Estimating the economic burden of status epilepticus to the health care system

PURPOSE

Status epilepticus (SE) is a major neurological condition associated with significant morbidity and mortality. No studies to evaluate the cost burden of SE have been performed to date. This study estimates the direct cost related to an inpatient admission for SE in an urban academic medical center.

METHODS

Cases of SE were defined based on a standard 30 min or greater seizure duration. The inpatient claims data were analyzed for 192 patients admitted with SE from 1 July 1993 through 30 June 1994. Patient demographic and clinical characteristics associated with increased cost were identified using multiple regression. The direct costs for SE were compared with other common DRGs.

RESULTS

The median reimbursement for a patient with SE was dollar 8417. The average length of stay for all SE patients was 12.9 days. Age groups (17-45 and 46-64) and etiology (acute CNS) were the only patient factors significantly associated with increased cost. SE patients had 30-60% higher reimbursements than patients admitted for other acute health problems including acute myocardial infarction or congestive heart failure.

CONCLUSIONS

The direct inpatient costs for SE are high compared with the direct costs of admissions for other major conditions such as acute myocardial infarction or congestive heart failure. Data from this study were used to estimate a dollar 4 billion annual direct cost for inpatient admissions for SE. Given the incidence and the high costs, further more detailed evaluation of these costs may be useful in assessing the adequacy of reimbursement for this subset of patients with epilepsy.

Costs of medical care after first-ever stroke in The Netherlands

BACKGROUND AND PURPOSE

Stroke causes high morbidity and mortality. The aging of the population further increases the demands on healthcare costs.

METHODS

We estimated the lifetime direct costs of care of first-ever stroke patients in the Netherlands in 1991 using epidemiological data from national and international studies. In addition, we examined the effect of an aging population on future healthcare costs.

RESULTS

The lifetime costs for 24,007 first-ever stroke patients are estimated to be 1870 million Dutch guilders (Dfl) (1 Dfl = 0.53 US dollar, 1991). Per-person costs are higher for women (83,000 Dfl) than for men (71,000 Dfl). The major cost component of first-year costs is hospital costs (45%), while nursing home costs dominate lifetime costs (50%). An increase of the elderly population older than 65 years of 27% between 1991 and 2010 might lead to a parallel increase of total costs of 30%, or 1.5% per year.

CONCLUSIONS

Long-term care rather than acute care dominates the lifetime costs for stroke patients now and in the future.

Management patterns and health care use after intracerebral hemorrhage. a cost-of-illness study from a societal perspective in Germany

BACKGROUND

The German cost-of-illness study of stroke is a multicenter study in 6 departments of internal medicine, 9 departments of general neurology and 15 departments of neurology with an acute stroke unit. The aims of this study are to describe the management patterns, cost of treatment and overall resource utilization after intracerebral hemorrhage (ICH) as well as the major differences to ischemic stroke (IS).

METHODS

During a 12-month period, 30 participating centers with a special interest in stroke prospectively included 586 patients with ICH which were collected in a joint data bank. About 75% of all patients could be centrally followed up via structured telephone interviews after 3 and 12 months to assess further acute hospital and rehabilitation stays, outpatient resource utilization, functional outcome and quality of life.

RESULTS

Mortality after 3 months (33.5%) was markedly higher than in patients with IS from the same hospitals. Accordingly, only 30.9% of patients had regained independent functional status after 3 months. Cumulative cost of treatment amounted to 5301 EUR for inpatient stay in the documenting hospital and 8920 EUR for the overall hospital stay including rehabilitation. Mean direct cost after discharge during the first year amounted to 4598 EUR and the loss of work force was equivalent to 5537 EUR in all surviving patients.

CONCLUSION

This study provides a comprehensive overview of patient characteristics, treatment strategies and health care cost of ICH from a societal perspective in Germany.

'Unqualified success' and 'unmitigated failure': number-needed-to-treat-related concepts for assessing treatment efficacy in the presence of treatment-induced adverse events

BACKGROUND

Common indices for the quantal assessment of treatment efficacy are reviewed. The absolute risk reduction is a practical index for public health considerations. Its reciprocal has been termed the 'Number Needed to Treat' (NNT), representing the health effort that must on average be expended to accomplish one tangible treatment target. We extend the NNT to evaluate outcome combinations of treatment benefits versus treatment harms.

METHODS

We describe the mathematical context of the NNT, and extend it to evaluate outcome combinations (treatment success/failure with/without treatment-induced adverse effects) in a treated population. These extensions are carried out assuming either independence or positive association between treatment benefit and treatment harm. A method is provided for calculating the standard errors of these extended NNT values. Applications to cost-effectiveness analysis are discussed.

RESULTS

We calculate NNT in three recent therapeutic studies. The results of a trial of the prevention of strokes with warfarin in patients with non-valvular atrial fibrillation are analysed to evaluate treatment success (stroke prevention) against treatment-induced bleeds. An NNT-related cost-benefit analysis is also carried out. We also analyse the results of a study of two modalities of chemotherapeutic treatment in small-cell lung cancer, and of two modalities of surgical intervention in the treatment of cholelithiasis.

CONCLUSIONS

The NNT are useful in direct evaluation of outcome-specific treatment benefits versus treatment-induced harms. They may also be used in cost-effectiveness analyses and are helpful in guiding public health programmes towards the identification of optimal treatment strategies.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

A prospective non-interventional multi-center study.

SETTING

Ten Japanese stroke centers.

STUDY PERIOD

Fourteen months between October 2000 and December 2001.

PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Resource utilization and costs of stroke unit care in Germany

OBJECTIVES

Stroke imposes a considerable economic burden on the individual and society. Recently, the concept of an integrated stroke unit has been established in several countries to improve the outcome of patients. This study evaluates the costs of acute care of the different cerebrovascular insults in a stroke unit.

METHODS

The study population included 340 patients who were consecutively admitted to the Department of Neurology, Philipps University Marburg, with the diagnosis of stroke or transient ischemic attack (TIA) between January 1 and June 30, 2000. Clinical status and course were evaluated by using the Barthel index and the modified Rankin scale. Employing a "bottom-up" approach, we calculated the costs from the perspective of the hospital and the third-party payer using data from provider departments and other published sources.

RESULTS

Inpatient costs were 3020 euros (3290 US dollars) for TIA, 3480 euros (3790 US dollars) for ischemic stroke (IS), and 5080 euros (5540 US dollars) for intracerebral hemorrhage (ICH) and differed significantly among these subgroups (P < .05). Patient subgroups ranked in the same order for average length of stay at 9.4 days for TIA, 10.2 days for IS, and 11.9 days for ICH (P > .05). Approximately 30% of the hospital costs are due to physician charges and care. Imaging amounted to 10% and lab investigations to 14% of total costs, independent of the diagnosis. Postacute treatment, including inpatient rehabilitation, cost 9880 euros per patient. Across all diagnostic groups, a mean clinical improvement was observed at time of discharge.

CONCLUSIONS

Care of patients with cerebrovascular events in a stroke unit causes a high demand of resources and has a considerable impact on health-care expenditure. Therefore, investigations comparing the stroke unit concept with other strategies in stroke care are necessary to evaluate the stroke unit concept for a rational use of available resources in patients with cerebrovascular events.

In-hospital direct cost of acute ischemic and hemorrhagic stroke in Greece

OBJECTIVES

The geographic inequity and the wide variation in the patterns of care of stroke found across Europe together with the lack of health economics evaluation in Greece led to this prospective study, aiming to provide data on in-hospital direct cost of patients with an acute stroke in Greece, and to identify independent prognostic factors.

METHODS

Demographic and clinical data were recorded on 429 consecutive patients with an acute ischemic or hemorrhagic stroke admitted to a tertiary care hospital in Greece during a period of 18 months. The costs incurred were estimated using the official financial charts listing in euro (euro), the real expenditure of all hospital departments.

RESULTS

The direct in-hospital cost for all stroke cases was 1,551,445euro for a total of 4674 days (331.9euro per day in-hospital). The mean in-hospital cost per stroke patient was 3624.9euro (+/-2695.4). Hemorrhagic strokes were significantly more expensive than the ischemic strokes [mean 5305.4 (+/-4204.8)euro and 3214.5 (+/-1976.2)euro, respectively) and lacunar strokes the least expensive among ischemic stroke subtypes. The length of stay was highly correlated with in-hospital total cost. Multivariate linear regression analysis showed that admission ward, stroke severity on admission, stroke type and status discharge were independent predictors of cost.

CONCLUSIONS

Purchasers in our health services should differentiate in their cost estimates and pricing schemes between types of cerebrovascular events. Future studies should focus on modifiable factors related, not only with stroke characteristics, but also with operational policies of hospitals, that may influence length of stay.

Cost-effectiveness of anticoagulation in nonrheumatic atrial fibrillation in the primary prevention of ischemic stroke

BACKGROUND AND PURPOSE

A number of clinical trials have shown the value of anticoagulating patients with nonrheumatic atrial fibrillation to prevent ischemic stroke. The purpose of this study was to assess the cost-effectiveness of anticoagulation in nonrheumatic atrial fibrillation with particular reference to the very elderly (aged >75 years) who have a higher incidence of bleeding events while undergoing anticoagulation.

METHODS

We calculated the incremental costs per life-year gained for 4 base cases using efficacy data from the Boston Area Anticoagulation Trial for Atrial Fibrillation, the meta-analysis of the 5 nonrheumatic atrial fibrillation trials, cost data from a district general hospital, and review of the literature.

RESULTS

The cost per life-year gained free from stroke over 10 years ranged from -pound sterling 400.45 (ie, a resource saving achieved for each life-year gained free from stroke) to pound sterling 13,221.29. The results were most sensitive to alteration in the frequency of anticoagulation monitoring.

CONCLUSIONS

For medical and economic reasons, anticoagulation treatment in the prevention of ischemic stroke is justified. Although older patients are more at risk of adverse events, anticoagulation is more cost-effective in this group.

Hospital costs for stroke care in Singapore

We performed this prospective study to determine the cost of care for acute stroke patients admitted to hospital. Stroke was subtyped into subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), nonlacunar infarct (NLC), lacunar infarct (LAC) and transient ischemic attack (TIA). Cost of care was computed for the various services the patient received. At the time of the study, US$ 1 = S$1. 50. 426 patients were studied. Mean length of stay (LOS) was 17 days. Mean cost/discharge was S$7,547. Ward charges accounted for 38.2%, radiology 14.5%, doctors' fees 10.3%, drugs 8.4%, therapy 7.3%. Cost was highly correlated with LOS, r(2) = 0.73. Mean cost/discharge was SAH S$28,539, IPH S$14,398, NLC S$7,476, LAC S$3,517, TIA S$1,962. Initial hospitalization cost for stroke is highly correlated with LOS. The bulk of cost is attributable to ward stay. Cost/discharge is highest with SAH, and in descending order IPH, NLC, LAC, TIA.

Outcome, cost analysis, and long-term follow-up in preterm infants with massive grade IV germinal matrix hemorrhage and progressive hydrocephalus

OBJECTIVE

The benefit of aggressive management and surgical intervention in preterm infants with massive Grade IV intracranial hemorrhage has been questioned based on the poor outcome of this group of patients despite such therapy. To further delineate this problem, we reviewed the records of premature neonates in this category as to outcome and initial hospital cost.

METHODS

We performed a retrospective review of the medical records at our institution from 1977 to 1987 to identify premature neonates who had sustained massive hemorrhagic infarction of one hemisphere in addition to having blood in both ventricles and progressive hydrocephalus.

RESULTS

During the study, a total of 52 such patients were identified, only 19 (6 female and 13 male patients) of whom survived. Intellectual function was observed to be greater than 2 standard deviations below the mean in 15 of the 19 patients, between 1 and 2 standard deviations below the mean in 1 of 19, and 1 standard deviation below the mean in 3 of 19. Motor function was as follows: 12 of 19 had marked spastic quadriparesis, 2 of 19 had moderate spastic quadriparesis, 3 of 19 had spastic hemiplegia, 1 of 19 had spastic diplegia, and 1 of 19 had mild spastic hemiparesis. Eleven of 19 had chronic seizure disorders. The first hospitalization cost for the group of patients exceeded, on the average, $150,000 per patient for the 19 long-term survivors.

CONCLUSION

As we have previously reported, logistic regression analysis determined that grade of hemorrhage was the only significant predictor of cognitive and motor outcomes. Most premature neonates with massive intracranial hemorrhages do not survive. The outcomes in those who do is very poor and the cost so high that we suggest that until therapeutic intervention exhibits efficacy, the consideration of withdrawal of life support should be presented as an option to the parents of these unfortunate children.

The societal costs of intracerebral hemorrhage in Spain

This study estimates the lifetime societal costs associated with incident intracerebral hemorrhage (ICH) in Spain. An epidemiological model of ICH incidence, survival and morbidity was developed using retrospective data from 28 hospitals in Andalusia and published data identified in a systematic literature review. Data on resource utilization and costs were obtained from five hospitals in the Canary Islands, whereas cost of outpatient care, informal care and lost productivity were obtained from standardized questionnaires completed by survivors of ICH. The lifetime societal costs of incident ICH in Spain is estimated at 46,193 euros per patient. Direct medical costs accounted for 32.7% of lifetime costs, whilst 67.3% were related to indirect costs. One-third of direct medical costs over the first year were attributable to follow-up care, including rehabilitation. Indirect costs were dominated by costs of informal care (71.2%). The aggregated lifetime societal costs for the estimated 12,534 Spanish patients with a first-ever ICH in 2004 was 579 million euros. ICH implies substantial costs to society primarily due to formal and informal follow-up care and support needed after hospital discharge. Interventions that offer survival benefits without improving patients' functional status are likely to further increase the societal costs of ICH.

Acute treatment costs of intracerebral hemorrhage and ischemic stroke in Argentina

BACKGROUND AND PURPOSE

Stroke is the third leading cause of death in Argentina, yet little information exists on the acute treatment provided for stroke or its costs. This study estimates the national costs of the acute treatment of first-ever intracerebral hemorrhage (ICH) and ischemic stroke (IS) in Argentina.

METHODS

Retrospective hospital-based inception study design using data on resource use and costs from high-volume stroke centers in Argentina, and published population-based incidence data. Treatment provided at two large urban hospitals were evaluated in all patients admitted with a first-ever stroke between 1 January 2004 and 31 August 2006, and costs were assigned using appropriate unit cost data for all resource use. Cost estimates in Argentinian pesos were converted to US dollars ($) using the 2005 purchasing power parity index. National costs of acute treatment for incident strokes were estimated by extrapolation of average costs estimates to national incidence data. Assumptions of the average cost of stroke treatment on a national scale were examined in sensitivity analysis.

RESULTS

The acute care of 167 patients with stroke was thoroughly evaluated from hospital admission to hospital discharge. Mean length of hospital stay was 35.4 days for ICH and 13.0 days for IS. Ninety-one percent of the patients with ICH and 68% of the patients with IS were admitted to an ICU for a mean length of stay (LOS) of 12.9 +/- 20.3 and 3.6 +/- 5.9 days respectively. Mean total costs of initial hospitalization were $12,285 (SD +/-14,336) for ICH and $3888 (SD +/-4018) for IS. Costs differed significantly by Glasgow Coma Scale (GCS) score at admission, development of pneumonia and infections during hospitalization, and functional outcome at hospital discharge. Aggregate national healthcare expenditures for acute treatment of incident ICH were $194.2m (range 97.1-388.4) and $239.9m for IS (range 119.9-479.7).

CONCLUSION

The direct hospital costs of incident ICH and IS in Argentina are substantial and primarily driven by stroke severity, in-hospital complications and clinical outcomes. With the expected increase in the incidence of stroke over the coming decades, these results emphasize the need for effective preventive and acute medical care.

Predictors of hospital length of stay and cost in patients with intracerebral hemorrhage

We used the 2002 Healthcare Cost and Utilization Project Nationwide Inpatient Sample to assess hospital length of stay (LOS) and cost among adults with a principal diagnosis of intracerebral hemorrhage (n = 13,239). Sixty-nine percent of patients were aged > or =65 years, and 31% died during hospitalization. Mean LOS (cost) was 7.7 days (15,256 dollars) (survivors: 9.6 days, 17,442 dollars). Patient, hospital, and payer characteristics accounted for 69.1% of variation in cost per discharge.

Cost-effectiveness of recombinant activated factor VII in the treatment of intracerebral hemorrhage

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) is among the most costly and debilitating forms of stroke. Results from a recent Phase IIb clinical trial demonstrate that administration of recombinant activated factor VII (rFVIIa) reduces ICH mortality and improves functional outcome. In the current analysis, we examine the cost-effectiveness of early treatment with rFVIIa for ICH in the United States.

METHODS

A decision-analytic model was developed to estimate the lifetime costs and outcomes associated with rFVIIa treatment at doses of 40, 80 and 160 microg/kg compared with current standard of care in treating ICH, from a US third-party payer perspective. The patient population was similar to that of the Phase IIb clinical trial. Model structure and inputs were obtained from published literature, clinical trial data, claims databases, and expert opinion. All costs are presented in 2005 US dollars. Outcomes included incremental cost per life-year (LY) saved and incremental cost per quality-adjusted life-year (QALY) gained. Costs and outcomes were discounted at 3% annually. Univariate and multivariate sensitivity analyses were conducted to assess model robustness.

RESULTS

Compared with standard care, treatment with rFVIIa 40 microg/kg, and 160 microg/kg results in total lifetime cost-effectiveness ratios of 6308 dollars/QALY and 3152 dollars/QALY, respectively. Treatment with rFVIIa 80 microg/kg was found to be cost saving and a gain of 1.67 QALYs is achieved over a patient's lifetime. These results are robust to changes in input parameters.

CONCLUSIONS

Treatment of ICH with rFVIIa 40 microg/kg and 160 microg/kg appears to be cost-effective (<or=50,000 dollars/QALY). At the 80 microg/kg dose, rFVIIa was not only cost-effective, but also cost saving.

Traumatic brain injury in children in Denmark: a national 15-year study

Demographic trends are reported concerning three types of traumatic brain injury (concussions, cranial fractures, and intracranial contusions/haemorrhages) among children in Denmark of ages up to and including 14 years, for a fifteen year period from 1979 through 1993. The data were derived from a national computer-based hospitalization register and include 49,594 children, of whom 60% were boys and 89% had suffered a concussion. Virtually all injuries were the result of accidents. A major finding was that there has been a general decline in the incidence of traumatic brain injuries, especially for boys from 5 to 14 years old, suggesting a degree of success in preventive measures, particularly regarding road safety. The incidence of fatal cases of intracranial contusions/haemorrhages approximately halved over the 15 year period. However, as a proportion of all diagnosed cases, mortality from intracranial contusions/haemorrhages remained fairly constant at about 22%, perhaps because there have been no markedly successful innovations in acute care. Among children surviving a intracranial contusions/haemorrhages, rather considerable numbers were found to have been awarded disability pension at ages under 30.

Cost and outcome in a series of shunted premature infants with intraventricular hemorrhage

This study examines cost and outcome in a series of 50 low birthweight infants who suffered severe intraventricular-periventricular hemorrhage and subsequently required ventriculoperitoneal shunting. Although nearly one third of these children might achieve some degree of self-sufficiency, a cost-benefit analysis in this shunted population is not encouraging.

Retrospective study of total healthcare costs associated with chronic nonvalvular atrial fibrillation and the occurrence of a first transient ischemic attack, stroke or major bleed

OBJECTIVE

To determine the direct healthcare costs associated with the onset of chronic nonvalvular atrial fibrillation (CNVAF), warfarin utilization and the occurrence of cerebrovascular events in a commercially-insured population.

RESEARCH DESIGN AND METHODS

This retrospective, observational cohort study utilized medical and pharmacy claims from a large, geographically diverse managed-care organization (N = 18.5 million) to identify continuously benefit-eligible CNVAF patients > or =45 years of age without prior valvular disease or warfarin use between January 1, 2001 and June 1, 2002. All patients were followed at least 6 months, until plan termination or the end of study follow-up. Stroke risk was assessed using the CHADS(2) (stroke-risk) index; warfarin use was defined as having filled at least one pharmacy claim. Inpatient and outpatient cost benchmarks were utilized to estimate total direct healthcare costs (pre- and post-AF index claim). For patients with transient ischemic attacks (TIA), ischemic stroke (IS) and major bleed (MB) total direct healthcare costs were also assessed. The limitations of this study included a descriptive retrospective study design without a comparison group or adjustment for baseline disease severity and drug exposure, as well as, the reliance upon administrative claims data and use of a standardized reference costing methodology.

RESULTS

The pre- and post-AF onset total direct healthcare costs (pmpm) for 3891 incidence CNVAF patients were $412 and $1235, respectively, a 200% increase. Of the 448 (12%) patients with a cerebrovascular event, pmpm costs post-AF ranged from $2235 to $3135 correlating with CHADS(2) stroke-risk status and exposure to warfarin. Total cohort pmpm costs pre and post event increased 24% from $3446.91 to $4262.12. Approximately 20% of all events occurred <2 days and 46% within 1 month after the index AF claim. Any warfarin exposure, regardless of CHADS(2) risk had an 18% to 29 % decrease in pmpm costs.

CONCLUSIONS

Post-AF total direct healthcare costs were 3 times greater than pre-AF costs. For those with a TIA, IS or MB, post-AF total direct healthcare costs increased 4.5 times from pre-AF costs; overall post-event costs in this cohort increased approximately 25% over pre-event costs. Nearly half of the events occurred within 1 month of a claim associated with an AF diagnosis. Warfarin exposure appeared to be associated with lower pmpm costs in this population.

Direct costs during the first year after intracerebral hemorrhage

OBJECTIVES

Knowledge of resource use and associated costs of treatment, care and rehabilitation at hospitals and in the health care and social service sectors is limited. This study presents data on the total resource use during the first year after spontaneous intracerebral hemorrhage.

METHODS

All patients hospitalized because of stroke at a university hospital in Copenhagen, Denmark, during a 1-year period 1994-1995 were included in a database. The patients were followed until 1 year after the stroke, and data on resource use during and after the hospital stay were collected prospectively. This study investigates a subgroup comprising 90 patients with intracerebral hemorrhage. Resource use is described and costs are calculated.

RESULTS

The cost of the hospital stay including acute care and rehabilitation had a mean of 90200 DKK (US$16100). The total cost of health care and social services during the first year had a mean of 123200 DKK (US$22000). Costs decreased significantly with age, but when differences of 30 days case fatality between age groups were considered, the association between costs and age disappeared.

CONCLUSIONS

The mean cost of treatment, care and rehabilitation during the first year after intracerebral hemorrhage was 123200 DKK, of which the primary hospital stay constituted 73%.

A multicenter comparison of outcomes associated with intravenous nitroprusside and nicardipine treatment among patients with intracerebral hemorrhage

INTRODUCTION

No clinical data exist to compare outcomes between patients with intracerebral hemorrhage (ICH) treated with different intravenous antihypertensive agents. This study was performed to compare outcomes among patients with ICH who were treated with intravenous infusion of different antihypertensive medications during the first 24 hours after admission.

METHODS

We analyzed one-year data (2005-2006) from the Premier database which is a nationally representative hospital discharge database containing data pertaining to admissions in the United States. We compared discharge outcomes, length of stay, and cost of hospitalization between groups of patients who were treated using either intravenous nicardipine or nitroprusside infusion. Chi-square and ANOVA were used for univariate analysis. Logistic and linear regression analyses were performed to adjust for baseline risk of mortality between the two groups.

RESULTS

A total of 12,767 admissions with primary diagnosis of ICH were identified. Nicardipine was administered in 926 patients (7.3%) and nitroprusside was administered in 530 (4.3%) patients. There was no difference in baseline disease severity or risk of mortality among patients who were administered nicardipine or nitroprusside. After adjustment for baseline risk of mortality, the risk of in-hospital mortality (odds ratio [OR] 1.7, 95% confidence interval [95% CI] 1.3-2.2) was higher among patients treated with nitroprusside compared with nicardipine. The risk of in-hospital mortality was also higher after adjustment for baseline risk of mortality and hospital characteristics in patients treated with nitroprusside (OR 1.6, 95% CI 1.2-2.1). After exclusion of patients who died during hospitalization, there was no difference in length of stay and total hospital cost in the multivariate analysis.

CONCLUSION

Use of nicardipine compared with nitroprusside infusion during the first 24 h after ICH may be associated with reduced risk of in-hospital mortality without any increase in the hospitalization cost or length of stay.

Racial Segregation and Intraventricular Hemorrhage in Preterm Infants

BACKGROUND

Intraventricular hemorrhage (IVH) disproportionately affects black neonates. Other conditions that are more common in black neonates, including low birth weight and preterm delivery, have been linked with residential racial segregation (RRS). In this study, we investigated the association between RRS and IVH.

METHODS

A retrospective cohort of neonates born between 24 and 32 weeks' gestation was constructed by using birth certificates linked to medical records from California, Missouri, and Pennsylvania between 1995 and 2009. Dissimilarity, a measure of RRS indicating the proportion of minorities in the census tract of the mother in comparison to the larger metropolitan area, was linked to patient data, yielding a cohort of 70 775 infants. Propensity score analysis matched infants born to mothers living in high segregation to those living in less segregated areas on the basis of race, sociodemographic factors, and medical comorbidities to compare the risk of developing IVH.

RESULTS

Infants born to mothers in the most segregated quartile had a greater risk of developing IVH compared with those in the lowest quartile (12.9% vs 10.4%; P < .001). In 17 918 pairs matched on propensity scores, the risk of developing IVH was greater in the group exposed to a segregated environment (risk ratio = 1.08, 95% confidence interval: 1.01-1.15). This effect was stronger for black infants alone (risk ratio = 1.16; 95% confidence interval: 1.03-1.30).

CONCLUSIONS

RRS is associated with an increased risk of IVH in preterm neonates, but the effect size varies by race. This association persists after balancing for community factors and birth weight, representing a novel risk factor for IVH.

Cost-effectiveness of prophylactic indomethacin in very-low-birth-weight infants

OBJECTIVE

To perform cost-effectiveness analysis to facilitate the decision-making process surrounding use of indomethacin in preterm infants to lower the incidence of patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH), and death.

METHODS

A MEDLINE literature search from 1966 to July 2000 was performed to identify relevant randomized, controlled trials (RCTs), as well as cohort and retrospective case-control studies. A decision tree was built representing the choice to use or not use indomethacin, and the potential outcome costs. Probabilities of being in each chance node were obtained from this search. Where data probabilities were not clear, a sensitivity analysis was conducted.

RESULTS

There was no difference in the expected survival per year; however, there was a significant difference when effectiveness was measured as quality-adjusted life years (QALYs), resulting in 11 and 10 years for the indomethacin and control groups, respectively. The indomethacin treatment cost was $95,157 and that of the control groups was $99,955. The cost effectiveness per life expectancy of being in the indomethacin and control groups was $7142 and $7727, respectively. The sensitivity analysis for PDA closure and prevention of IVH for infants eventually developing PDA versus those without PDA showed no difference. The cost-effectiveness analysis per QALY was $8443 for the indomethacin treatment and $9168 for the control group.

CONCLUSIONS

The prophylactic use of indomethacin is less costly and more effective within an important range of certainty. However, this analysis does not include several potentially confounding factors, such as antenatal steroid use or indomethacin-induced renal toxicity. Depending on the frequency with which these factors arise, economic projections may be considerably altered against the early use of indomethacin.

Chronic atrial fibrillation in the elderly: risks vs. benefits of long-term anticoagulation

Chronic atrial fibrillation is generally thought to cause stroke by atrial thrombus formation with subsequent embolization. Rheumatic heart disease previously led to most cases of atrial fibrillation, but recent substantial declines in the incidence of rheumatic fever have changed the distribution of causes of atrial fibrillation. Elderly patients have an appreciable prevalence of chronic atrial fibrillation. The risks and potential benefits of long-term anti-coagulation for elderly patients with atrial fibrillation are discussed and the quality of the evidence assessed. It is concluded that the evidence is sufficiently incomplete and imperfect for a large, well-designed trial to be needed; however, this would be difficult and expensive.

Distribution and predictors of hospital charges for haemorrhagic stroke patients in Beijing, China, March 2012 to February 2015: a retrospective study

OBJECTIVES

The purpose of this study is to analyse hospital charges for patients with haemorrhagic stroke in China and investigate potential factors associated with inpatient charges.

METHODS

The study participants were in-hospital patients with a primary diagnosis of haemorrhagic stroke from all the secondary and tertiary hospitals in Beijing during the period from 1 March 2012 to 28 February 2015. Distribution characteristics of detailed hospital charges were analysed. The influence of potential factors on hospital charges was researched using a stepwise multiple regression model.

RESULTS

A total of 34 890 patients with haemorrhagic stroke of mean age 61.19±14.37 years were included in the study, of which 37.2% were female. Median length of hospital stay (LOHS) was 15 days (IQR 9-23) and median hospital cost was 18 577 Chinese yuan (CNY) (IQR 10 442-39 784). The hospital costs for patients in Western medicine hospitals (median 19 651 CNY) were significantly higher (P<0.01) than those in traditional Chinese medicine hospitals (median 14 560 CNY), and were significantly higher (P<0.01) for Level 3 hospitals (median 20 029 CNY) than for Level 2 hospitals (median 16 095 CNY). The proportion of medicine fees and bed fees within total hospital charges showed a decreasing trend during the study period. With stepwise multiple regression, the major factors associated with hospital charges were LOHS, surgery, pulmonary infection, ventilator usage, hospital level, occupation, hyperlipidaemia, hospital type, in-hospital death, sex and age.

CONCLUSION

We conclude that medicines form the largest part of hospital charges but are showing a decreasing trend, and LOHS is strongly associated with patient charges for haemorrhagic stroke in China. This implies that the cost structure is very unreasonable in China and medical technology costs fail to be fully manifested. A reasonable decrease in medicine charges and shortening LOHS may be effective ways to reduce hospital charges.