A literature review of indirect costs associated with stroke

One-year direct and indirect costs of ischaemic stroke in China

BACKGROUND

This is the first real-world study to estimate the direct costs and indirect costs of first-ever ischaemic stroke with 1-year follow-up in China, based on a nationally representative sample.

METHODS

Patients were chosen from 20 geographically diverse sites from the nationally representative database China National Stroke Registry-III (CNSR-III). The inclusion criteria were surviving patients who were hospitalised with first-ever ischaemic stroke from February 2017 to February 2018 (the index event); aged 18-80 during the index event; no history of other stroke types. The primary endpoints were direct medical costs, direct non-medical costs, indirect costs and total cost (ie, the sum of all cost components). Patient characteristics and clinical data were extracted from CNSR-III. Stroke-related in-hospital direct medical costs were collected from hospital electronic medical records. The patient survey collected data related to out-of-hospital direct medical costs, direct non-medical costs and indirect costs. The secondary objective was to explore clinical factors associated with cost outcomes through univariate analysis and multiple regression.

RESULTS

The study enrolled 520 patients. The total cost was 57 567.48 CNY, with 26 612.67 CNY direct medical costs, 2 787.56 CNY direct non-medical costs and 28 167.25 CNY indirect costs. Univariate analysis showed that longer lengths of stay during the index event, higher National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale scores were associated with higher costs in all categories. Conversely, EuroQol 5 Dimension utility scores were associated with decreased costs except direct non-medical costs. Multiple regressions showed that higher admission NIHSS scores were independently associated with higher direct medical costs, indirect costs and total cost. Higher 3-month utilities were associated with lower total cost.

CONCLUSION

This real-world study showed substantial 1-year economic burden following first-ever ischaemic stroke in China, and that indirect costs are a non-negligible driver of costs.

Acceptance of disability in stroke: a systematic review

BACKGROUND

Evidence for the association between acceptance of disability (AOD) and positive rehabilitation outcomes, as well as for the use of AOD measurements in stroke rehabilitation practice, has increased in the international literature in the last decade. However, measurement tools for AOD are heterogenous and there has not been a systematic review summarizing the current evidence on the use of AOD measures and factors associated with AOD.

OBJECTIVE

This study aimed to summarize current evidence on measurement tools used, present existing AOD scores in people with stroke and identify risk factors for and protective factors against poor AOD in people with stroke.

METHODS

The original design and protocol of this systematic review were registered with PROSPERO. The included studies were published from 2008 to 2020 and identified from 5 databases-PubMed, EMBASE, CINAHL Plus, PsycInfo, and the Cochrane Library-using the following inclusion criteria: participants diagnosed with stroke and aged ≥16 years, measurement of AOD, and published in English in a peer-reviewed scientific journal. Review articles were excluded.

RESULTS

Five measurement tools for AOD were reported. The Revised Acceptance of Disability Scale (ADS-R) and the acceptance subscale of the Illness Cognition Questionnaire (ICQ) had the highest internal consistency. Scores ranged from 71.7 to 74.2 on the ADS-R, 16.9-18.3 on the ICQ, 16.5-26.9 on the Acceptance of Illness Scale, and 87.8-93.2 on the Attitudes towards Disabled Persons Form A. Poorer function and depressive symptoms were associated with poor AOD, whereas religious beliefs, support from others, and an understanding of stroke were associated with better AOD.

CONCLUSIONS

The ADS-R and the acceptance subscale of the ICQ are currently the most reliable measurement tools for measuring AOD in people with stroke. Further research to validate the measurement tools is required. This may help to identify people who require additional support.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42017077063; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77063.

Conventional Mirror Therapy versus Immersive Virtual Reality Mirror Therapy: The Perceived Usability after Stroke

Background

Stroke is a widespread and complex health issue, with many survivors requiring long-term rehabilitation due to upper-limb impairment. This study is aimed at comparing the perceived usability of two feedback-based stroke therapies: conventional mirror therapy (MT) and immersive virtual reality mirror therapy (VR).

Methods

The study involved 45 participants, divided into three groups: the stroke survivors (n = 15), stroke-free older adults (n = 15), and young controls (n = 15). Participants performed two tasks using both MT and VR in a semirandom sequence. Usability instruments (SUS and NASA-TLX) were applied at the end of the activities, along with two experience-related questions.

Results

The results indicated that both MT and VR had similar levels of perceived usability, with MT being more adaptable and causing less overall discomfort. Conversely, VR increased the perception of task difficulty and prevented participants from diverting their attention from the mirror-based feedback.

Conclusion

While VR was found to be less comfortable than MT, both systems exhibited similar perceived usability. The comfort levels of the goggles may play a crucial role in determining the usability of VR for upper limb rehabilitation after stroke.

The costs associated with stroke care continuum: a systematic review

Stroke, a leading cause of death and long-term disability, has a considerable social and economic impact. It is imperative to investigate stroke-related costs. The main goal was to conduct a systematic literature review on the described costs associated with stroke care continuum to better understand the evolution of the economic burden and logistic challenges. This research used a systematic review method. We performed a search in PubMed/MEDLINE, ClinicalTrial.gov, Cochrane Reviews, and Google Scholar confined to publications from January 2012 to December 2021. Prices were adjusted using consumer price indices of the countries in the studies in the years the costs were incurred to 2021 Euros using the World Bank and purchasing power parity exchange rate in 2020 from the Organization for Economic Co-operation and Development with the XE Currency Data API. The inclusion criteria were all types of publications, including prospective cost studies, retrospective cost studies, database analyses, mathematical models, surveys, and cost-of-illness (COI) studies. Were excluded studies that (a) were not about stroke, (b) were editorials and commentaries, (c) were irrelevant after screening the title and abstract,(d) grey literature and non-academic studies, (e) reported cost indicators outside the scope of the review, (f) economic evaluations (i.e., cost-effectiveness or cost-benefit analyses); and (g) studies not meeting the population inclusion criteria. There may be risk of bias because the effects are dependent on the persons delivering the intervention. The results were synthetized by PRISMA method. A total of 724 potential abstracts were identified of which 25 articles were pulled for further investigation. The articles were classified into the following categories: 1)stroke primary prevention, 2) expenditures related to acute stroke care, 3) expenditures for post-acute strokes, and 4) global average stroke cost. The measured expenditures varied considerably among these studies with a global average cost from €610-€220,822.45. Given the great variability in the costs in different studies, we can conclude that we need to define a common system for assessing the costs of strokes. Possible limitations are related to clinical choices exposed to decision rules that trigger decisions alerts within stroke events in a clinical setting. This flowchart is based on the guidelines for acute ischemic stroke treatment but may not be applicable to all institutions.

Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review

BACKGROUND

Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT.

METHODS

A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality.

RESULTS

Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%).

CONCLUSIONS

A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.

[Organization and costs of stroke care in outpatient settings: Systematic review]

OBJECTIVE

To review the bibliography on stroke costs (ICD-10 code I63) in the field of primary care.

DESIGN

Systematic review.

DATA SOURCES

PubMed/Medline, ClinicalTrials.gov, Cochrane Reviews, EconLit, and Ovid/Embase between 01/01/2012-12/31/2021 with descriptors included in Medical Subject Heading (MeSH).

SELECTION OF STUDIES

Those with a description of the costs of activities carried out in the out-of-hospital setting. Systematic reviews were included; prospective and retrospective observational studies; analysis of databases and total or partial costs of stroke as a disease (COI). Articles were added using the snowball method. The studies were excluded because: a) not specifically related to stroke; b) in editorial or commentary format; c) irrelevant after review of the title and abstract; and d) gray literature and non-academic studies were excluded.

DATA EXTRACTION

They were assigned a level of evidence according to the GRADE levels. Direct and indirect cost data were collected.

RESULTS AND CONCLUSIONS

Thirty studies, of which 14 (46.6%) were related to post-stroke costs and 12 (40%) to cardiovascular prevention costs. The results show that most of them are retrospective analyzes of different databases of short-term hospital care, and do not allow a detailed analysis of the costs by different segments of services. The possibilities for improvement are centered on primary and secondary prevention, selection and pre-hospital transfer, early discharge with support, and social and health care.

Optimal Cost-Effective Screening Strategy for Unruptured Intracranial Aneurysms in Female Smokers

BACKGROUND

The prevalence of intracranial aneurysms among female cigarette smokers was shown to be high in previous studies, yet the cost-effectiveness of screening them has never been explored.

OBJECTIVE

To explore the most cost-effective screening strategy for female smokers.

METHODS

A decision analytical study was performed with a Markov model to compare different screening strategies with no screening and to explore the most optimal screening strategy for female smokers. Input data for the model were extracted from literature. A single screening at different ages and multiple screening every 15 years, 10 years, 5 years, and 2 years were performed for female smokers in different age ranges. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of the model. Finally, value of information analysis was performed to investigate the value of collecting additional data.

RESULTS

Screening female smokers for unruptured intracranial aneurysm is cost-effective. All screening strategies yield extra quality-adjusted life years. Screening at younger age brings more health benefit at lower cost. Frequent screening strategies decrease rupture rate of aneurysms more with higher costs per quality-adjusted life year. Screening after age 70 years and frequent screening (every 2 years) after age 60 years is not optimal. Among all the parameters in the model, collecting additional data on utility of the unscreened population would be most valuable.

CONCLUSION

Screening female smokers for intracranial aneurysms once at younger age is most optimal. However, in clinical practice, the duration and intensity of exposure to cigarettes should be taken into consideration.

Cost-effectiveness analysis on small (< 5 mm) unruptured intracranial aneurysm follow-up strategies

OBJECTIVE

Unruptured intracranial aneurysms are frequently detected during routine clinical diagnostic processes. A significant portion are small aneurysms less than 5 mm in diameter. While follow-up of patients with small aneurysms has been advocated, the cost-effectiveness of such care and the optimal follow-up interval remain unknown. This study aimed to explore the most cost-effective follow-up interval for small (< 5 mm) unruptured intracranial aneurysms.

METHODS

A decision analysis study was performed using a Markov model with Monte Carlo simulations to simulate patients undergoing follow-up by MRA at different time intervals (1-, 2-, 3-, 5-, and 7-year intervals) for small (< 5 mm) unruptured intracranial aneurysms. Input data for the model were extracted from the current literature, primarily meta-analyses. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model.

RESULTS

Given the current literature and the model in this study, following up every 2 years with noninvasive imaging is the most cost-effective strategy (cost $126,996, effectiveness 21.9 quality-adjusted life-years), showing the highest net monetary benefit. The conclusion remains robust in probabilistic and deterministic sensitivity analyses. As the annual growth risk of small aneurysms and annual rupture risk of growing aneurysms increase, following up every year is optimal. When the cost for follow-up with MRA is less than $2223, following up every year is cost-effective.

CONCLUSIONS

The most cost-effective follow-up strategy for small (< 5 mm) unruptured aneurysms using MRA is following up every 2 years. More frequent follow-up strategies or prompt preventive treatment would be more appropriate in patients with higher risk factors for growth and aneurysm rupture.

Estimating the Burden of Stroke: Two-Year Societal Costs and Generic Health-Related Quality of Life of the Restore4Stroke Cohort

(1) Background: This study aimed to investigate two-year societal costs and generic health-related quality of life (QoL) using a bottom-up approach for the Restore4Stroke Cohort. (2) Methods: Adult post-stroke patients were recruited from stroke units throughout the Netherlands. The societal costs were calculated for healthcare and non-healthcare costs in the first two years after stroke. The QoL was measured using EQ-5D-3L. The differences between (sub)groups over time were investigated using a non-parametric bootstrapping method. (3) Results: A total of 344 post-stroke patients were included. The total two-year societal costs of a post-stroke were EUR 47,502 (standard deviation (SD = EUR 2628)). The healthcare costs decreased by two thirds in the second year -EUR 14,277 (95% confidence interval -EUR 17,319, -EUR 11,236). In the second year, over 50% of the total societal costs were connected to non-healthcare costs (such as informal care, paid help, and the inability to perform unpaid labor). Sensitivity analyses confirmed the importance of including non-healthcare costs for long-term follow-up. The subgroup analyses showed that patients who did not return home after discharge, and those with moderate to severe stroke symptoms, incurred significantly more costs compared to patients who went directly home and those who reported fewer symptoms. QoL was stable over time except for the stroke patients over 75 years of age, where a significant and clinically meaningful decrease in QoL over time was observed. (4) Conclusions: The non-healthcare costs have a substantial impact on the first- and second-year total societal costs post-stroke. Therefore, to obtain a complete picture of all the relevant costs related to a stroke, a societal perspective with a follow-up of at least two years is highly recommended. Additionally, more research is needed to investigate the decline in QoL found in stroke patients above the age of 75 years.

Interventions to Improve Social Participation, Work, and Leisure Among Adults Poststroke: A Systematic Review

IMPORTANCE

Sustaining a stroke frequently leads to difficulties in returning to work, leisure, and social participation. These outcomes are important for occupational therapy practitioners to address.

OBJECTIVE

To determine the current evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve social participation, work, and leisure among adults poststroke.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases.

STUDY SELECTION AND DATA COLLECTION

Primary inclusion criteria were peer-reviewed journal articles published between January 1, 2009, and December 31, 2019, within the scope of occupational therapy that evaluated an intervention to address work, leisure, or social participation poststroke (levels of evidence ranged from Level 1b to Level 2b). Reviewers assessed records for inclusion, quality, and validity following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Forty-seven articles met the inclusion criteria. Forty-four articles related to social participation were categorized as follows: occupation-based approaches, metacognitive strategy training, education and training approaches, impairment-based approaches, and enriched environment approaches. Three articles related to work and 3 articles related to leisure were not further categorized (2 articles were each included in two categories). Seventeen Level 1b and 30 Level 2b articles were included. The strength of evidence to support occupational therapy interventions for social participation, work, and leisure outcomes is predominantly low.

CONCLUSIONS AND RELEVANCE

Occupational therapy interventions may improve work, leisure, and social participation outcomes poststroke, with the strongest evidence existing for client education, upper extremity training, and cognitive training for improving social participation. What This Article Adds: Occupational therapy practitioners may use the available literature along with clinical reasoning to improve work, leisure, and social participation outcomes among clients poststroke. Additional research is required to build stronger evidence to support clinical decision making in stroke rehabilitation in these areas.

Time Course and Mechanisms Underlying Standing Balance Recovery Early After Stroke: Design of a Prospective Cohort Study With Repeated Measurements

Introduction

Although most stroke survivors show some spontaneous neurological recovery from motor impairments of the most-affected leg, the contribution of this leg to standing balance control remains often poor. Consequently, it is unclear how spontaneous processes of neurological recovery contributes to early improvements in standing balance.

Objective

We aim to investigate (1) the time course of recovery of quiet stance balance control in the first 12 weeks poststroke and (2) how clinically observed improvements of lower limb motor impairments longitudinally relate to this limb's relative contribution to balance control.

Methods and Analysis

In this prospective longitudinal study, a cohort of 60 adults will be recruited within the first 3 weeks after a first-ever hemispheric stroke and mild-to-severe motor impairments. Individual recovery trajectories will be investigated by means of repeated measurements scheduled at 3, 5, 8, and 12 weeks poststroke. The Fugl-Meyer Motor Assessment and Motricity Index of the lower limb serve as clinical measures of motor impairments at the hemiplegic side. As soon as subjects are able to stand independently, bilateral posturography during quietly standing will be measured. First, the obtained center-of-pressure (COP) trajectories at each foot will be used for synchronization and contribution measures that establish (a-)symmetries between lower limbs. Second, the COP underneath both feet combined will be used to estimate overall stability. Random coefficient analyses will be used to model time-dependent changes in these measures and, subsequently, a hybrid model will be used to investigate longitudinal associations with improved motor impairments.

Discussion

The current study aims to investigate how stroke survivors "re-learn" to maintain standing balance as an integral part of daily life activities. The knowledge gained through this study may contribute to recommending treatment strategies for early stroke rehabilitation targeting behavioral restitution of the most-affected leg or learning to compensate with the less-affected leg.

Adapting Clinical Practice of Thrombolysis for Acute Ischemic Stroke Beyond 4.5 Hours: A Review of the Literature

Several clinical trials have demonstrated that advanced neuroimaging can select patients for recanalization therapy in an extended time window. The favorable functional outcomes and safety profile of these studies have led to the incorporation of neuroimaging in endovascular treatment guidelines, and most recently, also extended to decision making on thrombolysis. Two randomized clinical trials have demonstrated that patients who are not amenable to endovascular thrombectomy within 4.5 hours from symptoms discovery or beyond 4.5 hours from the last-known-well time may also be safely treated with intravenous thrombolysis and have a clinical benefit above the risk of safety concerns. With the growing aging population, increased stroke incidence in the young, and the impact of evolving medical practice, healthcare and stroke systems of care need to adapt continuously to provide evidence-based care efficiently. Therefore, understanding and incorporating appropriate screening strategies is critical for the prompt recognition of potentially eligible patients for extended-window intravenous thrombolysis. Here we review the clinical trial evidence for thrombolysis for acute ischemic stroke in the extended time window and provide a review of new enrolling clinical trials that include thrombolysis intervention beyond the 4.5 hour window.

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.

Return on Investment in Endovascular Care: The Case of Endovascular Reperfusion Alberta

OBJECTIVE

We examined the return on investment (ROI) from the Endovascular Reperfusion Alberta (ERA) project, a provincially funded population-wide strategy to improve access to endovascular therapy (EVT), to inform policy regarding sustainability.

METHODS

We calculated net benefit (NB) as benefit minus cost and ROI as benefit divided by cost. Patients treated with EVT and their controls were identified from the ESCAPE trial. Using the provincial administrative databases, their health services utilization (HSU), including inpatient, outpatient, physician, long-term care services, and prescription drugs, were compared. This benefit was then extrapolated to the number of patients receiving EVT increased in 2018 and 2019 by the ERA implementation. We used three time horizons, including short (90 days), medium (1 year), and long-term (5 years).

RESULTS

EVT was associated with a reduced gross HSU cost for all the three time horizons. Given the total costs of ERA were $2.04 million in 2018 ($11,860/patient) and $3.73 million in 2019 ($17,070/patient), NB per patient in 2018 (2019) was estimated at -$7,313 (-$12,524), $54,592 ($49,381), and $47,070 ($41,859) for short, medium, and long-term time horizons, respectively. Total NB for the province in 2018 (2019) were -$1.26 (-$2.74), $9.40 ($10.78), and $8.11 ($9.14) million; ROI ratios were 0.4 (0.3), 5.6 (3.9) and 5.0 (3.5). Probabilities of ERA being cost saving were 39% (31%), 97% (96%), and 94% (91%), for short, medium, and long-term time horizons, respectively.

CONCLUSION

The ERA program was cost saving in the medium and long-term time horizons. Results emphasized the importance of considering a broad range of HSU and long-term impact to capture the full ROI.

Indirect costs associated with out-of-country referral for proton therapy: a survey of adult and pediatric patients in Alberta, Canada

Background

Patients in Alberta, Canada are referred to the United States (US) for proton treatment. The Alberta Ministry of Health pays for the proton treatment and the cost of flights to and from the United States. This study aimed to determine the out-of-pocket expenses incurred by patients or patients’ families.

Methods

An electronic survey was sent to 59 patients treated with proton therapy between January 2008 and September 2019. Survey questions asked about expenses related to travel to the US and those incurred while staying in the US, reimbursement of expenses, and whether any time away from work was paid or unpaid leave.

Results

Seventeen respondents (response rate, 29%) reported expenses of flights for family members (mean, CAD 1886; range CAD 0–5627), passports/visas and other travel costs (mean, CAD 124; range CAD 0–546), accommodation during travel to the US (mean, CAD 50; range CAD 0–563), food during travel to the US (mean, CAD 89; range CAD 0–338), accommodation in the US (rented home/apartment mean, CAD 7394; range CAD 3075-13,305; hotel mean, CAD 4730; range CAD 3564-5895; other accommodation mean CAD 2660; range CAD 0–13,842), transportation in the US (car mean, CAD 2760; range CAD 0–7649; bus/subway mean, CAD 413; range CAD 246–580), and food in the US (mean, CAD 2443; range 0–6921). Expenses were partially reimbursed or covered by not-for-profit organizations or government agencies for some patients (35%). Patients missed a mean of 59 days of work; accompanying family members missed an average of 34 days. For 29% this time away from work was paid, but unpaid for 71% of respondents.

Conclusions

Multiple factors contributed to the expenses incurred including age of the patient, number of accompanying individuals, available accommodation, mode of transportation within the US, and whether the patient qualified for financial support. Added to this burden is the potential loss of wages for time away from work. The study showed a large variation in indirect costs for each family and supports actively seeking more opportunities for financial support for families with children with cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06701-z.

Economic Impact of Poststroke Delirium and Associated Risk Factors: Findings From a Prospective Cohort Study

BACKGROUND AND PURPOSE

Delirium is a common severe complication of stroke. We aimed to determine the cost-of-illness and risk factors of poststroke delirium (PSD).

METHODS

This prospective single-center study included n=567 patients with acute stroke from a hospital-wide delirium cohort study and the Swiss Stroke Registry in 2014. Delirium was determined by Delirium Observation Screening Scale or Intensive Care Delirium Screening Checklist 3 times daily during the first 3 days of admission. Costs reflected the case-mix index and diagnosis-related groups from 2014 and were divided into nursing, physician, and total costs. Factors associated with PSD were assessed with multiple regression analysis. Partial correlations and quantile regression were performed to assess costs and other factors associated with PSD.

RESULTS

The incidence of PSD was 39.0% (221/567). Patients with delirium were older than non-PSD (median 76 versus 70 years; P<0.001), 52% male (115/221) versus 62% non-PSD (214/346) and hospitalized longer (mean 11.5 versus 9.3 days; P<0.001). Dementia was the most relevant predisposing factor for PSD (odds ratio, 16.02 [2.83-90.69], P=0.002). Moderate to severe stroke (National Institutes of Health Stroke Scale score 16-20) was the most relevant precipitating factor (odds ratio, 36.10 [8.15-159.79], P<0.001). PSD was a strong predictor for 3-month mortality (odds ratio, 15.11 [3.33-68.53], P<0.001). Nursing and total costs were nearly twice as high in PSD (P<0.001). There was a positive correlation between total costs and admission National Institutes of Health Stroke Scale (correlation coefficient, 0.491; P<0.001) and length of stay (correlation coefficient, 0.787; P<0.001) in all patients. Quantile regression revealed rising nursing and total costs associated with PSD, higher National Institutes of Health Stroke Scale, and longer hospital stay (all P<0.05).

CONCLUSIONS

PSD was associated with greater stroke severity, prolonged hospitalization, and increased nursing and total costs. In patients with severe stroke, dementia, or seizures, PSD is anticipated, and additional costs are associated with hospitalization.

The financial burden of non-communicable diseases in the European Union: a systematic review

BACKGROUND

Non-communicable diseases (NCDs) impose a significant and growing burden on the health care system and overall economy of developed (and developing) countries. Nevertheless, an up-to-date assessment of this cost for the European Union (EU) is missing from the literature. Such an analysis could however have an important impact by motivating policymakers and by informing effective public health policies.

METHODS

Following the PRISMA protocol, we conduct a systematic review of electronic databases (PubMed/Medline, Embase, Web of Science Core Collection) and collect scientific articles that assess the direct (health care-related) and indirect (economic) costs of four major NCDs (cardiovascular disease, cancer, type-2 diabetes mellitus and chronic respiratory disease) in the EU, between 2008 and 2018. Data quality was assessed through the Newcastle-Ottawa Scale.

RESULTS

We find 28 studies that match our criteria for further analysis. From our review, we conclude that the four major NCDs in the EU claim a significant share of the total health care budget (at least 25% of health spending) and they impose an important economic loss (almost 2% of gross domestic product).

CONCLUSION

The NCD burden forms a public health risk with a high financial impact; it puts significant pressure on current health care and economic systems, as shown by our analysis. We identify a further need for cost analyses of NCDs, in particular on the impact of comorbidities and other complications. Aside from cost estimations, future research should focus on assessing the mix of public health policies that will be most effective in tackling the NCD burden.

Adjusted productivity costs of stroke by human capital and friction cost methods: a Northern Finland Birth Cohort 1966 study

BACKGROUND

Productivity costs result from loss of paid and unpaid work and replacements due to morbidity and mortality. They are usually assessed in health economic evaluations with human capital method (HCM) or friction cost method (FCM). The methodology for estimating lost productivity is an area of considerable debate.

OBJECTIVE

To compare traditional and adjusted HCM and FCM productivity cost estimates among young stroke patients.

METHODS

The Northern Finland Birth Cohort 1966 was followed until the age of 50 to identify all 339 stroke patients whose productivity costs were estimated with traditional, occupation-specific and adjusted HCM and FCM models by using detailed, national register-based data on care, disability, mortality, education, taxation and labour market.

RESULTS

Compared to traditional HCM, taking into account occupational class, national unemployment rate, disability-free life expectancy and decline in work ability, the productivity cost estimate decreased by a third, from €255,960 to €166,050. When traditional FCM was adjusted for occupational class and national unemployment rate, the estimate more than doubled from €3,040 to €7,020. HCM was more sensitive to adjustments for discount rate and wage growth rate than FCM.

CONCLUSIONS

This study highlights the importance of adjustments of HCM and FCM. Routine register-based data can be used for accurate productivity cost estimates of health shocks.

Computed Tomography Angiography versus Digital Subtraction Angiography as a Primary Diagnostic Tool in Nontraumatic Subarachnoid Hemorrhage: Cost-Effectiveness Analysis Study

BACKGROUND

Digital subtraction angiography (DSA) and computed tomographic angiography (CTA) are used to identify the cause of nontraumatic subarachnoid hemorrhage (SAH). There is no consensus on which to choose as the first diagnostic tool. We aimed to compare the cost-effectiveness of CTA versus DSA as a primary tool for identifying the cause of nontraumatic SAH.

METHODS

A decision analysis model was built to simulate patients undergoing DSA or CTA as a primary diagnostic tool for the cause of nontraumatic SAH. The input data for the study were extracted from literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model.

RESULTS

In the base case calculation, it cost $1261.82 less and yielded 0.0001 quality-adjusted life year (QALY) when DSA was used as a primary diagnostic imaging tool for nontraumatic SAH. Choosing DSA as a primary tool was cost-effective in more than 65% of iterations in probabilistic sensitivity analysis. Deterministic sensitivity analyses show when the probability of using endovascular treatment is >47.2%, choosing DSA is more cost-effective; otherwise, CTA is more optimal. CTA is more cost-effective when the cost for DSA >2.6 × CTA + $600.

CONCLUSIONS

Based on current literature and our model DSA as a primary diagnostic tool for the cause of nontraumatic SAH is more cost-effective. However, in clinical practice physicians can choose either DSA or CTA according to the scale of endovascular procedures used in their center, as well as the cost correlation between CTA and DSA, which varies among institutions.

Staged treatment protocol for gait with hybrid assistive limb in the acute phase of patients with stroke

Hybrid Assistive Limb (HAL) is a wearable human assistant cyborg-type robot that helps lower-leg movement based on bioelectrical signals detected from the voluntary movement of the person wearing it. In this study, we developed a novel staged HAL treatment protocol for patients with acute stroke. The Regain Program for Gait with HAL (RPG-HAL) was formulated in four steps, based on the severity of limb paralysis. Twenty-one patients with acute stroke received a combination treatment of RPG-HAL and conventional rehabilitation. The feasibility and safety of RPG-HAL were evaluated based on changes in physical function and activities of daily living (ADL). RPG-HAL yielded improvement in gait speed, cadence, step length, and functional ambulation category (FAC). The effect size was >0.8 in all measurements. FAC (1.90) and Barthel Index (BI) (1.92) exhibited the highest scores. Twelve out of 14 patients with FAC 0 before RPG-HAL reached the upper FAC. Thus, earlier intervention using RPG-HAL as improving physical function, ADL, and gait ability in patients with stroke.

Initial and subsequent 3-year cost after hospitalization for first acute ischemic stroke and intracerebral hemorrhage

AIMS

To examine 1) the major drivers of index hospitalization and 3-year post-acute follow-up care, 2) cost for rehabilitation and homecare, and 3) indirect cost from lost productivity after acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH).

METHODS

Retrospective study of adults hospitalized with AIS (n = 811) and ICH (N = 145) between 2003 and 2014. Direct costs standardized to Medicare reimbursement rates were captured for hospitalization and 3-year follow-up or death. Adjusted cost estimates were assessed using generalized linear modeling with gamma distribution. Costs for rehabilitation, home healthcare, and lost productivity were assessed using sets of cost captured through literature review.

RESULTS

Calculated as mean cost per person: hospitalization $18,154 for AIS and $24,077 for ICH; monthly 3-year aggregate $5138 for AIS and $8172 for ICH; 3-year inpatient rehabilitation $4185 for AIS and $4196 for ICH; homecare $19,728 for AIS and $14,487 for ICH; indirect cost from lost productivity $77,078 for AIS and $56,601 for ICH. Age < 55 years, being non-white, and stroke severity were strongly associated with greater hospitalization cost for AIS and ICH. Hyperlipidemia incurred lower while cancer, coronary artery disease, asthma/chronic obstructive pulmonary disease, heart failure, and anemia incurred higher 3-year aggregate cost for AIS. Cancer and diabetes mellitus incurred higher 3-year aggregate cost for ICH.

CONCLUSIONS

We provide estimates of direct and indirect costs incurred for acute and continuing post-acute care through a 3-year follow-up period after first-ever AIS and ICH with important comparisons for predictors between index hospitalization and 3-year post-stroke costs.

Lifetime risks and health impacts of hemorrhagic and ischemic stroke in South Korea

This study is aimed toward estimating the lifetime risks, life expectancy, expected years of life lost (EYLL), and lifetime costs related to different subtypes of stroke in South Korea. We included 13,994 patients diagnosed with stroke (ICD-10, I60-I63) in the National Health Insurance Service-National Sample Cohort of Korea between 2006 and 2015. Lifetime risks were calculated using the cumulative incidence rate for patients aged 18–84. Lifetime survival data were obtained through the Kaplan–Meier method and extrapolated with a rolling-over extrapolation algorithm. The lifetime costs were estimated by multiplying the average monthly expenditures with the survival probabilities and adding the values over lifetime. The lifetime risks of stroke in Korea have been decreasing consistently over the last decade with the exception of subarachnoid hemorrhage in females, which appears to have slightly increased. The EYLL is higher in hemorrhagic stroke than in ischemic stroke (6–9.7 vs. 4.7). Expected lifetime costs reimbursed by the NHIS would amount to about $71,406 accompanied with $14,921 copayment from the patients for hemorrhagic stroke, and $50,551 and $11,666, respectively, for ischemic stroke. Further studies are warranted to combine survival with quality of life and functional disability to obtain a more detailed outcome assessment of the potential impact of the prevention of stroke.

Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study

BACKGROUND

While a nursing intervention program for immobile patients with stroke can improve clinic outcomes, less is known about the cost-effectiveness of these interventions.

OBJECTIVES

The goal of this study was to evaluate the cost-effectiveness of the intervention program for immobile patients with stroke in China.

DESIGN

A cost-effectiveness analysis alongside a pre-test/post-test (before and after) study was undertaken from a health care perspective.

SETTINGS

Participants were recruited from 25 hospitals among six provinces or municipal cities in eastern (Guangdong province, Zhejiang province, and Beijing municipal city), western (Sichuan province), and central (Henan province and Hubei province) China.

PARTICIPANTS

A total of 7,653 immobile stroke patients were included in our sample. Patients in routine care settings were recruited from November 2015 to June 2016, and the recruitment of the intervention group patients was from November 2016 to July 2017.

METHODS

To adjust for potential bias from confounding variables, the 1:1 propensity score matching yielded matched pairs of 2,966 patients in the routine care group and 2,966 patients in the intervention group, with no significant differences in sociodemographic or clinical characteristics between two groups. All patients were followed-up 3 months after enrolment in the study. Total healthcare costs were extracted from the hospital information system, with the health outcome effectiveness of the intervention program measured using the EuroQol five-dimensional questionnaire (EQ-5D) instrument and the cost-effectiveness of the intervention measured by the incremental cost-effectiveness ratio with a time horizon of 3 months.

RESULTS

Compared to routine care, the intervention program decreased the total costs of stroke patients by CN¥4,600 (95% confidence interval [CI]: [-7050, -2151]), while increasing quality-adjusted life year 0.009 (95% CI: [0.005, 0.013]). The incremental cost-effectiveness ratios over 3 months was CN¥-517,011 per quality-adjusted life year (95% CI: [-1,111,442, -203,912]). Subgroup analysis reveals that both the health-related quality of life and cost effectiveness improved significantly for ischemic patients and tertiary hospitals patients while for hemorrhagic patients and non-tertiary hospital patients only the health-related quality of life improved significantly.

CONCLUSIONS

Findings from this first cost-effectiveness analysis in immobile stroke patients provide evidence that an intervention program provided significant cost saving, but mainly in ischemic patients and tertiary hospital patients. Wider adoption of such programs may be a sensible approach to reducing the burden of stroke and for immobile patients more generally.

Injuries and their related household costs in a tertiary hospital in Ghana

Introduction

Injuries remain a leading cause of death in many developing countries, accounting for more deaths than HIV, tuberculosis, and malaria combined. This study set out to determine the associated patient costs of reported injury cases at the Accident and Emergency Department of the Korle-Bu Teaching Hospital (KBTH) in Accra, Ghana.

Method

A cross-sectional retrospective Cost-of-Illness study of 301 sampled patients was undertaken, following a review of injured patients' records from January–December 2016. Direct cost, (consisting of consultation, surgery, medicines, transportation, property damage, food and consumables) was estimated. Indirect cost was calculated using the Human capital approach. Intangible cost was assessed using Likert scale analysis. The overall household cost, average cost of various injuries and intangible costs were determined.

Results

The total annual household cost of injuries to patients who attended KBTH was US$11,327,461.96, of which 82% was the direct cost. The average household cost of injuries was US$ 1276.15. All injuries recorded some level of high intangible cost but was exceptional for burns.

Conclusion

Injured patients incur high direct treatment cost in all aetiology, with generally high intangible cost as well. It is therefore imperative that injury prevention strategies be prioritized in national health policies, while broader discussions continue on sustainable health financing of injury management.

Implications of achieving TICI 2b vs TICI 3 reperfusion in patients with ischemic stroke: a cost-effectiveness analysis

BACKGROUND

The benefit of endovascular thrombectomy (EVT) in stroke patients with large-vessel occlusion (LVO) depends on the degree of recanalization achieved. We aimed to determine the health outcomes and cost implications of achieving TICI 2b vs TICI 3 reperfusion in acute stroke patients with LVO.

METHODS

A decision-analytic study was performed with Markov modeling to estimate the lifetime quality-adjusted life years (QALY) of EVT-treated patients, and costs based on the degree of reperfusion achieved. The study was performed with a societal perspective in the United States' setting. The base case calculations were performed in three age groups: 55-, 65-, and 75-year-old patients.

RESULTS

Within 90 days, achieving TICI 3 resulted in a cost saving of $3676 per patient and health benefit of 11 days in perfect health as compared with TICI 2b. In the long term, for the three age groups, achieving TICI 3 resulted in cost savings of $46,498, $25,832, and $15 719 respectively, and health benefits of 2.14 QALYs, 1.71 QALYs, and 1.23 QALYs. Every 1% increase in TICI 3 in 55-year-old patients nationwide resulted in a cost saving of $3.4 million and a health benefit of 156 QALYs. Among 65-year-old patients, the corresponding cost savings and health benefit were $1.9 million and 125 QALYs.

CONCLUSION

There are substantial cost and health implications in achieving complete vs incomplete reperfusion after EVT. Our study provides a framework to assess the cost-benefit analysis of emerging diagnostic and therapeutic techniques that might improve patient selection, and increase the chances of achieving complete reperfusion.

Return to work after stroke and related factors in Poland and abroad: A literature review

BACKGROUND

The incidence of stroke is growing in various parts of the world and the condition most commonly affects the adult population.

OBJECTIVES

The purpose of the study is to provide a narrative review of papers published in the last 11 years in English and in Polish and focusing on demographic characteristics of individuals returning to work after stroke, return to work rates, length of time post stroke to return to work as well as health conditions, or personal and environmental factors associated with return to work after stroke. The study also presents the situation regarding return to work after stroke in Poland in comparison to other countries.

METHODS

The narrative review covers Polish and foreign literature published between 2007 and 2018. The number of records initially identified through English databases search amounted to 4,912. Five records were additionally identified through other sources (Polish databases). Ultimately 26 (21 foreign, 5 Polish) refereed publications were selected to be reviewed in this study, based on their relevance in terms of specific inclusion/exclusion criteria.

RESULTS

The appraisal of Polish and English-language literature shows that stroke survivors' ability to return to work varies; in our country the rate being 43% and outside of Poland reaching the rate of 74.7%. Average time frames for return to work for stroke survivors include from 3 to 6 months, from 12 to 18 months and up to 3 years post stroke. One of the most frequently reported positive factors in the English-language literature is individually tailored vocational rehabilitation. There is a scarcity of studies related to return to work after stroke in Poland.

CONCLUSIONS

The findings from studies included in this narrative review may suggest a need to improve the situation in Poland with regard to measures related to return to work after stroke, including vocational rehabilitation which is insufficiently available in Poland.

Effects of chronic antidepressant use on neurophysiological responses to tDCS post-stroke

BACKGROUND

Transcranial direct current stimulation (tDCS) induces neuroplastic changes in the motor cortex of healthy individuals and has become a candidate intervention to promote recovery post-stroke. However, neurophysiological effects of tDCS in stroke are poorly understood. Antidepressant medications, which are commonly prescribed post-stroke, have the potential to significantly affect cortical excitability and alter responsiveness to tDCS interventions, yet these effects have not previously been examined.

OBJECTIVE/HYPOTHESIS

To examine the effects of chronic antidepressant use, tDCS, and the interaction of the two on motor cortical excitability in people with chronic stroke. Based on previous literature in nondisabled adults, we hypothesized that post-stroke, antidepressant-takers would show decreased baseline motor cortical excitability but enhanced responsiveness to anodal tDCS.

METHODS

Twenty-six participants with chronic stroke (17 control, 9 antidepressant) received real and sham anodal tDCS during separate sessions at least a week apart. Motor cortical excitability was measured before and after tDCS was applied to the lesioned hemisphere primary motor cortex. We compared baseline cortical excitability and neurophysiological responses to tDCS between groups and sessions.

RESULTS

Baseline motor cortical excitability was not different between control and antidepressant groups. Following anodal tDCS over the ipsilesional primary motor cortex, cortical excitability in the non-lesioned hemisphere decreased in controls, but, surprisingly, increased in antidepressant-takers.

CONCLUSIONS

Chronic antidepressant use may not affect motor cortical excitability post-stroke, however it appears to reverse some of the expected effects of tDCS. Therefore future utilization of tDCS in post-stroke neurorehabilitation research should take antidepressant medication status into account.

Predicting Improved Daily Use of the More Affected Arm Poststroke Following Constraint-Induced Movement Therapy

BACKGROUND

Constraint-induced movement therapy (CI therapy) produces, on average, large and clinically meaningful improvements in the daily use of a more affected upper extremity in individuals with hemiparesis. However, individual responses vary widely.

OBJECTIVE

The study objective was to investigate the extent to which individual characteristics before treatment predict improved use of the more affected arm following CI therapy.

DESIGN

This study was a retrospective analysis of 47 people who had chronic (> 6 months) mild to moderate upper extremity hemiparesis and were consecutively enrolled in 2 CI therapy randomized controlled trials.

METHODS

An enhanced probabilistic neural network model predicted whether individuals showed a low, medium, or high response to CI therapy, as measured with the Motor Activity Log, on the basis of the following baseline assessments: Wolf Motor Function Test, Semmes-Weinstein Monofilament Test of touch threshold, Motor Activity Log, and Montreal Cognitive Assessment. Then, a neural dynamic classification algorithm was applied to improve prognostic accuracy using the most accurate combination obtained in the previous step.

RESULTS

Motor ability and tactile sense predicted improvement in arm use for daily activities following intensive upper extremity rehabilitation with an accuracy of nearly 100%. Complex patterns of interaction among these predictors were observed.

LIMITATIONS

The fact that this study was a retrospective analysis with a moderate sample size was a limitation.

CONCLUSIONS

Advanced machine learning/classification algorithms produce more accurate personalized predictions of rehabilitation outcomes than commonly used general linear models.

How relevant are social costs in economic evaluations? The case of Alzheimer's disease

BACKGROUND

The main objective of this study was to analyse how the inclusion (exclusion) of social costs can alter the results and conclusions of economic evaluations in the field of Alzheimer's disease interventions.

METHODS

We designed a systematic review that included economic evaluations in Alzheimer's disease. The search strategy was launched in 2000 and ran until November 2018. The inclusion criteria were: being an original study published in a scientific journal, being an economic evaluation of any intervention related to Alzheimer's disease, including social costs (informal care costs and/or productivity losses), being written in English, using QALYs as an outcome for the incremental cost-utility analysis, and separating the results according to the perspective applied.

RESULTS

It was finally included 27 studies and 55 economic evaluations. Around 11% of economic evaluations changed their main conclusions. More precisely, three of them concluded that the new intervention became cost-effective when the societal perspective was considered, whereas when using just the health care payer perspective, the new intervention did not result in a cost-utility ratio below the threshold considered. Nevertheless, the inclusion of social cost can also influence the results, as 37% of the economic evaluations included became the dominant strategy after including social costs when they were already cost-effective in the health care perspective.

CONCLUSIONS

Social costs can substantially modify the results of the economic evaluations. Therefore, taking into account social costs in diseases such as Alzheimer's can be a key element in making decisions about public financing and pricing of health interventions.

Stroke burden in Guinea: Results from the Conakry Ignace Deen Hospital stroke registry

Sub-Saharan Africa has extremely high stroke prevalence and case fatality. Most Sub-Saharan African regions are uncharted in terms of stroke characteristics, epidemiology, and burden. We report here the results from the first stroke registry in Guinea.

Cost-effectiveness of percutaneous closure of a patent foramen ovale compared with medical management in patients with a cryptogenic stroke: from the US payer perspective

Aims: To evaluate the cost-effectiveness of percutaneous patent foramen ovale (PFO) closure, from a US payer perspective. Lower rates of recurrent ischemic stroke have been documented following percutaneous PFO closure in properly selected patients. Stroke in patients aged <60 years is particularly interesting because this population is typically at peak economic productivity and vulnerable to prolonged disability. Materials and methods: A Markov model comprising six health states (Stable after index stroke, Transient ischemic attack, Post-Transient Ischemic Attack, Clinical ischemic stroke, Post-clinical ischemic stroke, and Death) was constructed to evaluate the cost-effectiveness of PFO closure in combination with medical management versus medical management alone. The base-case model employed a 5-year time-horizon, with transition probabilities, clinical inputs, costs, and utility values ascertained from published and national costing sources. Incremental cost-effectiveness ratio (ICER) was evaluated per US guidelines, utilizing a discount rate of 3.0%. Results: At 5 years, overall costs and quality-adjusted life-years (QALYs) obtained from PFO closure compared with medical management were $16,323 vs $7,670 and 4.18 vs 3.77, respectively. At 5 years, PFO closure achieved an ICER of $21,049, beneficially lower than the conventional threshold of $50,000. PFO closure reached cost-effectiveness at 2.3 years (ICER = $47,145). Applying discount rates of 0% and 6% had a negligible impact on base-case model findings. Furthermore, PFO closure was 95.4% likely to be cost-effective, with a willingness-to-pay (WTP) threshold of $50,000 and a 5-year time horizon. Limitations: From a cost perspective, our economic model employed a US patient sub-population, so cost data may not extrapolate to other non-US stroke populations. Conclusion: Percutaneous PFO closure plus medical management represents a cost-effective approach for lowering the risk of recurrent stroke compared with medical management alone.

Systematic review of societal costs associated with stroke, bleeding and monitoring in atrial fibrillation

Aim: Economic consequences associated with the rise in nonvitamin K antagonist oral anticoagulant use on a societal level remain unclear. Materials & methods: Evidence from the past decade on the societal economic burden associated with stroke, bleeding and international normalized ratio monitoring in atrial fibrillation was collected and summarized through a systematic literature review. Results: There were 14 studies identified that reported indirect costs, which were highest among patients with hemorrhagic stroke and intracranial hemorrhage. The contribution of indirect costs to the total was marginal during acute treatment but substantially increased (30-50%) 2 years after stroke and bleeding events. Conclusion: Limited data were available on societal costs in atrial fibrillation and further research is warranted.

The Use of Deep Learning to Predict Stroke Patient Mortality

The increase in stroke incidence with the aging of the Korean population will rapidly impose an economic burden on society. Timely treatment can improve stroke prognosis. Awareness of stroke warning signs and appropriate actions in the event of a stroke improve outcomes. Medical service use and health behavior data are easier to collect than medical imaging data. Here, we used a deep neural network to detect stroke using medical service use and health behavior data; we identified 15,099 patients with stroke. Principal component analysis (PCA) featuring quantile scaling was used to extract relevant background features from medical records; we used these to predict stroke. We compared our method (a scaled PCA/deep neural network [DNN] approach) to five other machine-learning methods. The area under the curve (AUC) value of our method was 83.48%; hence; it can be used by both patients and doctors to prescreen for possible stroke.

Management of Unruptured Intracranial Aneurysms in Older Adults: A Cost-effectiveness Analysis

Background Unruptured intracranial aneurysms (UIAs) are relatively common and are being increasingly diagnosed, with a significant proportion in older patients (˃ 65 years old). Serial imaging is often performed to assess change in size or morphology of UIAs since growing aneurysms are known to be at high risk for rupture. However, the frequency and duration of surveillance imaging have not been established. Purpose To evaluate the cost-effectiveness of routine treatment (aneurysm coil placement) versus four different strategies for imaging surveillance of UIAs in adults older than 65 years. Materials and Methods A Markov decision-analytic model was constructed from a societal perspective. Age-dependent input parameters were obtained from published literature. Analysis included adults older than 65 years, with incidental detection of UIA and no prior history of subarachnoid hemorrhage. Five different management strategies for UIAs in older adults were evaluated: (a) annual MR angiography, (b) biennial MR angiography, (c) MR angiography every 5 years, (d) coil placement and follow-up, and (e) limited MR angiography follow-up for the first 2 years after detection only. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Probabilistic, one-way, and two-way sensitivity analyses were performed. Results Imaging follow-up for the first 2 years after detection is the most cost-effective strategy (cost = $24 572, effectiveness = 13.73 QALYs), showing the lowest cost and highest effectiveness. The conclusion remains robust in probabilistic and one-way sensitivity analyses. Time-limited imaging follow-up remains the optimal strategy when the annual growth rate and rupture risk of growing aneurysms are varied. If annual rupture risk of nongrowing aneurysms is greater than 7.1%, coil placement should be performed directly. Conclusion Routine preventive treatment or periodic, indefinite imaging follow-up is not a cost-effective strategy in all adults older than 65 years with unruptured intracranial aneurysms. More aggressive management strategies should be reserved for patients with high risk of rupture, such as those with aneurysms larger than 7 mm and those with aneurysms in the posterior circulation. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Cloft in this issue.

Evaluating the cost-effectiveness of percutaneous closure of a patent foramen ovale versus medical management in patients with a cryptogenic stroke: from the UK payer perspective

AIMS

Percutaneous closure of a patent foramen ovale (PFO) is known to lower the risk of recurrent stroke in patients with a cryptogenic stroke. However, the economic implications of transcatheter PFO closure are less well known. From a UK payer perspective, a detailed economic appraisal of PFO closure was performed for prevention of recurrent ischemic stroke in patients with a PFO who had experienced a cryptogenic stroke.

MATERIALS AND METHODS

A Markov cohort model was constructed using a 5-year time-horizon with a patient mean age of 45.2 years, reflecting the characteristics reported in the REDUCE trial. Transition probabilities, clinical inputs, costs, and utility values were ascertained from published and national costing sources. Total costs, incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were calculated, utilizing a discount rate of 3.5%. A range of univariate and probabilistic sensitivity analyses were also performed.

RESULTS

When applying a willingness-to-pay (WTP) threshold of £20,000/QALY in accordance with NICE guidelines, PFO closure compared with antiplatelet therapy alone showed a beneficial cost/QALY of £18,584, attained at 4 years. Applying discount rates of 0% and 6% had a negligible effect on the base-case model findings. PFO closure demonstrated a 76.9% probability of being cost-effective at a WTP threshold of £20,000/QALY at a 5-year time-horizon.

LIMITATIONS

This model focused specifically on UK stroke patients and typically enrolled young (mean age <65 years old) patients. Hence, caution should be taken when comparing data vs non-UK populations, and it remains unclear how older patients might have affected cost-effectiveness findings, as the risk of paradoxical embolism can persist as patients age.

CONCLUSION

Percutaneous closure of a PFO is cost-effective compared with antiplatelet therapy alone, underlining the economic benefits potentially afforded by this treatment in selected patients.

The Economic Burden of Stroke Based on South Korea's National Health Insurance Claims Database

Background: This study was conducted to determine the scale and the nature of the economic burden caused by strokes and to use the results as an evidential source for determining the allocation of South Korea stroke cases in 2015.

Methods: For research subjects, the study analyzed demographic characteristics and economic burden based on data from national health insurance (NHI) claims for inpatient and outpatient cases of ischemic stroke and hemorrhagic stroke in 2015 through the Health Insurance Review and Assessment Service (HIRA) and statistical data regarding cause of death from the Korea National Statistical Office (KNSO). This study, in order to estimate economic burden due to stroke, deduced the direct and indirect costs of illness caused by stroke, using cost-of-illness (COI) methods. The economic burden is divided into direct and indirect costs, and indirect cost is estimated by summing lost productivity measured in opportunity cost lost by medical disposition due to a specific disease and lost productivity due to premature death.

Results: The total economic burden in Korea due to stroke was US$6.855 billion, that due to ischemic stroke was US$3.658 billion, and that due to hemorrhagic stroke was US$3.197 billion. The average economic burden per stroke case was about US$7247.

Conclusion: The results of estimating the annual economic burden in all of Korea due to stroke will be used as an evidential source for preparing medical insurance policies, priorities, and plans for arranging medical resources for stroke as well as for determining effective prevention of the disease and related priorities in national health care policies.

Economic Burden of Informal Caregiving Associated With History of Stroke and Falls Among Older Adults in the U.S

INTRODUCTION

Older adults are at high risk for stroke and falls, both of which require a large amount of informal caregiving. However, the economic burden of informal caregiving associated with stroke and fall history is not well known.

METHODS

Using the 2010 Health and Retirement Study, data on non-institutionalized adults aged ≥65 years (N=10,129) in 2015-2017 were analyzed. Two-part models were used to estimate informal caregiving hours. Based on estimates from the models using a replacement cost approach, the authors derived informal caregiving hours and costs associated with falls in the past 2 years for stroke and non-stroke persons.

RESULTS

Both the prevalence of falls overall and of falls with injuries were higher among people with stroke than those without (49.5% vs 35.1% for falls and 16.0% vs 10.3% for injurious falls, p<0.01). Stroke survivors needed more informal caregiving hours than their non-stroke counterparts, and the number of informal caregiving hours was positively associated with non-injurious falls and even more so with injurious falls. The national burden of informal caregiving (2015 U.S. dollars) associated with injurious falls amounted to $2.9 billion (95% CI=$1.1 billion, $4.7 billion) for stroke survivors (about 0.5 million people), and $6.5 billion (95% CI=$4.3 billion, $8.7 billion) for those who never had a stroke (about 3.6 million people).

CONCLUSIONS

In U.S. older adults, informal caregiving hours and costs associated with falls are substantial, especially for stroke survivors. Preventing falls and fall-related injuries, especially among stroke survivors, therefore has potential for reducing the burden of informal caregiving.

Factors associated with hospital arrival time after the onset of stroke symptoms: A cross-sectional study at two teaching hospitals in Harare, Zimbabwe

Background

Late presentation to hospital after onset of stroke affects management and outcomes of the patients. This study aimed to determine the factors associated with time taken to present to hospital after the onset of acute stroke symptoms.

Methods

A descriptive cross sectional study was conducted at two teaching hospitals in Zimbabwe. Participants included patients admitted with stroke and their relatives. A self-administered questionnaire was used to collect information on history of stroke occurrence and time taken to present to hospital. Data was analysed for means, frequencies, percentages and Odds ratios.

Results

Less than half (33%) of the participants were able to recognize symptoms of stroke. Not having money to pay for hospital bills was a predictor of late hospital presentation (OR =6.64; 95% CI, (2.05–21.53); p=0.002). The other factors, though not statistically significant included not perceiving stroke as a serious illness (OR = 2.43; 95% CI (0.78–5.51); p=0.083) and unavailability of transport (OR=2.33; 95% CI (0.71–7.56); p=0.161). Predictors for early presentation included receiving knowledge about stroke from the community (OR=0.46; 95% CI (0.15–1.39); p=0.170); seeking help at the hospital (OR=0.50; 95% CI (0.18–1.37); p=0.177) and having a stroke while at the workplace (OR =0.46; 95% CI (0.08–2.72); p=0.389).

Conclusions

Regarding stroke as an emergency that does not require prerequisite payment for services at hospitals and improved community awareness on stroke may improve time taken to present to hospital after the onset of stroke symptoms.

A literature review of cost-effectiveness of intravenous recombinant tissue plasminogen activator for treating acute ischemic stroke

BACKGROUND

Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for acute ischemic stroke patients, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischemic stroke is not well reviewed.

AIMS

To conduct a literature review of the cost-effectiveness studies about IV rtPA by treatment times.

SUMMARY OF REVIEW

A literature search was conducted using MEDLINE, EMBASE, CINAHL and Cochrane Library, with the key words acute ischemic stroke, tissue plasminogen activator, cost, economic benefit, saving, and incremental cost-effectiveness analysis. The review is limited to original research articles published during 1995-2016 in English-language peer-reviewed journals. We found 16 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0-3 hours after stroke onset, 2 studies within 3-4.5 hours, 3 studies within 0-4.5 hours, and 2 study within 0-6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within one year was marginally above $50,000 per QALY threshold. IV rtPA within 0-3 hours after stroke led to cost savings for lifetime or 30 years, and IV rtPA within 3-4.5 hours after stroke increased costs but still was cost-effective.

CONCLUSIONS

The literature generally showed that intravenous IV rtPA was a dominant or a cost-effective strategy compared to traditional treatment for acute ischemic stroke patients without IV rtPA. The findings from the literature lacked generalizability because of limited data and various assumptions.

Relationship between functional disability and costs one and two years post stroke

BACKGROUND AND PURPOSE

Stroke affects mortality, functional ability, quality of life and incurs costs. The primary objective of this study was to estimate the costs of stroke care in Sweden by level of disability and stroke type (ischemic (IS) or hemorrhagic stroke (ICH)).

METHOD

Resource use during first and second year following a stroke was estimated based on a research database containing linked data from several registries. Costs were estimated for the acute and post-acute management of stroke, including direct (health care consumption and municipal services) and indirect (productivity losses) costs. Resources and costs were estimated per stroke type and functional disability categorised by Modified Rankin Scale (mRS).

RESULTS

The results indicated that the average costs per patient following a stroke were 350,000SEK/€37,000-480,000SEK/€50,000, dependent on stroke type and whether it was the first or second year post stroke. Large variations were identified between different subgroups of functional disability and stroke type, ranging from annual costs of 100,000SEK/€10,000-1,100,000SEK/€120,000 per patient, with higher costs for patients with ICH compared to IS and increasing costs with more severe functional disability.

CONCLUSION

Functional outcome is a major determinant on costs of stroke care. The stroke type associated with worse outcome (ICH) was also consistently associated to higher costs. Measures to improve function are not only important to individual patients and their family but may also decrease the societal burden of stroke.

The Valuation of Informal Care in Cost-of-Illness Studies: A Systematic Review

BACKGROUND

There is a growing interest in incorporating informal care in cost-of-illness studies as a relevant part of the economic impact of some diseases.

OBJECTIVE

The aim of this paper was to review the recent literature valuating the costs of informal care in a group of selected diseases from 2005 to 2015.

METHODS

We carried out a systematic review on the economic impact of informal care, focusing on six selected diseases: arthritis or osteoarthritis, cancer, dementia, mental diseases, multiple sclerosis and stroke.

RESULTS

We selected 91 cost-of-illness articles. The average weight attributed to the informal care cost over the total cost was highly relevant for dementia, stroke, mental diseases, cancer and multiple sclerosis. The most frequent valuation method applied was the opportunity cost method, followed by the proxy good method. The annual cost of informal care presented a high variability depending on the disease and geographic location. Distinguishing by type of illness, the disease with the highest annual value of informal caregiving was dementia, followed by mental illness and multiple sclerosis. The average hourly unit cost was €11.43 (2015 values), varying noticeably depending on the geographic location.

CONCLUSION

This paper identifies several aspects that should be enhanced to promote comparability between studies and countries, and it sends key messages for incorporating informal care costs to adequately measure the economic impact of diseases.

Does suboccipital decompression and evacuation of intraparenchymal hematoma improve neurological outcome in patients with spontaneous cerebellar hemorrhage?

OBJECTIVE

Spontaneous cerebellar hemorrhages (SCH) can lead to life-threatening complications with high mortality rates of 20-50%. Although complications of SCH can be prevented by surgical therapy, there is a lack of consensus concerning the optimal surgical technique for evacuating SCH.

METHODS

In this retrospective study 85 patients with SCH were divided into four treatment groups: (1) Decompression and Hematoma Evacuation via suboccipital craniectomy and removal of the posterior arch of C1 (DHE). (2) Hematoma Evacuation Only via craniotomy (HEO). (3) External Ventricular Drainage (EVD). (4) Conservative treatment (C). To ascertain the level of consciousness, Glasgow Coma Scale (GCS) was calculated. To evaluate the clinical and neurological outcome, modified Rankin Score, Glasgow Outcome Scale and mortality rate were recorded after 6months.

RESULTS

The mean volume of hematoma was significant larger in the DHE- and HEO-group compared to the EVD- and C-group before treatment. DHE and HEO could significantly reduce the volume comparing pre- and postoperative measurements. Larger preoperative volume was a strong predictor of worse neurological outcome and high mortality. Overall mortality was 25.9%. After subdivision into the treatment groups, a comparison of the DHE- and HEO-groups showed a trend towards lower mortality and better neurological outcome in the DHE-group. Patients with the worst preoperative GCS scores profited significantly from DHE with respect to regaining consciousness.

CONCLUSIONS

Patients with SCH should receive surgical therapy when hemorrhages are space-occupying and when the patient's neurological condition deteriorates. With regards to surgical technique, and limited by the retrospective design of the study, our results indicate that patients might benefit most from DHE.

Regulation of mRNA following brain ischemia and reperfusion

There is growing appreciation that mRNA regulation plays important roles in disease and injury. mRNA regulation and ribonomics occur in brain ischemia and reperfusion (I/R) following stroke and cardiac arrest and resuscitation. It was recognized over 40 years ago that translation arrest (TA) accompanies brain I/R and is now recognized as part of the intrinsic stress responses triggered in neurons. However, neuron death correlates to a prolonged TA in cells fated to undergo delayed neuronal death (DND). Dysfunction of mRNA regulatory processes in cells fated to DND prevents them from translating stress-induced mRNAs such as heat shock proteins. The morphological and biochemical studies of mRNA regulation in postischemic neurons are discussed in the context of the large variety of molecular damage induced by ischemic injury. Open issues and areas of future investigation are highlighted. A sober look at the molecular complexity of ischemia-induced neuronal injury suggests that a network framework will assist in making sense of this complexity. The ribonomic network sits between the gene network and the various protein and metabolic networks. Thus, targeting the ribonomic network may prove more effective at neuroprotection than targeting specific molecular pathways, for which all efforts have failed to the present time to stop DND in stroke and after cardiac arrest. WIREs RNA 2017, 8:e1415. doi: 10.1002/wrna.1415 For further resources related to this article, please visit the WIREs website.

Neuroprotective properties of the PrP-like Shadoo glycoprotein assessed in the middle cerebral artery occlusion model of ischemia

Biochemical similarities have been noted between the natively unstructured region of the cellular prion protein, PrP^C, and a GPI-linked glycoprotein called Shadoo (Sho); these proteins are encoded by the Prnp and Sprn genes, respectively. Both proteins are expressed in the adult central nervous system and they share overlapping partners, including each other, in interactome studies. As prior studies have ascribed neuroprotective properties to the N-terminal region of PrP^C, specifically the octarepeat region, we investigated Sho's neuroprotective properties. To this end we assessed Sho-null (Sprn^0/0) and hemizygous (Sprn^0/+) mice in the middle cerebral artery occlusion (MCAO) model versus wild type mice and also vs. transgene-rescued Sprn^0/0-TgSprn mice. Sprn^0/0 mice had a tendency to greater fragility in reaching endpoint and deficits in parameters including infarct volume and neurogenesis, with a reciprocal trend noted in transgene-rescued mice; however these effects did not reach significance. Loss of both PrP^C and Sho immunostaining occurred in parallel to neuronal loss on the ipsilateral side of MCAO-lesioned animals; while focal elevations in immunostaining in the penumbra region were sometimes evident for PrP^C, they were not noted for Sho. Our studies argue against discernible neuroprotective action of Sho in the genetic backgrounds used for this MCAO paradigm. Whether or not the positively charged N-terminal regions in Sho and PrP^C fulfil different roles in vivo remains to be determined.