Economic burden of stroke in a rural South African setting

Stroke prevention strategies in Africa: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to map the existing strategies on methods and interventions for primary and secondary stroke prevention in Africa.

INTRODUCTION

Stroke is among the leading causes of disability globally. African nations have higher stroke mortality and case fatality rates than the industrialized world, leading to significant social and financial costs, which necessitates efficient preventative methods. Despite the high prevalence of stroke in Africa, the scope of stroke-prevention strategies in Africa is unknown. Consequently, mapping diverse approaches to preventing stroke in Africa could provide direction for future research into stroke prevention in Africa.

INCLUSION CRITERIA

This review will incorporate studies that report methods or strategies used for stroke prevention in Africa. All primary and gray literature will be considered for inclusion. No language or date restrictions will be applied.

METHODS

The JBI methodological framework for scoping reviews will be adopted for this scoping review. A 3-step search strategy consisting of an initial limited search, a full search, and a screening of the reference lists of all included articles will be undertaken. Databases such as CINAHL, Scopus, PubMed, PEDRo, DORIS, Global Health, Web of Science, and Open Access Thesis and Dissertations will be searched. All search results will be screened, and relevant data extracted by 2 independent reviewers. The findings will be presented in the final scoping review and illustrated in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

REVIEW REGISTRATION

Figshare https://doi.org/10.6084/m9.figshare.21679904.v1.

The Budget Impact Analysis of Adopting Direct Oral Anticoagulants for Stroke Prevention in Nonvalvular Atrial Fibrillation Patients in Malawi

OBJECTIVES

This study aimed to estimate the budget impact of adopting direct oral anticoagulants (DOACs) for stroke prevention in patients with nonvalvular atrial fibrillation in Malawi after the inclusion of DOACs in the World Health Organization's essential medicine list.

METHODS

A model was developed in Microsoft Excel. An eligible population of 201 491 was adjusted with 0.05 % incidence rate and mortality rates yearly according to the treatments. The model estimated the implication of supplementing rivaroxaban or apixaban to the standard treatment mix (also the comparator), thus warfarin and aspirin. The current market share of 43% aspirin and 57% warfarin was adjusted proportionally with 10% DOAC uptake in the first year and 5% annually over the subsequent 4 years. Clinical events of stroke and major bleeding from the ROCKET-AF and ARISTOTLE trials were used because health outcome indicators affect resource utilization. The analysis was conducted solely from the Malawi Ministry of Health perspective and it considered direct costs over 5 years. The sensitivity analysis involved varying drug costs, population, and care costs from both public and private sectors.

RESULTS

The research suggests that despite potential savings of $6 644 141 to $6 930 812 in stroke care because of fewer stroke events, the total Ministry of Health healthcare budget (approximately $260 400 000) may increase by between $42 488 342 to $101 633 644 in 5 years because drug acquisition costs are greater than savings.

CONCLUSIONS

With a fixed budget and current DOACs prices, Malawi can consider using DOACs in patients at the highest risk while waiting for cheaper generic versions.

Predictors of patient length of stay post stroke rehabilitation

Background

There is little research on length of hospital stay (LOS) in patients post stroke in South African rehabilitation facilities. As LOS is an important indicator of cost-of-care, this information may be useful to all stakeholders.

Objectives

To determine the predictors of hospital LOS in patients post stroke rehabilitation.

Methods

A retrospective file review of 243 patients.

Results

Patient functional ability was measured using the Functional Independence Measure (FIM). Predictors of LOS were determined with multiple regression analysis. The median admission and discharge FIM scores were 43 (range: 16-119) and 75 (range: 16-120) points respectively. The median LOS was 43 (range: 3-112) days. Predictors of LOS were premorbid psychiatric conditions, impaired speech, requiring oxygen support, the development of pneumonia and admission FIM motor score, with admission FIM motor score being the strongest individual predictor of LOS (41%).

Conclusion

Admission FIM score had an influence on patient outcomes and LOS. Patients with higher admission FIM motor scores may be able to participate in rehabilitation better and thus have shorter LOS. Being able to predict LOS on admission allows facility administrators to manage bed occupancy, human and clinical resources in post stroke rehabilitation.

In-hospital treatment outcomes of acute stroke and determinant factors in a teaching hospital in eastern Ethiopia

Objective

To assess the in-hospital mortality of acute stroke and determinant factors in a teaching hospital in eastern Ethiopia.

Method

A retrospective review of medical records of patients admitted to Hiwot Fana Specialized University Hospital was conducted. Adult patients aged 18 years and older with a diagnosis of either ischemic or hemorrhagic stroke were included. Data were analyzed using SPSS version 21.0 (SPSS Inc., Chicago, IL, USA). Multiple logistic regression analysis was used to identify predictors of in-hospital mortality.

Result

A total of 112 patients with acute stroke were included in the study and 56.0% of them were of hemorrhagic stroke. The mean age was 60.32 years and 61.6% were male. The mean length of hospitalization and the mean time of presentation from symptoms onset were 4.85 days and 33.64 h, respectively. The in-hospital mortality was 36.8% for ischemic stroke and 27% for hemorrhagic stroke. Aspiration pneumonia (35.0%), cerebral edema (17%), and seizure (14.3%) were the most common complications occurring during hospitalization. Atrial fibrillation (adjusted odds ratio = 15.45, 95% confidence interval: 1.089-219.2; p = 0.043) was the independent predictor of in-hospital mortality.

Conclusion

Hemorrhagic stroke was predominant in the study sample. One-third of patients died in the hospital and the mortality rate was slightly higher in patients with ischemic stroke. Atrial fibrillation was the predominant risk factor for hospital mortality from acute stroke. There is a need to promote cardiovascular health, early recognition, and management of risk factors, and implement coordinated stroke care services to reduce premature death from stroke.

A review of the framework and strategy for disability and rehabilitation services in South Africa

Background

Rehabilitation is imperative for the successful integration of persons with disabilities into their social environments. The Framework and strategy for disability and rehabilitation services (FSDR) in South Africa, 2015-2020.was developed to strengthen access to rehabilitation services and ensure the inclusion of persons with disabilities in all aspects of community life. Despite the FSDR being commissioned, access to rehabilitation is a challenge for persons with disabilities and further compounded in rural communities.

Objective

The study aimed to describe the barriers and facilitators that influenced the process of development, implementation and monitoring of the FSDR.

Method

This qualitative study employed a single case study design. Data was collected through document analysis and in-depth interviews utilising the Walt & Gilson policy analysis framework that outlines the context, content, actors and process of policy development and implementation. In-depth interviews were conducted with twelve key informants (N=12) who were selected purposively for the study. Data obtained from the in-depth interviews were analysed using inductive thematic analysis.

Results

We found many factors that influenced the implementation of the framework. Actor dynamics, insufficient resources, the rushed process, poor record-keeping, inappropriate leadership, negative attitudes of staff members and the insufficient monitoring impeded the successful implementation of the framework. While positive attitude, mentorship and support amongst the task team facilitated the implementation process, albeit with challenges.

Conclusion

There is a need to address implementation gaps so that the FSDR is responsive to the current rehabilitation needs of persons with disabilities in South Africa.

Contribution

This study may inform future disability policy, and can be used as a tool to advocate for the rights for persons with disabilities.

The costs of interventions for type 2 diabetes mellitus, hypertension and cardiovascular disease in South Africa - a systematic literature review

BACKGROUND

In the context of a move to universal health coverage, three separate systematic reviews were conducted to summarise available evidence on the direct costs of interventions for type 2 diabetes mellitus, hypertension, and cardiovascular disease in South Africa.

METHODS

PubMed® and Web of Science was searched for literature published between 01 and 1995 and 27 October 2022. Additionally, reference and citations lists of retrieved articles and experts were consulted. We also tracked reference lists of previous, related systematic reviews. Eligible publications were cost analyses of clinical interventions targeted at adults age 15 + reporting primary estimates of in- and out-of-hospital costs from a provider perspective. Costs were extracted and converted to 2021 US dollars, and article methodological and reporting quality was appraised using the 2013 CHEERS checklist.

RESULTS

Of the 600, 1,172 and 1,466 identified publications for type 2 diabetes mellitus, hypertension, and cardiovascular disease, respectively, 10, 12, and 17 met full inclusion criteria. 60% of articles reported cardiovascular disease costs, 52% were of good reporting quality, and 10%, 50%, and 39% of type 2 diabetes mellitus, hypertension and cardiovascular disease papers reported private-sector costs only. Hypertension drug costs ranged from $2 to $85 per person-month, while type 2 diabetes mellitus drug costs ranged between $57 and $630 per person-year (ppy). Diabetes-related complication treatment costs ranged from $55 for retinopathy treatment to $25,193 ppy for haemodialysis, while cardiovascular disease treatment costs were between $160 and $37,491 ppy. Drugs and treatment of complications were major cost drivers for hypertension and type 2 diabetes mellitus, while hospitalisation drove cardiovascular disease costs.

CONCLUSION

The intervention costs of type 2 diabetes mellitus, hypertension and cardiovascular disease care have received more attention recently, particularly diabetes-related complications and cardiovascular disease. However, 39% of identified cardiovascular disease treatment costs used a private sector perspective, leaving significant research gaps in the public sector and the cheaper to treat hypertension and type 2 diabetes mellitus. This review fills an information gap regarding the intervention costs of these diseases in South Africa.

Access to acute stroke care: A retrospective descriptive analysis of stroke patients' journey to a district hospital

Introduction

The burden of stroke in Africa has increased in the last two decades, with the population undergoing a rapid epidemiological transition, with a rise in the incidence of stroke risk factors together with the gradual aging of the population. Evidence-based guidelines for acute stroke care are often not feasible in resource challenged settings but even when resources are available, considerable delays to definitive care exists. This study aims to describe the factors that influence time from symptom onset to hospital arrival in patients that present to a district level hospital Emergency Centre with confirmed ischaemic strokes.

Methods

A descriptive analysis was performed using a retrospective folder and database review. All adult patients with a confirmed ischaemic stroke, on Computed Tomography (CT) scan, presenting to Mitchells Plain Hospital Emergency Centre during the study period of 12 months (1st of January 2019 to 31st of December 2019), were eligible for inclusion. Data were collected from existing electronic patient databases and the time from onset of symptoms to hospital arrival was extracted from the clinical notes.

Results

A total of 730 (2%) patients presented with a diagnosis of stroke, of which 381 (52%) were included (CT confirmed ischaemic strokes). Only 48 (13%) presented within 4.5 h of symptom onset and the median time from onset of symptoms to presentation to the hospital was 24 h (IQR 12-72 h). The majority of patients (31%) arrived via a primary public emergency medical service (EMS) call, while 29% presented directly to the hospital as self-referrals with private transport. Primary public EMS calls had the shortest call-to-hospital-arrival time (1 hour and 31 minutes), even though the median time from symptom onset to hospital arrival was still 16 h.

Conclusion

The median time from symptom onset to hospital arrival for patients with stroke symptoms is much longer than what evidence-based guidelines suggest. The chain of survival for emergency stroke care is only as strong as its weakest link and the data from this study suggest that improvement campaigns should target stroke education and access to care.

Circulating Biomarkers in Long-Term Stroke Prognosis: A Scoping Review Focusing on the South African Setting

Cerebrovascular disease, including both ischaemic and haemorrhagic strokes, remains one of the highest causes of global morbidity and mortality. Developing nations, such as South Africa (SA), are affected disproportionately. Early identification of stroke patients at risk of poor clinical prognosis may result in improved outcomes. In addition to conventional neuroimaging, the role of predictive biomarkers has been shown to be important. Little data exist on their applicability within SA. This scoping review aimed to evaluate the currently available data pertaining to blood biomarkers that aid in the long-term prognostication of patients following stroke and its potential application in the South African setting. This scoping review followed a 6-stage process to identify and critically review currently available literature pertaining to prognostic biomarkers in stroke. An initial 1191 articles were identified and, following rigorous review, 41 articles were included for the purposes of the scoping review. A number of potential biomarkers were identified and grouped according to the function or origin of the marker. Although most biomarkers showed great prognostic potential, the cost and availability will likely limit their application within SA. The burden of stroke is increasing worldwide and appears to be affecting developing countries disproportionately. Access to neuroradiological services is not readily available in all settings and the addition of biomarkers to assist in the long-term prognostication of patients following a stroke can be of great clinical value. The cost and availability of many of the reviewed biomarkers will likely hinder their use in the South African setting.

Family functioning and stroke: Family members' perspectives

Background

Stroke survivors often experience permanent or temporal physical and psychological stroke impairments. As a result, stroke survivors are often discharged to recover in their home environments and are cared for mostly by family members. Additionally, caregiving roles are often assumed without any formal training or preparation whatsoever. This can transform the family’s functional patterns due to adjustments that are made to accommodate the caregiving needs.

Objectives

To explore the experiences and influence of stroke on families and on family functioning.

Method

Explorative descriptive qualitative research design through the use of in-depth interviews were employed as the means of data collection. The sample size was eight (8) family members and was guided by the saturation point. Data was thematically analysed.

Results

Four themes emerged from the analysis: 1) reduced interactions with family members due to communication barriers, 2) the influence of stroke on family relationships, 3) emotional engagement in caring for a family member with a stroke and 4) financial implications of stroke on family functioning. This study found that stroke can influence the family functioning negatively as family members may be forced to change their functional patterns. However, some family members reported positive experiences, they developed a supportive structure to accommodate the new life of the stroke survivor.

Conclusion

Using the McMaster’s model of family functioning, this study found that stroke is a threat to the six dimensions of family functioning: 1) problem-solving, 2) communication, 3) roles, 4) affective responsiveness, 5) affective involvement, and 6) behaviour control.

Economic burden of comorbid chronic conditions among survivors of stroke in China: 10-year longitudinal study

Background

The coexistence of chronic diseases among people with stroke is common. However, little is known about the extent of incremental healthcare expenditures associated with having physically and psychologically chronic conditions among stroke survivors.

Methods

We used the nationally representative data from the China Health and Nutrition Survey, including 36,076 participants enrolled as our analytic cohort of ten years of follow-up visits (2006, 2009, 2011, 2015). Chronic conditions include hypertension, diabetes, obesity, and impaired cognitive function. Two-part models were used to estimate the effect of comorbid chronic conditions on total annual healthcare expenditure, out-of-pocket (OOP) healthcare expenditure, and incidence of catastrophic healthcare expenditure (CHE).

Results

Among survivors of stroke during 2006 to 2015, the prevalence rates of hypertension, diabetes, obesity and impaired cognitive function were 75.5, 9.8, 12.7 and 65.1%, significantly higher than those among adults without stroke history (27.9, 2.7, 10.0 and 41.2%). Having hypertension ($794.5, p = 0.004), diabetes ($3978.5, p < 0.001) were associated with the largest incremental total healthcare expenditures. Stroke survivors with diagnosed hypertension and diabetes had additional 5.7 (p < 0.001) and 10.4 (p < 0.001) percentage point of CHE rate, respectively. Total healthcare expenditures were $2413.0 (P < 0.001) and $5151.7 (P < 0.001) higher among patients with 2, and ≥ 3 chronic conditions, respectively, than those individuals with no chronic conditions.

Conclusions

Excess expenditures associated with chronic diseases were substantial among stroke survivors. These results highlight the needs for both prevention and better management of multimorbidity among stroke survivors, which in turn may lower the financial burden of treating these concurrent comorbidities.

The economic burden of stroke: a systematic review of cost of illness studies

Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.

Analysing and quantifying the effect of predictors of stroke direct costs in South Africa using quantile regression

BACKGROUND

In South Africa (SA), stroke is the second highest cause of mortality and disability. Apart from being the main killer and cause of disability, stroke is an expensive disease to live with. Stroke costs include death and medical costs. Little is known about the stroke burden, particularly the stroke direct costs in SA. Identification of stroke costs predictors using appropriate statistical methods can help formulate appropriate health programs and policies aimed at reducing the stroke burden. Analysis of stroke costs have in the main, concentrated on mean regression, yet modelling with quantile regression (QR) is more appropriate than using mean regression. This is because the QR provides flexibility to analyse the stroke costs predictors corresponding to quantiles of interest. This study aims to estimate stroke direct costs, identify and quantify its predictors through QR analysis.

METHODS

Hospital-based data from 35,730 stroke cases were retrieved from selected private and public hospitals between January 2014 and December 2018. The model used, QR provides richer information about the predictors on costs. The prevalence-based approach was used to estimate the total stroke costs. Thus, stroke direct costs were estimated by taking into account the costs of all stroke patients admitted during the study period. QR analysis was used to assess the effect of each predictor on stroke costs distribution. Quantiles of stroke direct costs, with a focus on predictors, were modelled and the impact of predictors determined. QR plots of slopes were developed to visually examine the impact of the predictors across selected quantiles.

RESULTS

Of the 35,730 stroke cases, 22,183 were diabetic. The estimated total direct costs over five years were R7.3 trillion, with R2.6 billion from inpatient care. The economic stroke burden was found to increase in people with hypertension, heart problems, and diabetes. The age group 55-75 years had a bigger effect on costs distribution at the lower than upper quantiles.

CONCLUSIONS

The identified predictors can be used to raise awareness on modifiable predictors and promote campaigns for healthy dietary choices. Modelling costs predictors using multivariate QR models could be beneficial for addressing the stroke burden in SA.

Economic Burden of Stroke Disease: A Systematic Review

Globally, one of the main causes of non-communicable disease as a cause of death every year is stroke. The objective of this study was to analyze the burden in consequence of stroke. This research used a systematic review method. Furthermore, a search for articles was carried out in June–July 2020. Four databases were used to search articles from 2015 to 2020. Eligible studies were identified, analyzed, and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The inclusion criteria were prospective cost studies, retrospective cost studies, database analysis, mathematical models, surveys, and COI studies that assess burden of stroke in primary and referral healthcare (hospital-based). The results showed that from four databases, 9270 articles were obtained, and 13 articles were qualified. A total of 9270 articles had the identified search keywords, but only 13 articles met the set criteria for inclusion. The criteria for inclusion were stroke patients, the economic burden of stroke disease based on cost of illness method, which is approximately equal to USD 1809.51–325,108.84 (direct costs 86.2%, and indirect costs 13.8%). Those that used the health expenditure method did not present the total cost; instead, only either direct or indirect cost of health expenditure were reported. For most hospital admissions due to stroke, LOS (length of stay) was the dominant cost. The high economic burden to manage stroke justifies the promotion and preventive efforts by the policymakers and motivates the practice of healthy lifestyles by the people.

Towards a needs-based design of the physical rehabilitation workforce in South Africa: trend analysis [1990-2017] and a 5-year forecasting for the most impactful health conditions based on global burden of disease estimates

BACKGROUND

Rehabilitation can improve function in many people with chronic health conditions. It is important to consider priority conditions requiring rehabilitation, so it can be realistically positioned and costed in national health financing systems like South Africa (SA)'s proposed National Health Insurance (NHI). This paper describes temporal trends of top-ranked conditions on years lived with disability (YLDs) rates in SA, for which physical rehabilitation can ameliorate associated disability.

METHODS

This study is a systematic synthesis of publicly available Global Burden of Disease (GBD) 2017 estimates. The top 11 conditions contributing most to YLDs and for which evidence-based rehabilitation interventions exist were identified. Age-standardized rates per 100,000 and YLDs counts were extracted from 1990 to 2017. Significance of changes in temporal trends was determined using Mann-Kendall trend tests. Best-fit rates of yearly changes were calculated per condition, using GBD estimates (2012-2017), and extrapolated (by imposing the best-fit regression line onto results for each subsequent predicted year) as forecasts (2018-2022).

RESULTS

Trends for YLDs counts per condition year (1990-2017) and forecasted values (2018-2022) showed an overall steady increase for all conditions, except HIV and respiratory conditions. YLDs counts almost doubled from 1990 to 2017, with a 17% predicted increase from 2017 to 2022. The proportionate contribution to YLDs counts reduced over time for all conditions, except HIV. Although age-standardized YLDs rates appear relatively stable over the analyzed periods for all conditions (except HIV, respiratory conditions and type 2 diabetes), trend changes in YLDs rates over 28 years were significant for all conditions, except neonatal (p = 0.855), hearing loss (p = 0.100) and musculoskeletal conditions (p = 0.300). Significant trend decreases were apparent for 4/9 conditions, implying that another 5/9 conditions showed trend increases over 28 years. Predicted all-age prevalence in 2022 suggests relatively large increases for cardiovascular disease and heart failure, and burns, while relative decreases are predicted for fractures and dislocations, stroke, and musculoskeletal conditions.

CONCLUSION

Rehabilitation needs in SA are potentially massive and unmet, highlighting the need for innovative and context-specific rehabilitation that considers current local needs and projected changes. These findings should be considered when designing the NHI and other schemes in SA to ensure human and financial resources are deployed efficiently.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

Acute stroke in the emergency department: A chart review at KwaZulu-Natal hospital

Background

Stroke is the second leading cause of death worldwide. There is limited literature detailing the clinical profile of stroke in developing countries’ emergency departments (EDs). The aim of this study is to describe the demographics and risk factors of patients presenting with stroke to an ED in South Africa.

Methods

This study was a retrospective chart review of all patients with a clinical diagnosis of stroke presenting to an ED of a regional hospital in rural KwaZulu-Natal from November 2018 to November 2019.

Results

A total of 362 patient charts were screened, and 136 of the charts met the inclusion criteria for the study. Seventy per cent of the patients had pre-existing hypertension, only one patient was not on treatment and two patients were not on secondary prevention. In human immunodeficiency virus–positive patients (20.5%; n = 28), 17 patients were under 50 years old. The most common finding on computer tomography was ischemic strokes (74%, n = 100). Thrombolysis was given to five patients included in the study. The overall in-hospital mortality rate was 4.06%.

Conclusion

This study adds to the limited data about stroke in South Africa. Our population represents a unique blend of infectious and lifestyle disease. More research in this setting is recommended to develop local guidelines on emergency stroke care.

Estimating the costs and benefits of stroke rehabilitation in South Africa

OBJECTIVE

This paper explores the economic value of rehabilitation to South Africa, using a costed example of cerebrovascular accident (CVA) (stroke) rehabilitation.

DESIGN

We report an economic modelling approach using a worked cost-effectiveness to validate the argument for the cost-saving benefits of stroke rehabilitation.

SETTING

South African health care, employing analysis of available secondary data from South African research and government reports.

PARTICIPANTS

In line with international trends in stroke epidemiology, we focused on people who were employed prior to having their stroke, with return-to-work as the desired rehabilitation outcome.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

We used information on stroke rehabilitation and secondary data derived from grey and published literature, to determine if early stroke rehabilitation represents value for money from the government perspective. For our worked example, we used return-to-work rates, intervention costs, and the cost of rehabilitation services to estimate cost-savings as a result of an individualized workplace intervention.

RESULTS

The cost of delivering the individualized intervention was estimated at R5633/patient. Combining survivor rates, return-to-work rate, and costs of the programme, a work intervention programme could result in a net saving of R133.1 million over 5 years (or about R26.6 per year (discount 3%).

CONCLUSION

The value of rehabilitation should not be considered in terms of cost-effectiveness alone, but also as an investment for the country. A staged, prioritized approach should be considered in future South African national health budget.

Levels and patterns of physical activity in stroke survivors with different ambulation status living in low-income areas of Cape Town, South Africa

Background: Little is known about physical activity (PA) in people with stroke living in low-income areas. The aim of this study was to characterize and contrast the levels and patterns of PA between stroke survivors with different ambulation status living in low-income areas in Cape Town, South Africa. Methods: In this cross-sectional study, 45 community-dwelling stroke survivors living in low-income areas in Cape Town participated. Accelerometers (Actigraph wGT3X-BT) were used to assess PA levels (vector magnitude counts and number of steps) and time spent sedentary, in light and moderate-to-vigorous PA (MVPA). Total daily PA and within-day activity patterns were compared between limited community ambulators (gait speed: <0.8 m/s) and community ambulators (gait speed: ≥0.8 m/s). Results: Limited community ambulators (n = 23) took fewer steps per day (1091 vs. 3524 steps, P < .001), spent more time sedentary (80% vs 68%, P = .002) and less time in light PA (18% vs 25%, P = .008) and MVPA (1% vs 5%, P < .001) than community ambulators (n = 22). The limited ambulation group had a consistent pattern of PA across the day without any significant variations in PA levels or intensity, whereas the unlimited ambulating group was most active in the morning followed by a gradual reduction in PA throughout the day. Conclusions: Community ambulating stroke survivors showed greater PA levels and a more variable diurnal pattern in contrast to the limited ambulation group. Different interventions may be required to assist the different groups to start engaging in health-enhancing PA.

Cost burden of neuroimaging during one-time admission for first-ever acute stroke in Nigeria

Objectives:

To determine the cost burden of Neuroimaging and its contribution to direct total hospitalization costs (HCs) during one-time admission for first-ever stroke.

Methods:

The clinical characteristics, direct itemised costs and total HCs for 170 consecutive patients with first-ever stroke, admitted at our public tertiary health facility over a 15-month period were evaluated.

Results:

The records of 170 stroke subjects were reviewed. The median total HCs for one-time admission per stroke patient was $183.30 with a median daily cost of $15.86. Median cost of radiological investigations was the highest among the categorized hospital costs. Among the radiological investigations, neuroimaging accounted for at least 99% of cost to patients.

Conclusion:

The financial burden of radiological investigations, particularly neuroimaging, is high during one-time admission of patients with first-ever stroke in our environment.