Costs of stroke in Sweden. A national perspective

BACKGROUND AND PURPOSE

Cost-effectiveness analyses of stroke management are hampered by paucity of economic data. We made an update of the direct and indirect costs of stroke in Sweden (population, 8.5 million).

METHODS

Direct costs (ie, the costs for hospital and outpatient care and social services) were estimated on the basis of two prospective population-based studies of stroke and of two nationwide cross-sectional inventories of bed-days and diagnoses. Indirect costs (ie, the costs for loss of productivity and early retirement) were based on official statistics.

RESULTS

The direct annual costs of care for stroke patients in 1991 equaled 7836 million Swedish krona (SKr) ($1306 million in US dollars), and the indirect costs, 2430 million SKr ($405 million). The cost of stroke care was 1208 SKr ($201) per inhabitant in Sweden. The expected direct costs per patient from first stroke to death were 440,000 SKr ($73,333). When prestroke costs for other diseases and advanced age were subtracted, the sum was reduced to 180,000 SKr ($30,000).

CONCLUSIONS

Costs for hospital and outpatient care and social services accounted for 76% of Swedish stroke costs and for 24% of costs for loss of production and early retirement. Only 41% of direct costs were stroke-related.

Effect of a stroke protocol on hospital costs of stroke patients

OBJECTIVE

To determine the impact of a protocol on hospitalization costs for patients admitted with stroke.

DESIGN AND SETTING

Nonrandomized control trial in an urban community hospital with 376 beds.

PATIENTS

All patients admitted with a diagnosis-related group code of 014 (cerebrovascular disease) were included (N = 390). Patients with subdural hematoma (N = 2) or subarachnoid hemorrhage (N = 2) were excluded.

INTERVENTION

A protocol for treatment of acute stroke was developed that included a critical path for nursing care, an algorithm for emergency department care, and suggested admission orders for physicians.

MAIN OUTCOME MEASURES

The hospital information system computer database was searched for hospitalization charges, length of stay, tests performed, and treatments provided.

RESULTS

Patients treated with the protocol had lower charges compared with historical (p = 0.026) and concurrent (p = 0.02) control groups. Lower charges were accounted for by a decreased length of stay in the protocol group compared with historical (p = 0.001) and concurrent (p = 0.13) controls. Tests and treatments provided were similar except that carotid Doppler studies and deep venous thrombosis prophylaxis were more frequently done in those treated with the protocol (p = 0.001 for carotid Doppler and p = 0.026 for deep venous thrombosis prophylaxis). There were no differences in outcome measures such as death or discharge disposition. Medical complications were similar in all groups.

CONCLUSIONS

There were significant savings in hospitalization cost for patients with acute stroke after introduction of a treatment protocol. These savings were almost entirely related to decreased length of stay. The protocol led to modest differences in tests ordered and treatments provided.

Cost of acute stroke care in Toronto, Canada

BACKGROUND AND PURPOSE

Stroke cost consumes a large proportion of the gross domestic product in all developed countries, and while health care costs are rising, the ability to contain them is diminishing.

METHODS

We calculated the cost of acute stroke care for all first admissions to a teaching hospital in Toronto, Canada, in 1991 through 1992 for 285 consecutive patients.

RESULTS

The average cost per patient was $27,500 Canadian, and strokes in men cost less than in women ($23,000 versus $32,000 Canadian), for a total cost of $8 million Canadian over 2 years. More women died than men (34% versus 17%, P < .02), mainly from systemic complications of stroke, but because women stayed hospitalized longer, they cost more in the long term. The major factor determining cost was social support, and more men than women went home or to rehabilitation units (P < .02). Family support was greater for men (82%) than women (39%, P < .0002).

CONCLUSIONS

Significant cost reductions are more likely to be achieved by altering discharge policies and improving social conditions for early return to the home than by reducing laboratory or medical personnel costs.

Cost-effectiveness of ticlopidine in preventing stroke in high-risk patients

BACKGROUND

Ticlopidine, an antiplatelet agent, when compared with aspirin has been found to reduce the risk of stroke in high-risk patients, ie, those with recent transient ischemic attack, reversible ischemic neurological deficit, amaurosis fugax, or minor stroke. Its cost-effectiveness in such use, however, is unknown.

METHODS

We developed a model of primary stroke prevention in which a hypothetical cohort of 100 high-risk men and women 65 years of age was assumed to receive either ticlopidine (500 mg daily) or aspirin (1300 mg daily). Using published data, we estimated lifetime incidence of stroke, life expectancy (unadjusted and adjusted for changes in quality of life), and lifetime medical care costs associated with each therapy.

RESULTS

Patients who receive ticlopidine would experience two fewer initial strokes per hundred than those treated with aspirin. Life expectancy would be extended by approximately one-half month, and lifetime medical care costs (discounted at 5%) would increase by about $2300. The cost-effectiveness of ticlopidine, compared with aspirin, is estimated to range from $31,200 to $55,500 per quality-adjusted life-year gained as the utility of life after nonfatal stroke is assumed to vary from 0.75 to 0.95.

CONCLUSIONS

Ticlopidine therapy to prevent stroke in high-risk patients is cost-effective by current standards of medical practice.

Cost comparison of domiciliary and hospital-based stroke rehabilitation. DOMINO Study Group

The DOMINO study (DOMiciliary rehabilitation In NOttingham) was a randomized controlled trial comparing domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital, stratified according to the ward at hospital discharge. The outcomes of these patients have been reported previously. In this paper, we present estimates of health service costs of care. No difference in outcome had been found between the overall services, but we have found the hospital-based costs to be 27% cheaper. However, different cost-effectiveness patterns are observable when the strata are analysed. Patients from geriatric wards had been shown to be 2.4 times less likely to die or become institutionalized by 6 months if allocated to a day hospital service, although the cost of this service was 25% more than that of the domiciliary service. Patients from the Stroke Unit who had received domiciliary rehabilitation had been shown to have greater household and leisure abilities at 6 months than those treated in outpatient departments, but the domiciliary service was found to cost 2.6 times more. Patients from general medical wards had similar outcomes whether treated at home or in outpatient departments, but the cost of the latter service was 56% of the former. Some patients may be best cared for in day hospitals and others may do better if treated at home, but for these groups the clinical advantages are achieved at an expense greater than that incurred by the alternative services. Other patients may do as well if treated in outpatient departments as at home, but the former approach is cheaper. A range of services is required for stroke patients leaving hospital.

The influence of stroke unit rehabilitation on functional recovery from stroke

BACKGROUND AND PURPOSE

Shorter lengths of hospital stay in stroke units could be due to quicker functional recovery or mechanisms of expediting hospital discharge.

METHODS

Stroke survivors with an intermediate prognosis at 2 weeks after stroke (n = 146) were randomized for management in a stroke rehabilitation unit or in general wards. Barthel scores were monitored at weekly intervals until hospital discharge. The duration and type of physiotherapy and occupational therapy received by patients in either setting were also recorded. The rate of change of Barthel scores, therapy input, and the duration of hospital stay were compared between the two settings.

RESULTS

Neurological deficits and median initial Barthel scores were comparable between patients in the stroke unit (n = 73) and general wards (n = 68). Median discharge Barthel score of patients managed in the stroke unit was significantly higher than that of patients managed in general wards (15 versus 12). Median Barthel scores in the stroke unit group rose rapidly after 2 weeks, reaching a plateau at 6 weeks. The change in median Barthel score in patients in general wards was significantly slower, reaching a plateau at 12 weeks despite similar therapy input. There was a significant delay in discharging stroke patients in general wards (20 weeks) compared with those in the stroke unit (6 weeks).

CONCLUSIONS

Functional recovery is significantly greater and more rapid in a stroke rehabilitation unit compared with general wards despite similar therapy input. These units also shorten hospital lengths of stay by expediting appropriate discharges.

A length of stay study of the dually entitled Medicare and Medicaid population: challenges for managed competition

Length of stay (LOS) differences were not observed between the dually entitled and other Medicare stroke patients when complexity of disease was considered. LOS for dually entitled heart failure patients was 33.2 percent longer than other Medicare heart failures and were equally likely to be in the extreme DRG subclass. Patients with extreme heart failure stayed 15.5 days longer than those with mild heart failure. LOS differences (+4.5 days) were observed between the dually entitled and other Medicare heart failures when complexity of disease was considered. Within these two DRGs, incremental health care needs for dually entitled equalled 10 percent of the hospital's total Medicare days associated with stroke and heart failure.

Quality of rehabilitation care in two inpatient geriatric settings

The study assessed the quality of care in 410 geriatric patients admitted for rehabilitation following a hip fracture (53%) or stroke (47%) to two types of inpatient setting: geriatric departments in general hospitals (GDs) and free-standing geriatric hospitals (GHs), 45% and 55% of patients, respectively. The assessment of care was based on two outcome criteria, change in functional status (Barthel Index) and patient destination on discharge. Findings suggest that rehabilitation performed in GHs had some advantage over that in GDs although the cost of stay in GHs is half of that in GDs, and GHs seem to be also more cost-efficient. The finding indicates one way in which assessment of quality contributes to health policy and planning.

The economic approach to the stroke work-up

Stroke is the leading cause of morbidity in the United States and the expenditure for stroke aftercare, including lost wages, is astronomical. Reduction of risk factors and use of the most accurate diagnostic technology allows for intervention prior to catastrophic neurologic deficit. The most advantageous combination of diagnostic testing with regard to risk-benefit has been debated, but it is generally agreed that the cost of even the most sophisticated stroke work-up is far less than that of stroke aftercare.

Cost effectiveness of primary stroke prevention in atrial fibrillation: Swedish national perspective

OBJECTIVE

To assess the potential effects of primary prevention with anticoagulants or aspirin in atrial fibrillation on Swedish population.

DESIGN

Analysis of cost effectiveness based on the following assumptions: about 83,000 people have atrial fibrillation in Sweden, of whom 22,000 would be potential candidates for treatment with anticoagulants and 55,000 for aspirin treatment; the annual 5% stroke rate is reduced by 64% (with anticoagulants) and 25% (with aspirin); incidence of intracranial haemorrhage of 0.3%, 1.3%, or 2.0% per year; direct and indirect costs of a stroke of Kr180,000 and Kr90,000; estimated annual cost of treatment is Kr5030 for anticoagulants and Kr100 for aspirin.

SETTING

Total Swedish population.

MAIN OUTCOME MEASURES

Direct and indirect costs of stroke saved, number of strokes prevented, and cost of preventive treatment.

RESULTS

Depending on the rate of haemorrhagic complications 34 to 83 patients would need to be treated annually with anticoagulants to prevent one stroke; 83 patients would need to be treated with aspirin. Giving anticoagulant treatment only would reduce costs by Kr60 million if the incidence of intracranial haemorrhage were 0.3% but would imply a net expense if the complication rate exceeded 1.3%. The total savings from giving anticoagulant (22,000 patients) and aspirin (55,000 patients) treatment would be Kr175 million per year corresponding to 2 million pounds per million inhabitants each year.

CONCLUSIONS

Treatment with anticoagulants and, if contraindications exist, with aspirin is cost effective provided that the risk of serious haemorrhage complications due to anticoagulants is kept low.

Cost-effective intervention in stroke

A rigorous assessment of current practice in all branches of medicine is necessary to ensure that we are minimising the costs and maximising the effectiveness of management and treatment. This is especially important in cerebrovascular disease which imposes a large burden of death; it is the third commonest cause of death after cancer and heart disease in most developed countries, and the commonest cause of long term disability on society. Stroke consumes up to 5% of healthcare expenditure in developed countries, and costs can be expected to remain static or increase with an increase in the proportion of elderly (who are at high risk of stroke) in the community over coming decades. This article reviews the epidemiology of stroke (risk factors, incidence, prevalence and the burden of disability and handicap), the various studies dealing with the community and individual costs of stroke, and the cost-effectiveness of interventions to prevent stroke such as control of hypertension, reduction in cigarette intake, encouragement of a healthy lifestyle, antiplatelet or anticoagulant therapy, and carotid endarterectomy. Acute treatment of stroke remains an area of major potential therapeutic benefit, but no widely applicable therapy currently exists, although many treatments are being investigated. Rehabilitation after stroke is costly, but may result in significant reduction in disability and handicap with reduced need for long term institutional care. The clinical implications of these studies and the potential for future research are also discussed.

Heart disease, cancer, and stroke in Maryland

Maryland has higher mortality rates from heart disease, cancer, and stroke (HCS) than the United States as a whole. More than 50% of deaths from HCS are premature, occurring before age 75. The health care and indirect costs from these three diseases total approximately $4.4 billion annually, placing a major economic burden on the state. A large body of scientific literature has shown the potential for the prevention of HCS. Currently, Maryland, like virtually all states, lacks the type of systematic, well-coordinated, comprehensive intervention campaign needed to lower morbidity, mortality, and health care costs from these three diseases. Such a campaign has now been planned by the University of Maryland at Baltimore. Similar campaigns are needed throughout much of the United States.

Analysis of diagnostic procedure costs for cerebrovascular disease admission to a highly specialized hospital

Length of stay and hospital costs for cerebrovascular disease admissions depend on several hospital-, patient- and disease-related factors. To determine the incidence of each of these factors we studied 240 admissions for cerebrovascular diseases in a neurology division and in two medical divisions of a highly specialized hospital. Statistical analysis of the data collected from the case records revealed the effect of several factors. Some increased only the length of stay (severe neurological sequels on discharge; stay in general medicine, diagnosis of hemorrhage, arterial hypertension). Others increased investigation costs (length of stay, marital status), and costs were higher in a specialists ward. Length of stay was shorter where the nurse/bed ratio was higher. Old age and male sex were associated with a lower cost of diagnostic procedures.

An analysis of strokes in a rural hospital

A four-year retrospective analysis of strokes in a rural hospital was undertaken for comparison with other areas as well as to understand the impact of the DRG system on the rural hospital. Risk factors, studies, treatment, disposition as well as resource considerations were all evaluated.