Population-based approaches for reducing stroke risk: an update on their success and the challenges ahead

INTRODUCTION

Stroke is a significant public health challenge as it is the second most common cause of death and the third leading cause of disability globally. Additionally, stroke incidence and the number of stroke deaths have been rising. Efforts to prevent stroke have been made, including high-risk approaches where patients are screened for cardiovascular risk factors, and population-based approaches which attempt to reduce stroke rates by improving overall population health.

AREAS COVERED

We summarize studies of population-based approaches to stroke prevention involving greater than 1,000 participants identified on a PubMed database search. Based on these programs, challenges of population-based stroke prevention programs are discussed and potential keys to success are highlighted.

EXPERT OPINION

Population-based stroke prevention programs face challenges including cost and interest of the public and certain stakeholders. Additionally, secular trends for improvement in risk factors and catastrophic adverse environmental circumstances add to the complexity of analyzing program success. Factors leading to successful programs include validated digital solutions for self-monitoring of risks, backing by global policy and legislation, flexibility to the needs of the population, intersectoral programs, community engagement, information dissemination back to the populations, and high-risk screening to develop a complementary combination approach to stroke prevention.

Relative Clinical and Cost Burden of Community-Acquired Pneumonia Hospitalizations in Older Adults in the United States-A Cross-Sectional Analysis

The relative burden of community-acquired pneumonia (CAP) in older adults (≥65 years old) compared to other serious diseases is important to prioritize preventive treatment. A retrospective analysis was conducted using the 2014 National Readmission Database to evaluate the length of stay, inpatient mortality, 30-day readmissions, and costs of CAP compared to diabetes mellitus (DM), myocardial infarction (MI), and stroke. 275,790 hospitalizations were analyzed and represented a national estimate of 616,300 hospitalizations, including 269,961 for CAP, 71,284 for DM, 126,946 for MI, and 148,109 for stroke. The mean length of stay in CAP was 5.2 days, which was higher than DM (4.6) and MI (4.3) but similar to stroke (5.6). The inpatient mortality risk was lower for DM (RR: 0.37, 95% CI: 0.29–0.46) but higher for MI (RR: 1.67, 95% CI: 1.50–1.85) and stroke (RR: 1.67, 95% CI: 1.51–1.83). The median costs for CAP ($7282) were higher compared to DM ($6217) but lower compared to MI ($14,802) and stroke ($8772). The 30-day readmission rate was 17% in CAP, which was higher compared to MI (15%) and stroke (11.5%) and lower compared to DM (20.3%). In patients with CAP, disease burden is on par with other serious diseases. CAP should be prioritized for prevention in older adults with strategies such as vaccination and smoking cessation.

The relative burden of community-acquired pneumonia hospitalizations in older adults: a retrospective observational study in the United States

Background

The risk of community-acquired pneumonia (CAP) increases with age and significantly impacts morbidity and mortality in the elderly population. The burden of illness and cost of preventing CAP has not been compared to other serious diseases.

Methods

This retrospective analysis used claims data from 2014 to 2015 and compared hospitalizations for CAP, myocardial infarction (MI), stroke, and osteoporotic fractures (OF) in adults aged ≥65 years enrolled in a Medicare Advantage insurance plan. Individuals who had not already been hospitalized for one of these conditions and did not have evidence of long-term care were included in the study. Hospitalizations for each condition were described by length of stay, readmissions, mortality, and total costs. Preventive measures included vaccinations for CAP and medications for MI, stroke, and OF.

Results

A total of 1,949,352 individuals were included in the cohort. In 2015, the rate of CAP-related hospitalizations was the highest at 846.7 per 100,000 person-years compared to 405 for MI, 278.9 for stroke, and 343.9 for OF. Vaccination costs for CAP were $40.2 million including $14.1 million for pneumococcal and $26.1 million for influenza vaccines. The cost of preventive medications for MI and stroke reached over $661 million and OF totaled $169 million.

Conclusions

Although CAP has a higher burden of hospitalization and total costs than MI, stroke, and OF in the elderly population, prevention efforts were disproportionately smaller for CAP. Prioritization of CAP prevention is needed to substantially reduce the burden of CAP.

Adaptation of neurological practice and policy to a changing US health-care landscape

Health care in the USA is undergoing a drastic transformation under the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act is driving major health-care policy changes by connecting payment for traditional health-care services to value-based care initiatives and emphasising population health and innovative mechanisms to deliver care. Under the Patient Protection and Affordable Care Act, neurological practice will need to adapt and transform. Therefore, neurological policy should consider employing a new framework for neurological residency training, developing interdisciplinary team approaches to neurological subspecialty care, and strengthening the primary care-neurological specialty care interface to avoid redundancies and other medical waste. Additionally, neurological policy will need to support a more robust review of diagnostic and care pathway use to reduce avoidable expenditures, and test and implement bundled payments for key neurological diagnoses. In view of an anticipated 19% shortage of US neurologists in the next 10 years, development of new neurological policy under the Patient Protection and Affordable Care Act is paramount.