Cost of stroke in low and middle income countries: a systematic review

Cost Effectiveness of Colorectal Cancer Screening Strategies in Middle- and High-Income Countries: A Systematic Review

BACKGROUND AND AIM

Colorectal cancer (CRC) is a significant global health burden, and screening can greatly reduce CRC incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide the cost-effectiveness of CRC screening strategies across countries with different income levels.

METHODS

We searched relevant scientific databases (PubMed, Embase, Ovid, Web of Science, Scopus) from January 1, 2010, to December 31, 2023. We selected English-language studies related to model-based economic evaluations of CRC screening strategies. Information such as the characters of screening tests, model characteristics, and key cost-effectiveness findings were collected. The net monetary benefit approach was used to compare the outcomes of various strategies.

RESULTS

A total of 56 studies were identified, including 46 from high-income countries (HICs), 6 from upper-middle-income countries (UMICs), and 4 from lower-middle-income countries (LMICs). Most annual fecal occult blood tests and fecal immunochemical tests were cost-saving, and colonoscopy every 10 years was cost-saving. Other strategies involving multitarget fecal FIT-DNA detection, computed tomography colonography, and flexible sigmoidoscopy were cost-effective compared with no screening. Newer strategies such as magnetic resonance colonography every 5 years, annual urine metabolomic tests, and fecal bacterial biomarkers were cost-effective compared with no screening.

CONCLUSION

In our updated review, we found that common CRC screening strategies and magnetic resonance colonography continued to be cost-effective compared with no screening. Areas for further development include accurately modeling the natural history of colorectal cancer and obtaining more evidence from UMICs and LMICs.

Cost evaluation of acute ischemic stroke in Latin America: a multicentric study

Background

Current literature highlights a gap in precise stroke cost data for Latin America. This study measures the real costs associated with acute ischemic stroke care in Latin America using Time-Driven Activity-Based Costing (TDABC). The findings aim to lay a solid foundation for adopting value-based healthcare (VBHC) strategies in the region.

Methods

The study is an observational, multicenter, international analysis of direct costs and outcomes for patients hospitalised with acute ischemic stroke from December 2021 to December 2022. Data from stroke centres in Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, Peru, and Uruguay were analysed. Costs were stratified by country. Factors such as favourable outcomes based on the modified Rankin Scale (mRS 0-2), clinical risk levels, and treatment interventions were considered for the analysis. Generalized Estimating Equation (GEE) models were utilised to assess the relationship of clinical variables with the total cost per patient.

Findings

A total of 1106 patients were included in the study. Among these patients, 74% received medical treatment alone, 18% received intravenous thrombolysis (IVT), 4% underwent mechanical thrombectomy (MT), and 3% received combined IVT plus MT. The mean cost per patient was I$ 12,203 (SD I$ 15,055), with 49% achieving a favourable functional outcome. Compared to medical treatment alone, MT incurred costs 3.1 times higher, with an incremental cost of I$ 20,418 per patient (p < 0.0001). Across all countries, costs increased according to patients' clinical risk and treatment options, with length of hospital stay emerging as the primary cost driver.

Interpretation

Our study highlights significant disparities in stroke costs across healthcare services in Latin America, influenced by variations in treatment accessibility, patient outcomes, and clinical risk profiles. These findings offer essential insights for shaping health policy decisions to enhance the long-term sustainability of stroke care in the region.

Funding

The project received funding from the World Stroke Organization and Boehringer Ingelheim (BI) IS 0135-0352.

Paid Leave to Meet the Health Needs of Aging Family Members in 193 Countries

Women and workers over 50 disproportionately provide care for aging family members worldwide, including the 101 million who are care-dependent. Paid leave for adult health needs, which temporarily replaces employment income for workers providing care, can critically support both caregivers' economic outcomes and care recipients' wellbeing. We created quantitatively comparable data on paid leave policies that can be used to meet adult family members' health needs in all United Nations member states. Globally, 112 countries fail to provide any paid leave that can be used to meet the serious health needs of an aging parent, spouse, or adult child. These gaps have profound consequences for older workers providing care as well as care access by aging, ill, and disabled adults.

Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management

OBJECTIVES

A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke.

DESIGN

A cohort observational study over a 4-year period.

SETTING

Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France).

PARTICIPANTS

We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017.

INTERVENTION

Patients transferred in the PSGU were compared to those admitted in other rehabilitation units.

MEASUREMENTS

The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score).

RESULTS

Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88).

CONCLUSION

The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

Challenges in adapting a stroke unit in a middle-income country: warning about costs and underfunding to achieve the Brazilian Ministry of Health's benchmark

Background

Since the implementation of the stroke care line in Brazil, the relationship (adequacy) of costs spent during hospitalization with the Brazilian Ministry of Health indicators for a stroke unit have not yet been analyzed.

Aims

This study aimed to assess the adequacy of a comprehensive stroke center for key performance indicators and analyze the costs involved in hospitalization. We verified the association between stroke severity at admission and care costs during hospitalization.

Methods

A retrospective medical chart review of 451 patients was performed using semiautomatic electronic data from a single comprehensive stroke center in Brazil between July 2018 and January 2020. Clinical and resource utilization data were collected, and the mean acute treatment cost per person was calculated. The Kruskal-Wallis test with Dunn's post-test was used to compare the total costs between stroke types and reperfusion therapies. A robust linear regression test was used to verify the association between stroke severity at hospital admission and the total hospitalization costs. Good adequacy rates were observed for several indicators.

Results

Data from 451 patients were analyzed. The stroke unit had good adaptation to key performance indicators, but some critical points needed revision and improvement to adapt to the requirements of the Ministry of Health. The average total cost of the patient's stay was the USD 2,637.3, with the daily hospitalization, procedure, operating room, and materials/medication costs equating to USD 2,011.1, USD 220.7, USD 234.1, and USD 98.8, respectively. There was a positive association between the total cost and length of hospital stay (p < 0.001).

Conclusion

The stroke unit complied with most of the main performance indicators proposed by the Brazilian Ministry of Health. Underfunding of the costs involved in the hospitalization of patients was verified, and high costs were associated with the length of stay, stroke severity, and mechanical thrombectomy.

Impact of the Health Gym Program on hospital admissions for stroke in the state of Pernambuco, Brazil

This study aimed to evaluate the impact of the Health Gym Program (HGP) on hospital admissions for stroke in the state of Pernambuco, Brazil. This policy impact evaluation used a quasi-experimental approach consisting of a difference-in-differences estimator, weighted by propensity score matching to deal with potential confounding variables. The study comprised socioeconomic, demographic, and epidemiological data from official Brazilian databases from 2010 to 2019. The treatment group was composed of the 134 municipalities that implemented the HGP since 2011. The 51 municipalities that did not were allocated to the comparison group. The nearest neighbor algorithm (N5) was used to pair treatment and comparison group municipalities and create the weights to evaluate the average treatment effect on the treated (ATT) in the difference-in-differences estimator. In 2010, 2,771 people were hospitalized for stroke (0.51% of all hospitalizations) and in 2019, 11,542 (2%). Municipalities that implemented the HGP had 18.37% fewer hospitalizations than their counterparts in the comparison group. The program's impact in reducing hospitalization rates was incrementally greater among men (ATT: -0.1932) and those aged 71 to 80 years (ATT: -0.1911). All results were statistically significant at the 5% level. The HGP reduced hospitalization for stroke in several population groups, but primarily in those whose underlying prevalence of stroke is highest, reinforcing the importance of public investments in health promotion policies designed to encourage lifestyle changes.

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

Objective

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

Method

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

Result

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

Conclusion

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

Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study

Background: Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Methods: Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. Results: There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966−12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084−0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087−8.148, p = 0.034) were risk factors for pneumonia. Spearman’s correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Conclusions: Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.

Household financial burden associated with healthcare for older people in Viet Nam: a cross-sectional survey

BACKGROUND

Population ageing and the associated increase in the healthcare needs of older people are putting pressure on the healthcare system in Viet Nam. The country prioritizes healthcare for older people and has developed financial protection policies to mitigate financial hardship due to out-of-pocket health expenditures (OOPHEs) borne by their households. This study examines the level and determinants of the financial burden of OOPHE among households with people aged ≥ 60 years in Viet Nam.

METHODS

A cross-sectional household survey was conducted among a sample of 1536 older people living in 1477 households in three provinces representing the North, Central and South regions of Viet Nam during 2019-2020. The financial outcomes were catastrophic health expenditure (CHE), using WHO's definition, and financial distress due to OOPHE. Multivariate binary logistic regression analysis was employed to determine the factors associated with these outcomes.

RESULTS

OOPHE for older household members accounted for 86.3% of total household health expenditure. Of households with older people, 8.6% (127) faced CHE, and 12.2% (181) experienced financial distress due to OOPHE. Households were at a higher risk of incurring financial burdens related to health expenditures if they had fewer household members; included only older people; were in rural or remote, mountainous areas; and had older members with noncommunicable diseases. There was no significant association between health insurance coverage and financial burden. However, when older people sought tertiary care or private care, the possibility of a household facing CHE increased. Regardless of the type and level of care, health service utilization by older people results in a higher likelihood of a household encountering financial distress.

CONCLUSIONS

This study reveals that OOPHE for older people can impose substantial financial burdens on households, leading them to face CHE and financial distress. This study provides evidence to justify reforming financial protection policies and introducing policy interventions targeted at better protecting older people and their households from the financial consequences of OOPHE. There is also the need to strengthen the grassroots health facilities to provide primary care closer to home at lower costs, particularly for the management of noncommunicable diseases.

Stroke-related length of hospitalization trends and in-hospital mortality in Peru

Background

Peru faces challenges to provide adequate care to stroke patients. Length of hospitalization and in-hospital mortality are two well-known indicators of stroke care. We aimed to describe the length of stay (LOS) of stroke in Peru, and to assess in-hospital mortality risk due to stroke, and subtypes.

Methods

This retrospective cohort study used hospitalization registries coding with ICD-10 from 2002 to 2017 (N = 98,605) provided by the Ministry of Health; in-hospital mortality was available for 2016-2017 (N = 6,566). Stroke cases aged ≥35 years were divided into subarachnoid hemorrhage (I60), intracerebral hemorrhage (I61), cerebral infarction (I63), and stroke not specified as hemorrhage or infarction (I64). Data included stroke LOS and in-hospital mortality; socio-demographic and clinical variables. We fitted a region- and hospital level-stratified Weibull proportional hazard model to assess the in-hospital mortality.

Results

The median LOS was 7 days (IQR: 4-13). Hemorrhagic strokes had median LOS longer than ischemic strokes and stroke not specified as hemorrhage or infarction (P = <0.001). The case fatality rate (CFR) of patients with stroke was 11.5% (95% CI [10-12%]). Subarachnoid hemorrhage (HR = 2.45; 95% CI [1.91-3.14]), intracerebral hemorrhage (HR = 1.95; 95% CI [1.55-2.46]), and stroke not specified as hemorrhage or infarction (HR = 1.45; 95% CI [1.16-1.81]) were associated with higher in-hospital mortality risk in comparison to ischemic strokes.

Discussion

Between 2002 and 2017, LOS due to stroke has not changed in Peru in stroke patients discharged alive. Hemorrhagic cases had the longest LOS and highest in-hospital mortality risk during 2016 and 2017. The findings of our study seem to be consistent with a previous study carried out in Peru and similar to that of HIC and LMIC, also there is an increased median LOS in stroke cases managed in specialized centers. Likewise, LOS seems to depend on the type of stroke, where ischemic stroke cases have the lowest LOS. Peru needs to improve access to stroke care.

The World Stroke Academy: A World Stroke Organization global pathway to improve knowledge in stroke care

BACKGROUND

The World Stroke Academy (WSA) (www.world-stroke-academy.org) is the educational platform of the World Stroke Organization (WSO). It facilitates educational activities (e.g. webinars and eLearning modules) and supports the WSO mission by providing high-quality stroke education to healthcare professionals. It provides evidence-based educational materials in a variety of formats to meet the needs of the WSO membership.

AIM

This article introduces the WSA, its core activities, and outlines how to access the many educational resources it offers.

RESULTS

The WSA offers high-quality peer reviewed stroke education material and uses outcome metrics to assess and improve the quality of medical training of healthcare professionals. This article also highlights the importance of identifying knowledge and knowledge-to-action gaps through the creation of special projects and initiatives. It describes three areas in which the WSA has carried out recent educational initiatives, namely: life after stroke, women in stroke, and stroke checklist/pre-printed stroke orders.

CONCLUSION

WSA material is freely available, and we would encourage the global stroke community to use, and contribute to, its resources.

Accuracy and Validity of a Single Inertial Measurement Unit-Based System to Determine Upper Limb Kinematics for Medically Underserved Populations

Stroke is one of the leading causes of death and disability worldwide, with a disproportionate burden represented by low- and middle-income countries (LMICs). To improve post-stroke outcomes in LMICs, researchers have sought to leverage emerging technologies that overcome traditional barriers associated with stroke management. One such technology, inertial measurement units (IMUs), exhibit great potential as a low-cost, portable means to evaluate and monitor patient progress during decentralized rehabilitation protocols. As such, the aim of the present study was to determine the ability of a low-cost single IMU sensor-based wearable system (named the T’ena sensor) to reliably and accurately assess movement quality and efficiency in physically and neurologically healthy adults. Upper limb movement kinematics measured by the T’ena sensor were compared to the gold standard reference system during three functional tasks, and root mean square errors, Pearson’s correlation coefficients, intraclass correlation coefficients, and the Bland Altman method were used to compare kinematic variables of interest between the two systems for absolute accuracy and equivalency. The T’ena sensor and the gold standard reference system were significantly correlated for all tasks and measures (r range = 0.648—0.947), although less so for the Finger to Nose task (r range = 0.648—0.894). Results demonstrate that single IMU systems are a valid, reliable, and objective method by which to measure movement kinematics during functional tasks. Context-appropriate enabling technologies specifically designed to address barriers to quality health services in LMICs can accelerate progress towards the United Nations Sustainable Development Goal 3.

Stroke epidemiology in southern Brazil: Investigating the relationship between stroke severity, hospitalization costs, and health-related quality of life

We aimed with the present study to fill the gap on the performance and safety of stroke management and the costs related to hospitalizations, the relevant comorbidities associated with stroke patients, and the stroke patient outcomes health-related quality of life (HRQOL) progress. Our study investigated the clinical, neurological, and social impact of stroke in 220 patients in a tertiary hospital located in the countryside of the state of Santa Catarina, Brazil. Description of clinical and neurological characteristics of stroke patients between 2015 to 2020 was analyzed using electronic medical records. The most affected age group was 61-80 years, being female the most affected sex. Almost 89.5% of the patients had some risk factor, with a higher prevalence of ischemic stroke. This type of stroke was the expensive, in terms of hospitalization, with an average cost of $74.10. Considering the stroke-specific quality of life scale (SSQOL) score, 88.3% of patients who demonstrated some comorbidity and 47.6% of women had lower quality of life levels post-stroke. Our data could be useful to substantiate a data-base with epidemiology statistics characterization of stroke hospitalizations, indicating the severity of stroke for the patient.

Younger age of stroke in low-middle income countries is related to healthcare access and quality

Stroke is the second leading cause of mortality globally with higher burden and younger age in low‐middle income countries (LMICs) than high‐income countries (HICs). However, it is unclear to what extent differences in healthcare access and quality (HAQ) and prevalence of risk factors between LMICs and HICs contribute to younger age of stroke in LMICs. In this systematic review, we conducted meta‐analysis of 67 articles and compared the mean age of stroke between LMICs and HICs, before and after adjusting for HAQ index. We also compared the prevalence of main stroke risk factors between HICs and LMICs. The unadjusted mean age of stroke in LMICs was significantly lower than HICs (63.1 vs. 68.6), regardless of gender (63.9 vs. 66.6 among men, and 65.6 vs. 70.7 among women) and whether data were collected in population‐ (64.7 vs. 69.5) or hospital‐based (62.6 vs. 65.9) studies (all p < 0.01). However, after adjusting for HAQ index, the difference in the mean age of stroke between LMICs and HICs was not significant (p ≥ 0.10), except among women (p = 0.048). In addition, while the median prevalence of hypertension in LMICs was 23.4% higher than HICs, the prevalence of all other risk factors was lower in LMICs than HICs. Our findings suggest a much larger contribution of HAQ to the younger mean age of stroke in LMICs, as compared with other potential factors. Additional studies on stroke care quality and accessibility are needed in LMICs.

Geographical Disparities in Pooled Stroke Incidence and Case Fatality in Mainland China, Hong Kong, and Macao: Protocol for a Systematic Review and Meta-analysis

Background

Geographical variations in stroke incidence and case fatality in China have been reported. Nonetheless, pooled estimates in major Chinese regions are unknown.

Objective

This systematic review and meta-analysis aims to investigate pooled estimates of incidence and short-term case fatality of stroke in Mainland China, Hong Kong, and Macao.

Methods

Longitudinal studies published in English and indexed in PubMed/MEDLINE, Embase, CINAHL, and Web of Science, or in Chinese and indexed in SinoMed and CQVIP will be targeted. Articles reporting on adults living in China who experience first-ever stroke or die within 1 year from newly onset stroke will be included. The 95% confidence intervals of the event will be estimated using the exact method based on the Poisson distribution. The log incidence rates together with their corresponding log standard errors will be meta-analyzed using DerSimonian and Laird random effects models. Pooled case fatality rates will also be estimated using a random effect model. Time trends in pooled age-standardized stroke incidence and case fatality will be estimated. The heterogeneity of the included studies will be measured using the I² statistic and meta-regressions will be run to analyze the effect of reported covariates on found heterogeneity. Risk of bias will be examined using the Newcastle-Ottawa Scale. Publication bias will be tested using funnel plots and Egger tests. Sensitivity analysis will be run by risk of bias.

Results

This study was funded and registered in 2020. The systematic searches, study selections, and quality assessments were completed in July 2021. Data extraction and analysis and manuscript writing are scheduled to be completed by December 2021.

Conclusions

This will be the first study to provide regional differences in pooled estimates of stroke incidence with case fatality in Mainland China, Hong Kong, and Macao. This study will assist in addressing inequalities in stroke care across China.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020170724; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170724

International Registered Report Identifier (IRRID)

PRR1-10.2196/32566

Radioimaging and Demographic Profiles of Patients with Spontaneous Intracerebral Hemorrhage: A Need for the Pragmatic Referral System

Referring patients with severe medical conditions, like brain stroke, from small or rural hospitals to tertiary care centers is often overexploited leading to a kind of defensive medicine. The issue of a patient referral system remains unaddressed in Nepal. In this article, we investigated the legitimacy of referring patients with spontaneous intracranial hemorrhage (ICH) from country peripheral hospitals to the leading tertiary neurological center in Nepal. We found that 81 out of the 130 ICH patients reviewed in the study were referred. We further show that the classifiers to be considered most in the decision-making on the patient referral are as follows: hematoma volume, midline shift found in radioimaging, ventricular extension of bleeding, and appearance of hydrocephalus. An improper referral of the patient to the tertiary care center decreases limited resources of healthcare services in low-income countries. We believe the study reflects a prevailing belief among healthcare professionals that the current referral system could be improved with the inception of the "hub and spoke" model of healthcare. In this model, a network of secondary health institutions, capable of offering limited treatment, would refer ICH patients to an anchor tertiary institution, respecting the proper dichotomization of patients based on the clinical classifiers. We conclude that the use of the "hub and spoke" model, legitimizing the patient referral system, is posed to offer medical benefits for patients hit by a stroke and would be economically viable for both patients and healthcare services.

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

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

Economic burden associated with stroke in India: insights from national sample survey 2017-18

Objective: To estimate the out-of-pocket (OOP) expenditure and catastrophic expenditure due to stroke-related hospitalization and determine associated predictors.Methods: Secondary analysis of household-based survey conducted by National Sample Survey Organization from June 2017 to 2018.Results: A total of 1152 and 407 individuals reported stroke-related hospitalization and outpatient care, respectively, in the survey. Stroke-related hospitalization rate in India is 46 per 100,000 persons. The mean and median expenditure per episode of stroke-related hospitalization was INR 40,360 (US$ 539.75) and INR 17,140 (US$ 229.22), respectively, with significant OOP hospitalization expenditure across wealth quintiles (p < 0.001). About 29% (25-34%) of households seeking stroke treatment in public medical institutions experienced catastrophic expenditure. 37% (34-40%) of households resorted to distress health financing due to stroke-related hospitalization. Medicines accounted on an average 38% and 73% of public sector hospitalization and outpatient care, respectively. Patients treated in a private facility, hospitalized for over 7 days, within the poorest wealth quintiles had higher odds of incurring catastrophic expenditure.Conclusion: Economic burden associated with stroke-related hospitalization is substantial in India. The publicly funded health insurance scheme should cover expenses on stroke-related medicines to reduce OOP expenditure of patients seeking treatment in public sector facilities.

Economic Burden of Acute Stroke Care in Beneficiaries and Non-Beneficiaries under Social Security Schemes at Tertiary Care Hospitals of Western Rajasthan

Objective

A cost of illness study was conducted with aims to asses various cost of acute stroke care and its determinants among beneficiary (patients enrolled in any social security scheme) and non beneficiary (patients not enrolled in any social security scheme) of various social security schemes.

Method

A cross-sectional study was conducted at government hospitals in western Rajasthan from March to May 2019. All consecutive stroke patients were enrolled during study period. Data related to socio-demographic, disease-related and cost-related data was collected by direct patient and main caregiver's interview. Primary study outcome was description of direct and indirect cost of acute stroke care among beneficiary and non beneficiary patients. Secondary outcome was description of determinants of cost or significant cost-driven variables.

Results

Total of 126 stroke patients were enrolled in 3 months. Mean age was 57.67 ± 15.0 and male: female ratio was 82:44. Both beneficiary and non-beneficiary patients were similar in baseline characteristic except monthly income (P < 0.01) Mean hospital stay was 6.52 ± 2.23 Total out of pocket direct cost among beneficiary was INR 12727.21 [95% C.I. 8658.50, 16795.92] and among non beneficiary was INR 23649.68 [95%C.I. 18591.37, 28707.99]. There was significant difference indirect cost of beneficiary and non-beneficiary patients (P < 0.01). Mean Indirect cost (wages loss) among beneficiary was INR 12414.75 [95% C.I. 9691.13, 15138.37] and among non-beneficiary was INR 16460 [95% C.I. 13044.81, 19875.19]. There was no significant difference in Indirect cost of beneficiary and non-beneficiary patients (P = 0.06). Monthly income, stroke severity (modified Rankin score) and hospital stay were significant direct cost determinants.

Conclusion

Public health insurance scheme reduces direct cost of acute stroke care significantly. Severity of stroke and prolonged hospital stay were main cost-driven variables.

The benefits of action to reduce household air pollution (BAR-HAP) model: A new decision support tool

Cooking with polluting and inefficient fuels and technologies is responsible for a large set of global harms, ranging from health and time losses among the billions of people who are energy poor, to environmental degradation at a regional and global scale. This paper presents a new decision-support model–the BAR-HAP Tool–that is aimed at guiding planning of policy interventions to accelerate transitions towards cleaner cooking fuels and technologies. The conceptual model behind BAR-HAP lies in a framework of costs and benefits that is holistic and comprehensive, allows consideration of multiple policy interventions (subsidies, financing, bans, and behavior change communication), and realistically accounts for partial adoption and use of improved cooking technology. It incorporates evidence from recent efforts to characterize the relevant set of parameters that determine those costs and benefits, including those related to intervention effectiveness. Practical aspects of the tool were modified based on feedback from a pilot testing workshop with multisectoral users in Nepal. To demonstrate the functionality of the BAR-HAP tool, we present illustrative calculations related to several cooking transitions in the context of Nepal. In accounting for the multifaceted nature of the issue of household air pollution, the BAR-HAP model is expected to facilitate cross-sector dialogue and problem-solving to address this major health, environment and development challenge.

Cost Assessment of Inpatient Care Episodes of Stroke in Romania

Introduction: Stroke is the second leading cause of death worldwide and Romania is no exception. There is a high economic burden associated with the treatment of stroke patients, which puts pressure on the healthcare budget. This study aims to measure the inpatient treatment costs of stroke patients in Romania. Methods: Our retrospective analysis follows stroke patients in six Romanian hospitals at different progressivity level from different regions. Patients are identified from the official hospital databases, reported for reimbursement purposes. Mean inpatient costs incurred with the treatment of these stroke patient episodes are calculated using the gross costing method. The cost data are derived from the management control system of the study hospitals. Results: 3,155 patient episodes of stroke were identified in the study hospitals. The average cost per stroke inpatient care episode sums up to EUR 995.57 (95% CI: EUR 963.74-EUR 1 027.39) in 2017, while the overall yearly healthcare burden adds up to EUR 140 million, representing 2.18% of the total national health insurance budget and a cost of EUR 7.15 per capita. Conclusion: The hospital cost of stroke inpatient care episode in Romania is high and it represents a sizable part of the healthcare budget, but it is among the lowest in Europe, which can mainly be explained by the level of economic development of the country. As both the number of patients and the cost of acute care are expected to increase in the future, the economic burden of stroke is also expected to increase.

Factors Associated With Length of Stay for Patients With Stroke in Malaysia

Introduction

Globally, stroke continues to become a significant public health issue contributing to one of the significant causes of morbidity and mortality. The study aimed to describe the characteristics of patients with stroke who were admitted to a teaching hospital in Malaysia and to determine the factors associated with length of stay (LOS).

Methods

This is a single-center, cross-sectional study using in-patient data maintained by the Case-Mix Unit of a teaching hospital in Malaysia from 2016 to 2017. The study included all patients with International Classification of Disease (ICD) code 164 (stroke, not specified as hemorrhage or infarct). The significance of association was determined using nonparametric tests in the form of the Mann-Whitney U test and the Kruskal-Wallis test.

Results

A total of 162 stroke patients from 2016 to 2017 from Case-Mix database were included in the study. The age ranged from 31 to 97 years old. The minimum and maximum LOS for patients with stroke ranged from 1 to 17 days. The severity of illness was found to be significantly associated with longer LOS (p < 0.001); however, age, sex, and presence of co-morbidities did not show any significant association.

Conclusion

Despite its limitations, this study is an essential first step to examine the characteristics of patients with stroke and to determine the factors associated with LOS.

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.

A Systematic Review of Direct Cardiovascular Event Costs: An International Perspective

INTRODUCTION

There is a lack of comprehensive cost information for cardiovascular events since 2013.

OBJECTIVE

A systematic review on the contemporary cost of cardiovascular events was therefore undertaken.

METHODS

Methods complied with those recommended by the Cochrane Collaboration and the Centre for Reviews and Dissemination. Studies were unrestricted by language, were from 2013 to 23 December 2017, and included cost-of-illness data in adults with the following cardiovascular conditions: myocardial infarction (MI), stroke, transient ischaemic attack (TIA), heart failure (HF), unstable angina (UA), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), or peripheral artery disease (PAD). Seven electronic databases were searched, namely Embase (Ovid), MEDLINE (Ovid), MEDLINE In-Process Citations and Daily Update (Ovid), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) database, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. The included studies reported data from a variety of years (sometimes prior to 2013), so costs were inflated and converted to $US, year 2018 values, for standardization.

RESULTS

After de-duplication, 29,945 titles and abstracts and then 403 full papers were screened; 82 studies (88 papers) were extracted. Year 1 average cost ranges were as follows: MI ($11,970 in Sweden to $61,864 in the USA), stroke ($10,162 in Spain to $46,162 in the USA), TIA ($6049 in Sweden to $25,306 in the USA), HF ($4456 in China to $49,427 in the USA), UA ($11,237 in Sweden to $31,860 in the USA), PCI ($17,923 in Italy to $45,533 in the USA), CABG ($17,972 in the UK to $76,279 in the USA). One Swedish study reported PAD costs in a format convertible to $US, 2018 values, with a mean annual cost of $15,565.

CONCLUSIONS

There was considerable unexplained variation in contemporary costs for all major cardiovascular events. One emerging theme was that average costs in the USA were considerably higher than anywhere else.

Impact of Evidence-Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study

Background

The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence‐based processes of care for acute ischemic stroke (AIS) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke.

Methods and Results

Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0–2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or “defect‐free” care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18–1.65) and better survival (odds ratio, 2.23; 95% CI, 1.62–3.09). Defect‐free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0–1) (odds ratio, 1.22; 95% CI, 1.04–1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates.

Conclusions

Use of evidence‐based care is associated with improved clinical outcome in AIS. Strategies are required to address regional variation in the use of proven AIS treatments.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02162017.

Effects of Real-Time (Sonification) and Rhythmic Auditory Stimuli on Recovering Arm Function Post Stroke: A Systematic Review and Meta-Analysis

Background: External auditory stimuli have been widely used for recovering arm function post-stroke. Rhythmic and real-time auditory stimuli have been reported to enhance motor recovery by facilitating perceptuomotor representation, cross-modal processing, and neural plasticity. However, a consensus as to their influence for recovering arm function post-stroke is still warranted because of high variability noted in research methods. Objective: A systematic review and meta-analysis was carried out to analyze the effects of rhythmic and real-time auditory stimuli on arm recovery post stroke. Method: Systematic identification of published literature was performed according to PRISMA guidelines, from inception until December 2017, on online databases: Web of science, PEDro, EBSCO, MEDLINE, Cochrane, EMBASE, and PROQUEST. Studies were critically appraised using PEDro scale. Results: Of 1,889 records, 23 studies which involved 585 (226 females/359 males) patients met our inclusion criteria. The meta-analysis revealed beneficial effects of training with both types of auditory inputs for Fugl-Meyer assessment (Hedge's g: 0.79), Stroke impact scale (0.95), elbow range of motion (0.37), and reduction in wolf motor function time test (-0.55). Upon further comparison, a beneficial effect of real-time auditory feedback was found over rhythmic auditory cueing for Fugl-meyer assessment (1.3 as compared to 0.6). Moreover, the findings suggest a training dosage of 30 min to 1 h for at least 3-5 sessions per week with either of the auditory stimuli. Conclusion: This review suggests the application of external auditory stimuli for recovering arm functioning post-stroke.

Rehabilitative post-acute care for stroke patients delivered by per-diem payment system in different hospitalization paths: A Taiwan pilot study

Objective

To explore how post-acute care (PAC) for stroke patients delivered by per-diem payment system in varying hospitalization paths affects medical care utilization and functional status.

Design, setting and patients

A longitudinal prospective cohort study of 181 acute stroke patients in a southern Taiwan hospital and patients were separated into two groups: patients transferred from regional hospitals (group 1) and patients referred from medical centers (group 2).

Intervention

The intervention was a hospital based, function oriented, 3- to 12-weeks rehabilitative PAC intervention for patients with cerebrovascular diseases.

Measurements

Barthal Index, Functional Oral Intake Scale, Instrumental Activities of Daily Living Scale, EuroQoL Quality of Life Scale, and Berg Balance Scale.

Results

The average duration between day of stroke onset and day of admission to PAC ward was significantly (P < 0.001) shorter in group 1 (9.88 days) compared to group 2 (17.11 days). The average duration of PAC was also significantly (P < 0.01) shorter in group 1 (25.51 days) compared to group 2 (34.11 days). Finally, the average cost of PAC under per-diem payment was significantly lower (P < 0.01) in group 1 (US$2637) compared to group 2 (US$3450). Functional status significantly (P < 0.05) improved in patients who had received rehabilitative PAC. However, functional status did not significantly differ between the two groups.

Conclusions

The most effective way to reduce the costs of PAC for stroke patients is to minimize the duration of their hospital stay before transfer to rehabilitative PAC. Because it substantially reduces medical costs, rehabilitative PAC should be considered standard care for stroke patients.

Distribution and predictors of hospital charges for haemorrhagic stroke patients in Beijing, China, March 2012 to February 2015: a retrospective study

OBJECTIVES

The purpose of this study is to analyse hospital charges for patients with haemorrhagic stroke in China and investigate potential factors associated with inpatient charges.

METHODS

The study participants were in-hospital patients with a primary diagnosis of haemorrhagic stroke from all the secondary and tertiary hospitals in Beijing during the period from 1 March 2012 to 28 February 2015. Distribution characteristics of detailed hospital charges were analysed. The influence of potential factors on hospital charges was researched using a stepwise multiple regression model.

RESULTS

A total of 34 890 patients with haemorrhagic stroke of mean age 61.19±14.37 years were included in the study, of which 37.2% were female. Median length of hospital stay (LOHS) was 15 days (IQR 9-23) and median hospital cost was 18 577 Chinese yuan (CNY) (IQR 10 442-39 784). The hospital costs for patients in Western medicine hospitals (median 19 651 CNY) were significantly higher (P<0.01) than those in traditional Chinese medicine hospitals (median 14 560 CNY), and were significantly higher (P<0.01) for Level 3 hospitals (median 20 029 CNY) than for Level 2 hospitals (median 16 095 CNY). The proportion of medicine fees and bed fees within total hospital charges showed a decreasing trend during the study period. With stepwise multiple regression, the major factors associated with hospital charges were LOHS, surgery, pulmonary infection, ventilator usage, hospital level, occupation, hyperlipidaemia, hospital type, in-hospital death, sex and age.

CONCLUSION

We conclude that medicines form the largest part of hospital charges but are showing a decreasing trend, and LOHS is strongly associated with patient charges for haemorrhagic stroke in China. This implies that the cost structure is very unreasonable in China and medical technology costs fail to be fully manifested. A reasonable decrease in medicine charges and shortening LOHS may be effective ways to reduce hospital charges.

Xingnao Kaiqiao needling method for acute ischemic stroke: a meta-analysis of safety and efficacy

OBJECTIVE:

To evaluate the effectiveness and safety of the Xingnao Kaiqiao needling method for treating acute ischemic stroke.

DATA SOURCES:

We retrieved relevant randomized controlled trials involving Xingnao Kaiqiao acupuncture for treatment of acute ischemic stroke. The China National Knowledge Infrastructure, Weipu Information Resources System, Wanfang Medical Data System, Chinese Biomedical Literature Database, Cochrane Library, and PubMed were searched from June 2006 to March 2016.

DATA SELECTION:

We analyzed randomized and semi-randomized clinical controlled trials that compared Xingnao Kaiqiao acupuncture with various control treatments, such as conventional drugs or other acupuncture therapies, for treatment of acute ischemic stroke. The quality of articles was evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1), and the study was carried out using Cochrane system assessment methods. RevMan 5.2 was used for the meta-analysis of the included studies.

OUTCOME MEASURES:

The mortality rate, disability rate, activities of daily living (Barthel Index), and clinical efficacy were observed.

RESULTS:

Twelve studies met the inclusion criteria for this review. The meta-analysis showed that between Xingnao Kaiqiao acupuncture and the control treatment, Xingnao Kaiqiao acupuncture reduced the disability rate [risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.27–0.98, z = 2.03, P < 0.05], elevated the activities of daily living (weighted mean difference = 12.23, 95% CI: 3.66–20.08, z = 2.80, P < 0.005), and had greater clinical efficacy (RR = 1.61, 95% CI: 1.23–2.09, z = 3.53, P < 0.0004). However, there was no significant difference in mortality rate (RR = 0.61, 95% CI: 0.15–2.45, z = 0.70, P > 0.05).

CONCLUSION:

The Xingnao Kaiqiao needling method is effective and safe for acute ischemic stroke. However, there was selective bias in this study, and the likelihood of measurement bias is high. Thus, more high-quality randomized controlled trials are needed to provide reliable evidence of the efficacy and safety of Xingnao Kaiqiao acupuncture in the treatment of acute ischemic stroke.

Difference of hospital charges for stroke inpatients between hospitals with different levels and therapeutic modes in Beijing, China

OBJECTIVES

The present study analyzed the hospital charges for stroke patients in China and determined the factors associated with hospital costs.

METHODS

Medical records of hospitalized patients with a primary diagnosis of acute stroke were collected from 121 hospitals in Beijing (2012). Distribution characteristics of hospital charges for different stroke types, hospital levels and types were studied. Factors influencing total hospital charges were analyzed.

RESULTS

60.8% of the 94 906 stroke patients were male and the mean age of these patients was 66.5 ± 13.2 years. The median length of hospital stay (LOHS) for these patients was 14 d (interquartile range, IQR 9-19). The mean hospital charge per patient was 19 270 Chinese Yuan. Forty-five percent of these charges were for medicine, 18% for laboratory and examination, 16% for material, 15% for therapy, 5% for service and 1% for blood product. The mean hospital charge for patients suffering from hemorrhagic stroke was significantly more than ischemic stroke (34 937 vs. 17 049, p < 0.001), and was significantly more for Level 3 than Level 2 hospitals (23 762 vs. 14 554, p < 0.001). LOHS, hospital level and stroke severity were key determinants of the hospital charge.

CONCLUSIONS

Though hospital charges for stroke patients in China were low, it brought a heavy economic burden for the larger stroke population. Medicine accounted for the largest percentage of hospital charges in China. LOHS emerged to be the main predictor of the cost. Decreasing medicine charge and LOHS might be strategies to decrease hospital charges and reduce economic burden of stroke in China.

Regional variation in acute stroke care organisation

BACKGROUND

Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST).

METHODS

HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification.

RESULTS

94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P=0.002) compared to MIC hospitals.

CONCLUSIONS

Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.

The effects of socioeconomic status on stroke risk and outcomes

The latest evidence on socioeconomic status and stroke shows that stroke not only disproportionately affects low-income and middle-income countries, but also socioeconomically deprived populations within high-income countries. These disparities are reflected not only in risk of stroke but also in short-term and long-term outcomes after stroke. Increased average levels of conventional risk factors (eg, hypertension, hyperlipidaemia, excessive alcohol intake, smoking, obesity, and sedentary lifestyle) in populations with low socioeconomic status account for about half of these effects. In many countries, evidence shows that people with lower socioeconomic status are less likely to receive good-quality acute hospital and rehabilitation care than people with higher socioeconomic status. For clinical practice, better implementation of well established treatments, effective management of risk factors, and equity of access to high-quality acute stroke care and rehabilitation will probably reduce inequality substantially. Overcoming barriers and adapting evidence-based interventions to different countries and health-care settings remains a research priority.

Exploring the impact of intravenous thrombolysis on length of stay for acute ischemic stroke: a retrospective cohort study

Background

Understanding the factors that influence the hospital length of stay (LOS) for patients with stroke will help in discharge planning and stroke unit management. We explored how intravenous thrombolysis (IVT) affects LOS in an acute-care hospital setting.

Methods

We analyzed adult patients with ischemic stroke who presented within 48 h of onset from a hospital-based stroke registry. The relationship between IVT and prolonged LOS (LOS ≥ 7 days) was studied by both multivariate logistic regression and the classification and regression tree (CART) analyses.

Results

Among the study population of 3054 patients, 1110 presented within 4.5 h. The median LOS (interquartile range) was 7 (4 to 11) days, and 1619 patients had prolonged LOS. Multivariate logistic regression revealed that IVT (odds ratio, 0.53; 95 % confidence interval 0.38–0.74) was an independent factor that reduced the risk of prolonged LOS, whereas age, National Institutes of Health Stroke Scale (NIHSS) score, diabetes mellitus, and leukocytosis at admission predicted prolonged LOS. CART analysis identified 4 variables (NIHSS score, IVT, leukocytosis at admission, and age) as important factors to partition the patients into six subgroups. The patient subgroup that had an NIHSS score of 5 to 7 and received IVT had the lowest probability (19 %) of prolonged LOS.

Conclusions

IVT reduced the risk of prolonged LOS in patients with acute ischemic stroke. Measures to increase the rate of IVT are encouraged.

Cost and cost-effectiveness analysis of a bundled intervention to enhance outcomes after stroke in Nigeria: Rationale and design

The economic and social costs of stroke to the society can be enormous. These costs can cause serious economic damage to both the individual and the nation. It is thus important to conduct a cost effectiveness analysis to indicate whether an intervention provides high value where its health benefits justify its costs. This study will provide evidence based on the costs of stroke with a view of improving intervention and treatments of stoke survivors in Nigeria. This study utilizes two types of economic evaluation methods - cost-effectiveness analysis and cost-benefit analysis - to determine the economic impact of Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES) intervention. The study is conducted in four Nigerian hospitals where 400 patients are recruited to participate in the study. The cost-effectiveness of THRIVES post-discharge intervention is compared with the control Intervention scenario, which is the usual and customary care delivered at each health facility in terms of cost per quality adjusted life years (QALYs). It is expected that successful implementation of the project would serve as a model of cost-effective quality stroke care for implementation.

Case characteristics, hyperacute treatment, and outcome information from the clinical research center for stroke-fifth division registry in South Korea

Characteristics of stroke cases, acute stroke care, and outcomes after stroke differ according to geographical and cultural background. To provide epidemiological and clinical data on stroke care in South Korea, we analyzed a prospective multicenter clinical stroke registry, the Clinical Research Center for Stroke-Fifth Division (CRCS-5). Patients were 58% male with a mean age of 67.2±12.9 years and median National Institutes of Health Stroke Scale score of 3 [1-8] points. Over the 6 years of operation, temporal trends were documented including increasing utilization of recanalization treatment with shorter onset-to-arrival delay and decremental length of stay. Acute recanalization treatment was performed in 12.7% of cases with endovascular treatment utilized in 36%, but the proportion of endovascular recanalization varied across centers. Door-to-IV alteplase delay had a median of 45 [33-68] min. The rate of symptomatic hemorrhagic transformation (HT) was 7%, and that of any HT was 27% among recanalization-treated cases. Early neurological deterioration occurred in 15% of cases and were associated with longer length of stay and poorer 3-month outcomes. The proportion of mRS scores of 0-1 was 42% on discharge, 50% at 3 months, and 55% at 1 year after the index stroke. Recurrent stroke up to 1 year occurred in 4.5% of patients; the rate was higher among older individuals and those with neurologically severe deficits. The above findings will be compared with other Asian and US registry data in this article.