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.

Cost-effectiveness of anticoagulation in nonrheumatic atrial fibrillation in the primary prevention of ischemic stroke

BACKGROUND AND PURPOSE

A number of clinical trials have shown the value of anticoagulating patients with nonrheumatic atrial fibrillation to prevent ischemic stroke. The purpose of this study was to assess the cost-effectiveness of anticoagulation in nonrheumatic atrial fibrillation with particular reference to the very elderly (aged >75 years) who have a higher incidence of bleeding events while undergoing anticoagulation.

METHODS

We calculated the incremental costs per life-year gained for 4 base cases using efficacy data from the Boston Area Anticoagulation Trial for Atrial Fibrillation, the meta-analysis of the 5 nonrheumatic atrial fibrillation trials, cost data from a district general hospital, and review of the literature.

RESULTS

The cost per life-year gained free from stroke over 10 years ranged from -pound sterling 400.45 (ie, a resource saving achieved for each life-year gained free from stroke) to pound sterling 13,221.29. The results were most sensitive to alteration in the frequency of anticoagulation monitoring.

CONCLUSIONS

For medical and economic reasons, anticoagulation treatment in the prevention of ischemic stroke is justified. Although older patients are more at risk of adverse events, anticoagulation is more cost-effective in this group.

The value of stroke prevention and treatment

An emerging issue in stroke prevention and stroke treatment is that therapies shown to be effective in clinical trials are not being used or are being used suboptimally. One of many explanations relates to cost, ranging from concerns about inappropriate use of societal resources to more immediate concerns of organizations and individuals about their financial well-being. Assessing the cost impact of a new therapy, and thus the financial incentives faced by decision-makers, is crucial to understanding and influencing real-world treatment decisions. Assessing cost in the context of health benefits is the object of cost-effectiveness analysis. A cost-effectiveness analysis typically compares the new treatment with a less efficacious yet less costly alternative. This article provides a brief overview of the cost implications of stroke and stroke-related treatments. The example of stroke prevention is used to illustrate how to calculate an incremental cost-effectiveness ratio and help clarify what makes a treatment an especially good value. Because stroke is tremendously expensive and because severe strokes are especially expensive, treatments to prevent stroke and to diminish stroke disability are likely to be an excellent value.

The role of clinical pathways in reducing the economic burden of stroke

Clinical pathways are a potentially beneficial, but largely untested, management strategy for both improving healthcare efficiency and decreasing costs while also maintaining or improving quality of care. Although relatively few clinical pathways for stroke have been described in the medical literature and although the reported benefits have been mixed, more and more hospitals are adopting clinical pathways as a management strategy for patients with stroke. In published clinical pathways for acute stroke, the following benefits have been reported: (i) reduced use of expensive diagnostic studies; (ii) fewer complications (particularly the frequency of urinary tract infections and aspiration pneumonia); (iii) reduced duration of hospital stay; (iv) reduced patient charges; and (v) lower mortality. However, these reported benefits are not consistent across all studies and some outcomes are highly correlated. Despite potential benefits, many clinical pathway programmes fail because of inadequate planning and shortcomings of implementation. Effective implementation of clinical pathways requires strong administrative and medical staff leadership, active participation of all clinical disciplines involved in the care of patients on the pathway, provision of regular feedback to clinicians, sufficient resources, improved documentation, incorporation of the entire episode of care into the pathway, integration with ongoing quality and utilisation management programmes, and periodic evaluation and modification.

Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system

OBJECTIVES

Function-related groups based on the Functional Independence Measure have been proposed as a model for a prospective payment system for medical rehabilitation. This study describes discharge destination and motor function outcomes in a sample of patients with stroke from the FIM-FRG STR1 classification.

STUDY DESIGN

A retrospective review of 293 cases of stroke from the years 1993 to 1995. The demographic and outcome characteristics of this sample were described.

RESULTS/CONCLUSIONS

Forty-five percent of the patients were discharged to home after a mean length of stay of 23.8 days in acute medical rehabilitation. Patients who were discharged home had higher admission and discharge motor FIM scores than those discharged to a subacute facility or long-term care facility, although the correlation between motor FIM score and discharge destination was low to moderate. Median discharge motor FIM scores indicate considerable residual disability in this classification after rehabilitation. Research problems that address methods to improve the usefulness of the FIM-FRG system in a prospective payment system are discussed.

Direct medical costs of complications resulting from type 2 diabetes in the U.S

OBJECTIVE

To estimate direct medical costs of managing the complications of type 2 diabetes.

RESEARCH DESIGN AND METHODS

Costs were estimated for 15 diabetic complications by applying unit costs to typical resource-use profiles. Resource used and unit costs were estimated from many sources, including acute care discharge databases, clinical guidelines, government reports, fee schedules, and peer-reviewed literature. For each complication, the event costs are those associated with resource use that is specific to the acute episode and any subsequent care occurring in the 1st year. State costs are the annual costs of continued management. All costs are expressed in 1996 U.S. dollars.

RESULTS

As expected, the more severe or debilitating events, such as acute myocardial infarction ($27,630 event cost; $2,185 state cost), generate a greater financial burden than do early-stage complications, such as microalbuminuria ($62 event cost; $14 state cost). Yet, complications that are initially relatively low in cost (e.g., microalbuminuria) can progress to more costly advanced stages (e.g., end-stage renal disease, $53,659 state cost); therefore, minor complications should also be considered in any economic analysis of diabetes.

CONCLUSIONS

The recent literature has lacked cost estimates that may be readily translated into patient-level cost inputs for an economic model. Emerging therapies that may reduce the incidence of some diabetic complications will need to be scrutinized economically in today's cost-conscious environment. The cost estimates from this study provide one piece of the economic analysis needed to evaluate these new interventional therapies.

Stroke-attributable nursing home use: a population-based study

OBJECTIVE

To estimate 1) among patients with stroke, nursing home use attributable to stroke, and 2) the savings in nursing home use, assuming strokes were prevented.

METHODS

All confirmed cases of first stroke among Rochester, Minnesota, residents from 1987 through 1989 (n = 290) and one nonstroke control of same gender and similar age for each patient were followed up in provider-linked medical records and State of Minnesota nursing home files until emigration, death, or December 31, 1994. Data included disability and place of residence at baseline (i.e., date of stroke for each patient and their corresponding control), length of follow-up, cumulative incidence of nursing home admission, proportion of follow-up spent in a nursing home, and number of nursing home days.

RESULTS

Before baseline, patients and controls were similar in the level of disability (mean Rankin = 1.7 for patients and 1.6 for controls) and the proportion in a nursing home (11% for both groups). Among those not in the nursing home at baseline, 5-year cumulative incidence of first admission was 48% for cases versus 20% for controls. Survival was significantly shorter for cases than for controls; the proportion of follow-up spent in the nursing home was 20% for cases versus 11% for controls. When controlling for survival, cases experienced an average of 110 (95% CI, 63 to 156) more nursing home days per person than controls in the first five years. When nursing home use during differential survival was included, the difference in nursing home days between cases and controls was no longer significant (p = 0.16).

CONCLUSIONS

Stroke prevention would result in fewer cases admitted to the nursing home, older age at first admission, and a smaller proportion of remaining life spent in the nursing home, but stroke prevention would not result in fewer nursing home days.

Multiplane transesophageal echocardiography and stroke

Transesophageal echocardiography (TEE) is considered a basic tool in the diagnostic and follow-up evaluation of stroke patients, since up to 40% of cerebral ischemic events are presumed to have a cardiac origin. TEE offers a superior resolution of the posterior cardiac structures, such as left atrium and appendage and atrial septum, as well as of the aorta. By means of TEE, evidence has accumulated that some cardiovascular abnormalities (left-sided thrombi, tumors and vegetative lesions, complicated plaques of the aortic arch) are associated with ischemic stroke. Nevertheless, some issues remain unresolved. Will exclusion of atrial thrombus by multiplane TEE preclude embolism after cardioversion of atrial fibrillation? If anticoagulation before and after cardioversion is needed to provide adequate protection against embolism, will TEE be indicated in all patients? Moreover, can the detection of spontaneous echo contrast or enlarged and hypokinetic left atrial appendage in atrial fibrillation modify the therapeutic strategy? Is atrial septal aneurysm (ASA) a real embolic source, particularly when a right-to-left shunt is not associated? Considering the high prevalence of patent foramen ovale (PFO) in normal subjects, how can we identify patients at higher risk of embolism? Furthermore, methodologic points have to be taken into account when we analyze data from the literature. First, most studies are retrospective; a sole prospective study demonstrated that atherosclerotic plaques >4 mm thick in the aortic arch are significant predictors of recurrent brain infarction and other cardiovascular events in patients > or =60 years of age. Second, the association between the aforementioned cardiac abnormalities (mainly ASA and PFO) and cardiogenic embolism is biased by the patient-enrollment criteria used in those studies so that their pathogenetic role has not yet been established. Prospective studies with the enrollment of appropriate control groups will be necessary to define what can be considered a marker of embolic risk; the diagnosis "cardiogenic embolism" will not be a definitive diagnosis in most cases.

Clinical efficiency tools improve stroke management in a rural southern health system

BACKGROUND AND PURPOSE

Ischemic stroke is a high-volume and financially draining diagnosis at this rural health system. The purpose of this clinical practice analysis was to identify resource utilization and clinical process inefficiencies and to promote clinically efficient, evidence-based improvements.

METHODS

A retrospective analysis of medical record and financial databases of 356 patients with ischemic stroke was performed. The medical record data were adjusted for severity, and outliers were eliminated. The resources utilized by each physician were determined. Comparative graphs were prepared, presented, and discussed. The physicians implemented two types of changes: (1) alteration of resource utilization and consultation patterns and (2) support of clinical process improvement. In 1997, a follow-up analysis of 399 patients was performed.

RESULTS

The initial comparison of internists' to neurologists' patient populations found the following: patient age (75 versus 65 years), patient severity ratings (2.8 versus 2.5), length of stay (10.7 versus 8.8 days), costs ($7360 versus $6862), mortality rates (12.5% versus 8.9%), and aspiration pneumonia rate (8.5% versus 3.8%). A comparison of the 1995 analysis to the 1997 analysis revealed the following per patient resource utilization decreases (all P < 0.05): chemistry laboratory, 2.65 to 1.95 studies; intravenous fluids, 2.85 to 1.85 L; oxygen use, 6.06 to 2.75 U; and nifedipine use, 1.62 to 0.33 capsules. The clinical process improvements resulted in the following overall outcomes (all P < 0.05 except mortality): length of stay (7.2 days), nonadjusted costs ($6246), mortality (6.5%), and rates of pneumonia (2.7%).

CONCLUSIONS

Objective analysis of resource utilization resulted in physicians changing their individual management of stroke and collectively supporting clinical process changes that improved clinical and financial outcomes.

Prevention, education programs head off high cost of stroke

Stroke is the nation's third leading cause of death and represents a human as well as a financial catastrophe. Find out how these DM programs are identifying patients with specific risk factors for stroke, teaching patients about the disease and its warning signs, and following up with multidisciplinary management.

[Risks, benefits and costs of hormone replacement therapy in menopause]

Hormone replacement therapy (HRT) acts both as an effective treatment of menopausal symptoms and genital atrophy, and as an effective prevention of osteoporosis. It is also probably cardioprotective and potentially preventing cerebrovascular disease. The risk of oestrogen-induced endometrial cancer is eliminated by the addition of a progestin. An increase in breast cancer risk is however possible after 10 years or more of HRT use. This multifactorial risk-benefit balance altogether with other variables (numerous and expensive hormonal therapies, low compliance of postmenopausal women, need for monitoring, therapy-related adverse events) explain why so few global pharmaco-economic appraisals have been devoted to HRT. Computer model studies have been set up to study hypothetical cohorts of menopausal women treated for 5-10 years or more, comprising hysterectomized women (receiving an estrogen alone) and non hysterectomized women (receiving an oestrogen-progestogen therapy) compared with untreated controls. Treatment of hysterectomized women as well as non hysterectomized symptomatic menopausal women appears relatively cost-effective. In terms of mortality and morbidity, a reduction in cardiovascular disease risk and, to a smaller extent, in osteoporosis has a strikingly greater impact than the small increase in breast cancer risk related to HRT use. A significant increase in life expectancy seems associated with long-term use and the quality-adjusted life years gain, is particularly impressive, as quality of life appears distinctly improved by HRT utilization. In the future, this beneficial cost-effectiveness equation will probably be optimized thanks to the introduction of alternative and innovative replacement therapies allowing longer treatment periods without increasing the risk of breast cancer.

[An acetylsalicylic acid-dypiridamole combination (Asasantine) in the prevention of the recurrence of cerebrovascular accidents (a cost-effectiveness analysis)]

On the basis of the results of the European stroke Prevention Study (ESPS 2) obtained on 6,602 patients, we used a Markov model to perform a cost-effectiveness analysis of a combination of a low-dose of acetylsalicylic acid (ASA) (25 mg b.i.d.) and sustained-release dipyridamole (DP) (200 mg b.i.d.) versus a low-dose of acetylsalicylic acid alone in the prevention of recurrent stroke in Belgium. The perspective was that of the Social Security. Total costs per patient over 5 years amounted to 1,317,718 FB for placebo, 1,312,015 FB for ASA and 1,326,526 FB for ASA-DP, with respectively 3.16, 3.25 and 3.33 stroke-free life years (SFLY). For 1,000 patients followed over 5 years, the number of SFLYs gained by ASA-DP is 170 when compared to placebo and 100 when compared to ASA. As compared to placebo, ASA is a dominant strategy and the combination AAS-DP has a cost-effectiveness ratio of 50,569 FB per SFLY gained. The cost-effectiveness ratio of ASA-DP vs. ASA was 176,963 FB per SFLY gained and was not substantially modified in sensitivity analyses. The favourable cost-effectiveness ratio for ASA-DP is mainly explained by the reduction of costs associated with the acute treatment of stroke.

Analysis of costs borne by families of patients hospitalized for stroke

BACKGROUND

Studies focusing on the economic impact of cancer on families have emphasized that costs of chronic disease are substantial for patients and their families. However, little effort has been devoted to measuring the costs of care for families of patients hospitalized with stroke.

METHODS

A total of 215 stroke patients and their families from four teaching hospitals in the Taipei metropolitan area were monitored from the date of the patient's admission to hospital until the date of discharge. The value of labor contributed by families was estimated by assigning the current monetary market rate of providing health aide to the time families spent caring for patients in hospital. Lost earnings of patients and families, expenditure for medical care, and expenses for food, clothes, adult diapers, transportation and other miscellaneous items were determined and summed to arrive at the total family cost of providing care.

RESULTS

The average cost of care for one family per inpatient day was NT$4,358.20. A total of 98.6% of the families incurred labor costs, which accounted for about half of family costs for providing care. Hospital bills accounted for almost 19% of total family costs. The income loss for families and patients accounted for about 25% of total family costs. Expenses for food, clothes, transportation, diapers and other illness-related miscellaneous items accounted for about 12% of total family costs. Multiple regression analyses demonstrated that the number of family members involved in giving care and the length of stay are important predictors for the total cost of care. Average total family costs per day increased by 24.3% when an additional family member was involved in providing care. Total family costs increased 2.5% for each hospital day.

CONCLUSIONS

If direct and indirect nonmedical costs are not included in the total cost calculation for providing hospital care to stroke patients, the economic impact of care on families is likely to be underestimated.

Treating hypertension--effect of treatment and cost-effectiveness in respect to later cardiovascular diseases

A large number of prospective intervention trials have clearly demonstrated that drug treatment of hypertension lower cardiovascular morbidity and mortality. In the elderly, where treatment results in higher absolute decreases in morbidity and mortality, drug treatment is clearly cost-effective or even cost-saving in some groups of patients. Although the concept of treating hypertension is generally well accepted, a significant portion of patients remain insufficiently treated. In spite of major advances in the management of hypertension during the last decades, there is an excess morbidity and mortality in the hypertensive population. Thus, treatment is still imperfect, and a number of measures need to be taken in order to bring down cardiovascular risk in hypertensive patients to that of the normotensive population.

A study of the factors which influence the length of hospital stay of stroke patients

OBJECTIVE

To examine the factors which influence the length of hospitalization of stroke patients.

DESIGN

Analysis of the relative importance of 10 preselected variables on the length of hospital stay of all patients admitted with a clinical diagnosis of stroke. The data were collected prospectively.

SETTING

Two teaching hospitals serving the city of Southampton and southwest Hampshire, England (approximate population 450000).

SUBJECTS

Forty-six consecutive stroke patients.

RESULTS

Data were complete on 38 patients. The mean and (median) length of hospital stay was 74.9 (80.5) days for men and 74.7 (73.5) for women. The mean age of women in the study sample was higher than that of men (73.2 vs 71.6). Patients who were less than 70 years of age stayed shorter periods in hospital than older subjects. Other factors associated with shorter hospitalization were a stroke type other than total anterior circulation infarct, a Barthel score of 12 or more on admission or at the time of discharge and a frequency of consultants' ward rounds of more than one per week. A delay in the provision of equipment and home adaptations and waiting for placement in a private nursing home were the best predictors of long hospital stays of stroke patients.

CONCLUSIONS

Early liaison of rehabilitation staff with Social Services in order to secure the quick provision of environmental aids and adaptations or placement in residential care of stroke patients with a poor prognosis for functional recovery would probably reduce the unnecessary hospitalization of these patients.

Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke. NINDS rt-PA Stroke Study Group

Tissue plasminogen activator (tPA) has been shown to improve 3-month outcome in stroke patients treated within 3 hours of symptom onset. The costs associated with this new treatment will be a factor in determining the extent of its utilization. Data from the NINDS rt-PA Stroke Trial and the medical literature were used to estimate the health and economic outcomes associated with using tPA in acute stroke patients. A Markov model was developed to estimate the costs per 1,000 patients eligible for treatment with tPA compared with the costs per 1,000 untreated patients. One-way and multiway sensitivity analyses (using Monte Carlo simulation) were performed to estimate the overall uncertainty of the model results. In the NINDS rt-PA Stroke Trial, the average length of stay was significantly shorter in tPA-treated patients than in placebo-treated patients (10.9 versus 12.4 days; p = 0.02) and more tPA patients were discharged to home than to inpatient rehabilitation or a nursing home (48% versus 36%; p = 0.002). The Markov model estimated an increase in hospitalization costs of $1.7 million and a decrease in rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per 1,000 eligible treated patients for a health care system that includes acute through long-term care facilities. Multiway sensitivity analysis revealed a greater than 90% probability of cost savings. The estimated impact on long-term health outcomes was 564 (3 to 850) quality-adjusted life-years saved over 30 years of the model per 1,000 patients. Treating acute ischemic stroke patients with tPA within 3 hours of symptom onset improves functional outcome at 3 months and is likely to result in a net cost savings to the health care system.

Predicting the cost of illness: a comparison of alternative models applied to stroke

Predictions of cost over well-defined time horizons are frequently required in the analysis of clinical trials and social experiments, for decision models investigating the cost-effectiveness of interventions, and for macro-level estimates of the resource impact of disease. With rare exceptions, cost predictions used in such applications continue to take the form of deterministic point estimates. However, the growing availability of large administrative and clinical data sets offers new opportunities for a more general approach to disease cost forecasting: the estimation of multivariable cost functions that yield predictions at the individual level, conditional on intervention(s), patient characteristics, and other factors. This raises the fundamental question of how to choose the "best" cost model for a given application. The central purpose of this paper is to demonstrate how to evaluate competing models on the basis of predictive validity. This concept is operationalized according to three alternative criteria: 1) root mean square error (RMSE), for evaluating predicted mean cost; 2) mean absolute error (MAE), for evaluating predicted median cost; and 3) a logarithmic scoring rule (log score), an information-theoretic index for evaluating the entire predictive distribution of cost. To illustrate these concepts, the authors conducted a split-sample analysis of data from a national sample of Medicare-covered patients hospitalized for ischemic stroke in 1991 and followed to the end of 1993. Using test and training samples of about 500,000 observations each, they investigated five models: single-equation linear models, with and without log transform of cost; two-part (mixture) models, with and without log transform, to directly address the problem of zero-cost observations; and a Cox proportional-hazards model stratified by time interval. For deriving the predictive distribution of cost, the log transformed two-part and proportional-hazards models are superior. For deriving the predicted mean or median cost, these two models and the commonly used log-transformed linear model all perform about the same. The untransformed models are dominated in every instance. The approaches to model selection illustrated here can be applied across a wide range of settings.

Anticoagulation to prevent stroke in atrial fibrillation and its implications for managed care

Nonrheumatic atrial fibrillation (AFib) is the most potent common risk factor for stroke, raising the risk of stroke 5-fold. Six randomized trials of anticoagulation in AFib consistently demonstrated a reduction in the risk of stroke by about two-thirds. In these trials, anticoagulation in AFib was quite safe. In contrast, randomized trials indicate that aspirin confers only a small reduction in risk of stroke, at best. Pooled data from the first set of randomized trials indicate that prior stroke, hypertension, diabetes, and increasing age are independent risk factors for future stroke with AFib. Individuals < 65 years old with none of the other risk factors might safely avoid anticoagulation; for all others, anticoagulation seems indicated. Studies of hemorrhagic risk highlight the importance of keeping the international normalized ratio (INR) < 4.0. Recent analyses also reveal that risk of ischemic stroke in AFib increases greatly at INR levels < 2.0. Efficacy and safety of anticoagulation in AFib depend on maintaining the INR between 2.0-3.0. Cost-effectiveness studies indicate that anticoagulation for AFib is among the most efficient preventive interventions in adults. Importantly, the benefits of anticoagulation in AFib accrue immediately. The implications for managed care organizations are that anticoagulation for AFib should be encouraged in their covered populations, and that dedicated anticoagulation services should be developed to promote system-wide control of anticoagulation intensity. Quality measures would include the proportion of patients with AFib who are anticoagulated, and the percentage of time patients' INR levels are between 2.0-3.0. Managed care organizations can benefit from recent research on anticoagulation for AFib; they have a responsibility to support future research and development efforts.

Outcomes management for stroke patients using thrombolytics

In the current health care market, there is a sharp awareness by both consumers and managed care providers that hospitals are only as good as the outcomes they can produce. Collaboration among disciplines that provide services, in this case treatment for stroke has enhanced patient outcomes. The synergy that has developed among those involved has thus far created a win-win situation. The key to successful outcomes is to have all those involved possessing a clear picture of their role, accepting it, and taking ownership of it.

[Factors affecting three elements of the medical expense for the aged]

The per capita medical expense was studied for inpatients and outpatients aged 70 years and over under the National health insurance for fiscal year 1990 among 678 cities in Japan. Per capita medical expense consists of three factors, i.e. service-acceptance rate, bed-days per receipt and the medical expense per day. To clarify what factors are associated with these three factors of the medical expense, multiple regression analyses were performed using several indices of medical supply and medical need, family type, health projects and socioeconomics. The results are as follows. (1) The major factor that was correlated significantly and positively with the expense and service-acceptance rate for inpatients was medical supply. (2) Both the bed-days receipt and the service-acceptance rate for inpatients were negatively correlated with cerebral apoplexy. (3) Medical expenses per day for inpatients and outpatients were negatively correlated with medical supply, such as the number of hospitals per population. (4) The major factor that was correlated positively with medical expenses for outpatients was medical need, such as cancer and heart disease. (5) Service-acceptance rate of outpatients was correlated positively with the factors of accessibility, such as number of medical institutions per area. (6) Days per receipt of outpatients was correlated negatively with the level of health among cities.

Stroke and TIA charges, LOS show wide geographic variation

Data Library: How do your rates compare? This month's column features geographic hospital and physician charge and LOS data for high-cost stroke and T/A patients, which vary as much as 159% between states.

Economic burden of stroke and the evaluation of new therapies

Stroke is a major health problem in all industrialised countries and evidence is mounting that this problem also affects the developing countries. In the industrialised countries, it is the third largest killer and, of the survivors, about one-half are left with a permanent handicap. Despite the huge burden of stroke on healthcare and social services (several USA studies estimate the annual cost of stroke to be between US $6.5 and 11.2 billion) the cost of strokes has aroused little attention. An absence of effective therapies may be one of the reasons for this lack of interest; the costs have been taken as inevitable. With the advent of new therapies for acute ischaemic stroke (thrombolytics and neuroprotectants) there is renewed interest in improving both the management and outcome for patients. Key to the evaluation (both clinical and economic) of new stroke therapies is the choice of evaluation scales/instruments. Increasingly, stroke investigators are using measures of functional outcome (for example the Barthel index) as a primary endpoint in stroke trials. This is pertinent, as functional outcome has been found to reflect reasonably well the degree to which a patient needs support after stroke, irrespective of whether this is provided by the family or society.