The future cost of stroke in Ireland: an analysis of the potential impact of demographic change and implementation of evidence-based therapies

Volumetry as a Criterion for Suboccipital Craniectomy after Cerebellar Infarction

Objective: The aim of this study was to investigate the use of image-guided volumetry in cerebellar infarction during the decision-making process for surgery. Particular emphasis was placed on the ratio of the infarction volume to the cerebellar volume or cranial posterior fossa volume. Methods: A retrospective, multicenter, multidisciplinary study design was selected. Statistical methods such as regression analysis and ROC analysis included the volumetric data of the infarction, the posterior fossa and the cerebellum itself as new factors. Results: Thirty-eight patients (mean age 75 (SD: 13.93) years, 16 (42%) female patients) were included. The mean infarction volume was 37.79 (SD: 25.24) cm3. Patients treated surgically had a 2.05-fold larger infarction than those managed without surgery (p ≤ 0.001). Medical and surgical treatment revealed a significant difference in the ratio of the cranial posterior fossa volume to the infarction volume (medical 12.05, SD:9.09; surgical 5.14, SD: 5,65; p ≤ 0.001) and the ratio of the cerebellar volume to the infarction volume (medical 8.55, SD: 5.97; surgical 3.82, SD: 3.39; p ≤ 0.001). Subsequent multivariate regression analysis for surgical therapy showed significant results only for the posterior fossa volume to infarction volume ratio ≤/> 4:1 (OR: 1.162, CI: 1.007-1.341, p = 0.04). Younger (≤60 years) patients also had a significantly better outcome at discharge (p ≤ 0.017). A cut-off value for the infarction volume of 31.35 cm3 (sensitivity = 0.875, specificity = 0.2) was determined for the necessity of surgery. Conclusions: Volumetric data on the infarction, the posterior fossa and the cerebellum itself could be meaningful in decision-making towards surgery.

Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults

OBJECTIVE

There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age).

METHODS

Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III).

RESULTS

56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years).

CONCLUSION

Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.

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.

[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.

Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years

BACKGROUND AND PURPOSE

Prediction of stroke impact provides essential information for healthcare planning and priority setting. We aim to estimate 30-year projections of stroke epidemiology in the European Union using multiple modeling approaches.

METHODS

Data on stroke incidence, prevalence, deaths, and disability-adjusted life years in the European Union between 1990 and 2017 were obtained from the global burden of disease study. Their trends over time were modeled using 3 modeling strategies: linear, Poisson, and exponential regressions-adjusted for the gross domestic product per capita, which reflects the impact of economic development on health status. We used the Akaike information criterion for model selection. The 30-year projections up to 2047 were estimated using the best fitting models, with inputs on population projections from the United Nations and gross domestic product per capita prospects from the World Bank. The technique was applied separately by age-sex-country groups for each stroke measure.

RESULTS

In 2017, there were 1.12 million incident strokes in the European Union, 9.53 million stroke survivors, 0.46 million deaths, and 7.06 million disability-adjusted life years lost because of stroke. By 2047, we estimated an additional 40 000 incident strokes (+3%) and 2.58 million prevalent cases (+27%). Conversely, 80 000 fewer deaths (-17%) and 2.31 million fewer disability-adjusted life years lost (-33%) are projected. The largest increase in the age-adjusted incidence and prevalence rates are expected in Lithuania (average annual percentage change, 0.48% and 0.7% respectively), and the greatest reductions in Portugal (-1.57% and -1.3%). Average annual percentage change in mortality rates will range from -2.86% (Estonia) to -0.08% (Lithuania), and disability-adjusted life years' from -2.77% (Estonia) to -0.23% (Romania).

CONCLUSIONS

The number of people living with stroke is estimated to increase by 27% between 2017 and 2047 in the European Union, mainly because of population ageing and improved survival rates. Variations are expected to persist between countries showing opportunities for improvements in prevention and case management particularly in Eastern Europe.

The Impact of Cognitive Impairment on Poststroke Outcomes: A 5-Year Follow-Up

AIM

To explore the impact of cognitive impairment poststroke on outcomes at 5 years.

METHODS

Five-year follow-up of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) prospective cohort. Two hundred twenty-six ischemic stroke survivors completed Montreal Cognitive Assessments at 6 months poststroke. Outcomes at 5 years included independence in activities of daily living, receipt of informal care, quality of life, and depressive symptoms. Data were analyzed using logistic and linear regression models. Adjusted odds ratios (ORs; 95% confidence interval [CI]) and β coefficients (95% CI) are reported.

RESULTS

One hundred one stroke survivors were followed up at 5 years. Cognitive impairment at 6 months was independently associated with worse quality of life (B [95% CI]: -0.595 [-0.943 to -0.248]), lower levels of independence (B [95% CI]: -3.605 [-5.705 to -1.505]), increased likelihood of receiving informal care (OR [95% CI]: 6.41 [1.50-27.32]), and increased likelihood of depressive symptoms (OR [95% CI]: 4.60 [1.22-17.40]). Conclusion: Cognitive impairment poststroke is associated with a range of worse outcomes. More effective interventions are needed to improve outcomes for this vulnerable group of patients.

First year post-stroke healthcare costs and fall-status among those discharged to the community

INTRODUCTION

Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community.

PATIENTS AND METHODS

Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation.

RESULTS

A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p < 0.01, respectively).

DISCUSSION

The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included.

CONCLUSION

This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.

Economic burden of stroke

Objectives

This study aims to estimate the annual economic cost per hemiplegic patient in Turkey.

Patients and methods

Between September 2014 and December 2014, a total of 84 hemiplegic patients (53 males, 31 females; mean age 61.4±13.5 years; range 28-89 years) with stroke for 12 months were included in the study. Type of cerebrovascular accident and complications were evaluated. Hospital records and data from the relatives of the patients were used to calculate the cost. Annual costs were evaluated starting from first hospitalization. Direct costs were calculated with the sum of hospital care (acute care, diagnostic investigations, treatment and rehabilitation), medications, medical visits, outpatient rehabilitation and orthopedic aids. Indirect costs were calculated by taking the income loss due to absence from work into consideration. Prices of medical resources were obtained from the 2014 Healthcare Implementation Notification payment list.

Results

At the end of the study, the average direct cost and indirect cost per patient were calculated respectively as 10,594.90±6,554.20 Turkish liras and 9,357.10±10,195.60 Turkish liras (4,606.47±2,849.65 USD and 4,068.30±4,432.86 USD). We found a negative correlation between total cost and age (p=0.001), and a positive correlation with duration of hospitalization (p=0.001) and number of complications (p=0.049). We were unable to find any relation of cost with sex and cerebrovascular accident type. Spasticity (p=0.028) and epilepsy (p=0.037) being among the complications were observed to increase the cost.

Conclusion

Stroke is an important economic burden for Turkish population. Preventive social measures are necessary to reduce this cost.

Secondary prevention and cognitive function after stroke: a study protocol for a 5-year follow-up of the ASPIRE-S cohort

INTRODUCTION

Cognitive impairment is common following stroke and can increase disability and levels of dependency of patients, potentially leading to greater burden on carers and the healthcare system. Effective cardiovascular risk factor control through secondary preventive medications may reduce the risk of cognitive decline. However, adherence to medications is often poor and can be adversely affected by cognitive deficits. Suboptimal medication adherence negatively impacts secondary prevention targets, increasing the risk of recurrent stroke and further cognitive decline. The aim of this study is to profile cognitive function and secondary prevention, including adherence to secondary preventive medications and healthcare usage, 5 years post-stroke. The prospective associations between cognition, cardiovascular risk factors, adherence to secondary preventive medications, and rates of recurrent stroke or other cardiovascular events will also be explored.

METHODS AND ANALYSIS

This is a 5-year follow-up of a prospective study of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort of patients with stroke. This cohort will have a detailed assessment of cognitive function, adherence to secondary preventive medications and cardiovascular risk factor control.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted by the Research Ethics Committees at Beaumont Hospital, Dublin and Connolly Hospital, Dublin, Mater Misericordiae University Hospital, Dublin, and the Royal College of Surgeons in Ireland. Findings will be disseminated through presentations and peer-reviewed publications.

Older people remain on blood pressure agents despite being hypotensive resulting in increased mortality and hospital admission

BACKGROUND

the use of antihypertensive medication in older people in order to prevent cardiovascular events is well established. The use of such agents has been encouraged by incentive schemes in the United Kingdom including the Quality and Outcomes Framework. In addition, many guidelines recommend good blood pressure (BP) control in the elderly. However, in older people antihypertensives can cause adverse effects related to hypotension.

AIM

the aim of this study was to assess the prevalence of low BP and impact on outcomes, particularly in the presence of antihypertensive treatment, in a primary care population of older people.

DESIGN

a retrospective observational cohort study in people over the age of 70 years registered with primary care providers in Kent.

RESULTS

a total of 11,167 patients over 70 years old were analysed, 6,373 female (57%). Systolic blood pressure (SBP) was below 120 mmHg in 1,297 people (844 on antihypertensives), below 110 mmHg in 474 (313 on antihypertensives) and below 100 mmHg in 128 (89 on antihypertensives). Hypotension was independently associated with mortality, acute kidney injury and hospital admission.

CONCLUSIONS

the results demonstrate that low SBP is associated with adverse events, it is possible that the pursuit of BP control at a population level may lead to over-treatment in certain groups of patients. This may result in an increased incidence of adverse events particularly in older people.

Direct medical costs of hospitalizations for cardiovascular diseases in Shanghai, China: trends and projections

Few studies in China have focused on direct expenditures for cardiovascular diseases (CVDs), making cost trends for CVDs uncertain. Epidemic modeling and forecasting may be essential for health workers and policy makers to reduce the cost burden of CVDs.To develop a time series model using Box-Jenkins methodology for a 15-year forecasting of CVD hospitalization costs in Shanghai.Daily visits and medical expenditures for CVD hospitalizations between January 1, 2008 and December 31, 2012 were analyzed. Data from 2012 were used for further analyses, including yearly total health expenditures and expenditures per visit for each disease, as well as per-visit-per-year medical costs of each service for CVD hospitalizations. Time series analyses were performed to determine the long-time trend of total direct medical expenditures for CVDs and specific expenditures for each disease, which were used to forecast expenditures until December 31, 2030.From 2008 to 2012, there were increased yearly trends for both hospitalizations (from 250,354 to 322,676) and total costs (from US $ 388.52 to 721.58 million per year in 2014 currency) in Shanghai. Cost per CVD hospitalization in 2012 averaged US $ 2236.29, with the highest being for chronic rheumatic heart diseases (US $ 4710.78). Most direct medical costs were spent on medication. By the end of 2030, the average cost per visit per month for all CVDs was estimated to be US $ 4042.68 (95% CI: US $ 3795.04-4290.31) for all CVDs, and the total health expenditure for CVDs would reach over US $1.12 billion (95% CI: US $ 1.05-1.19 billion) without additional government interventions.Total health expenditures for CVDs in Shanghai are estimated to be higher in the future. These results should be a valuable future resource for both researchers on the economic effects of CVDs and for policy makers.