The medical economics of stroke

Development of a patient-reported outcome measure for patients who have recovered from a subarachnoid hemorrhage: the "questionnaire for the screening of symptoms in aneurysmal subarachnoid hemorrhage" (SOS-SAH)

Background

Patients who have been successfully treated for an aneurysmal subarachnoid hemorrhage (aSAH) often retain multiple health complaints, including mood disorders, cognitive complaints, fatigue, and problems with social participation. These problems are not always fully addressed during hospital visits or in current outcome measures, such as the modified Rankin score and the Glasgow Outcome Scale. Here, we present the development of the “Questionnaire for the Screening of Symptoms in aneurysmal Subarachnoid Hemorrhage” (SOS-SAH), which screens for the self-reported symptoms of patients with mild disabilities.

Methods

During the development of the SOS-SAH we adhered to the PROM-cycle framework for the selection and implementation of patient-reported outcome measures (PROMs). The SOS-SAH was developed in an iterative process informed by a literature study. Patients and healthcare professionals were involved in the development process through participating in a working group, interviews, and a cognitive validation study.

Results and conclusions

Relevant patient-reported outcomes (PROs) were identified for patients with aSAH. The SOS-SAH was developed primarily using domains and items from existing PROMs and, if necessary, by developing new items. The SOS-SAH consists of 40 items and covers 14 domains: cognitive abilities, hypersensitivity to stimuli, anxiety, depression, fatigue, social roles, personality change, language, vision, taste, smell, hearing, headache, and sexual function. It also includes a proxy measurement for use by family members to assess cognitive functioning and personality change.

Association of outdoor air pollution with the medical expense of ischemic stroke: The case study of an industrial city in western China

Ischemic stroke, the most frequent cause of severe disability, imposes a significant mental and economic burden on patients and their families. There is increasing evidence to indicate that air pollution contributes to the risk of ischemic stroke. This study aimed to examine the correlation between air pollution and the expense imposed by an ischemic stroke. Data were obtained from hospitals and environmental monitoring stations in an industry city, Longspring, in western China. We used a generalized additive model to estimate the associations between the two factors, measured during 2015-2017. Counter-intuitively, the medical expenses arising from ischemia were negatively associated with the level of air pollution. The corresponding ER for per interquartile range increase of PM2.5, PM10, SO₂ , and NO₂ in lag10 was -0.17% (95% confidence interval (95% CI -0.31%, -0.03%), -0.11% (95% CI -0.2%, -0.02%), -1.04% (95% CI -1.92%, -0.17%) and -0.44% (95% CI -0.66%, -0.22%), respectively (p < 0.05). Subgroups based on gender, age, and season were considered in the analysis. The results indicated that pollutants had significant effects on ischaemia's medical expenses, which were stronger for older people, patients who survived, and warm seasons. This study is the first step in optimizing medical resources, which are essential for policymaking and service planning.

Wall Shear Stress and Flow Patterns in Unruptured and Ruptured Anterior Communicating Artery Aneurysms Using Computational Fluid Dynamics

Objective

The goal of this study was to compare several parameters, including wall shear stress (WSS) and flow pattern, between unruptured and ruptured anterior communicating artery (ACoA) aneurysms using patient-specific aneurysm geometry.

Methods

In total, 18 unruptured and 24 ruptured aneurysms were analyzed using computational fluid dynamics (CFD) models. Minimal, average, and maximal wall shear stress were calculated based on CFD simulations. Aneurysm height, ostium diameter, aspect ratio, and area of aneurysm were measured. Aneurysms were classified according to flow complexity (simple or complex) and inflow jet (concentrated or diffused). Statistical analyses were performed to ascertain differences between the aneurysm groups.

Results

Average wall shear stress of the ruptured group was greater than that of the unruptured group (9.42% for aneurysm and 10.38% for ostium). The average area of ruptured aneurysms was 31.22% larger than unruptured aneurysms. Simple flow was observed in 14 of 18 (78%) unruptured aneurysms, while all ruptured aneurysms had complex flow (p<0.001). Ruptured aneurysms were more likely to have a concentrated inflow jet (63%), while unruptured aneurysms predominantly had a diffused inflow jet (83%, p=0.004).

Conclusion

Ruptured aneurysms tended to have a larger geometric size and greater WSS compared to unruptured aneurysms, but the difference was not statistically significant. Flow complexity and inflow jet were significantly different between unruptured and ruptured ACoA aneurysms.

The High Cost of Stroke and Stroke Cytoprotection Research

Acute ischemic stroke is inadequately treated in the USA and worldwide due to a lengthy history of neuroprotective drug failures in clinical trials. The majority of victims must endure life-long disabilities that not only affect their livelihood, but also have an enormous societal economic impact. The rapid development of a neuroprotective or cytoprotective compound would allow future stroke victims to receive a treatment to reduce disabilities and further promote recovery of function. This opinion article reviews in detail the enormous costs associated with developing a small molecule to treat stroke, as well as providing a timely overview of the cell-death time-course and relationship to the ischemic cascade. Distinct temporal patterns of cell-death of neurovascular unit components provide opportunities to intervene and optimize new cytoprotective strategies. However, adequate research funding is mandatory to allow stroke researchers to develop and test their novel therapeutic approach to treat stroke victims.

Neutrophil-to-Lymphocyte Ratio Predicts Length of Stay and Acute Hospital Cost in Patients with Acute Ischemic Stroke

BACKGROUND

Although several risk factors for prolonged length of stay (LOS) and increased hospital cost have been identified, the association between LOS, hospital cost, and neutrophil-to-lymphocyte ratio (NLR) has not yet been investigated. We aimed to investigate the influence of NLR on LOS and hospital cost in patients with acute ischemic stroke.

METHODS

Patients with acute ischemic stroke diagnosed within 24 hours of symptom onset were included. Univariate analysis and stepwise multiple regression analysis were used to identify independent predictors of LOS and hospital cost.

RESULTS

A total of 346 patients were included in the final analysis. The median LOS was 11 days (range 8-13 days). The median acute hospital cost per patient was 19,030.6 RMB (U.S. $ 3065.8) (range 14,450.8 RMB-25,218.2 RMB). Neutrophil count to lymphocyte count (NLR) (P < .001), diabetes mellitus (P = .034), stroke subtype (P = .005), and initial stroke severity (P < .001) were significantly associated with prolonged LOS in the univariate analysis. NLR (P < .001), smoking (P = .04), stroke subtype (P < .001), initial stroke severity (P < .001), and LOS (P < .001) were significantly associated with increased hospital cost in the univariate analysis. Multivariate regression analysis showed that NLR was an independent predictor of both LOS and acute hospital cost. In addition, high NLR was significantly correlated with poor outcome at discharge, prolonged LOS, and increased hospital cost.

CONCLUSIONS

NLR is significantly associated with LOS and acute hospital cost in patients presenting with acute ischemic stroke. It is a simple, inexpensive, and readily available biomarker and may serve as a clinically practical indicator for assessing the economic burden of stroke.

Generalized versus patient-specific inflow boundary conditions in computational fluid dynamics simulations of cerebral aneurysmal hemodynamics

BACKGROUND AND PURPOSE

Attempts have been made to associate intracranial aneurysmal hemodynamics with aneurysm growth and rupture status. Hemodynamics in aneurysms is traditionally determined with computational fluid dynamics by using generalized inflow boundary conditions in a parent artery. Recently, patient-specific inflow boundary conditions are being implemented more frequently. Our purpose was to compare intracranial aneurysm hemodynamics based on generalized versus patient-specific inflow boundary conditions.

MATERIALS AND METHODS

For 36 patients, geometric models of aneurysms were determined by using 3D rotational angiography. 2D phase-contrast MR imaging velocity measurements of the parent artery were performed. Computational fluid dynamics simulations were performed twice: once by using patient-specific phase-contrast MR imaging velocity profiles and once by using generalized Womersley profiles as inflow boundary conditions. Resulting mean and maximum wall shear stress and oscillatory shear index values were analyzed, and hemodynamic characteristics were qualitatively compared.

RESULTS

Quantitative analysis showed statistically significant differences for mean and maximum wall shear stress values between both inflow boundary conditions (P < .001). Qualitative assessment of hemodynamic characteristics showed differences in 21 cases: high wall shear stress location (n = 8), deflection location (n = 3), lobulation wall shear stress (n = 12), and/or vortex and inflow jet stability (n = 9). The latter showed more instability for the generalized inflow boundary conditions in 7 of 9 patients.

CONCLUSIONS

Using generalized and patient-specific inflow boundary conditions for computational fluid dynamics results in different wall shear stress magnitudes and hemodynamic characteristics. Generalized inflow boundary conditions result in more vortices and inflow jet instabilities. This study emphasizes the necessity of patient-specific inflow boundary conditions for calculation of hemodynamics in cerebral aneurysms by using computational fluid dynamics techniques.

Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition

BACKGROUND AND PURPOSE

The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience.

METHODS

We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices.

RESULTS

Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures.

CONCLUSIONS

Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

Performance of current guidelines for coronary heart disease prevention: optimal use of the Framingham-based risk assessment

BACKGROUND

There is a strong positive association between Framingham Risk Scores (FRS) in a population and incidence of hard coronary heart disease (hCHD) events. Under current Adult Treatment Panel III guidelines, individuals with FRS that indicate ≥20% 10-year risk of hCHD are recommended to receive intensive medical risk factor modification. We sought to assess the performance of FRS as a predictive tool when used as in current guidelines.

METHODS

A retrospective analysis of two prospective cohort studies, the Atherosclerosis Risk in Communities (ARIC) study, and Cardiovascular Health Study (CHS), including 11,436 and 2569 participants, respectively, without known cardiovascular disease or diabetes at baseline, with available FRS variables were analyzed. The FRS was computed according to standard algorithm. The main outcome was hCHD event defined as MI or coronary death. Using Receiver Operating Characteristics (ROC) curves, sensitivity, specificity, accuracy and other test performance characteristics were determined at various 10-year risk thresholds. ROC curves were plotted.

RESULTS

During 10-year follow-up, 822 hCHD events occurred. FRS was significantly associated with hCHD with an AUC of 0.77 and 0.68 for ARIC and CHS, respectively (p-values <0.0001). However, at standard "high risk" cut-off (≥20%), the sensitivity of FRS was only 13% and 25%, respectively and Youden's Index was only 0.10 and 0.15. Lowering the 10-year risk threshold to >5% improved prediction sensitivity to 75% and 83%, with specificity of 66% and 40%, respectively.

CONCLUSION

When used dichotomously as in current guidelines, sensitivity of the conventional 20% 10-year risk threshold for subsequent hCHD events is quite low. Since the 20% 10-year risk threshold for intensive medical risk factor therapy is on the steep part of the ROC curve, lowering the threshold results in substantial increases in sensitivity with much smaller losses in specificity, even to a threshold as low as 5%.

[Management of stroke in sub-Saharan Africa: current issues]

In sub-Saharan Africa, stroke is likely to present an increasingly important public health problem with a larger relative share of overall morbidity and mortality. Overall, sub-Saharan Health Care is characterized by a lack of human resources, lack of facilities for special investigations, and especially an absence of specific programs addressing the prevention of cardiovascular conditions. Current data on the epidemiology of stroke in sub-Saharan Africa, although sparse and fragmentary, indicate a comparatively high incidence of cerebral hemorrhage associated with high blood pressure, while ischemic stroke in black Africans still appears to be related primarily to small artery disease, HIV infection, and sickle cell disease. With urbanization, the role of large-vessel atherosclerosis is increasing. It is thus essential to coordinate government funding, health care professionals and development agencies to address this rising health problem. Access to health care needs to be better structured, and screening programs should be developed in order to identify and treat vascular risk factors. Improved training of health care professionals is also required in the areas of prevention, diagnosis and management of stroke. Implementation of best-practice recommendations for the management of stroke adapted to the specificities and resources of African countries would help rationalize the scarce resources currently available.

Which variables help explain the poor health-related quality of life after subarachnoid hemorrhage? A meta-analysis

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) are younger than typical stroke patients. Poor psychosocial outcome after SAH therefore leads to a disproportionately high impact on patients, relatives, and society. Addressing this problem requires an understanding of what causes poor psychosocial outcome. Numerous studies have examined potential predictors but produced conflicting results. We aim to resolve this uncertainty about the potential value of individual predictors by conducting a meta-analysis. This approach allows us to quantitatively combine the findings from all relevant studies to identify promising predictors of psychosocial outcome and determine the strength with which those predictors are associated with measures of psychosocial health.

METHODS

Psychosocial health was measured by health-related quality of life (HRQOL). We included in our analysis those predictors that were most frequently examined in this context, namely patient age, sex, neurologic state at the time of hospital admission, bleed severity, physical disability, cognitive impairment, and time between ictus and psychosocial assessment.

RESULTS

Only 1 of the traditional variables, physical disability, had any notable affect on HRQOL. Therefore, the cause of most HRQOL impairment after SAH remains unknown. The situation is even worse for mental HRQOL, an area that is often significantly affected in SAH patients. Here, 90% of the variance remains unexplained by traditional predictors.

CONCLUSION

Studies need to turn to new factors to account for poor patient outcome.

Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients

BACKGROUND

Length of hospital stay (LOHS) is the largest determinant of direct cost for stroke care. Institutional discharges (acute care and nursing homes) from rehabilitation settings add to the direct cost. It is important to identify potentially preventable medical and non-medical reasons determining LOHS and institutional discharges to reduce the direct cost of stroke care.

AIM

The aim of the study was to ascertain the total direct cost, LOHS, frequency of institutional discharges and their determinants from rehabilitation settings.

METHODOLOGY

Observational study was conducted on 200 stroke patients in two rehabilitation settings. The patients were examined for various socio-demographic, neurological and clinical variables upon admission to the rehabilitation hospitals. Information on total direct cost and medical complications during hospitalization were also recorded. The outcome variables measured were total direct cost, LOHS and discharges to institutions (acute care and nursing home facility) and their determinants.

RESULTS

The mean and median LOHS in our study were 34 days (SD = 18) and 32 days respectively. LOHS and the cost of hospital stay were significantly correlated. The significant variables associated with LOHS on multiple linear regression analysis were: (i) severe functional impairment/functional dependence Barthel Index < or = 50, (ii) medical complications, (iii) first time stroke, (iv) unplanned discharges and (v) discharges to nursing homes. Of the stroke patients 19.5% had institutional discharges (22 to acute care and 17 to nursing homes). On multivariate analysis the significant predictors of discharges to institutions from rehabilitation hospitals were medical complications (OR = 4.37; 95% CI 1.01-12.53) and severe functional impairment/functional dependence. (OR = 5.90, 95% CI 2.32-14.98).

CONCLUSION

Length of hospital stay and discharges to institutions from rehabilitation settings are significantly determined by medical complications. Importance of adhering to clinical pathway/protocol for stroke care is further discussed.

Cerebrovascular Diseases as Primary Hospital Discharge Diagnoses: National Trend (1970-2000) Among Older Adults

BACKGROUND

Cerebrovascular diseases are a common cause of mortality, morbidity, and hospitalization among older adults. However, the long-term national trends in cerebrovascular disease-related hospitalizations in this age group are not well known.

METHODS

We used the National Center for Health Statistics trend data from the National Hospital Discharge Surveys (1970-2000) to determine incidence of cerebrovascular disease-related hospitalizations among persons 65 years and older in the United States. Only patients discharged with a primary discharge diagnosis of cerebrovascular disease were included. We estimated rates of hospitalization per 1000 civilian residents 65 years and older, for all patients and stratified by age, sex, and race.

RESULTS

Among persons 65 years of age and older, the total number of cerebrovascular disease-related hospitalizations increased from 372,000 in 1970 to 711,000 in 2000. However, the rates of hospitalization due to cerebrovascular disease remained unchanged at 20.7/1000 in 1970 and 20.4/1000 in 2000. The rates for persons 75-84 years and >85 years were, respectively, 2 and 3 times higher than that for persons 65-74 years throughout the study period. Rates for men and women were comparable and stable during the study period. Rates for African Americans, in contrast, increased from 14/1000 in 1970 to 20.6/1000 in 2000, peaking in 1985 (27.4/1000).

CONCLUSIONS

The overall rates of hospitalization due to cerebrovascular disease remained high yet stable. However, the absolute number of hospitalizations due to cerebrovascular disease increased considerably, with potential for serious social, financial, and public health implications for the coming decades.

[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.

Cost-effective outcome for treating poor-grade subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The goal of this study was to prospectively assess outcome and cost for poor-grade subarachnoid hemorrhage patients presenting to a regional neurosurgical center (Addenbrooke's Hospital, Cambridge, UK) between 1994 and 2001. Outcome measures were clinical outcome at 6 months, number needed to treat (NNT) for favorable outcomes, and cost analysis.

METHODS

Poor-grade patients (World Federation of Neurological Surgeons grades 4 and 5) were transferred to the neurocritical care unit after intubation and ventilation. After resuscitation and drainage of ventricular cerebrospinal fluid for 24 hours, sedation was stopped, and patients were assessed clinically. Patients with a Glasgow Motor Score (GMS) > or =4 underwent angiography and surgical treatment of culprit aneurysms. Patients with a subsequent GMS of 6 were not deemed poor grade and were discounted from the study.

RESULTS

We deemed 166 ventilated patients genuinely poor grade (mean age, 53.4 years; 94 women [56.6%]). Of these, 88 patients (4<GMS<6; 53%) progressed to angiography and possible definitive treatment. Seventy-five patients had an identifiable aneurysm, but only 64 survived for treatment. Operative mortality was 31.3%, and of the 44 survivors, 22 (34.4% of operated patients) achieved a favorable outcome. Favorable outcomes were more frequently seen in women than men (21.3% versus 6.9%) but were unrelated to patient age. The NNT for 1 favorable outcome was 7 (male NNT, 15; female NNT, 5) at a cost of pound 84 336 per favorable outcome (female, pound 60 240; male, pound 180 720).

CONCLUSIONS

Poor-grade aneurysmal subarachnoid hemorrhage is associated with a high mortality but a significant subset of patients can achieve favorable outcomes.

The economics of smoking and cardiovascular disease

The direct medical cost of cardiovascular and circulatory diseases was $151 billion in 1995, approximately 17% of all direct medical care costs in the United States. Incidence and prevalence based estimates indicate that smoking is a major contributing factor for cardiovascular disease and associated costs. Statewide smoking control programs and workplace and public area smoking bans are effective in reducing smoking prevalence. Smoking cessation therapies are very cost-effective interventions for the prevention of cardiovascular disease. Incidence based estimates indicate that smoking cessation control expenditures in the United States have been a cost effective method for reducing the direct medical costs of cardiovascular disease in the past, and may be cost saving in the future. The expected cost of producing an additional ex-smoker has been estimated to be approximately $1,000 to $1,500. Most or all of this cost can be recovered in the short run from savings in avoided heart attacks and strokes alone in healthy quitters. Observational studies of the direct medical costs following cessation in those observed to quit show a reduction utilization, but which may occur only after a lag of three to five years.

Assessment of the effect of ramipril therapy on direct health care costs for first and recurrent strokes in high-risk cardiovascular patients using data from the Heart Outcomes Prevention Evaluation (HOPE) study

BACKGROUND

In the Heart Outcomes Prevention Evaluation (HOPE) Study, the angiotensin-converting enzyme (ACE) inhibitor ramipril was shown to significantly reduce the relative risk of stroke by 32% in high-risk cardiovascular patients (P < 0.001). However, the study did not examine the economic implications of these findings.

OBJECTIVE

The purpose of this economic analysis was to estimate the potential economic benefits of the differences in direct health care costs attributable to the prevention of first and recurrent strokes in the HOPE Study patient population through the use of ramipril.

METHODS

The epidemiologic component of the model examined the incidence of first and recurrent strokes in the HOPE Study population, assessed at annual increments, for the years 1995 through 1997. An economic decision model was constructed by the application of costs to the epidemiologic foundation. Direct costs for stroke hospitalization and follow-up were calculated based on estimates provided by Samsa et al (1999). The estimated cost of ramipril treatment was based on the average wholesale price for the corresponding year of the analysis. The Samsa index costs are given in 1991 US $; they were converted to study-year US $ using the Consumer Price Index for the corresponding year.

RESULTS

The mean age of the patient population was 69 years, with >70% of patients aged >/=65 years. When ACE-inhibitor treatment costs were included in the calculation of treatment costs, the expense to avert 1 stroke was estimated at $13,766 for years 1 to 2 after randomization and $12,281 for years 2 to 3. By years 3 to 4, ramipril treatment resulted in 21 fewer strokes and produced an estimated savings of $52,861.

CONCLUSION

Ramipril 10 mg/d was a cost-effective means of preventing first and recurrent ischemic strokes in the HOPE Study patient population.

The estimated cost of managing focal spasticity: a physician practice patterns survey

The purpose of this study was to estimate the overall cost of managing focal spasticity after stroke (CVA) and traumatic brain injury (TBI) and the cost impact of individual treatments. Sixty physicians described management strategies over six treatment visits for four focal spasticity case studies (one upper and one lower extremity case for CVA and TBI). Mean and median per-case costs were determined across physicians; median per-case costs of physicians who did or did not report use of specific treatments were compared. Mean per-case costs of managing spasticity are as follows: CVA upper, $5,131; CVA lower, $5,384; TBI upper, $14,615; and TBI lower, $13,966. Median per-case costs for strategies including botulinum toxin type A (BTX-A) were less than those without BTX-A in CVA upper; median costs for strategies including oral baclofen were more than those without baclofen in CVA lower. Fewer total treatments were reported with BTX-A than without; more total treatments were reported with baclofen than without. No individual treatment had a significant impact on median treatment costs in TBI. Physician-reported spasticity management costs are substantial. Despite higher drug costs for BTX-A compared with oral therapies like baclofen, strategies for managing spasticity in CVA that include BTX-A may cost less than those without BTX-A.