Lille Apathy Rating Scale-Patient Version in Stroke Survivors: Psychometric Properties and Diagnostic Accuracy

OBJECTIVES

This study evaluated the factorial structure, psychometric properties, and diagnostic accuracy of the Persian version of the Lille Apathy Rating Scale-Patient version (LARS-P) in stroke survivors.

PARTICIPANTS

This study comprised 105 stroke survivors and 41 healthy controls.

METHODS AND SETTING

Exploratory factor analysis was used to determine the factors of the LARS-P. The acceptability, reliability, and validity of the LARS-P were also assessed. Agreement between the LARS-P and the Lille Apathy Rating Scale-informed version (LARS-I) was evaluated using the Bland-Altman plot. The diagnostic accuracy of the LARS-P was determined by categorizing stroke survivors into apathetic and nonapathetic groups based on the "diagnostic criteria of apathy."

RESULTS

The exploratory factor analysis showed 3 factors (action initiation and social life; novelty and motivation; and emotional and self-awareness), explaining 67.35% of the variance. Cronbach's alpha was 0.85 for between-items and 0.74 for between-subscales. Intra-class correlation coefficient (ICC)2,1 was >0.88 for test-retest and inter-rater reliability. The LARS-P showed moderate to strong correlations with the LARS-I and Neuropsychiatric Inventory-Apathy subscale (r = 0.70-0.82). In addition, the LARS-P had significant moderate correlations with 2 subscales of the Hospital Anxiety and Depression Scale, modified Rankin Scale, Barthel Index, and Lawton Instrumental Activities of Daily Living (r or ƿ = 0.47-0.63). There was a 96.19% agreement between LARS-P and LARS-I. The identified cutoff point (>17) for LARS-P exhibited 77.14% sensitivity and 90% specificity in diagnosing apathetic and nonapathetic stroke survivors.

CONCLUSIONS AND IMPLICATIONS

The LARS-P exhibits acceptable psychometric properties in stroke survivors, presenting a promising instrument for assessing apathy through a multidimensional framework.

Cost-effectiveness analysis of transthoracic echocardiographic assessment in patients with ischemic stroke or TIA of undetermined cause

BACKGROUND

The multicenter ATTEST study recently assessed 1084 patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause and found that routine transthoracic echocardiography (TTE) detects abnormalities with treatment implications (i.e., major cardiac sources of embolism) in only 1 % of patients, of whom most (91 %) also had major electrocardiographic (ECG)-abnormalities. In this study, we performed a cost-effectiveness analysis of different TTE strategies.

METHODS

We compared the cost-effectiveness of three strategies of TTE assessment: (1) TTE in all patients; (2) TTE only in patients with major ECG-abnormalities; and (3) TTE not performed. Input data were derived from ATTEST and systematic literature reviews. A Markov model was developed that simulated recurrent ischemic stroke or TIA and intracranial and gastro-intestinal bleeding complications in patients with ischemic stroke or TIA of undetermined cause. Primary outcome was the additional costs per additional quality-adjusted life-year (QALY) from a Dutch societal perspective.

RESULTS

Performing TTE only in patients with major ECG-abnormalities led to 0.0083 additional QALYs and €108 additional costs per patient as compared with not performing TTE (€12,987/QALY). Performing TTE in all patients resulted in 0.0005 additional QALYs and €422 additional costs per patient as compared with performing TTE only in case of major ECG-abnormalities (€805,336/QALY).

CONCLUSIONS

In patients with ischemic stroke or TIA of undetermined cause, a strategy of performing TTE only in patients who also had major ECG-abnormalities resulted in the most favorable ratio of additional costs per additional QALY. This supports performing TTE only in patients, who also have major ECG-abnormalities.

An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis

BACKGROUND AND OBJECTIVE

The Modified Rankin Scale (mRS) is a widely adopted scale for assessing stroke recovery. Despite limitations, the mRS has been adopted as primary outcome in most recent clinical acute stroke trials. Designed to be used by multidisciplinary clinical staff, the congruency of this scale is not consistent, which may lead to mistakes in clinical or research application. We aimed to develop and validate an interactive and automated digital tool for assessing the mRS-the iRankin.

METHODS

A panel of five board-certified and mRS-trained vascular neurologists developed an automated flowchart based on current mRS literature. Two international experts were consulted on content and provided feedback on the prototype platform. The platform contained five vignettes and five real video cases, representing mRS grades 0-5. For validation, we invited neurological staff from six comprehensive stroke centers to complete an online assessment. Participants were randomized into two equal groups usual practice versus iRankin. The participants were randomly allocated in pairs for the congruency analysis. Weighted kappa (kw) and proportions were used to describe agreement.

RESULTS

A total of 59 professionals completed the assessment. The kw was dramatically improved among nurses, 0.76 (95% confidence interval (CI) = 0.55-0.97) × 0.30 (0.07-0.67), and among vascular neurologists, 0.87 (0.72-1) × 0.82 (0.66-0.98). In the accuracy analysis, after the standard mRS values for the vignettes and videos were determined by a panel of experts, and considering each correct answer as equivalent to 1 point on a scale of 0-15, it revealed a higher mean of 10.6 (±2.2) in the iRankin group and 8.2 (±2.3) points in the control group (p = 0.02). In an adjusted analysis, the iRankin adoption was independently associated with the score of congruencies between reported and standard scores (beta coefficient = 2.22, 95% CI = 0.64-3.81, p = 0.007).

CONCLUSION

The iRankin adoption led to a substantial or near-perfect agreement in all analyzed professional categories. More trials are needed to generalize our findings. Our user-friendly and free platform is available at https://www.irankinscale.com/.

Cost and Utility Estimates per Modified Rankin Scale Score up to 2 Years Post Stroke: Data to Inform Economic Evaluations From a Societal Perspective

OBJECTIVES

Model-based health economic evaluations of ischemic stroke are in need of cost- and utility estimates related to relevant outcome measures. This study aims to describe societal cost- and utility estimates per modified Rankin Scale (mRS)-score at different time points within 2 years post stroke.

METHODS

Included patients had a stroke between 3 months and 2.5 years ago. mRS and EQ-5D-5L were scored during a telephone interview. Based on the interview date, records were categorized into a time point: 3 months (3M; 3-6 months), 1 year (Y1; 6-18 months), or 2 years (Y2; 18-30 months). Patients completed a questionnaire on healthcare utilization and productivity losses in the previous 3 months. Initial stroke hospitalization costs were assessed. Mean costs and utilities per mRS and time point were derived with multiple imputation nested in bootstrapping. Cost at 3 months post stroke were estimated separately for endovascular treatment (EVT)-/non-EVT-patients.

RESULTS

1106 patients were included from 18 Dutch centers. At each time point, higher mRS-scores were associated with increasing average costs and decreasing average utility. Mean societal costs at 3M ranged from €11 943 (mRS 1, no EVT) to €55 957 (mRS 5, no EVT). For Y1, mean costs in the previous 3 months ranged from €885 (mRS 0) to €23 215 (mRS 5), and from €1655 (mRS 0) to €22 904 (mRS 5) for Y2. Mean utilities ranged from 0.07 to 0.96, depending on mRS and time point.

CONCLUSIONS

The mRS-score is a major determinant of costs and utilities at different post-stroke time points. Our estimates may be used to inform future model-based health economic evaluations.

Impact of Early Mobilization on Patients With Acute Ischemic Stroke Treated With Thrombolysis or Thrombectomy: A Randomized Controlled Trial

BACKGROUND

Early mobilization (EM) within 24 to 72 hours post-stroke may improve patients' performance and ability. However, after intravenous thrombolysis (IVT) or mechanical thrombectomy (MT), the increased risk of hemorrhagic complications impacts the implementation of early out-of-bed mobilization. Few studies have investigated EM after IVT or MT for acute ischemic stroke (AIS), and its impact in these patients is unknown.

OBJECTIVE

To investigate the effect of EM on AIS treated with IVT or MT.|.

METHODS

We recruited 122 patients with first AIS; 60 patients were treated with IVT, and 62 patients were treated with MT. For each IVT and MT cohort, the control groups received standard early rehabilitation, and the intervention groups received an EM protocol. The training lasted 30 minutes/day, 5 days/week until discharge.

MAIN OUTCOMES MEASURES

The effectiveness of the interventions was evaluated using the motor domain of the Functional Independence Measure (FIM-motor) and the Postural Assessment Scale for Stroke Patients (PASS) at baseline, 2-week, 4-week, and 3-month post-stroke, the Functional Ambulation Category 2-week post-stroke, and the total length of stay at the stroke center.

RESULTS

Both IVT and MT treatment groups showed improved FIM-motor and PASS scores over time; however, only the IVT EM group had significantly improved FIM-motor performance within 1 month after stroke than the control group. Conclusion. An EM protocol with the same intervention time and session frequency per day as in the standard care protocol was effective in improving the functional ability of stroke patients after IVT.

Cost-effectiveness of ticagrelor plus aspirin versus aspirin in acute ischaemic stroke or transient ischaemic attack: an economic evaluation of the THALES trial

Objective

THALES demonstrated that ticagrelor plus aspirin reduced the risk of stroke or death but increased bleeding versus aspirin during the 30 days following a mild-to-moderate acute non-cardioembolic ischaemic stroke (AIS) or high-risk transient ischaemic attack (TIA). There are no cost-effectiveness analyses supporting this combination in Europe. To address this, a cost-effectiveness analysis was performed.

Methods

Cost-effectiveness was evaluated using a decision tree and Markov model with a short-term and long-term (30-year) horizon. Stroke, mortality, bleeding and EuroQol-5 Dimension (EQ-5D) data from THALES were used to estimate short-term outcomes. Model transitions were based on stroke severity (disabling stroke was defined as modified Rankin Scale >2). Healthcare resource utilisation and EQ-5D data beyond 30 days were based on SOCRATES, another trial in AIS/TIA that compared ticagrelor with aspirin. Long-term costs, survival and disutilities were based on published literature. Unit costs were derived from national databases and discounted at 3% annually from a Swedish healthcare perspective.

Results

One-month treatment with ticagrelor plus aspirin resulted in 12 fewer strokes, 4 additional major bleeds and cost savings of €95 000 per 1000 patients versus aspirin from a Swedish healthcare perspective. This translated into increased quality-adjusted life-years (0.04) and reduced societal costs (-€1358) per patient over a lifetime horizon. Key drivers of cost-effectiveness were number of patients experiencing subsequent disabling stroke and degree of disability. Findings were robust over a range of input assumptions.

Conclusion

One month of treatment with ticagrelor plus aspirin is likely to improve outcomes and reduce costs versus aspirin in mild-to-moderate AIS or high-risk TIA.

Trial registration number

NCT03354429.

Estimating the impact of balloon guide catheter with mechanical thrombectomy for acute ischemic stroke: A U.S. cost analysis

BACKGROUND

Balloon guide catheters (BGCs) can be used adjunctively during mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Evaluating the potential economic impact associated with adjunctive BGC use is an important consideration for resource allocation.

METHODS

Decision tree models were used to estimate the economic value of BGC use in MT through its impact on functional outcomes. Healthcare utilization cost estimates in the short- and long-term for patients with different 90-day mRS scores were analyzed for MT-only and MT + BGC scenarios. Deterministic (one-way) and probabilistic sensitivity analyses were performed to evaluate the robustness and uncertainty of model parameters.

RESULTS

Per-patient index hospitalization cost was estimated at $65,260 for MT-only and $62,883 for MT + BGC scenarios. Per-patient one-year post-index hospitalization cost was estimated at $27,569 for MT-only and $24,830 for MT + BGC. MT + BGC had a total cost savings of $5117 compared with MT-only. Deterministic (one-way) sensitivity analysis demonstrated that cost saving per patient was most sensitive to the proportion of patients in the mRS 0-2 category in both MT + BGC and MT-only. In a probabilistic sensitivity analysis, mean per-patient costs for the index hospitalization were estimated at $63,737 for MT-only and $61,425 for MT + BGC. Mean per-patient cost estimates one-year post-index hospitalization was $27,445 for MT-only and $24,715 for MT + BGC. MT + BGC had a total cost savings of $5043 compared with MT-only.

CONCLUSION

Mechanical thrombectomy with adjunctive BGC use may reduce short-term and long-term patient costs due to improved functional outcomes when compared to MT treatment alone for AIS.

Early mobilization in acute stroke phase: a systematic review

BACKGROUND

Early mobilization is defined as out-of-bed activities in acute stroke phase, and has led to improvements in functional capacity and reduction of complications after stroke.

OBJECTIVE

This study aimed to investigate the effectiveness and safety of early mobilization in the acute stroke phase.

METHODS

This was a systematic review. We searched for studies with the keywords: "Stroke," "Early mobilization" and "Functional outcomes." Data source: NLM, LILACS, MEDLINE, PEDro, and Science Direct. Studies published up to June 2020 were included; (b) study eligibility criteria: clinical trials; (c) participants: stroke patients in the acute phase; (d) interventions: early mobilization; (e) study appraisal: two authors independently assessed the risk of bias, Grading of Recommendations Assessment, Development and Evaluation, and the Oxford Center for Evidence-Based Medicine Levels of Evidence. The safety was evaluated based on related and non-related adverse effects.

RESULTS

Altogether, 476 studies were retrieved. After exclusion, seven studies involving 8663 patients were included in the qualitative synthesis. The main activities were elevation of the headboard, sitting, standing, and walking. The most important outcome assessed was the modified Rankin scale score (disability) after 3 months of stroke, and two studies showed that early mobilization improves functional capacity after stroke.

CONCLUSION

the optimal time to start early mobilization is > 24 h of stroke according to hemodynamic stability and safety criteria. The duration of mobilization is recommended between 15 and 45 minutes, divided into one, two, or three times a day. The focus of early mobilization should be on sitting, standing, and walking activity.

Increased neutrophil-to-lymphocyte ratio is associated with unfavorable functional outcomes in acute pontine infarction

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is positively associated with unfavorable outcomes in patients with cerebral infarction. This study aimed to investigate the relationship between the NLR and the short-term clinical outcome of acute pontine infarction.

METHODS

Patients with acute pontine infarction were consecutively included. Clinical and laboratory data were collected. All patients were followed up at 3 months using modified Rankin Scale (mRS) scores. An unfavorable outcome was defined as an mRS score ≥ 3. Receiver operating characteristic (ROC) curve analysis was used to calculate the optimal cutoff values for patients with acute pontine infarction. risk factors can be predictive factors for an unfavorable outcome after acute pontine infarction.

RESULTS

Two hundred fifty-six patients with acute pontine infarction were included in this study. The NLR was significantly higher in the unfavorable outcome group than in the favorable outcome group (P < 0.05). Additionally, the infarct size was significantly higher in the high NLR tertile group than in the low NLR tertile group (P < 0.05). Multivariate logistic regression analysis revealed that the baseline National Institutes of Health Stroke Scale (NIHSS) score, NLR, platelet count, and fasting blood glucose (FBG) level were significantly associated with unfavorable outcomes 3 months after acute pontine infarction. The optimal cutoff value of the NLR for predicting the 3-month outcome of acute pontine infarction was 3.055. The negative and positive predictive values of NLR were 85.7% and 61.3%, respectively, and the sensitivity and specificity of NLR were 69.2% and 80.9%.

CONCLUSIONS

We found that the NLR may be an independent predictive factor for the outcome of acute pontine infarction.

A cost-utility analysis comparing endovascular coiling to neurosurgical clipping in the treatment of aneurysmal subarachnoid haemorrhage

Endovascular coiling (EC) has been identified in systematic reviews and meta-analyses to produce more favourable clinical outcomes in comparison to neurosurgical clipping (NC) when surgically treating a subarachnoid haemorrhage from a ruptured aneurysm. Cost-effectiveness analyses between both interventions have been done, but no cost-utility analysis has yet been published. This systematic review aims to perform an economic analysis of the relative utility outcomes and costs from both treatments in the UK. A cost-utility analysis was performed from the perspective of the National Health Service (NHS), over a 1-year analytic horizon. Outcomes were obtained from the randomised International Subarachnoid Aneurysm Trial (ISAT) and measured in terms of the patient's modified Rankin scale (mRS) grade, a 6-point disability scale that aims to quantify a patient's functional outcome following a stroke. The mRS score was weighted against the Euro-QoL 5-dimension (EQ-5D), with each state assigned a weighted utility value which was then converted into quality-adjusted life years (QALYs). A sensitivity analysis using different utility dimensions was performed to identify any variation in incremental cost-effectiveness ratio (ICER) if different input variables were used. Costs were measured in pounds sterling (£) and discounted by 3.5% to 2020/2021 prices. The cost-utility analysis showed an ICER of - £144,004 incurred for every QALY gained when EC was utilised over NC. At NICE's upper willingness-to-pay (WTP) threshold of £30,000, EC offered a monetary net benefit (MNB) of £7934.63 and health net benefit (HNB) of 0.264 higher than NC. At NICE's lower WTP threshold of £20,000, EC offered an MNB of £7478.63 and HNB of 0.374 higher than NC. EC was found to be more 'cost-effective' than NC, with an ICER in the bottom right quadrant of the cost-effectiveness plane-indicating that it offers greater benefits at lower costs. This is supported by the ICER being below the NICE's threshold of £20,000-£30,000 per QALY, and both MNB and HNB having positive values (> 0).

Bimanual motor skill learning after stroke: Combining robotics and anodal tDCS over the undamaged hemisphere: An exploratory study

Background

Since a stroke can impair bimanual activities, enhancing bimanual cooperation through motor skill learning may improve neurorehabilitation. Therefore, robotics and neuromodulation with transcranial direct current stimulation (tDCS) are promising approaches. To date, tDCS has failed to enhance bimanual motor control after stroke possibly because it was not integrating the hypothesis that the undamaged hemisphere becomes the major poststroke hub for bimanual control.

Objective

We tested the following hypotheses: (I) In patients with chronic hemiparetic stroke training on a robotic device, anodal tDCS applied over the primary motor cortex of the undamaged hemisphere enhances bimanual motor skill learning compared to sham tDCS. (II) The severity of impairment correlates with the effect of tDCS on bimanual motor skill learning. (III) Bimanual motor skill learning is less efficient in patients than in healthy individuals (HI).

Methods

A total of 17 patients with chronic hemiparetic stroke and 7 healthy individuals learned a complex bimanual cooperation skill on the REAplan® neurorehabilitation robot. The bimanual speed/accuracy trade-off (biSAT), bimanual coordination (biCo), and bimanual force (biFOP) scores were computed for each performance. In patients, real/sham tDCS was applied in a crossover, randomized, double-blind approach.

Results

Compared to sham, real tDCS did not enhance bimanual motor skill learning, retention, or generalization in patients, and no correlation with impairment was noted. The healthy individuals performed better than patients on bimanual motor skill learning, but generalization was similar in both groups.

Conclusion

A short motor skill learning session with a robotic device resulted in the retention and generalization of a complex skill involving bimanual cooperation. The tDCS strategy that would best enhance bimanual motor skill learning after stroke remains unknown.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT02308852, identifier: NCT02308852.

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Background

Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.

Objectives

The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.

Design

A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.

Setting

The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.

Participants

A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.

Interventions

The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.

Main outcome measures

The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.

Data sources

National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.

Review methods

Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).

Limitations

Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.

Conclusions

Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.

Future work

Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.

Trial registration

This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.

Funding

The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

Vertebral artery stenosis predicts cerebrovascular diseases following radiotherapy for nasopharyngeal carcinoma

PURPOSE

Radiotherapy for nasopharyngeal carcinoma (NPC) may induce cerebrovascular diseases including ischemic stroke and transient ischemic attack (TIA), which can cause severe disability. However, information on the incidence and predictors of cerebrovascular diseases is scarce. This study aimed to estimate the incidence of cerebrovascular diseases following NPC, and attempts to ascertain the predictors of cerebrovascular diseases to facilitate early prevention.

METHODS

We performed a retrospective cohort study on 655 NPC patients who received radiotherapy between 2006 and 2018 in a medical center. This study analyzed the incidence, clinical and imaging presentation of patients with cerebrovascular diseases. Cox proportional hazard model was used to identify risk factors associated with cerebrovascular diseases following radiotherapy.

RESULTS

There were 14 patients who developed an ischemic stroke, and 3 patients developed a TIA after a mean follow-up of 5.8 years. Most ischemic events were from large-artery atherosclerosis (76.5%), and the most common symptom of ischemic stroke was unilateral limb weakness (57.1%). The cumulative incidence of ischemic stroke or TIA 15 years after radiotherapy was 9.1% (95% confidence interval [CI] = 4.7-17.2%). Multivariate Cox regression identified vertebral artery stenosis (HR: 18.341; 95% CI = 3.907-86.100; P < 0.001), atrial fibrillation (HR: 13.314; 95% CI = 1.306-135.764; P = 0.029), and hypertension (HR: 7.511; 95% CI = 1.472-38.320; P = 0.015) as independent predictors of ischemic stroke or TIA.

CONCLUSION

Our study found that NPC patients with vertebral artery stenosis, atrial fibrillation, or hypertension carry a higher risk for ischemic stroke or TIA. Regular assessment of vertebral artery after radiotherapy was suggested.

Thrombectomy is a cost-saving procedure up to 24 h after onset

INTRODUCTION AND AIM

The treatment of ischemic stroke due to large-vessel occlusion has been revolutionized by mechanical thrombectomy (MT), as multiple trials have consistently shown improved functional outcomes compared to standard medical management both in the early and late time windows after symptom onset. However, MT is an interventional procedure that is more costly than best supportive care (BSC).

METHODS

We set out to study the cost-utility and budget impact of MT + BSC versus BSC alone for large-vessel occlusion using a combined decision tree and Markov model. The analysis was conducted from a Belgian payer perspective over a lifetime horizon, and health states were defined by the modified Rankin Scale (mRS). The treatment effect of MT + BSC combined clinical outcomes from all published early and late treatment window studies showing improved mRS after 90 days. Resource use and utilities were informed by an observational Belgian study of 569 stroke patients. Long-term mRS transitions were sourced from the Oxford Vascular study.

RESULTS

MT + BSC generated 1.31 additional quality-adjusted life years and resulted in cost savings of €10,216 per patient over lifetime. Deterministic sensitivity analyses demonstrated dominance of MT over a wide range of parameter inputs. In a Belgian setting, adding MT to BSC within an early time window for 1575 eligible stroke patients every year produced cost savings between €6.3 million (year 1) and €14.6 million (year 5), or a total cost saving of €56.2 million over 5 years.

CONCLUSION

Mechanical thrombectomy is a highly cost-effective treatment for ischemic stroke patients, providing quality-adjusted survival at lower health care cost, both when given in an early time window, as well as in a late time window.

Direct Medical Cost of Stroke and the Cost-Effectiveness of Direct Oral Anticoagulants in Atrial Fibrillation-Related Stroke: A Cross-Sectional Study

BACKGROUND

Stroke has significant direct medical costs, and direct oral anticoagulants (DOACs) are better alternatives to warfarin for stroke prevention in atrial fibrillation (AF). This study aimed to determine the direct medical costs of stroke, with emphasis on AF stroke and the cost-effectiveness of DOACs among stroke patients in a tertiary hospital in Malaysia.

METHODS

This study utilised in-patient data from the case mix unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 2011 and 2018. Direct medical costs of stroke were determined using a top-down costing approach and factors associated with costs were identified. Incremental cost effectiveness ratio (ICER) was calculated to compare the cost-effectiveness between DOACs and warfarin.

RESULTS

The direct medical cost of stroke was MYR 11,669,414.83 (n = 3689). AF-related stroke cases had higher median cost of MYR 2839.73 (IQR 2269.79-3101.52). Regression analysis showed that stroke type (AF versus non-AF stroke) (p = 0.013), stroke severity (p = 0.010) and discharge status (p < 0.001) significantly influenced stroke costs. DOACs were cost-effective compared to warfarin with an ICER of MYR 19.25.

CONCLUSIONS

The direct medical cost of stroke is substantial, with AF-stroke having a higher median cost per stroke care. DOACs were cost effective in the treatment of AF-related stroke in UKMMC.

Modeling the Clinical Implications of Andexanet Alfa in Factor Xa Inhibitor-Associated Intracerebral Hemorrhage

BACKGROUND AND OBJECTIVES

Andexanet alfa was recently approved as a reversal agent for the factor Xa inhibitors (FXais) apixaban and rivaroxaban, but its impact on long-term outcomes in FXai-associated intracerebral hemorrhage (ICH) is unknown. We aimed to explore potential clinical implications of andexanet alfa in FXai-associated ICH in this simulation study.

METHODS

We simulated potential downstream implications of andexanet alfa across a range of possible hemostatic effects using data from a single center that treats FXai-associated ICH with prothrombin complex concentrate (PCC). We determined baseline probabilities of inadequate hemostasis across patients taking FXai and those not taking FXai via multivariable regression models and then determined the probabilities of unfavorable 3-month outcome (modified Rankin Scale score 4-6) using models comprising established predictors and each patient's calculated probability of inadequate hemostasis. We applied bootstrapping with model parameters from this derivation cohort to simulate a range of hemostatic improvements and corresponding outcomes and then calculated absolute risk reduction (relative to PCC) and projected number needed to treat (NNT) to prevent 1 unfavorable outcome.

RESULTS

Training models using real-world patients (n = 603 total, 55 on FXai) had good accuracy in predicting inadequate hemostasis (area under the curve [AUC] 0.78) and unfavorable outcome (AUC 0.78). Inadequate hemostasis was strongly associated with unfavorable outcome (odds ratio 4.5, 95% confidence interval [CI] 2.0-9.9) and occurred in 11.4% of patients taking FXai. Across simulated patients taking FXai comparable to those in A Study in Participants With Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors (ANNEXA-4) study, predicted absolute risk reduction of unfavorable outcome was 4.9% (95% CI 1.3%-7.8%) when the probability of inadequate hemostasis was reduced by 33% and 7.4% (95% CI 2.0%-11.9%) at 50% reduction, translating to projected NNT of 21 (cumulative cost $519,750) and 14 ($346,500), respectively.

DISCUSSION

Even optimistic simulated hemostatic effects suggest that the costs and potential benefits of andexanet alfa should be carefully considered. Placebo-controlled randomized trials are needed before its use can definitively be recommended.

Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States

PURPOSE OF THE REVIEW

This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States.

RECENT FINDINGS

There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective.

SUMMARY

Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.

The Association Between Serum Endocan Level and Short-Term Prognosis of Patients With Acute Ischemic Stroke

This cohort study was designed to assess the association between serum endocan levels and the prognosis of acute ischemic stroke. A total of 227 patients were recruited consecutively. Study outcome data on death and major disability (modified Rankin Scale score ≥3) were collected at 3 months after stroke onset. After 3 months of follow-up, death and disability occurred in 48 and 85 patients, respectively, while the primary (death) and secondary (death or disability) outcome incident rate was 21.15% and 37.44%, respectively. The multivariable adjusted odds ratio (OR) (95% confidence interval, 95% CIs) of the highest endocan quartile for death or major disability was 1.21 (1.10, 4.13) compared with the lowest quartile. After adjusting for confounding factors, the increase in the risk of death was not significant. Receiver operating characteristic curve analysis showed that endocan predicted primary and secondary outcomes with C-statistical values (95% CIs) of 0.61 (0.55-0.67, P = .001) and 0.68 (0.59-0.76, P < .001), respectively. Elevated endocan levels were independently related to increased risk of poor outcome at 3 months after ischemic stroke onset. Endocan is a potential prognostic factor for ischemic stroke.

A Cost Utility Analysis of Minimally Invasive Surgery with Thrombolysis Compared to Standard Medical Treatment in Spontaneous Intracerebral Haemorrhagic Stroke

OBJECTIVES

Standard medical management of spontaneous intracerebral haemorrhage (ICH) and surgical hematoma evacuation starkly differ, and whilst landmark randomised control trials report no clinical benefit of early surgical evacuation compared with medical treatment in supratentorial ICH, minimally invasive surgery (MIS) with thrombolysis has been neglected within these studies. However, recent technological advancements in MIS have renewed interest in the surgical treatment of ICH. Several economic evaluations have focused on the benefits of MIS in ischaemic stroke management, but no economic evaluations have yet been performed comparing MIS to standard medical treatment for ICH.

MATERIALS AND METHOD

All costs were sourced from the UK in GBP. Where possible, the 2019/2020 NHS reference costs were used. The MISTIE III study was used to analyse the outcomes of patients undergoing either MIS or standard medical treatment in this economic evaluation.

RESULTS

The incremental cost-effectiveness ratio (ICER) for MIS was £485,240.26 for every quality-adjusted life year (QALY) gained. Although MIS resulted in a higher QALY compared to medical treatment, the gain was insignificant at 0.011 QALY. Four sensitivity analyses based on combinations of alternative EQ-5D values and categorisation of MIS outcomes, alongside alterations to the cost of significant adverse events, were performed to check the robustness of the ICER calculation. The most realistic sensitivity analysis showed a potential increase in cost effectiveness when clot size is reduced to <15ml, with the ICER falling to £74,335.57.

DISCUSSION

From the perspective of the NHS, MIS with thrombolysis is not cost-effective compared to optimal medical treatment. ICER shows that intention-to-treat MIS would require a cost of £485,240.26 to gain one extra QALY, which is significantly above the NHS threshold of £30,000. Further UK studies with ICH survivor utilities, more replicable surgical technique, and the reporting of clot size reduction are indicated as the present sensitivity analysis suggests that MIS is promising. Greater detail about outcomes and complications would ensure improved cost-benefit analyses and support valid and efficient allocation of resources by the NHS.

Mechanical thrombectomy is efficacious in patients with pre-stroke moderate disability

INTRODUCTION

Patients with ischaemic stroke due to large vessel occlusion (LVO) can be treated successfully with mechanical thrombectomy (MT) and/or intravenous thrombolysis. In the landmark trials, MT was only performed for those with no functional disability prior to stroke (mRS 0-2). There are limited data available regarding clinical outcomes for patients with pre-stroke moderate disability (mRS ≥ 3). The aims of this study were to analyse the clinical outcomes and financial implications in regard to accommodation costs of performing MT in patients with pre-stroke mRS = 3.

METHODS

An observational cohort study was performed of 802 patients with anterior circulation LVO ischaemic stroke who underwent MT between October 2016 and January 2020 at three tertiary hospitals. Patient demographics, premorbid mRS, stroke and interventional data, 90-day mRS and accommodation situation were recorded.

RESULTS

Eighty-two patients with anterior circulation LVO ischaemic stroke were pre-stroke mRS 3. 38% had a good clinical outcome, as defined by mRS 3 at 90 days. Mortality rate was 38%. The majority of patients presented from home (83%) and greater than one third of those returned home during the 90 days post treatment. 81% of patients had no increase in accommodation cost at 90 days.

CONCLUSION

Patients with pre-stroke moderate disability may benefit from MT if they are appropriately selected. This may result in fewer patients requiring nursing home placement and less financial burden on the public health system, indicating significant savings are possible.

Cost Effectiveness of Interhospital Transfer for Mechanical Thrombectomy of Acute Large Vessel Occlusion Stroke: Role of Predicted Recanalization Rates

BACKGROUND

Emergency interhospital transfer of patients with stroke with large vessel occlusion to a comprehensive stroke center for mechanical thrombectomy is resource-intensive and can be logistically challenging. Imaging markers may identify patients in whom intravenous thrombolysis (IVT) alone is likely to result in thrombus resolution, potentially rendering interhospital transfers unnecessary. Here, we investigate how predicted probabilities to achieve IVT-mediated recanalization affect cost-effectiveness estimates of interhospital transfer.

METHODS

We performed a health economic analysis comparing emergency interhospital transfer of patients with acute large vessel occlusion stroke after administration of IVT with a scenario in which patients also receive IVT but remain at the primary hospital. Results were stratified by clinical parameters, treatment delays, and the predicted probability to achieve IVT-mediated recanalization. Estimated 3-month outcomes were combined with a long-term probabilistic model to yield quality-adjusted life years (QALYs) and costs. Uncertainty was quantified in probabilistic sensitivity analyses.

RESULTS

Depending on input parameters, marginal costs of interhospital transfer ranged from USD -61 366 (cost saving) to USD +20 443 and additional QALYs gained from 0.1 to 3.0, yielding incremental cost-effectiveness ratios of <USD 0 (dominant) to USD 310 000 per QALY. For some elderly patients with moderate or severe stroke symptoms treated in a remote primary stroke center, transfer was unlikely to be cost effective at a willingness-to-pay threshold of USD 100 000 and 50 000 per QALY (20% and 1%, respectively) if the predicted probability to achieve IVT-related recanalization was high. On the other hand, in some younger patients, the analysis yielded incremental cost-effectiveness ratio estimates below USD 20 000 per QALY independent of the predicted recanalization rate.

CONCLUSIONS

Predicted probabilities to achieve IVT-mediated recanalization significantly affect the cost-effectiveness of interhospital transfer for MT, in particular in elderly patients with moderate or severe stroke symptoms. However, high predicted recanalization rates alone do not generally imply that patients should not be considered for transfer.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of oxiracetam combined with ginkgo biloba extract in the treatment of acute intracerebral hemorrhage: A clinical study

PURPOSE

The present clinical study was conducted to investigate the effect of oxiracetam combined with ginkgo biloba extract in treating patients with acute intracerebral hemorrhage.

METHODS

Ninety-eight patients with acute cerebral hemorrhage admitted to our hospital were divided into three groups. The differences of brain edema and cerebral hemorrhage were compared between the three groups after 1 and 2 weeks of treatment, and the recovery of neurological function, serum inflammatory factors, AQP-4, MMP-9, cognitive function, activities of daily living, and adverse reactions were compared between the three groups after 2 weeks of treatment.

RESULTS

There was no significant difference among the three groups before treatment (p > .05). After treatment, the recovery of neurological function, serum inflammatory factors, AQP-4, MMP-9 levels, cognitive function, and activities of daily living were improved. Among them, the neurological function recovery, serum inflammatory factors, AQP-4, MMP-9 levels, cognitive function, and activities of daily living in the combined treatment group and the control group elicited greater results than those in the routine group. The results of the combined treatment group showed the most significant difference (p < .05). The concentration of IL-6 decreased from 135.98 ± 12.54 to 91.83 ± 7.69 pg/ml, AQP-4 from 227.55 μg/L ± 21.06 to 114.31 ± 9.22 μg/L, and MMP-9 from 172.39 ± 9.81 to 94.98 ± 5.01 ng/ml. In addition, the neurological function recovery, the levels of serum inflammatory factors, cognitive function, and activities of daily living in the combined treatment group were better than those in the control group (p < .05). The mean score of MRS in the combined treatment group decreased from 3.36 ± 0.98 at admission to 1.91 ± 0.38.

CONCLUSION

Oxiracetam combined with Ginkgo biloba extract in the treatment of acute cerebral hemorrhage has a significant improvement effect.

Haptic Nudges Increase Affected Upper Limb Movement During Inpatient Stroke Rehabilitation: Multiple-Period Randomized Crossover Study

BACKGROUND

As many as 80% of stroke survivors experience upper limb (UL) disability. The strong relationships between disability, lost productivity, and ongoing health care costs mean reducing disability after stroke is critical at both individual and society levels. Unfortunately, the amount of UL-focused rehabilitation received by people with stroke is extremely low. Activity monitoring and promotion using wearable devices offer a potential technology-based solution to address this gap. Commonly, wearable devices are used to deliver a haptic nudge to the wearer with the aim of promoting a particular behavior. However, little is known about the effectiveness of haptic nudging in promoting behaviors in patient populations.

OBJECTIVE

This study aimed to estimate the effect of haptic nudging delivered via a wrist-worn wearable device on UL movement in people with UL disability following stroke undertaking inpatient rehabilitation.

METHODS

A multiple-period randomized crossover design was used to measure the association of UL movement with the occurrence of haptic nudge reminders to move the affected UL in 20 people with stroke undertaking inpatient rehabilitation. UL movement was observed and classified using movement taxonomy across 72 one-minute observation periods from 7:00 AM to 7:00 PM on a single weekday. On 36 occasions, a haptic nudge to move the affected UL was provided just before the observation period. On the other 36 occasions, no haptic nudge was given. The timing of the haptic nudge was randomized across the observation period for each participant. Statistical analysis was performed using mixed logistic regression. The effect of a haptic nudge was evaluated from the intention-to-treat dataset as the ratio of the odds of affected UL movement during the observation period following a "Planned Nudge" to the odds of affected limb movement during the observation period following "No Nudge."

RESULTS

The primary intention-to-treat analysis showed the odds ratio (OR) of affected UL movement following a haptic nudge was 1.44 (95% CI 1.28-1.63, P<.001). The secondary analysis revealed an increased odds of affected UL movement following a Planned Nudge was predominantly due to increased odds of spontaneous affected UL movement (OR 2.03, 95% CI 1.65-2.51, P<.001) rather than affected UL movement in conjunction with unaffected UL movement (OR 1.13, 95% CI 0.99-1.29, P=.07).

CONCLUSIONS

Haptic nudging delivered via a wrist-worn wearable device increases affected UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. The promoted movement appears to be specific to the instructions given.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry 12616000654459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370687&isReview=true.

Comparison of Three Instruments for Activity Disability in Acute Ischemic Stroke Survivors

BACKGROUND

Disabilities in physical activity and functional independence affect the early rehabilitation of stroke survivors. Moreover, a good instrument for assessing activity disability allows accurate assessment of physical disability and assists in prognosis determination.

OBJECTIVE

To compare three assessment tools for physical activity in acute-phase stroke survivors.

METHODS

We conducted this prospective observational study at an affiliated hospital of a Medical University in Shanghai, China, from June 2018 to November 2019. We administered three instruments to all patients during post-stroke days 5-7, including the Modified Barthel Index (MBI), Instrumental Activities of Daily Living (IADL), and modified Rankin scale (mRs). We analyzed correlations among the aforementioned scales and the National Institutes of Health Stroke Scale (NIHSS) using Spearman's rank-order correlations test. Univariate analyses were performed using the Mann-Whitney U test. We used a binary logistic regression model to assess the association between the NIHSS (30 days) and patient-related variables. Finally, we used receiver operating characteristic (ROC) curves to assess the predictive value of the multivariate regression models.

RESULTS

There was a high correlation among the three instruments; furthermore, the MBI had a higher correlation with the NIHSS (days 5-7). The NIHSS (day 30) was correlated with thrombolysis. ROC analysis revealed that the mRs-measured disability level had the highest predictive value of short-term stroke severity (30 days).

CONCLUSION

The MBI was the best scale for measuring disability in physical activity, whereas the mRs showed better accuracy in short-term prediction of stroke severity.

Preserved motor skill learning in acute stroke patients

Recovery is dynamic during acute stroke, but whether new motor skills can be acquired with the paretic upper limb (UL) during this recovery period is unknown. Clarifying this unknown is important, because neurorehabilitation largely relies on motor learning. The aim was to investigate whether, during acute stroke, patients achieved motor skill learning and retention with the paretic UL. Over 3 consecutive days (D1-D3), 14 patients practiced with their paretic UL the CIRCUIT, a motor skill learning task with a speed/accuracy trade-off (SAT). A Learning Index (LI) was used to quantify normalised SAT changes in comparison with baseline. Spontaneous motor recovery was quantified by another task without SAT constraint (EASY), by grip force (GF), and the Box and Blocks test (BBT). In patients, CIRCUIT LI improved 98% ± 66.2 (mean ± SD). This improvement was similar to that of young healthy individuals (n = 30) who trained with a slightly different protocol for 3 consecutive days (83.8% ± 58.8%). Generalisation of SAT gains to an untrained circuit was observed in both groups. From D1 to D3, stroke patients improved their performance on EASY, while changes in GF and BBT were heterogeneous. During acute stroke, patients retained SAT gains for a motor skill learned with the paretic UL in a manner similar to that of healthy individuals. These results demonstrate acute stroke patients achieved motor skill learning and retention that exceeded paretic UL improvements explained by spontaneous recovery.

Three-month modified Rankin Scale as a determinant of 5-year cumulative costs after ischemic stroke

Objective

Stroke is a devastating and costly disease; however, there is a paucity of information on long-term costs and on how they differ according to 3-month modified Rankin scale (mRS) score, which is a primary outcome variable in acute stroke intervention trials.

Methods

We analyzed a prospective multicenter stroke registry (Clinical Research Collaboration for Stroke in Korea) database through linkage with claims data from the National Health Insurance Service with follow-up to December 2016. Healthcare expenditures were converted into daily cost individually, and annual and cumulative costs up to 5 years were estimated and compared according to the 3-month mRS score.

Results

Between January 2011 and November 2013, 11,136 patients were enrolled in the study. The mean age was 68 years, and 58% were men. The median follow-up period was 3.9 years (range 0–5 years). Mean cumulative cost over 5 years was $117,576 (US dollars [USD]); the cost in the first year after stroke was the highest ($38,152 USD), which increased markedly from the cost a year before stroke ($8,718 USD). The mean 5-year cumulative costs differed significantly according to the 3-month mRS score (p < 0.001); the costs for a 3-month mRS score of 0 or 5 were $53,578 and $257,486 USD, respectively. Three-month mRS score was an independent determinant of long-term costs after stroke.

Conclusions

We show that 3-month mRS score plays an important role in the prediction of long-term costs after stroke. Such estimates relating to 3-month mRS categories may be valuable when undertaking health economic evaluations related to stroke care.

Estimating the effectiveness and cost-effectiveness of establishing additional endovascular Thrombectomy stroke Centres in England: a discrete event simulation

BACKGROUND

We have previously modelled that the optimal number of comprehensive stroke centres (CSC) providing endovascular thrombectomy (EVT) in England would be 30 (net 6 new centres). We now estimate the relative effectiveness and cost-effectiveness of increasing the number of centres from 24 to 30.

METHODS

We constructed a discrete event simulation (DES) to estimate the effectiveness and lifetime cost-effectiveness (from a payer perspective) using 1 year's incidence of stroke in England. 2000 iterations of the simulation were performed comparing baseline 24 centres to 30.

RESULTS

Of 80,800 patients admitted to hospital with acute stroke/year, 21,740 would be affected by the service reconfiguration. The median time to treatment for eligible early presenters (< 270 min since onset) would reduce from 195 (IQR 155-249) to 165 (IQR 105-224) minutes. Our model predicts reconfiguration would mean an additional 33 independent patients (modified Rankin scale [mRS] 0-1) and 30 fewer dependent/dead patients (mRS 3-6) per year. The net addition of 6 centres generates 190 QALYs (95%CI - 6 to 399) and results in net savings to the healthcare system of £1,864,000/year (95% CI -1,204,000 to £5,017,000). The estimated budget impact was a saving of £980,000 in year 1 and £7.07 million in years 2 to 5.

CONCLUSION

Changes in acute stroke service configuration will produce clinical and cost benefits when the time taken for patients to receive treatment is reduced. Benefits are highly likely to be cost saving over 5 years before any capital investment above £8 million is required.

Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study

BACKGROUND/OBJECTIVE

The selection of surgical technique in patients with cervical spondylotic myelopathy relies on the surgeon(s) and patients' conditions. The objectives of the study were to test the hypotheses that French-door laminoplasty recovers faster than laminectomy and has good outcome measures.

METHODS

Data regarding surgical, radiological, and clinical outcome measures of 330 patients with cervical spondylotic myelopathy operated under French-door laminoplasty (fdLP group, n = 110), open-door laminoplasty (odLP group, n = 110), or laminectomy (LC group, n = 110) were collected from the records of institute and analyzed.

RESULTS

Patients of fdLP group (p < 0.0001, q = 11.65) and odLP group (p < 0.0001, q = 11.27) both had significantly improved modified Rankin scale score than those of LC group. In addition, patients of fdLP group had minimum blood loss during operations and that was maximum for patients of the LC group. Unlike patients of fdLP group (p < 0.0001, q = 80) and LC group (p < 0.0001, q =122), those of odLP group had lost more amount of cervical lordotic after surgery. Open-door laminoplasty had significantly reduced cervical range of motion than laminectomy (p < 0.0001, q = 15.45) and French-door laminoplasty (p < 0.0001, q = 13.45). After 12-months, fdLP group had higher bone union rate than odLP group (p = 0.007, q = 3.395) and LC group (p = 0.007, q = 4.243). French door laminoplasty had a better postoperative quality of life.

CONCLUSIONS

Among the posterior decompression spine surgeries, French-door laminoplasty is superior surgical procedure than laminectomy and could be superior surgical technique than open-door laminoplasty.

Multidiscipline Stroke Post-Acute Care Transfer System: Propensity-Score-Based Comparison of Functional Status

Few studies have investigated the characteristics of stroke inpatients after post-acute care (PAC) rehabilitation, and few studies have applied propensity score matching (PSM) in a natural experimental design to examine the longitudinal impacts of a medical referral system on functional status. This study coupled a natural experimental design with PSM to assess the impact of a medical referral system in stroke patients and to examine the longitudinal effects of the system on functional status. The intervention was a hospital-based, function oriented, 12-week to 1-year rehabilitative PAC intervention for patients with cerebrovascular diseases. The average duration of PAC in the intra-hospital transfer group (31.52 days) was significantly shorter than that in the inter-hospital transfer group (37.1 days) (p < 0.001). The intra-hospital transfer group also had better functional outcomes. The training effect was larger in patients with moderate disability (Modified Rankin Scale, MRS = 3) and moderately severe disability (MRS = 4) compared to patients with slight disability (MRS = 2). Intensive post-stroke rehabilitative care delivered by per-diem payment is effective in terms of improving functional status. To construct a vertically integrated medical system, strengthening the qualified local hospitals with PAC wards, accelerating the inter-hospital transfer, and offering sufficient intensive rehabilitative PAC days are the most essential requirements.

The combined impact of dependency on caregivers, disability, and coping strategy on quality of life after ischemic stroke

BACKGROUND

To estimate the additional impact of coping and of being dependent on caregivers, over and above the large effects of disability on utility after ischemic stroke.

METHODS

A total of 539 patients were recruited into an observational, retrospective study when returning for a check-up between 3 and 36 months after an ischemic stroke. Patients' modified Rankin Scale (mRS), dependency on caregivers, the Brandtstädter and Renner Coping questionnaire (with summary scores: Tenacity of Goal Pursuit (TGP) and Flexible Goal Adjustment (FGA) coping styles), EQ-5D-3 L and co-morbidities were evaluated.

RESULTS

In multivariable regression, greater disability (mRS) resulted in large utility losses, between 0.06 for mRS 1 to 0.65 for mRS 5 (p < 0.0001). Dependency on caregivers caused an additional dis-utility of 0.104 (p = 0.0006) which varied by mRS (0.044, 0.060, 0.083, 0.115, 0.150 and 0.173 for mRS 0-5). The effect of coping on utility varied by coping style, by the disability level of the patient and by his or her dependency on caregivers. FGA coping was associated with additional increases in utility (p < 0.0001) over and above the effect of disability and dependency, whereas TGA had no significant impact. FGA coping was associated with larger utility changes among more disabled patients (0.018 to 0.105 additional utility, for mRS 0 to mRS 5 respectively). Dependent patients had more to gain from FGA coping than patients who function independently of caregivers: utility gains were between 0.049 and 0.072 for moderate to high levels of FGA coping. In contrast, the same positive evolution in FGA coping resulted in 0.039 and 0.057 utility gain among independent patients. Finally, we found that important stroke risk factors and co-morbidities, such as diabetes and atrial fibrillation, were not predictors of EQ-5D utility in a multivariable setting.

CONCLUSIONS

This study suggests that treatment strategies targeting flexible coping styles and decreasing dependency on caregivers may lead to significant gains in quality of life above and beyond treatment strategies that solely target disability.

Clinical Outcome after Thrombectomy in Patients with Stroke with Premorbid Modified Rankin Scale Scores of 3 and 4: A Cohort Study with 136 Patients

BACKGROUND AND PURPOSE

We aimed to analyze the clinical outcome after mechanical thrombectomy in patients with premorbid mRS 3 and 4 because there are currently no data on this patient group.

MATERIALS AND METHODS

Between January 2009 and November 2017, all patients with premorbid mRS 3 or 4 undergoing mechanical thrombectomy due to anterior circulation stroke were selected. Good outcome was defined as a clinical recovery to the status before stroke onset (ie, equal premorbid mRS and mRS at 90 days). In addition, mortality at discharge and at 90 days was analyzed.

RESULTS

One hundred thirty-six patients were included, of whom 81.6% presented with premorbid mRS 3; and 18.4%, with premorbid mRS 4; 24.0% of patients with premorbid mRS 4 achieved clinical recovery compared with 20.7% of patients with premorbid mRS 3 (P = .788). However, the proportion of hospital mortality and mortality at 90 days was nonsignificant, but markedly higher in patients with premorbid mRS 4. Multivariate analysis identified low NIHSS scores (OR, 0.92; 95% CI, 0.85-0.99; P = .040), high ASPECTS (OR, 1.45; 95% CI, 1.02-2.16; P = .049), and TICI 2b-3 (OR, 7.11; 95% CI, 1.73-49.90; P = .017) as independent predictors of good outcome.

CONCLUSIONS

Good outcome in patients with premorbid mRS 3 and 4 is less frequent compared with premorbid mRS 0-2. Nevertheless, about 20% of the patients return to their premorbid mRS, which may justify endovascular treatment. The most important predictor of good outcome is successful recanalization.

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.