermore, a recent meta-analysis has documented that the institution of stroke units, consisting of multidisciplinary specialised stroke teams, also decreased length of hospital stay, death and dependency. Because only a minority of patients who have a stroke are currently eligible for thrombolysis, implementation of specialised and standardised stroke care may further enhance cost benefits and improve patient outcomes.

Stroke rehabilitation: clinical predictors of resource utilization

OBJECTIVE

To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission.

DESIGN

Statistical analysis of data prospectively collected from stroke rehabilitation patients.

SETTING

Large, urban, academic freestanding rehabilitation facility.

PARTICIPANTS

A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation.

MAIN OUTCOME MEASURES

Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD).

METHODS

Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis.

RESULTS

Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001).

CONCLUSION

Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.

Maximizing the cost-effectiveness of lipid-lowering therapy

Cardiovascular disease, including coronary heart disease, is the leading cause of death both in men and in women in the United States. The purpose of this review is to describe the effectiveness of lipid-lowering therapy in reducing cardiovascular morbidity and mortality, which has recently been extended to patients with mild to moderate hypercholesterolemia, and the cost of providing therapy, which would be prohibitive if all persons with hypercholesterolemia received treatment. Cost-effectiveness analysis provides a rational means of allocating limited health care resources by allowing the comparison of the costs of lipid-lowering therapy, in particular, therapy with beta-hydroxy-beta-methylglutaryl-CoA (coenzyme A) reductase inhibitors (statins), with the costs of atherosclerosis that could be prevented by lowering cholesterol. To extend the benefits of treatment to the large number of persons not receiving therapy, we need to implement more cost-effective treatment by improving risk assessment, increasing treatment effectiveness, and reducing the cost of therapy.

Stroke in Trinidad and Tobago: burden of illness and risk factors

This study describes the burden of stroke on hospital services in a Caribbean community. The settings are the two main acute general hospitals in Trinidad observed over a 12-month period. All subjects were admitted with a clinical diagnosis of acute stroke. The measures were hospital admission rates, length of hospital stay, case-fatality rates, disability at discharge, and risk factors for stroke. There were 1,105 hospital admissions with a diagnosis of stroke. The median length of stay was 4 days, with an interquartile range of 2 to 9, and stroke accounted for approximately 9,478 bed days per annum. The hospital admission fatality rate was 29%. Among surviving patients, 437 (56%) were severely disabled at discharge. Age-standardized admission rates for first strokes in persons aged 35-64 years were 114 (95% CI: 83 to 145) per 100,000 in Afro-Trinidadian men and 144 (109 to 179) in Indo-Trinidadian men. The equivalent rates for women were 115 (84 to 146) and 152 (118 to 186). Among patients with first strokes, 348/531 (66%) reported physician-diagnosed hypertension, but only 226 (65%) of these reported being on antihypertensives at admission. Stroke in Trinidad and Tobago is associated with a high case-fatality rate and severe disability in survivors. Modifiable risk factors were reported in a majority of stroke cases, and there is a need to develop effective preventive strategies.

Medical costs and lost productivity from health conditions at volatile organic compound-contaminated superfund sites

This paper estimates the health costs at Superfund sites for conditions associated with volatile organic compounds (VOCs) in drinking water. Health conditions were identified from published literature and registry information as occurring at excess rates in VOC-exposed populations. These health conditions were: (1) some categories of birth defects, (2) urinary tract disorders, (3) diabetes, (4) eczema and skin conditions, (5) anemia, (6) speech and hearing impairments in children under 10 years of age, and (7) stroke. Excess rates were used to estimate the excess number of cases occurring among the total population living within one-half mile of 258 Superfund sites. These sites had evidence of completed human exposure pathways for VOCs in drinking water. For each type of medical condition, an individual's expected medical costs, long-term care costs, and lost work time due to illness or premature mortality were estimated. Costs were calculated to be approximately $330 million per year, in the absence of any remediation or public health intervention programs. The results indicate the general magnitude of the economic burden associated with a limited number of contaminants at a portion of all Superfund sites, thus suggesting that the burden would be greater than that estimated in this study if all contaminants at all Superfund sites could be taken into account.

Implementation and evaluation of stroke clinical pathways and the impact on cost of stroke care

Saint Luke's Hospital is a 642-bed urban, tertiary, teaching hospital in metropolitan Kansas City, Missouri. In 1992, Saint Luke's developed a "Collaborative Care" program supported by tools such as clinical paths as a means to assure quality stroke care and to continually improve outcomes. This article describes the development of a comprehensive Collaborative Care Program for stroke patients, highlights the development of a dedicated stroke unit, and stroke clinical path, and describes the clinical and fiscal outcomes from these efforts.