Sex differences in direct healthcare costs following stroke: a population-based cohort study

Differences in Cumulative Long-Term Care Costs by Dental Visit Pattern Among Japanese Older Adults: The JAGES Cohort Study

BACKGROUND

Long-term care (LTC) costs create burdens on aging societies. Maintaining oral health through dental visits may result in shorter LTC periods, thereby decreasing LTC costs; however, this remains unverified. We examined whether dental visits in the past 6 months were associated with cumulative LTC insurance (LTCI) costs.

METHODS

This cohort study of the Japan Gerontological Evaluation Study targeted independent adults aged≥65 years in 2010 over an 8-year follow-up. We used data from a self-reported questionnaire and LTCI records from the municipalities. The outcome was cumulative LTCI costs, and exposure was dental visits within 6 months for prevention, treatment, and prevention or treatment. A 2-part model was used to estimate the differences in the predicted cumulative LTCI costs and 95% confidence intervals (CIs) for each dental visit.

RESULTS

The mean age of the 8 429 participants was 73.7 years (standard deviation [SD] = 6.0), and 46.1% were men. During the follow-up period, 17.6% started using LTCI services. The mean cumulative LTCI cost was USD 4 877.0 (SD = 19 082.1). The predicted cumulative LTCI costs were lower among those had dental visits than among those who did not. The differences in predicted cumulative LTCI cost were -USD 1 089.9 (95% CI = -1 888.5 to -291.2) for dental preventive visits, -USD 806.7 (95% CI = -1 647.4 to 34.0) for treatment visits, and -USD 980.6 (95% CI = -1 835.7 to -125.5) for preventive or treatment visits.

CONCLUSIONS

Dental visits, particularly preventive visits, were associated with lower cumulative LTCI costs. Maintaining oral health through dental visits may effectively reduce LTCI costs.

Sex Disparities in the Direct Cost and Management of Stroke: A Population-Based Retrospective Study

(1) Background: Previous studies have identified disparities in stroke care and outcomes by sex. Therefore, the main objective of this study was to evaluate the average cost of stroke care and the existence of differences in care provision by biological sex. (2) Methods: This observational study adhered to the recommendations of the STROBE statement. The calculation of costs was performed based on the production cost of the service or the rate paid for a set of services, depending on the availability of the corresponding information. (3) Results: A total of 336 patients were included, of which 47.9% were women, with a mean age of 73.3 ± 11.6 years. Women were typically older, had a higher prevalence of hypertension (p = 0.005), lower pre-stroke proportion of mRS 0-2 (p = 0.014), greater stroke severity (p < 0.001), and longer hospital stays (p = 0.017), and more were referred to residential services (p = 0.001) at 90 days. Women also required higher healthcare costs related to cardiovascular risk factors, transient ischemic strokes, institutionalization, and support needs; in contrast, they necessitated lower healthcare costs when undergoing endovascular therapy and receiving rehabilitation services. The unadjusted averaged cost of stroke care was EUR 22,605.66 (CI95% 20,442.8-24,768.4), being higher in women [p = 0.027]. The primary cost concept was hospital treatment (38.8%), followed by the costs associated with dependence and support needs (36.3%). At one year post-stroke, the percentage of women not evaluated for a degree of dependency was lower (p = 0.008). (4) Conclusions: The total unadjusted costs averaged EUR 22,605.66 (CI95% EUR 20,442.8-24,768.4), being higher in women compared to men. The primary cost concept was hospital treatment (38.8%), followed by the costs associated with dependence and support needs (36.3%).

The Utility of Echocardiogram in the Workup of Ischemic Stroke Patients

BACKGROUND

Cardiac sources of emboli can be identified by transthoracic echocardiogram (TTE). The Canadian Best Practice Guidelines recommend routine use of TTE in the initial workup of ischemic stroke when an embolic source is suspected. However, TTEs are commonly ordered for all patients despite insufficient evidence to justify cost-effectiveness. We aim to evaluate the TTE ordering pattern in the initial workup of ischemic stroke at a regional Stroke Center in Central South Ontario and determine the proportion of studies which led to a change in management and affected length of stay (LOS).

METHODS

Hospital records of 520 patients with a discharge diagnosis of TIA or ischemic stroke between October 2016 and June 2017 were reviewed to gather information.

RESULTS

477 patients admitted for TIA or ischemic stroke met inclusion criteria. 67.9% received TTE, out of which 6.0% had findings of cardiac sources of emboli including left ventricular thrombus, atrial septal aneurysm, PFO, atrial myxoma, and valvular vegetation. 2.5% of all TTE findings led to change in medical management. The median LOS of patients who underwent TTE was 2 days longer (p < 0.00001).

CONCLUSION

TTE in the initial workup of TIA or ischemic stroke remains common practice. The yield of TTEs is low, and the proportion of studies that lead to changes in medical management is minimal. TTE completion was associated with increased LOS and may result in increased healthcare spending; however, additional factors prolonging the LOS could not be excluded.

Attributable Costs of Stroke in Ontario, Canada and Their Variation by Stroke Type and Social Determinants of Health

BACKGROUND

Estimates of attributable costs of stroke are scarce, as most prior studies do not account for the baseline health care costs in people at risk of stroke. We estimated the attributable costs of stroke in a universal health care setting and their variation across stroke types and several social determinants of health.

METHODS

We undertook a population-based administrative database-derived matched retrospective cohort study in Ontario, Canada. Community-dwelling adults aged ≥40 years with a stroke between 2003 and 2018 were matched (1:1) on demographics and comorbidities with controls without stroke. Using a difference-in-differences approach, we estimated the mean 1-year direct health care costs attributable to stroke from a public health care payer perspective, accounting for censoring with a weighted available sample estimator. We described health sector-specific costs and reported variation across stroke type and social determinants of health.

RESULTS

The mean 1-year attributable costs of stroke were Canadian dollars 33 522 (95% CI, $33 231-$33 813), with higher costs for intracerebral hemorrhage ($40 244; $39 193-$41 294) than ischemic stroke ($32 547; $32 252-$32 843). Most of these costs were incurred in acute care hospitals ($15 693) and rehabilitation facilities ($7215). Compared with all patients with stroke, the mean attributable costs were higher among immigrants ($40 554; $39 316-$41 793), those aged <65 years ($35 175; $34 533-$35 818), and those residing in low-income neighborhoods ($34 687; $34 054-$35 320) and lower among rural residents ($29 047; $28 362-$29 731).

CONCLUSIONS

Our findings of high attributable costs of stroke, especially in immigrants, younger patients, and residents of low-income neighborhoods, can be used to evaluate potential health care cost savings associated with different primary stroke prevention strategies.

Healthcare cost and race: analysis of young women with stroke

BACKGROUND

Over the last decade, the prevalence of young stroke has increased 40% particularly among vulnerable populations. These strokes are often more severe with worse outcomes. However, few studies have examined the impact on annual healthcare costs.

METHODS

Data from the 2008 to 2018 Medical Expenditure Panel Survey (MEPS) was used to identify a sample of female stroke survivors aged 18 and 60. MEPS includes demographics, health status, healthcare use, and expenditures for all participants providing the largest nationally representative data source of healthcare costs in the US. First, differences in racial and ethnic healthcare expenditure among young women with stroke were evaluated controlling for insurance type and demographic characteristics. Second, the relationship between healthcare expenditure and 1) time post stroke, 2) comorbidities, 3) healthcare utilization, and 4) post-stroke functional status was assessed. Finally, differential healthcare quality was tested as a potential mitigating differential.

RESULTS

Young Black women with stroke spend roughly 20% more on healthcare than White women after controlling for insurance, time post-stroke, healthcare utilization, and demographic differences. Costs remain 17% higher after controlling for comorbidities. Differences in expenditure are larger if survivors have diabetes, high blood pressure, or high cholesterol (78%, 24%, and 28%, respectively). Higher expenditure could not be explained by higher healthcare utilization, but lower quality of healthcare may explain part of the differential.

CONCLUSION

Young Black women with stroke have 20% greater healthcare expenditure than other groups. Cost differentials cannot be explained by differentials in comorbidities, utilization, time post stroke, or functionality. Additional research is needed to explain these differences.

Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes

Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.

Costs of Stroke and Incidence of First Diagnosis of Atrial Fibrillation at Time of Stroke. Neurology Ward Hospital Poznań, Poland 2018

Stroke is a major cause of morbidity in industrialized countries, representing 8% of total deaths across Europe in 2017. It is also a very costly disorder, frequently caused by atrial fibrillation. We aimed to calculate the cost of stroke hospitalization in 2018 in Poznań (Poland). We also intended to present patients with the first AF diagnosis at the time of stroke. The study was conducted from January 2019 to July 2020. Data were obtained from hospital records and from the hospital accounting department. Out of 164 patients included in the study, 41 had AF and in 18 cases AF was first diagnosed at the time of stroke. The cost of hospitalization in Poznań was EUR 139,257.21 (x¯= EUR 849.13). Among those with concomitant AF, the general cost of inpatient care was EUR 33,859.18 (x¯= EUR 825.83). Considering those who had AF first diagnosed during hospitalization the cost was EUR 16,248.97 (x¯= EUR 906.24). Stroke is associated with high costs of inpatient care, which turned out to be higher among those with AF first diagnosed at the time of stroke. The number of patients who used oral anticoagulants at the time of admission was relatively low. The most frequently used NOAC was dabigatran.