Cost of stroke in The Netherlands from a societal perspective

Care and Charges for Acute Cerebral Infarction Inpatients in China: A Hospital Based Study in Soochow

Objective

The objective of the present study is to evaluate the current status of care and charges of acute ischaemic stroke in a university teaching hospital in China, and to identify the main determinants of such charges.

Methods

Acute ischaemic stroke patients from July 2009 to June 2010 were considered. We examined demographic data, clinical data, hospital care and outcomes at discharge and hospital charges retrospectively. The influence of medical factors on total charges was analyzed.

Results

The mean initial National Institutes of Health Stroke Scale score of all acute ischaemic stroke patients was 7.2 points. Thirteen percents were total anterior circulation syndrome, 20% were partial anterior circulation syndrome, 7% were posterior circulation syndrome and 60% were lacunar syndrome. The mean hospital length of stay (LOS) was 8.5 days. All patients underwent neuroimaging studies, 2% of whom received thrombolysis, 93% received traditional Chinese medicine injection, 83% received antiplatelet and 6% received anticoagulation therapy, only 29% received in-hospital rehabilitation. The mean hospital charges per patient was ¥9230.2 (US$1357.3), of which 56.2% was attributed to the charges for medications, 13.4% for imaging studies, 12.1% for laboratory examinations. Total hospital charges were correlated strongly with LOS, admission to care unit, and computed tomography angiography or digital subtraction angiography of the brain.

Conclusions

Total hospital charges correlates significantly with hospital LOS, admission to care unit, investigation with computed tomography angiography or digital subtraction angiography of the brain, while clinical syndromes do not influence total charges independently. The cost of drug is the largest portion of the mean hospital charge. A treatment protocol in acute ischaemic stroke might optimise cost. (Hong Kong j.emerg.med. 2011;18:383-390)

Mechanical Intracranial Embolectomy

Cerebral ischaemia due to thrombo-embolic complications of intracranial endovascular therapy remains one of the more obvious hazards of this otherwise rather gentle treatment. In this connection the time factor is usually well controlled and the possibility to achieve a good result from thrombolysis are possibly better7. To directly extract an embolus mechanically would be an attractive alternative.

This has so far been hampered by the lack of suitable tools. The use of a microsnare intended for intravascular retrieval of foreign bodies like displaced coils or broken catheters shown here must further encourage development of specially designed “thrombectomy devices” for intracranial use. Such a tool may well have an impact on the treatment of noniatrogenic emboli as well.

The burden of stroke in the Netherlands: estimating quality of life and costs for 1 year poststroke

OBJECTIVES

To assess and explore over 1 year poststroke (1) the societal costs, (2) changes in costs and quality of life (QoL) and (3) the relation between costs and QoL.

DESIGN

The current study is a burden of disease study focusing on the cost-of-illness (in Euros) and QoL (in utilities) after stroke.

SETTING

Adult patients with stroke were recruited from stroke units in hospitals and followed for 1 year.

PARTICIPANTS

Data were collected from 395 patients with stroke.

MAIN OUTCOME MEASURES

Costs and QoL expressed in utilities.

METHODS

Cost categories were identified through a bottom-up method. The Dutch 3-level 5-dimensional EuroQol (EQ-5D-3L) was used to calculate utilities. Non-parametric bootstrapping was applied to test for statistical differences in costs. Subgroup analyses were performed to identify predictors for costs and QoL. Robustness of results was tested via sensitivity analyses.

RESULTS

The total societal costs for 1 year poststroke were €29 484 (n=352) of which 74% were in the first 6 months. QoL remained stable over time. The discharge location was a significant predictor for cost and QoL; men had a significantly higher QoL than women and younger patients (<65) had significantly more costs than older patients (>65). Ceiling effects appear on all dimension of the EQ-5D-3L. Costs and QoL show a weak correlation (r=-0.29). Sensitivity analyses showed robustness of results.

CONCLUSIONS

We found lower patient costs and higher QoL than expected. This may be explained by the good state of health of our study population and by change in the Dutch healthcare system, which has led to considerable shorter hospitalisation poststroke. Future research must question the use of the EQ-5D-3L in a similar population due to ceiling effects.

TRIAL REGISTRATION NUMBER

NTR3051.

Hospital costs of ischemic stroke and TIA in the Netherlands

OBJECTIVES

There have been no ischemic stroke costing studies since major improvements were implemented in stroke care. We therefore determined hospital resource use and costs of ischemic stroke and TIA in the Netherlands for 2012.

METHODS

We conducted a retrospective cost analysis using individual patient data from a national diagnosis-related group registry. We analyzed 4 subgroups: inpatient ischemic stroke, inpatient TIA, outpatient ischemic stroke, and outpatient TIA. Costs of carotid endarterectomy and costs of an extra follow-up visit were also estimated. Unit costs were based on reference prices from the Dutch Healthcare Insurance Board and tariffs provided by the Dutch Healthcare Authority. Linear regression analysis was used to examine the association between hospital costs and various patient and hospital characteristics.

RESULTS

A total of 35,903 ischemic stroke and 21,653 TIA patients were included. Inpatient costs were €5,328 ($6,845) for ischemic stroke and €2,470 ($3,173) for TIA. Outpatient costs were €495 ($636) for ischemic stroke and €587 ($754) for TIA. Costs of carotid endarterectomy were €6,836 ($8,783). Costs of inpatient days were the largest contributor to hospital costs. Age, hospital type, and region were strongly associated with hospital costs.

CONCLUSIONS

Hospital costs are higher for inpatients and ischemic strokes compared with outpatients and TIAs, with length of stay (LOS) the most important contributor. LOS and hospital costs have substantially declined over the last 10 years, possibly due to improved hospital stroke care and efficient integrated stroke services.

A literature review of indirect costs associated with stroke

BACKGROUND

Stroke is a leading cause of mortality and long-term disability. However, the indirect costs of stroke, such as productivity loss and costs of informal care, have not been well studied. To better understand this, we conducted a literature review of the indirect costs of stroke.

METHODS

A literature search using PubMed, MEDLINE, and EconLit, with the key words stroke, cerebrovascular disease, subarachnoid hemorrhage, intracerebral hemorrhage, cost-of-illness, productivity loss, indirect cost, economic burden, and informal caregiving was conducted. We identified original research articles published during 1990-2012 in English-language peer-reviewed journals. We summarized indirect costs by study type, cost categories, and study settings.

RESULTS

We found 31 original research articles that investigated the indirect cost of stroke. Six of these investigated indirect costs only; the other 25 studies were cost-of-illness studies that included indirect costs as a component. Of the 31 articles, 6 examined indirect costs in the United States, with 2 of these focused solely on indirect costs. Because of diverse methods, kinds of data, and definitions of cost used in the studies, the literature indicated a very wide range internationally in the proportion of the total cost of stroke that is represented by indirect costs (from 3% to 71%).

CONCLUSIONS

Most of the literature indicates that indirect costs account for a significant portion of the economic burden of stroke, and there is a pressing need to develop proper approaches to analyze these costs and to make better use of relevant data sources for such studies or establish new ones.

The effectiveness of problem solving therapy for stroke patients: study protocol for a pragmatic randomized controlled trial

Background

Coping style is one of the determinants of health-related quality of life after stroke. Stroke patients make less use of active problem-oriented coping styles than other brain damaged patients. Coping styles can be influenced by means of intervention. The primary aim of this study is to investigate if Problem Solving Therapy is an effective group intervention for improving coping style and health-related quality of life in stroke patients. The secondary aim is to determine the effect of Problem Solving Therapy on depression, social participation, health care consumption, and to determine the cost-effectiveness of the intervention.

Methods/design

We strive to include 200 stroke patients in the outpatient phase of rehabilitation treatment, using a multicenter pragmatic randomized controlled trial with one year follow-up. Patients in the intervention group will receive Problem Solving Therapy in addition to the standard rehabilitation program. The intervention will be provided in an open group design, with a continuous flow of patients. Primary outcome measures are coping style and health-related quality of life. Secondary outcome measures are depression, social participation, health care consumption, and the cost-effectiveness of the intervention.

Discussion

We designed our study as close to the implementation in practice as possible, using a pragmatic randomized trial and open group design, to represent a realistic estimate of the effectiveness of the intervention. If effective, Problem Solving Therapy is an inexpensive, deliverable and sustainable group intervention for stroke rehabilitation programs.

Trial registration

Nederlands Trial Register, NTR2509

A systematic evaluation of stroke surveillance studies in low- and middle-income countries

OBJECTIVE

Reliable quantification of the burden of stroke in low- and middle-income (LMI) countries is difficult as population-based surveillance reports are scarce and may vary considerably in methodology. We aimed to evaluate all available primary stroke surveillance studies by applying components of a benchmark protocol (WHO STEPwise approach to stroke surveillance) and quantify the reported burden of stroke in LMI settings.

METHODS

Electronic databases Medline, Embase, Scopus, and Web of Knowledge were searched for population-based surveillance studies. Studies conducted in the LMI countries that reported on incident stroke were included. Data were extracted from each study using a prestructured format. Information on epidemiologic measures including crude and age-adjusted incidence rates, person-years, admission rates, case fatality rates, death certification, autopsy rates, measures of disability, and other study-specific information, in line with WHO STEPS stroke protocol, were recorded. Age-adjusted incidence rate data of stroke were combined using random-effects meta-analyses.

RESULTS

We identified 7 studies that reported on burden of stroke in 9 LMI countries, including aggregate information from 1,711,372 participants collected over 5,240,923 person-years. The age-adjusted incidence rates across the LMI countries varied widely, with the burden of total first-ever strokes ranging from 41 to 909 events per 100,000 person-years.

CONCLUSIONS

Systematic evaluation of all available primary surveillance studies, particularly in the context of WHO STEPS guidelines, indicates inadequate adherence to standardized surveillance methodology in LMI countries. Incorporation of standardized approaches is essential to enhance generalizability and estimate stroke burden accurately in these resource-poor settings.

Social and economic costs and health-related quality of life in stroke survivors in the Canary Islands, Spain

BACKGROUND

Cost-of-illness analysis is the main method of providing an overall vision of the economic impact of a disease. Such studies have been used to set priorities for healthcare policies and inform resource allocation. The aim of this study was to determine the economic burden and health-related quality of life (HRQOL) in the first, second and third years after surviving a stroke in the Canary Islands, Spain.

METHODS

Cross-sectional, retrospective study of 448 patients with stroke based on ICD 9 discharge codes, who received outpatient care at five hospitals. The study was approved by the Research Ethics Committee of Nuestra Señora de la Candelaria University Hospital. Data on demographic characteristics, health resource utilization, informal care, labor productivity losses and HRQOL were collected from the hospital admissions databases and questionnaires completed by stroke patients or their caregivers. Labor productivity losses were calculated from physical units and converted into monetary units with a human capital-based method. HRQOL was measured with the EuroQol EQ-5D questionnaire. Healthcare costs, productivity losses and informal care costs were analyzed with log-normal, probit and ordered probit multivariate models.

RESULTS

The average cost for each stroke survivor was €17 618 in the first, €14 453 in the second and €12 924 in the third year after the stroke; the reference year for unit prices was 2004. The largest expenditures in the first year were informal care and hospitalizations; in the second and third years the main costs were for informal care, productivity losses and medication. Mean EQ-5D index scores for stroke survivors were 0.50 for the first, 0.47 for the second and 0.46 for the third year, and mean EQ-5D visual analog scale scores were 56, 52 and 55, respectively.

CONCLUSIONS

The main strengths of this study lie in our bottom-up-approach to costing, and in the evaluation of stroke survivors from a broad perspective (societal costs) in the first, second and third years after surviving the stroke. This type of analysis is rare in the Spanish context. We conclude that stroke incurs considerable societal costs among survivors to three years and there is substantial deterioration in HRQOL.

Resource utilization and outcome at a university versus a community teaching hospital in tPA treated stroke patients: a retrospective cohort study

Background

Comparing patterns of resource utilization between hospitals is often complicated by biases in community and patient populations. Stroke patients treated with tissue plasminogen activator (tPA) provide a particularly homogenous population for comparison because of strict eligibility criteria for treatment. We tested whether resource utilization would be similar in this homogenous population between two hospitals located in a single Midwestern US community by comparing use of diagnostic testing and associated outcomes following treatment with t-PA.

Methods

Medical records from 206 consecutive intravenous t-PA-treated stroke patients from two teaching hospitals (one university, one community-based) were reviewed. Patient demographics, clinical characteristics and outcome were analyzed, as were the frequency of use of CT, MRI, MRA, echocardiography, angiography, and EEG.

Results

Seventy-nine and 127 stroke patients received t-PA at the university and community hospitals, respectively. The two patient populations were demographically similar. There were no differences in stroke severity. All outcomes were similar at both hospitals. Utilization of CT scans, and non-invasive carotid and cardiac imaging studies were similar at both hospitals; however, brain MR, TEE, and catheter angiography were used more frequently at the university hospital. EEG was obtained more often at the community hospital.

Conclusions

Utilization of advanced brain imaging and invasive diagnostic testing was greater at the university hospital, but was not associated with improved clinical outcomes. This could not be explained on the basis of stroke severity or patient characteristics. This variation of practice suggests substantial opportunities exist to reduce costs and improve efficiency of diagnostic resource use as well as reduce patient exposure to risk from diagnostic procedures.

[Socioeconomic costs of stroke in Korea: estimated from the Korea national health insurance claims database]

OBJECTIVES

To estimate the annual socioeconomic costs of stroke in Korea in 2005 from a societal perspective.

METHODS

We identified those 20 years or older who had at least one national health insurance (NHI) claims record with a primary or a secondary diagnosis of stroke (ICD-10 codes: I60-I69, G45) in 2005. Direct medical costs of the stroke were measured from the NHI claims records. Direct non-medical costs were estimated as transportation costs incurred when visiting the hospitals. Indirect costs were defined as patients' and caregivers' productivity loss associated with office visits or hospitalization. Also, the costs of productivity loss due to premature death from stroke were calculated.

RESULTS

A total of 882,143 stroke patients were identified with prevalence for treatment of stroke at 2.44%. The total cost for the treatment of stroke in the nation was estimated to be 3,737 billion Korean won (KRW) which included direct costs at 1,130 billion KRW and indirect costs at 2,606 billion KRW. The per-capita cost of stroke was 3 million KRW for men and 2 million KRW for women. The total national spending for hemorrhagic and ischemic stroke was 1,323 billion KRW and 1,553 billion KRW, respectively, which together consisted of 77.0% of the total cost for stroke. Costs per patient for hemorrhagic and ischemic stroke were estimated at 6 million KRW and 2 million KRW, respectively.

CONCLUSIONS

Stroke is a leading public health problem in Korea in terms of the economic burden. The indirect costs were identified as the largest component of the overall cost.

Process skill rather than motor skill seems to be a predictor of costs for rehabilitation after a stroke in working age; a longitudinal study with a 1 year follow up post discharge

BACKGROUND

In recent years a number of costs of stroke studies have been conducted based on incidence or prevalence and estimating costs at a given time. As there still is a need for a deeper understanding of factors influencing these costs the aim of this study was to calculate the direct and indirect costs in a younger (<65) sample of stroke patients and to explore factors affecting the costs.

METHODS

Fifty-eight patients included in a study of home rehabilitation and followed for 1 year after discharge from the rehabilitation unit, were interviewed about their use of health care services, assistance, medications and assistive devices. Costs (defined as the cost for society) were calculated. A linear regression of cost and variables of functioning, ability, community integration and health-related quality of life was done.

RESULTS

Inpatient care contributed substantially to the direct cost with a mean length of stay of 92 days. Rehabilitation during the first year constituted of an average of 28 days in day clinics, 38 physiotherapy sessions and 20 occupational therapy sessions. The total direct mean cost was 80 020 euro and the indirect cost 35 129 euro. The direct costs were influenced by the process skill (the ability to plan and perform a given task and to adapt when needed) and presence of aphasia. Indirect costs for informal care giving increased for patients with a lower health-related quality of life as well as a low score on home integration.

CONCLUSION

Costs are high in this group of young (< 65 years) stroke patients compared to other studies, partly due to the length of the stay and partly to loss of productivity.

The Orpington Prognostic Scale within the first 48 hours of admission as a predictor of outcome in ischemic stroke

This study investigates the prognostic ability of the Orpington Prognostic Scale within 48 hours (OPS-1) after admission in predicting outcome at 6 months and 2 years in acute ischemic stroke and compares it with the 2 week OPS (OPS-2). All consecutive ischemic stroke patients (n = 117) were scored on the OPS, Barthel activities of daily living, Oxford handicap scale, European stroke scale, and Rivermead motor assessment at 48 hours, 2 weeks, 6 months, and 2 years post-stroke. Baseline OPS scores at 48 hours and 2 weeks were used to predict outcomes at 6 months and 2 years. The OPS-1 was an excellent predictor of length of hospital stay (P < .001), place of discharge (P < .01), and outcome at 6 months and 2 years (P < .0001, Fisher's exact). The OPS-2 was marginally better than the OPS-1 though this benefit was outweighed by the earlier stratification of the 48-hour measure. The sensitivity, specificity, and positive predictive values (PPV) of the "good" OPS-1 versus the OPS-2 at predicting independence at 6 months were 85% vs 92%, 85% vs 63% and 87% vs 92%, respectively. The sensitivity, specificity, and PPV of the "poor" OPS-1 versus OPS-2 were 48% v 35%, 97% v 100%, and 93% v 100% respectively. The OPS at 48 hours is a good predictor of outcome at 6 months and 2 years after ischemic stroke and allows early identification of 3 prognostic groups, which may help in identifying patients most likely to benefit from intensive rehabilitation.

An economic assessment of losartan-based versus atenolol-based therapy in patients with hypertension and left-ventricular hypertrophy: results from the Losartan Intervention For Endpoint reduction (LIFE) study adapted to The Netherlands

BACKGROUND

The Losartan Intervention For Endpoint reduction (LIFE) study was a randomized, doubleblind trial that compared the effects of losartan-based treatment with those of atenolol-based treatment on cardiovascular disease (CVD)-related morbidity and mortality in 9193 patients with hypertension and left-ventricular hypertrophy (LVH). Compared with atenolol, losartan reduced the combined risk for CVD-related morbidity and mortality by 13% (P = 0.021), and reduced the risk for stroke by 25% (P = 0.001), with comparable blood pressure control in both trial arms.

OBJECTIVE

The aim of this study was to analyze the cost-effectiveness of losartan compared with atenolol in the treatment of stroke from the Dutch health care perspective.

METHODS

Utilization of losartan and atenolol within the trial period (mean, 4.8 years) and an estimation of direct medical costs of stroke for The Netherlands were combined with estimates of reduction in life expectancy through stroke. Medication costs and stroke incidence during 5.5 years of patient follow-up were estimated separately, adjusted for the baseline degree of LVH and Framingham risk score. To estimate lifetime stroke costs, the cumulative incidence of stroke was multiplied by the lifetime direct medical costs attributable to stroke. All costs are in 2006 Dutch prices and discounted following the former (4% costs and effects) and new Dutch guideline (4% costs, 1.5% effects) for conducting pharmacoeconomic analyses.

RESULTS

With 4% discounting, prevention of stroke was associated with a gain of 3.7 life-years. As a consequence, losartan treatment was associated with 0.059 life-year gained (LYG) per patient treated with losartan. Losartan reduced stroke-related costs by 1,076 Euros (US $1,349) per patient. After inclusion of study medication cost, net cost per patient was 51 Euros ($64) higher for losartan than atenolol. The net cost per LYG was 864 Euros ($1083), which is below the Dutch pharmacoeconomic threshold of 20,000 Euros/LYG (~$25,000/LYG) for accepting interventions. The corresponding probability of a cost-effectiveness ratio below this Dutch threshold was 0.95. Discounting money and health following the new Dutch guideline resulted in an even more favorable cost-effectiveness for losartan.

CONCLUSIONS

Results from the present analysis suggest that, in The Netherlands, treatment with losartan compared with atenolol may well be a cost-effective intervention based on the reduced risk for stroke observed in the LIFE trial.

Costs of acute stroke care on regular neurological wards: A comparison with stroke unit setting

OBJECTIVES

Stroke unit care has been shown to be beneficial but costly. In an own previous study, the resource utilization of stroke unit care has been evaluated. Since the resource utilization on regular neurological wards is widely unknown, we determined the costs for acute stroke care on regular neurological wards to compare both treatment settings.

METHODS AND PATIENTS

We included 253 consecutive in-patients with the diagnosis of ischemic stroke (IS), intracerebral hemorrhage (ICH) or transient ischemic attack (TIA) treated on regular wards at a German University Department of Neurology, between 1 January and 30 June 1998. The modified Rankin scale (mRS) was used to assess outcome. Costs of stroke care were calculated from the perspective of the healthcare provider (hospital) by using a bottom-up approach. Resource utilization was compared to stroke unit care as determined in a previous study. Prices of 2002 were used (in Euros).

RESULTS

IS was present in 78% (n=196), TIA in 13% (n=34), and ICH in 9% (n=23) of patients. Length of stay was 11.1+/-8.9 (mean+/-S.D., IS), 11.1+/-6.5 (TIA), and 16.9+/-15.5 (ICH) days (p>0.05). Mean costs of stroke care were euro 3060 (US$ 3180) for TIA, euro 3070 (US$ 3200) for IS and euro 5210 (US$ 5430) for ICH (p<0.05, ICH versus IS and TIA). The highest costs were due to non-medical care (46%) and personnel (25%). The mRS improved during hospitalization from 3.0+/-1.6 to 2.2+/-1.8 (p<0.01). Compared to care on regular neurological wards, mean costs per admission with treatment on stroke units increased by 7.0%, mean costs per day by 15.6%.

CONCLUSION

The comparison - considering a potential bias of patient selection - shows that acute stroke unit care is approximately 16% more costly than treatment on regular neurological wards due to higher resource use of personnel and diagnostic procedures. Stroke unit treatment tends to decrease post-acute in-patient care costs.

Cost-of-illness studies : a review of current methods

The number of cost-of-illness (COI) studies has expanded considerably over time. One outcome of this growth is that the reported COI estimates are inconsistent across studies, thereby raising concerns over the validity of the estimates and methods. Several factors have been identified in the literature as reasons for the observed variation in COI estimates. To date, the variation in the methods used to calculate costs has not been examined in great detail even though the variations in methods are a major driver of variation in COI estimates. The objective of this review was to document the variation in the methodologies employed in COI studies and to highlight the benefits and limitations of these methods. The review of COI studies was implemented following a four-step procedure: (i) a structured literature search of MEDLINE, JSTOR and EconLit; (ii) a review of abstracts using pre-defined inclusion and exclusion criteria; (iii) a full-text review using pre-defined inclusion and exclusion criteria; and (iv) classification of articles according to the methods used to calculate costs. This review identified four COI estimation methods (Sum_All Medical, Sum_Diagnosis Specific, Matched Control and Regression) that were used in categorising articles. Also, six components of direct medical costs and five components of indirect/non-medical costs were identified and used in categorising articles.365 full-length articles were reflected in the current review following the structured literature search. The top five cost components were emergency room/inpatient hospital costs, outpatient physician costs, drug costs, productivity losses and laboratory costs. The dominant method, Sum_Diagnosis Specific, was a total costing approach that restricted the summation of medical expenditures to those related to a diagnosis of the disease of interest. There was considerable variation in the methods used within disease subcategories. In several disease subcategories (e.g. asthma, dementia, diabetes mellitus), all four estimation methods were represented, and in other cases (e.g. HIV/AIDS, obesity, stroke, urinary incontinence, schizophrenia), three of the four estimation methods were represented. There was also evidence to suggest that the strengths and weaknesses of each method were considered when applying a method to a specific illness. Comparisons and assessments of COI estimates should consider the method used to estimate costs both as an important source of variation in the reported COI estimates and as a marker of the reliability of the COI estimate.

Valuing patient and caregiver time: a review of the literature

As healthcare expenditures continue to rise, financial pressures have resulted in a desire for countries to shift resources away from traditional areas of spending. The consequent devolution and reform have resulted in increased care being provided and received within homes and communities, and in an increased reliance on unpaid caregivers. Recent empirical work indicates that costs incurred by care recipients and unpaid caregivers, including time and productivity costs, often account for significant proportions of total healthcare expenditures. However, many economic evaluations do not include these costs. Moreover, when indirect costs are assessed, the methods of valuation are inconsistent and frequently controversial. This paper provides an overview and critique of existing valuation methods. Current methods such as the human capital method, friction cost method and the Washington Panel approach are presented and critiqued according to criteria such as potential for inaccuracy, ease of application, and ethical and distributional concerns. The review illustrates the depth to which the methods have been theoretically examined, and highlights a paucity of research on costs that accrue to unpaid caregivers and a lack of research on time lost from unpaid labour and leisure. To ensure accurate and concise reporting of all time costs, it is concluded that a broad conceptual approach for time costing should be developed that draws on and then expands upon theoretical work to date.

Hospital cost of ischemic stroke and intracerebral hemorrhage in Japanese stroke centers

BACKGROUND

In Japan, the healthcare expenditure has increased to 8.0% of the gross domestic products in 2001. Stroke care is costly.

OBJECTIVE

To examine hospital costs and clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) in Japanese stroke centers.

DESIGN

A prospective non-interventional multi-center study.

SETTING

Ten Japanese stroke centers.

STUDY PERIOD

Fourteen months between October 2000 and December 2001.

PATIENTS

Patients were those who were consecutively hospitalized with acute IS or ICH within 72 h of onset, excluding subarachnoid hemorrhage. Stroke was defined as focal neurological deficits lasting more than 24 h and the relevant lesions were to be confirmed by brain CT and/or MRI.

METHODS

We examined demography, in-hospital cares, length of hospital stay, clinical outcomes at discharge, and direct hospital medical costs including physician's fees. The hospital medical cost data were collected from official hospital medical cost charts for reimbursement to the healthcare insurance systems.

RESULTS

There were a total of 1113 patients with a mean age of 70 years, of whom 913 (82%) patients had an IS and 200 (18%) patients had an ICH. The 317 patients (28%) experienced a recurrent stroke. Patients with ICH had the higher baseline stroke severity, resulting in longer hospitalization (39 days for IS and 46 days for ICH; P<0.001), lower independence rate at discharge (55 and 40%; P<0.001), higher mortality rate (5 and 10%; P=0.03), and higher medical costs (US dollar 8662 and US dollar 10,260; P<0.001) than those with IS. Patients with recurrent stroke had significantly older age, higher stroke severity, and lower independence rate at discharge than those with first-ever stroke. The length of stay, in-hospital mortality, and hospital medical costs were similar among first-ever and recurrent strokes. In subtype of IS, patients with cardioembolic stroke had the worst neurological deficits, poorest outcomes, and highest medical costs. The hospital costs had a greatest association with length of stay.

CONCLUSIONS

Stroke care is costly in Japan. ICH is more likely to impose substantial physical and economic burden than IS. Because the cares of both first-ever and recurrent stroke were costly, primary and secondary prevention of stroke is important on the healthcare aspects.

[Socio-economic aspects of stroke management]

BACKGROUND

Stroke is the third leading cause of death and the first leading cause of disability in developed and developing countries. It is one of the most demanding public health problems to be faced in the upcoming years, particularly because of population aging.

STATE OF THE ART

New therapeutic advances in the management of acute stroke have changed our perception of this condition and have had a major impact on healthcare organization and subsequently healthcare expenditures. Care required for the stroke victim is costly in both developing countries and in developed countries. Hemmorhagic events are the most costly, but their prevalence in Western countries is lower than ischemic events. Prevalence of ischemic events is higher in Asian countries. The direct costs of stroke, both for primary and secondary events, constitute the larger part of healthcare expenditures. The mean cost of stroke in France is estimated at 18,000 euros for the first 12 months. Disability accounts for 42 percent of the variable cost of stroke. During the first year, the acute phase accounts for 40 percent of the cost, rehabilitation and mid-term hospitalization for 29 percent, and ambulatory care for 8 percent. After 46 months, the cost of ambulatory care exceeds the cost of the first six months of care during and following the acute phase.

CONCLUSION

Any improvement in the primary or secondary prevention of stroke will lead to a decrease in the incidence and prevalence of stroke, and any therapeutic advance capable of reducing disability will consequently reduce the overall cost of stroke.

Population impact of losartan use on stroke in the European Union (EU): projections from the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study

The Losartan Intervention for Endpoint reduction in hypertension (LIFE) study was designed to compare losartan- vs atenolol-based antihypertensive treatment on cardiovascular morbidity and mortality in a population of 9193 hypertensive patients with left ventricular hypertrophy (LVH). In LIFE, the losartan-based treatment further reduced the primary composite end point (cardiovascular death, myocardial infarction, or stroke) by 13% (risk reduction (RR) 0.87, 95% confidence interval (CI) 0.77-0.98, P=0.021). The further reduction in stroke with losartan (RR 0.75, 95% CI 0.63-0.89, P=0.001) was the major contributing factor to the reduction in the primary end point. Our objective was to project the reduction in stroke observed with a losartan- vs an atenolol-based antihypertensive treatment regimen in the LIFE study to the European Union (EU) population. The number of stroke events averted was estimated by identifying the number of persons in the EU expected to meet the LIFE inclusion criteria, and multiplying this figure by the cumulative incidence risk difference in stroke from LIFE at 5.5 years. The age- and gender-specific prevalence of hypertension, electrocardiographically (ECG)-diagnosed LVH among those with hypertension (inclusion criteria), and heart failure among those with LVH and hypertension (exclusion criteria) were applied to the EU census estimates. We conservatively projected that an estimated 7.8 million individuals aged 55-80 years in the EU are affected by hypertension and ECG-diagnosed LVH. Use of a losartan-based antihypertensive treatment in this population is projected to prevent approximately 125 000 first strokes over a 5.5-year period. A population-wide prevention strategy of using losartan in patients with LVH and hypertension has the potential to have a major public health impact by reducing the morbidity and mortality of stroke in the EU.

Cost of stroke in Sweden: An incidence estimate

Objectives:To estimate the excess cost of stroke in Sweden and the potential costs that could be avoided by preventing first-ever strokes.

Methods:We adopted the incidence approach for estimating the present value of both direct and indirect costs. Data on mortality, stroke recurrence, and inpatient care were estimated from a national register of patient data with a four-year follow-up period. To estimate costs for social services, we used survey data on living conditions before stroke onset and at three and at twenty-four months. Costs for outpatient visits, rehabilitation, drugs, and production losses due to premature death and early retirement were estimated on the basis of both published and nonpublished sources. Lifetime costs were based on life tables adjusted for excess mortality of stroke, and costs in year 4 were extrapolated to subsequent years.

Results:The present value direct cost for an average stroke patient is SEK513,800 (US$56,024 or Euro60,825). The corresponding indirect cost is SEK125,110 (US$13,640 or Euro14,810). Almost 45 percent of the direct costs were attributable to social services. Women had higher costs than men, and costs for survivors increased with age due to social services.

Conclusions:With an incidence of 213 first-ever strokes per 100,000 individuals, the total excess direct and indirect cost of stroke would be SEK12.3 billion (approximately US$1.3 billion or Euro1.5 billion). Hence, there are large potential cost offsets both in the health-care sector and in the social service sector if the incidence of first-ever stroke could be reduced.

Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK

OBJECTIVE

To evaluate the cost of atrial fibrillation (AF) to health and social services in the UK in 1995 and, based on epidemiological trends, to project this estimate to 2000. DESIGN, SETTING, AND MAIN OUTCOME MEASURES: Contemporary estimates of health care activity related to AF were applied to the whole population of the UK on an age and sex specific basis for the year 1995. The activities considered (and costs calculated) were hospital admissions, outpatient consultations, general practice consultations, and drug treatment (including the cost of monitoring anticoagulant treatment). By adjusting for the progressive aging of the British population and related increases in hospital admissions, the cost of AF was also projected to the year 2000.

RESULTS

There were 534 000 people with AF in the UK during 1995. The "direct" cost of health care for these patients was 244 million pounds sterling (approximately 350 million euros) or 0.62% of total National Health Service (NHS) expenditure. Hospitalisations and drug prescriptions accounted for 50% and 20% of this expenditure, respectively. Long term nursing home care after hospital admission cost an additional 46.4 million pounds sterling (approximately 66 million euros). The direct cost of AF rose to 459 million pounds sterling (approximately 655 million euros) in 2000, equivalent to 0.97% of total NHS expenditure based on 1995 figures. Nursing home costs rose to 111 million pounds sterling (approximately 160 million euros).

CONCLUSIONS

AF is an extremely costly public health problem.

‘Out of pocket’ costs to stroke patients during the first year after stroke – results from the North East Melbourne Stroke Incidence Study

Non-reimbursed 'out of pocket' costs to stroke patients have not been included in existing cost of illness studies. We aimed to determine the nature and magnitude of 'out of pocket' costs to stroke patients during the first year after stroke. 'Out of pocket' costs during the first year after stroke were documented for 165 persons registered in a community-based stroke incidence study during 1996/1997. Virtually all cases reported some 'out of pocket' costs. The average cost over 12 months was A$1110. The highest cost items were home modifications, aids and equipment. The most commonly incurred expense was for prescription medications. Total 'out of pocket' costs incurred by first-ever stroke patients in Australia in 1997 were estimated to be A$29 million or 5% of the total cost of stroke. The majority of 'out of pocket' costs relate to post-acute care aimed at minimising disability and handicap rather than to 'acute' healthcare.

Analysis of hospital charges for ischemic stroke in Fukuoka, Japan

OBJECTIVES

Stroke is a heavy economic burden on individuals, society, and health services in Japan, where health expenditures are rising rapidly. The objective of the present study was to examine medical services and demographic factors associated with increased inpatient charges for ischemic stroke in Japan.

SUBJECTS AND METHODS

The study subjects were 316 patients with a principal diagnosis of acute ischemic stroke who were discharged from the National Kyushu Medical Center Hospital from 1 July 1995 through 31 June 1999. Demographic, clinical, and administrative data were retrospectively collected from medical records and the hospital Clinical Financial Information System (CFIS). The influence of social and medical factors on total charges was analyzed using the stepwise multiple regression model.

RESULTS

Among the total subjects, the mean (median) length of hospital stay (LOHS) was 33 (30) days (range, 2-155 days). The mean (median) hospital charge per patient was US dollars 9020 (dollars 7974) with a range of dollars 336-54,509. The distribution of charges was 42% for fundamental, 17% for injection therapies, 13% for radiological test, 11% for other laboratory examinations, 3% for drugs, and 3% for operations. Stepwise multiple regression analysis revealed that LOHS was the key determinant of the hospital charge (partial R2=0.5993, P=0.0001). Operations (P=0.0001) and angiography (P=0.03) were also independent but less contributory determinants of the hospital charge.

CONCLUSIONS

LOHS was strongly, positively associated with inpatient charges for ischemic stroke in Japan. This implies that significant charge reductions are more likely to rely on shortening LOHS, which probably can be achieved by altering reimbursement policies.

The costs of epilepsy in three different populations of patients with epilepsy

The purpose of this study was to estimate the costs of care in three different populations of patients with epilepsy (general practices (GP), University Hospital (UH), and Epilepsy Center (EC)), and to analyse the distribution of costs by type of services for each patient group. A cost diary was developed to obtain prospective information on epilepsy-attributable service use over a period of 3 months. Similar information over the previous 3 months was obtained from a cost questionnaire. In addition, a quality of life inventory (QOLIE-31) was used. Standard cost lists were applied for the valuation of the direct cost items. A sensitivity analysis was performed for certain cost items for which no reliable data were available. One hundred and sixteen patients with established epilepsy were included, and the mean costs per patient per month (in Euros) ranged from 52.08 to 357.63. Patients from GP appeared to have lower direct costs, spent less time in seeking or undergoing a treatment, and reported lower seizure frequencies and less severe seizure types than the patients from the other patient groups. Patients from the EC reported the highest productivity changes and unemployment rates and also had the lowest scores on the QOLIE-31. The cost items anti-epileptic drugs, hospital services, unpaid care, and transportation accounted for the majority of the total direct costs.

Setting priorities for a discharge plan for stroke patients entering nursing home care

OBJECTIVE

To agree priorities for the structure and content of the discharge process for stroke patients entering nursing home care.

DESIGN

A formal priority-setting exercise using the Nominal Group Technique.

PARTICIPANTS

A panel of 12 members of a multidisciplinary team from a hospital and community setting with experience in the management of stroke patients on a daily basis.

RESULTS

Agreement was good and improved during the process (Kendall coefficient of concordance 'W increased from 0.48 to 0.58 for physical care needs, 0.45 to 0.75 for care needs and 0.56 to 0.72 for the discharge process). The priorities for discharge were: 1) Plans need to be co-ordinated by one person 2) Clear written information on medication should be provided 3) Clear written information on nutritional needs should be provided.

CONCLUSION

Agreement was reached by a panel of clinicians on an evidence-based discharge plan for stroke patients entering nursing home care.

Socioeconomic variations in the course of stroke: unequal health outcomes, equal care?

STUDY OBJECTIVE

The aim of this paper is to quantify the socioeconomic gap in long term health outcomes after stroke and related health care utilisation, in order to evaluate whether those in need of care do actually receive appropriate levels of care.

DESIGN

Stroke patients from the lower socioeconomic group were compared with stroke patients from the higher socioeconomic group with respect to sociodemographic and clinical characteristics, health outcomes, and related health care utilisation.

SETTING

Patients were recruited from admissions to 23 randomly selected hospitals in the Netherlands.

PATIENTS

465 patients were included who had had a stroke six months earlier and were followed up three years and five years after stroke.

MAIN RESULTS

The observed odds ratios suggest that patients from the lower socioeconomic group experienced more disabilities up to three years after stroke and more handicaps up to five years after stroke. After adjusting for health care needs there were no significant associations between socioeconomic status and health care utilisation. The observed figures, however, suggest that a lower socioeconomic status tended to increase admission to nursing homes and to decrease receiving care in non-institutional settings.

CONCLUSIONS

Overall, inequalities in long term health outcomes were observed but solid indications for large inequalities in health care utilisation were not found. More investments in coordinated stroke services are needed to alleviate the unfavourable health situation of disadvantaged groups and to ensure that health care services respond appropriately to the health care needs of different socioeconomic groups.

Predicting the cost of hospital stay for stroke patients: the use of diagnosis related groups

In order to provide tailor-made care, governments are considering the implementation of output-pricing based on hospital case-mix measures, such as diagnosis related groups (DRG). The question is whether the current DRG classification system can provide a satisfactory prediction of the variance of costs in stroke patients and if not, in what way other variables may enhance this prediction. In this study, data from 731 stroke patients hospitalized at University Hospital Maastricht during 1996-1998 are used in the cost analysis. The DRG classification for this group uses information--in addition to the DRG classification operation or no operation--on the patient's age combined with discharge status. The results of regression analysis show that using DRGs, the variance explained in the costs amounts to 34%. Adding other variables to the DRGs, the variance explained increases to about 61%. Additional factors highly correlating with inpatient costs are the level of functioning after stroke, comorbidity, complications, and 'days of stay for non-medical reasons'. Costs decreased for stroke patients discharged during the latter part of the years studied, and if stroke patients happened to die during their hospital stay. The results do suggest that future implementation of output-pricing based on the DRG case-mix measures is feasible for stroke patients only if it is enhanced with information on complications and the level of functioning.

Analysis of hospital charges for cerebral infarction stroke inpatients in Beijing, People's Republic of China

OBJECTIVE

Stroke is a heavy economic burden on the individuals, society and health services in China, where health expenditure is rising rapidly. The purpose of the present study is to examine health services and demographic factors associated with inpatient charges for cerebral infarction in China, focusing on hospital charges of insured and uninsured patients.

METHODS

The study subjects were 545 patients with a principal diagnosis of cerebral infarction stroke who were discharged from the China-Japan Friendship Hospital from January 1, 1997 through December 31, 1998. Demographic, clinical and administrative data were retrospectively collected from the medical record and financial database. The influence of social and medical factors on total charges was analyzed with stepwise multiple regression model.

RESULTS

Of 545 subjects, 429 (79%) were the insured patients and 116 (21%) were the uninsured patients. Length of hospital stay (LOHS) for the insured patients (median, 32 days) was significantly longer (P<0.001) than that for the uninsured (median, 23 days). The hospital charges per discharge for the insured was significantly higher (geometric mean, 10407 yuan) (P<0.0001) than that for the uninsured patients (geometric mean, 5857 yuan). With stepwise multiple regression, factors associated independently with the hospital charge were: longer hospital stay, insurance status, increased number of head magnetic resonance imaging (MRI) and computerized tomography (CT), infection in hospital stay, and more severe condition of stroke.

CONCLUSIONS

Inpatient charge for cerebral infarction stroke was positively associated with being the insured. The findings suggest an overuse of health care resources in insured patients and limited use of resources by those who are not.

Long term cost-of-illness in stroke: an international review

An international review of the costs of stroke was conducted to explore data sources, and cost variables as well as to compare estimates of the annual aggregated cost (prevalence-based) and total per patient long-term cost (incidence-based) of care. Dutch, English, French, German, Italian and Spanish literature was searched using the keywords stroke, ischaemic stroke, haemorrhagic stroke, cerebrovascular accident, cerebral infarction, cost(s), economics, and cost analysis. Criteria for study inclusion were: provides estimates of direct and/or indirect costs of stroke, published after 1989, methods described in adequate detail, and for studies of long-term costs, estimates based on a minimum 5 years of care following the event. Cost estimates are presented in original currencies and US dollars. Among studies representing Australia, New Zealand, Western Europe and North America, six prevalence studies reported total annual aggregated costs of US dollars 7,975 (1988 values) to US dollars 54,546 (1993 values) per patient; eight incidence-based studies reported total long-term per patient costs of US dollars 18,538 (1991 values) to US dollars 228,038 (1990 values). Identifiable factors underlying variation included: perspective employed, cost variables considered, and exclusion of comorbidities. Although lack of uniformity hampers inter-study comparisons, it is evident that stroke poses a significant economic burden. Consensus on standard cost variables and methods for projections of resource use and survival over time are clearly warranted.

Economic assessment of the secondary prevention of ischaemic events with lysine acetylsalicylate

OBJECTIVE

To analyse the economic benefits, in comparison with placebo, of the secondary prevention of ischaemic stroke and myocardial infarction (MI) with lysine acetylsalicylate (Kardégic) in patients with a history of ischaemic stroke, MI or stable and unstable angina pectoris.

DESIGN AND SETTING

This was a modelling study from the perspectives of direct medical costs, the social security system and society in France.

METHODS

Efficacy data for the secondary prevention of ischaemic events were derived from the Antiplatelet Trialists' Collaboration meta-analysis on antithrombotics. The rates and costs of ischaemic disease and of serious gastrointestinal adverse affects arising from long term aspirin treatment, as well as the costs of treatment with lysine acetylsalicylate, were taken from published sources, using French data where possible.

RESULTS

From the social security perspective, the estimated cost-effectiveness ratios show that the prevention of MI in patients with a history of unstable angina (with a 1-year follow-up) is a cost-saving strategy, with net benefits ranging from $US5703 (1996 prices) per avoided MI for lysine acetylsalicylate 300 mg/day to $US5761 per avoided MI for lysine acetylsalicylate 75 mg/day. The prevention of MI and stroke is also a cost-saving strategy in patients with prior MI [net benefits in a 2-year follow-up (5% discount rate) ranging from $US15 to $US494 per avoided MI and from $US37 to $US1170 per avoided stroke]. This was also true in patients with prior ischaemic stroke (net benefits in a 3-year follow-up ranging from $US610 to $US2082 per avoided MI and from $US176 to $US599 per avoided stroke). Finally, a 4-year follow-up in patients with a history of stable angina pectoris shows that prophylactic treatment with lysine acetylsalicylate is associated with net costs per avoided MI, ranging from $US4375 to $US3608 per avoided event. Sensitivity analysis confirmed that prophylaxis with lysine acetylsalicylate in patients at high risk of cardiovascular and cerebrovascular events results in savings in social security expenditure.

CONCLUSIONS

Our results underline the high economic benefit of using lysine acetylsalicylate to prevent secondary ischaemic stroke and MI in patients at high risk of cardiovascular and/or cerebrovascular events, leading to savings for the social security system and society.

The relationship between cholesterol and stroke: implications for antihyperlipidaemic therapy in older patients

Various studies on the relationship between serum cholesterol level and the risk of stroke have been published recently. Subsequent reviews have extrapolated information on stroke from the clinical trials originally aimed at lowering cholesterol for the primary and secondary prevention of myocardial infarction (MI) in middle-aged patients. We have reviewed the epidemiological knowledge on the relationship between serum cholesterol levels and stroke, and also focused on possible reduction of the risk of stroke with hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor treatment. Possible benefits from such therapy are particularly relevant for the elderly population which is at particularly high risk for stroke. The effects of serum cholesterol levels on the risk for haemorrhagic and ischaemic stroke have been evaluated. Indirect epidemiological evidence indicates that serum levels of total cholesterol and its subfractions are determinants of stroke, but their associations are relatively weak. When exploring the possible association of serum cholesterol levels with the increased risk of stroke with aging, we concluded that, as in younger adults, elevated total cholesterol and decreased high density lipoprotein-cholesterol levels predispose to ischaemic stroke in the elderly. The mechanism through which serum cholesterol levels increase stroke risk is based on its actions on the artery walls. Indirect evidence suggests that the reduction in the stroke risk with HMG-CoA reductase inhibitors is larger than would be expected with reduction of elevated serum cholesterol level alone. Therefore, antioxidant and endothelium-stabilising properties of HMG-CoA reductase inhibitors may contribute in reducing the risk of stroke in recipients. Lowering high serum cholesterol with HMG-CoA reductase inhibitors has been beneficial in the primary and secondary prevention of MI. No trials have specifically tested the effect of cholesterol lowering with HMG-CoA reductase inhibitors on stroke occurrence. High serum cholesterol levels are a risk factor for ischaemic stroke, although the risk imparted is lower than that for MI. Although the relative risk of stroke associated with elevated serum cholesterol levels is only moderate, its population attributable risk is high given the increase in the elderly population worldwide. The effect of cholesterol reduction with HMG-CoA reductase inhibitors on prevention of ischaemic stroke should be evaluated in prospective, randomised, placebo-controlled trials in the elderly. The tolerability of lipid-lowering drugs in the elderly and the cost effectiveness of primary prevention of stroke using lipid-lowering drugs also needs to be assessed in the elderly.

Transcranial Doppler-directed Dextran-40 therapy is a cost-effective method of preventing carotid thrombosis after carotid endarterectomy

OBJECTIVES

perioperative stroke reduces the clinical effectiveness of carotid endarterectomy (CEA). Postoperative thrombotic stroke may be reduced in incidence by the use of transcranial Doppler-directed Dextran-40 therapy. This programme requires the purchase of additional equipment and employment of more staff. This study examined whether this additional financial outlay was cost-effective in terms of saving expenditure by preventing postoperative thrombotic stroke.

MATERIALS AND METHODS

data was collected prospectively on a series of 600 consecutive CEAs. The costs of the monitoring programme were analysed over 1- and 5-year periods. Formulae were derived allowing other units to calculate whether this technique will be cost-effective for them.

RESULTS

after the introduction of TCD monitoring the postoperative thrombotic stroke rate fell from 2.7% to 0% (8 strokes prevented). Our local unit cost for the treatment of stroke was 25,702 pounds. After allowing for the additional costs of the monitoring programme, we calculate that postoperative TCD has saved 171,393 pounds.

CONCLUSIONS

postoperative TCD monitoring is a clinically effective and also cost-effective method of reducing the stroke rate associated with CEA. For units performing more than 50 CEAs per year who experience occasional postoperative carotid thrombosis, its introduction should be considered.

The scope for rehabilitation in severely disabled stroke patients

PURPOSE

To argue the case that patients who are severely disabled by stroke may benefit from rehabilitation. To identify critical areas where more research may be helpful.

METHOD

Discussion of four negative views which could be cited as drawbacks to rehabilitation in this group. These are: (1) that patients with severe stroke do not recover; (2) that they are too ill to receive rehabilitation; (3) that rehabilitation is ineffective even when possible; and (4) that even if rehabilitation is effective, it is not cost-effective.

RESULTS

There is little work in this area. There are problems with measurement of disability in this group. None of the four negative views are supported by current evidence, and what little evidence there is provides grounds for optimism that further work could be worthwhile.

CONCLUSIONS

Specific recommendations for further work include: (1) the development of better measurement scales; (2) to determine the cost of care of severely disabled stroke patients; (3) to gain a better appreciation of the value of changes in disability states; and (4) to perform an overview analysis of rehabilitation interventions examining the degree to which severity of disability affects the response to treatment.