Progressive multifocal leukoencephalopathy and Creutzfeldt-Jakob disease: population-wide incidences, comorbidities, costs of care, and outcomes

Neurological disorders associated with chronic infections are often progressive as well as challenging to diagnose and manage. Among 4.4 million persons from 2004 to 2019 receiving universal health, progressive multifocal leukoencephalopathy (PML, n = 58) and Creutzfeldt-Jakob disease (CJD, n = 93) cases were identified, revealing stable yearly incidence rates with divergent comorbidities: HIV/AIDS affected 37.8% of PML cases while cerebrovascular disease affected 26.9% of CJD cases. Most CJD cases died within 1 year (73%) although PML cases lived beyond 5 years (34.1%) despite higher initial costs of care. PML and CJD represent important neurological disorders with evolving risk variables and impact on health care.

Exploration of Medical Trajectories of Stroke Patients Based on Group-Based Trajectory Modeling

A high mortality rate is an issue with acute cerebrovascular disease (ACVD), as it often leads to a high medical expenditure, and in particular to high costs of treatment for emergency medical conditions and critical care. In this study, we used group-based trajectory modeling (GBTM) to study the characteristics of various groups of patients hospitalized with ACVD. In this research, the patient data were derived from the 1 million sampled cases in the National Health Insurance Research Database (NHIRD) in Taiwan. Cases who had been admitted to hospitals fewer than four times or more than eight times were excluded. Characteristics of the ACVD patients were collected, including age, mortality rate, medical expenditure, and length of hospital stay for each admission. We then performed GBTM to examine hospitalization patterns in patients who had been hospitalized more than four times and fewer than or equal to eight times. The patients were divided into three groups according to medical expenditure: high, medium, and low groups, split at the 33rd and 66th percentiles. After exclusion of unqualified patients, a total of 27,264 cases (male/female = 15,972/11,392) were included. Analysis of the characteristics of the ACVD patients showed that there were significant differences between the two gender groups in terms of age, mortality rate, medical expenditure, and total length of hospital stay. In addition, the data were compared between two admissions, which included interval, outpatient department (OPD) visit after discharge, OPD visit after hospital discharge, and OPD cost. Finally, the differences in medical expenditure between genders and between patients with different types of stroke-ischemic stroke, spontaneous intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH)-were examined using GBTM. Overall, this study employed GBTM to examine the trends in medical expenditure for different groups of stroke patients at different admissions, and some important results were obtained. Our results demonstrated that the time interval between subsequent hospitalizations decreased in the ACVD patients, and there were significant differences between genders and between patients with different types of stroke. It is often difficult to decide when the time has been reached at which further treatment will not improve the condition of ACVD patients, and the findings of our study may be used as a reference for assessing outcomes and quality of care for stroke patients. Because of the characteristics of NHIRD, this study had some limitations; for example, the number of cases for some diseases was not sufficient for effective statistical analysis.

Socioeconomic gap between neighborhoods of Budapest: Striking impact on stroke and possible explanations

Introduction

Hungary has a single payer health insurance system offering free healthcare for acute cerebrovascular disorders. Within the capital, Budapest, however there are considerable microregional socioeconomic differences. We hypothesized that socioeconomic deprivation reflects in less favorable stroke characteristics despite universal access to care.

Methods

From the database of the National Health Insurance Fund, we identified 4779 patients hospitalized between 2002 and 2007 for acute cerebrovascular disease (hereafter ACV, i.e. ischemic stroke, intracerebral hemorrhage, or transient ischemia), among residents of the poorest (District 8, n = 2618) and the wealthiest (District 12, n = 2161) neighborhoods of Budapest. Follow-up was until March 2013.

Results

Mean age at onset of ACV was 70±12 and 74±12 years for District 8 and 12 (p<0.01). Age-standardized incidence was higher in District 8 than in District 12 (680/100,000/year versus 518/100,000/year for ACV and 486/100,000/year versus 259/100,000/year for ischemic stroke). Age-standardized mortality of ACV overall and of ischemic stroke specifically was 157/100,000/year versus 100/100,000/year and 122/100,000/year versus 75/100,000/year for District 8 and 12. Long-term case fatality (at 1,5, and 10 years) for ACV and for ischemic stroke was higher in younger District 8 residents (41–70 years of age at the index event) compared to D12 residents of the same age. This gap between the districts increased with the length of follow-up. Of the risk diseases the prevalence of hypertension and diabetes was higher in District 8 than in District 12 (75% versus 66%, p<0.001; and 26% versus 16%, p<0.001).

Discussion

Despite universal healthcare coverage, the disadvantaged district has higher ACV incidence and mortality than the wealthier neighborhood. This difference affects primarily the younger age groups. Long-term follow-up data suggest that inequity in institutional rehabilitation and home-care should be investigated and improved in disadvantaged neighborhoods.

Power Relations and Premature Mortality in Spain's Autonomous Communities

This trends ecological study analyzes, across 17 autonomous communities of Spain from 1989 to 1998, the relationship between mortality (total and by main causes of death) and power relations (type of government: social democratic (SDP), conservative (CDP), and others), labor market variables, welfare state variables, income inequality, absolute income, poverty, and number of civil associations. The authors conducted a descriptive analysis; a bivariate analysis (Pearson correlation coefficients) between mortality and each of the independent variables; and a multivariate analysis, adjusting multilevel linear regression models. All dimensions of the conceptual power relations model were related to premature mortality in the direction hypothesized. The cross-pooled multilevel regression models show that total premature mortality in males, male and female cerebrovascular mortality, male and female cirrhosis mortality, and male lung cancer mortality decreased somewhat more in communities where primary health care reform was implemented more quickly. Premature mortality decreased somewhat more in SDP than in CDP communities for male and female total premature mortality, cerebrovascular mortality, and cirrhosis mortality, and male lung cancer mortality. These results are in accord with earlier studies that found a relationship among health indicators and variables related to labor market, welfare state, income inequalities, civil associations, and power relations.

Healthcare Costs Associated with an Adequate Intake of Sugars, Salt and Saturated Fat in Germany: A Health Econometrical Analysis

Non-communicable diseases (NCDs) represent not only the major driver for quality-restricted and lost life years; NCDs and their related medical treatment costs also pose a substantial economic burden on healthcare and intra-generational tax distribution systems. The main objective of this study was therefore to quantify the economic burden of unbalanced nutrition in Germany—in particular the effects of an excessive consumption of fat, salt and sugar—and to examine different reduction scenarios on this basis. In this study, the avoidable direct cost savings in the German healthcare system attributable to an adequate intake of saturated fatty acids (SFA), salt and sugar (mono- & disaccharides, MDS) were calculated. To this end, disease-specific healthcare cost data from the official Federal Health Monitoring for the years 2002–2008 and disease-related risk factors, obtained by thoroughly searching the literature, were used. A total of 22 clinical endpoints with 48 risk-outcome pairs were considered. Direct healthcare costs attributable to an unbalanced intake of fat, salt and sugar are calculated to be 16.8 billion EUR (CI95%: 6.3–24.1 billion EUR) in the year 2008, which represents 7% (CI95% 2%-10%) of the total treatment costs in Germany (254 billion EUR). This is equal to 205 EUR per person annually. The excessive consumption of sugar poses the highest burden, at 8.6 billion EUR (CI95%: 3.0–12.1); salt ranks 2^nd at 5.3 billion EUR (CI95%: 3.2–7.3) and saturated fat ranks 3^rd at 2.9 billion EUR (CI95%: 32 million—4.7 billion). Predicted direct healthcare cost savings by means of a balanced intake of sugars, salt and saturated fat are substantial. However, as this study solely considered direct medical treatment costs regarding an adequate consumption of fat, salt and sugars, the actual societal and economic gains, resulting both from direct and indirect cost savings, may easily exceed 16.8 billion EUR.

Disease staging as a measure of disease severity

Disease staging, first developed in 1970, has been used to assess the levels of biological severity, defined as the risk of organ failure or death, of specific medical diseases. Because few studies to date have evaluated disease staging in Japan, a small pilot study was designed to determine whether disease staging is available and useful in actual medical practice in Japan. The relationships between disease staging and length of stay, medical costs and age were retrospectively evaluated in patients admitted to Japan Association for Development of Community Medicine - Tokyo Bay Urayasu Ichikawa Medical Center for appendicitis, type 2 diabetes mellitus, and cerebrovascular diseases from April 2012 to March 2013. Patients were easily staged based on information at the time of hospital discharge. Disease stages were found to be affected significantly by length of hospital stay and medical costs. Age also affected disease stages in patients with appendicitis. These findings indicate that disease staging was available in Japan and was affected by hospital resources, including length of hospital stay and medical costs.

Direct medical costs of hospitalizations for cardiovascular diseases in Shanghai, China: trends and projections

Few studies in China have focused on direct expenditures for cardiovascular diseases (CVDs), making cost trends for CVDs uncertain. Epidemic modeling and forecasting may be essential for health workers and policy makers to reduce the cost burden of CVDs.To develop a time series model using Box-Jenkins methodology for a 15-year forecasting of CVD hospitalization costs in Shanghai.Daily visits and medical expenditures for CVD hospitalizations between January 1, 2008 and December 31, 2012 were analyzed. Data from 2012 were used for further analyses, including yearly total health expenditures and expenditures per visit for each disease, as well as per-visit-per-year medical costs of each service for CVD hospitalizations. Time series analyses were performed to determine the long-time trend of total direct medical expenditures for CVDs and specific expenditures for each disease, which were used to forecast expenditures until December 31, 2030.From 2008 to 2012, there were increased yearly trends for both hospitalizations (from 250,354 to 322,676) and total costs (from US $ 388.52 to 721.58 million per year in 2014 currency) in Shanghai. Cost per CVD hospitalization in 2012 averaged US $ 2236.29, with the highest being for chronic rheumatic heart diseases (US $ 4710.78). Most direct medical costs were spent on medication. By the end of 2030, the average cost per visit per month for all CVDs was estimated to be US $ 4042.68 (95% CI: US $ 3795.04-4290.31) for all CVDs, and the total health expenditure for CVDs would reach over US $1.12 billion (95% CI: US $ 1.05-1.19 billion) without additional government interventions.Total health expenditures for CVDs in Shanghai are estimated to be higher in the future. These results should be a valuable future resource for both researchers on the economic effects of CVDs and for policy makers.

[Direct economic burden of cerebrovascular disease, during 1993-2008 in China]

OBJECTIVE

To evaluate the status and trend of direct economic burden on cerebrovascular disease, from 1993 to 2008 in China.

METHODS

Using two-step model to calculate the economic cost with related trend of cerebrovascular disease within the population among the over 30-year-olds, from 1993 to 2008. Data was gathered from the National Health Service Surveys Analysis Reports of 1993, 1998, 2003 and 2008, that including both direct outpatient and inpatient cost.

RESULTS

There appeared a significant increase on the burden of cerebrovascular diseases in the period of 15 years, with direct economic cost increasing from 8.473 billion to 103.125 billion RMB. In fact, the actual increase was 5.3 times, without the influence of the price. The average annual growth rate was 13.1%, exceeding the rate of total expenditure on health and GDP during the same time span. In addition, the growth rate in 2003-2008 was the fastest, which appeared to be 19.8%.

CONCLUSION

Burden that caused by cerebrovascular disease on individuals and the whole society was heavy which warrented further theoratical and practical studies on it.

Ninety-day readmission risks, rates, and costs after common vascular surgeries

OBJECTIVES

There are relatively sparse data regarding readmission after vascular surgery. The goal of our study is to analyze readmission rates and hospital cost for several common open and endovascular surgical procedures.

METHODS

We accessed our local ACS NSQIP clinical database and hospital cost accounting for vascular surgery cases and their 30- and 90-day readmissions from January 1, 2010, to November 30, 2011. Direct hospital costs (DHC$) were analyzed during the index admission and for all readmissions. Risk factors were compared in the readmitted versus non-readmitted groups using parametric or non-parametric tests as appropriate. Significance was set at P < .05.

RESULTS

We identified 170 patients who were readmitted. The 30-day all-cause readmission rate was 9.1% and at 90 days almost doubled to 17.9%. When readmissions occurred, on average they added DHC$ (000's) 12.4 ± 12.3, comprising an additional 61.1% beyond index admission DHC$. Preoperative risk factors associated with 90-day readmission included chronic obstructive pulmonary disease (COPD) (P = .027), open wound/infection (P = .005), and functional dependence (P = .027). Readmissions had longer index operative duration (P = .031) and more often received transfusions within 72 hours of the index case (P = .031). Wound infections were associated with a 90-day readmission (P = .012), as was treated DVT (P = .032) and cerebrovascular or cardiovascular events (P = .013).

CONCLUSIONS

Ninety-day readmissions after common vascular surgeries occurred at about twice our 30-day rate. The use of endovascular procedures is associated with significant readmission cost. COPD, open wounds with infection, functional dependence, lengthy procedures, and transfusion are associated with 90-day readmission after vascular surgery.

Compensation for work-related cerebrocardiovascular diseases

The purpose of this study was to discuss the history of, and concerns regarding, the newly amended criteria of occupational cerebrovascular or cardiovascular diseases (CCVDs). Since the early 1990s, CCVDs have been the second most common occupational disease, despite fluctuations in their criteria. The first issue was the deletion of cerebral hemorrhage on duty as a recognized occupational disease in 2008. The second issue was the obscurity regarding definitions of an acute stressful event (within 24 hr before disease occurrence), short-term overwork (within 1 week), and chronic overwork (for 3 or more months). In this amendment, chronic overwork was defined as work exceeding 60 hr per week. If the average number of weekly working hours does not exceed 60 hr, night work, physical or psychological workload, or other risk factors should be considered for the recognition of occupational CCVDs. However, these newly amended criteria still have a few limitations, considering that there is research evidence for the occurrence of disease in those working fewer than 60 hr per week, and other risk factors, particularly night work, are underestimated in these criteria. Thus, we suggest that these concerns be actively considered during future amendment and approval processes.

Socioeconomic characteristics of patients undergoing ambulatory diagnostic cerebral angiography in four US States

AIMS

Several groups have demonstrated the safety of ambulatory cerebral angiography, with no patients experiencing complications related to early discharge. Although this practice appears to be safe, the socioeconomic characteristics factoring in the selection of the patients have not been investigated.

METHODS

We performed a retrospective cohort study involving 45,226 patients undergoing outpatient and 159,046 undergoing inpatient cerebral angiography, who were registered in the State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID) respectively for 4 US States (New York, California, Florida, North Carolina).

RESULTS

In a multivariate analysis of diagnostic cerebral angiography, Caucasian race (OR 1.36, 95% CI, 1.31, 1.42) and male gender (OR 1.36, 95% CI, 1.31, 1.41), were significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (CCI) (OR 0.60, 95% CI, 0.54, 0.67), high income (OR 0.70, 95% CI, 0.67, 0.73), high volume hospitals (OR 0.69, 95% CI, 0.66, 0.73), and coverage by Medicare/Medicaid (OR 0.96, 95% CI, 0.92, 0.99) were associated with a decreased chance of outpatient procedures. Institutional charges were significantly less for outpatient cerebral angiography. The median charge for inpatient diagnostic cerebral angiography was $26,968 as compared to $16,151 in the outpatient setting (P < 0.0001, Student's t-test).

CONCLUSION

Access to ambulatory diagnostic cerebral angiography appears to be more common for patients with private insurance and less comorbidities, in the setting of lower volume hospitals. Further investigation is needed in the direction of mapping these disparities in resource utilization.

Favorable circulatory system outcomes as adjuvant traditional Chinese medicine (TCM) treatment for cerebrovascular diseases in Taiwan

BACKGROUND

This study searches the National Health Insurance Research Database (NHIRD) used in a previous project, aiming for reconstructing possible cerebrovascular disease-related groups (DRG),and estimating the costs between cerebrovascular disease and related diseases.

METHODS AND MATERIALS

We conducted a nationwide retrospective cohort study in stroke inpatients, we examined the overall costs in 3 municipalities in Taiwan, by evaluating the possible costs of the expecting diagnosis related group (DRG) by using the international classification of diseases version-9 (ICD-9) system, and the overall analysis of the re-admission population that received traditional Chinese medicine (TCM) treatment and those who did not.

RESULTS

The trend demonstrated that the non-participant costs were consistent with the ICD-9 categories (430 to 437) because similarities existed between years 2006 to 2007. Among the TCM patients, a wide variation and additional costs were found compared to non-TCM patients during these 2 years. The average re-admission duration was significantly shorter for TCM patients, especially those initially diagnosed with ICD 434 during the first admission. In addition, TCM patients demonstrated more severe general symptoms, which incurred high conventional treatment costs, and could result in re-admission for numerous reasons. However, in Disease 7 of ICD-9 category, representing the circulatory system was most prevalent in non-TCM inpatients, which was the leading cause of re-admission.

CONCLUSION

We concluded that favorable circulatory system outcomes were in adjuvant TCM treatment inpatients, there were less re-admission for circulatory system events and a two-third reduction of re-admission within ICD-9 code 430 to 437, compared to non-TCM ones. However, there were shorter re-admission duration other than circulatory system events by means of unfavorable baseline condition.

[Epidemiology of cerebrovascular disease in Spain]

In Spain, cerebrovascular disease (CVD) is a very common cause of morbidity and hospitalization. They are the second leading cause of mortality in the general population, and the first in women. They also constitute a very high social spending, which is estimated to increase in coming years, due to the aging of our population. Data from the Hospital Morbidity Survey of the National Statistics Institute recorded, in 2011, 116,017 strokes and 14,933 transient ischemic attacks, corresponding, respectively, to an incidence of 252 and 32 events per 100,000 people. In 2002, the cost of hospitalization for each stroke was estimated at €3,047. The amount of total cost health care throughout the life of a stroke patient is calculated at €43,129. Internationally, the direct costs of stroke constitute 3% of national health spending, this being similar amount in different countries around us. Hypertension was the cardiovascular risk factor (CVRF) more prevalent in both ischemic and hemorrhagic strokes, followed by dyslipidemia and diabetes mellitus. Peripheral arterial disease and hypertension were more frequently associated with atherothrombotic events, atrial fibrillation with cardioembolic strokes, and obesity and high blood pressure to lacunar infarcts. In Spain, as showing several studies, we are far from optimal control of CVRF, especially in secondary prevention of stroke. According to the ICTUSCARE study, achieving recommended values was 17.6% in the case of hypertension, 29.8% in LDL-cholesterol, 74.9% of smoking, and 50.2% in diabetes mellitus. In this review, we analyze in detail the epidemiology, prevention and costs originated by CVD.

Cost-effectiveness of enhancing adherence to therapy with blood pressure-lowering drugs in the setting of primary cardiovascular prevention

OBJECTIVE

To estimate the cost-effectiveness of enhancing adherence to blood pressure (BP)-lowering drug therapy in a large population without signs of preexisting cardiovascular (CV) disease.

METHODS

A cohort of 209,650 patients aged 40 to 79 years resident in the Italian Region of Lombardia and newly treated with BP-lowering drugs during 2000 to 2001 was followed from index prescription to 2007. During the follow-up, the 10,688 patients who experienced a hospitalization for a coronary or cerebrovascular event were identified (outcome). Adherence was measured by the proportion of days covered by the therapy with BP-lowering drugs. The cost-effectiveness of enhancing adherence was measured through the incremental cost-effectiveness ratio.

RESULTS

Enhancing adherence from 52% (baseline) to 60% and 80% led to a reduced rate for CV outcomes (from 85 to 83 and 77 events every 10,000 person-year, respectively) and increased the cost for drug therapy (from €1,325k to €1,507k and €1,934k every 10,000 person-year, respectively). The resulting incremental cost-effectiveness ratio decreased from €76k (95% confidence interval €74k-€77k) to €74k (95% confidence interval €72k-€75k) for each CV event avoided by enhancing adherence from baseline to 60% and 80%, respectively.

CONCLUSIONS

Enhancing adherence to BP-lowering medications in the setting of primary CV prevention might offer important benefits in reducing the risk of CV outcome, but at a substantial cost.

Effect of increasing active travel in urban England and Wales on costs to the National Health Service

Increased walking and cycling in urban areas and reduced use of private cars could have positive effects on many health outcomes. We estimated the potential effect of increased walking and cycling in urban England and Wales on costs to the National Health Service (NHS) for seven diseases--namely, type 2 diabetes, dementia, cerebrovascular disease, breast cancer, colorectal cancer, depression, and ischaemic heart disease--that are associated with physical inactivity. Within 20 years, reductions in the prevalences of type 2 diabetes, dementia, ischaemic heart disease, cerebrovascular disease, and cancer because of increased physical activity would lead to savings of roughly UK£17 billion (in 2010 prices) for the NHS, after adjustment for an increased risk of road traffic injuries. Further costs would be averted after 20 years. Sensitivity analyses show that results are invariably positive but sensitive to assumptions about time lag between the increase in active travel and changes in health outcomes. Increasing the amount of walking and cycling in urban settings could reduce costs to the NHS, permitting decreased government expenditure on health or releasing resources to fund additional health care.

Cost of hospitalization for cerebrovascular disorders in Belgium

BACKGROUND

There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of these figures permits targeted allocation of resources and aids cost efficacy estimates.

METHODS

We analysed a nationwide administrative database used for reimbursement of hospitals in Belgium. This database allows analysis of the rate of all hospital admissions for TIA, acute ischemic stroke, intracranial hemorrhage and carotid surgery or angioplasty. We compared the costs of hospitalization for stroke and related disorders with the costs of hospitalization for coronary artery disease.

RESULTS

There were 32970 admissions for stroke related disorders in 2007 at a cost of 191.6 million EUROS. There was a decline of 4.7% of the rate of hospitalization for stroke and associated disorders over the period 2002-2007. Despite this decline the total costs did not diminish substantially. In 2007 stroke and related disorders accounted for 2.0% of all Belgian hospitalizations, whereas coronary artery disease hospitalization accounted for 4.4%. The length of stay was longer for stroke and associated disorders. The average cost of hospitalizations in 2007 for stroke related disorders was 6188 EURO and the average cost of coronary artery related disorders was 5026 EURO.

CONCLUSION

The cost of hospitalization for stroke and related disorders is high. Although coronary artery disease is more frequent and has a larger impact on the health care expenditures, the average cost per hospitalization is higher for stroke and related diseases. This is mainly due to the longer hospitalization duration for stroke.

Work-related cerebro-cardiovascular diseases in Korea

Cerebro-cardiovascular disease (CVD) is one of compensable occupational diseases in Korea as in Japan or Taiwan. However, most countries accept only cardiovascular diseases (ischemic heart diseases) as compensable occupational diseases if any, but not cerebrovascular diseases. Korea has a prescribed list of compensable occupational diseases. CVD was not included in the list until 1993. In the early 1990s, a case of cerebral infarction was accepted as occupational disease by the Supreme Court. The decision was based on the concept that workers' compensation system is one of the social security systems. In 1994, the government has established a diagnostic criterion of CVD. The crude rate of compensated cerebrovascular disease decreased by 60.0% from 18.5 in 2003 to 7.4 in 2008 per 100,000 workers, and that of compensated coronary heart disease decreased by 60.5% from 3.8 in 2003 to 1.5 in 2008 per 100,000 workers. The compensated cases of CVD dramatically increased and reached its peak in 2003. Since many preventive activities were performed by the government and employers, the compensated cases have slowly decreased since 2003 and sharply decreased after 2008 when the diagnostic criterion was amended. The strategic approach is needed essentially because CVDs are common, serious and preventable diseases which lead to economic burden.

Assessing medical expenditures on 4 smoking-related diseases, 1996-2001

OBJECTIVE

To examine the current-period cost of treating 4 major smoking-related diseases: lung cancer, chronic obstructive pulmonary disease, ischemic heart disease, and cerebrovascular disease.

METHODS

Analyses are based on the MarketScan database, a medical claims database from large employers.

RESULTS

We found that total expenditures to treat ischemic heart disease were highest, followed by those to treat chronic obstructive pulmonary disease (COPD). When median expenditures per claim and disease severity were considered, lung cancer was the most expensive condition to treat and ischemic heart disease the least expensive. Median treatment expenditures increased as the severity of disease increased.

CONCLUSION

Treating smoking-related diseases is costly in the current-period and over a lifetime.

Changes in Cost and Outcome Among US Patients With Stroke Hospitalized in 1990 to 1991 and Those Hospitalized in 2000 to 2001

Background and Purpose— The purpose of this study was to evaluate the impact of new treatments by examining the changes between 1990 to 1991 and 2000 to 2001 in in-hospital mortality rates and hospital charges in adult patients with stroke.

Methods— From the Nationwide Inpatient Survey, the largest all-payer inpatient care database in the United States, patients with stroke admitted in 1990 to 1991 or 2000 to 2001 were studied. We analyzed hospital charges (adjusted for inflation based on the Consumer Price Index of the Bureau of Labor Statistics) and patient outcomes by type of institution: rural, urban nonteaching, and urban teaching in 1990 to 1991 and in 2000 to 2001.

Results— In 1990 to 1991, there were 1 736 352 admissions for cerebrovascular diseases, and in 2000 to 2001, there were 1 958 018 admissions. The number of admissions in urban teaching hospitals increased by 13%, 19%, and 25%, for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, respectively. The overall in-hospital mortality rate relatively declined by 36% for ischemic stroke, by 6% for intracerebral hemorrhages, and by 10% for subarachnoid hemorrhage. The mean hospital charges increased from $10 500 to $16 200 for patients with ischemic stroke, from $18 300 to $28 800 for patients with intracerebral hemorrhage, and from $37 400 to $65 900 for patients with subarachnoid hemorrhage. Mortality rates among patients admitted after ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage were all lower in urban teaching hospitals than in rural and urban nonteaching hospitals and the mean charges per admission were all higher.

Conclusions— There has been an increase in the inflation-adjusted hospital charges for all patients with stroke and a reduction in mortality rates for all stroke subtypes probably related to an increase in the proportion of patients with stroke admitted to urban teaching hospitals.

An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population

BACKGROUND

Chronic medical conditions have been associated with periodontal disease. This study examined if periodontal treatment can contribute to changes in overall risk and medical expenditures for three chronic conditions [Diabetes Mellitus (DM), Coronary Artery Disease (CAD), and Cerebrovascular Disease (CVD)].

METHODS

116,306 enrollees participating in a preferred provider organization (PPO) insurance plan with continuous dental and medical coverage between January 1, 2001 and December 30, 2002, exhibiting one of three chronic conditions (DM, CAD, or CVD) were examined. This study was a population-based retrospective cohort study. Aggregate costs for medical services were used as a proxy for overall disease burden. The cost for medical care was measured in Per Member Per Month (PMPM) dollars by aggregating all medical expenditures by diagnoses that corresponded to the International Classification of Diseases, 9th Edition, (ICD-9) codebook. To control for differences in the overall disease burden of each group, a previously calculated retrospective risk score utilizing Symmetry Health Data Systems, Inc. Episode Risk Groups (ERGs) were utilized for DM, CAD or CVD diagnosis groups within distinct dental services groups including; periodontal treatment (periodontitis or gingivitis), dental maintenance services (DMS), other dental services, or to a no dental services group. The differences between group means were tested for statistical significance using log-transformed values of the individual total paid amounts.

RESULTS

The DM, CAD and CVD condition groups who received periodontitis treatment incurred significantly higher PMPM medical costs than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001). DM, CAD, and CVD condition groups who received periodontitis treatment had significantly lower retrospective risk scores (ERGs) than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001).

CONCLUSION

This two-year retrospective examination of a large insurance company database revealed a possible association between periodontal treatment and PMPM medical costs. The findings suggest that periodontitis treatment (a proxy for the presence of periodontitis) has an impact on the PMPM medical costs for the three chronic conditions (DM, CAD, and CVD). Additional studies are indicated to examine if this relationship is maintained after adjusting for confounding factors such as smoking and SES.

Economic evaluation of the impact of nicorandil in angina (IONA) trial

OBJECTIVE

To estimate the net cost of adding nicorandil to usual treatment for patients with angina and to compare this with indicators of health benefit.

DESIGN

Cost effectiveness analysis.

SETTING

Based on results of the IONA (impact of nicorandil on angina) trial.

PATIENTS

Patients with angina fulfilling the entry criteria for the IONA trial.

INTERVENTIONS

In one arm of the trial nicorandil was added to existing antianginal treatment and compared with existing treatment alone.

MAIN OUTCOME MEASURES

Costs were for use of hospital resources (for cardiovascular, cerebrovascular, and gastrointestinal reasons), nicorandil, and care after hospital discharge. Benefits were assessed in three ways: (1) IONA trial primary outcome (coronary heart disease (CHD) death, non-fatal myocardial infarction, or hospital admission for cardiac chest pain); (2) acute coronary syndrome (CHD death, non-fatal myocardial infarction, or unstable angina); and (3) event-free survivors at the end of the trial.

RESULTS

The net cost for each additional IONA trial end point averted was -5 pounds sterling (-7 euros). The net cost for each case of acute coronary syndrome averted was -8 pounds sterling (-12 euros). The net cost for each event-free survivor was -5 pounds sterling (-7 euros). These figures are based on gastrointestinal events that were judged definitely or probably related to nicorandil. When all gastrointestinal events were included these three ratios rose to 567 pounds sterling (835 euros), 886 pounds sterling (1305 euros), and 516 pounds sterling (760 euros), respectively.

CONCLUSIONS

A substantial amount of the additional cost of nicorandil is offset by reduced use of hospital services. The limited comparisons possible with other CHD interventions suggest that nicorandil compares favourably.

Patterns of healthcare utilization and costs for vascular dementia in a community-dwelling population

BACKGROUND

While vascular dementia (VaD) is the second most prevalent dementia diagnosis, little is known about healthcare use and costs for VaD.

PURPOSE

This study compares the healthcare use and costs of community-dwelling patients with VaD to patients with Alzheimer's disease (AD), other dementias (OD), cerebrovascular disease without dementia (CVD), and patients without dementia or cerebrovascular disease (controls).

METHODS

Using diagnoses codes from medical claims and encounter records, 678 VaD, 1,722 AD, 957 OD, 2,718 CVD, and 14,023 controls were identified from patients enrolled in a 100,000-member group practice Medicare HMO during 1999-2002. Annual healthcare use and costs of the study groups were compared, using regression analysis to control for patient characteristics.

RESULTS

VaD patients had the highest annual costs, dollars 14,387, followed by dollars 10,716 for OD, dollars 8,254 for CVD, and dollars 7,839 for AD, and dollars 5,494 for controls (p<0.0001 for all comparisons to VaD). Despite higher total direct costs, VaD patients had lower costs for physician visits and prescription drugs compared with all study groups except OD. In contrast, CVD patients had the highest costs for these services. Moreover, hospital admissions for VaD were nearly twice those for CVD, and hospital days for VaD nearly three times those for CVD, despite the high prevalence of cardiovascular conditions for both VaD and CVD.

CONCLUSIONS

VaD patients had higher healthcare costs compared to all other patient groups. The substantially higher costs for VaD compared to CVD and the differences in use of healthcare services by VaD compared to CVD suggest that dementia, not cerebrovascular disease, is a major source of the cost differences. Lower costs for physician visits and prescription drugs for VaD suggest possible opportunities for improving ambulatory care and preventing high-cost hospitalizations.

Cost-effectiveness of Intraoperative Imaging in Carotid Endarterectomy

OBJECTIVE:

There has never been a large, randomized controlled trial to assess the impact of intraoperative imaging on the success of carotid endarterectomy (CEA). This comparison involves cost-effectiveness analysis.

METHODS:

We constructed a decision-analytic model to compare effectiveness and costs of intraoperative ultrasound (IUS) and completion angiography as adjuncts to CEA. Data on procedural mortality, morbidity, and costs were obtained from the English-language literature. The review included a total of 52 reports, encompassing more than 22,000 patients. The main components of costs were those of the monitoring interventions and the care of perioperative stroke.

RESULTS:

Mean perioperative outcome without completion imaging is approximately 96.7% of what it would be in the absence of perioperative stroke or death. IUS and completion angiography each result in approximately 2% improvement in expected outcome. Mean perioperative costs are $396.50 for IUS, $721.30 for no monitoring, and $840.90 for completion angiography. Because IUS is significantly more effective at detecting technical errors that would likely result in perioperative stroke than no imaging and is significantly less costly than angiography, this strategy dominates the other two (i.e., it provides greater effectiveness at lower cost).

CONCLUSION:

Although surgical complications are uncommon, IUS substantially lowers the rate of perioperative stroke and mortality and thus is significantly more cost-effective than either completion angiography or no operative imaging.

[Assessment of the budgetary impact of treatment guidelines in type II diabetes mellitus in France]

BACKGROUND

Type II diabetes mellitus is associated with an increasing prevalence and incidence, and with a heavy economic burden in Western countries. As a consequence, health authorities consider that avoidance or delay of occurrence of diabetes-related micro- and macro-angiopathic complications is a public health priority, leading to the definition of treatment guidelines. The aim of the study was to assess the budgetary impact of the application of the French guidelines.

METHODS

Etiologic cost ratios.

RESULTS

Our results conclude that 10% decrease in body mass index (BMI) among overweight patients, smoking cessation, initiation to undertake a preventive treatment with low-dose aspirin, initiation to undertake or intensify blood pressure control, initiation to undertake or intensify lipidic control, and shift to biguanides among overweight patients are factors associated with significant benefits (avoided costs) which compensate for the increase in treatment costs. The main beneficial strategies are, in decreasing order, initiation to undertake a preventive treatment with low-dose aspirin, smoking cessation, and control of BMI.

CONCLUSION

Our results support interest in reinforcing the application of current treatment guidelines for type II diabetes mellitus.

One-hour postload plasma glucose in middle age and Medicare expenditures in older age among nondiabetic men and women: the Chicago Heart Association Detection Project in Industry

OBJECTIVE

To examine associations in nondiabetic individuals of 1-h postload plasma glucose measured in young adulthood and middle age with subsequent Medicare expenditures for cardiovascular disease (CVD), diabetes, cancer, and all health care at age 65 years or older using data from the Chicago Heart Association Detection Project in Industry (CHA).

RESEARCH DESIGN AND METHODS

Medicare data (1984-2000) were linked with CHA baseline records (1967-1973) for 8,580 men and 6,723 women ages 33-64 years who were free of coronary heart disease, diabetes, and major electrocardiogram (ECG) abnormalities and who were Medicare eligible (65+ years) for at least 2 years. Participants were classified based on 1-h postload plasma glucose levels <120, 120-199, or > or =200 mg/dl.

RESULTS

With adjustment for baseline age, cigarette smoking, serum cholesterol, systolic blood pressure, BMI, ethnicity, education, and minor ECG abnormalities, the average annual and cumulative Medicare, total, and diabetes- and CVD-related charges were significantly higher with higher baseline plasma glucose in women, while only diabetes-related charges were significantly higher in men. For example, in women, multivariate-adjusted CVD-related cumulative charges were, respectively, USD 14,260, 18,909, and 21,183 for the three postload plasma glucose categories (P value for trend = 0.035).

CONCLUSIONS

These findings suggest that maintaining low glucose levels early in life has the potential to reduce health care costs in older age.

[The cost of cerebrovascular accident]

INTRODUCTION AND AIM

One out of three persons will die of cerebrovascular accident (CVA), another one will be disabled, and the third one will recover. This research has been taken to estimate the costs of CVA in the Basque Country.

MATERIALS AND METHODS

The cost of illness is studied from a societal perspective. It is based on the prevalence of the disease. Population costs has been estimated from the use of resources of a randomized sample of patients admitted to hospital with stroke during the year 2000, and followed for 12 months. Transitions costs (those that happen just once) and state costs (those remaining in patients lifetime) have been studied separately.

RESULTS

The prevalence of CVA was 1.780 x 10(5). Average transition cost per patient was 4,762 euros and average state cost for patient/year was 10,506 euros. The estimated cost for the Basque Country is 120,249,986 euros in the year 2000. Transition costs were 16,460,729 euros and state costs 103,789,257 euros in the same year. State costs were due to disability.

CONCLUSIONS

The analysis of the costs of CVA from a societal perspective gets us to the heart of illness causing disability, the social costs of CVA are 74.3% of the total cost.

Are Cost Benefits of Anticoagulation for Stroke Prevention in Atrial Fibrillation Underestimated?

BACKGROUND AND PURPOSE

Stroke outcomes in patients with atrial fibrillation (AF) tend to be worse than those in patients without AF. The objective of this study was to evaluate whether the cost benefits of anticoagulation for stroke prevention in AF may currently be underestimated by existing economic models that do not distinguish between different stroke outcomes.

METHODS

A literature review was conducted in 3 areas: (1) studies comparing stroke outcomes in AF and non-AF patients; (2) studies providing long-term cost of stroke estimates; and (3) studies modeling the cost-effectiveness of anticoagulation with a vitamin K antagonist (eg, warfarin) in AF patients.

RESULTS

There is considerable evidence that stroke in AF patients has a worse outcome than in patients without AF, including higher mortality, severity, and recurrence rates, and greater functional impairment and dependency. Estimates of the long-term cost of stroke of different severities were between US 24,991 dollars for a mild stroke over 5 years and US 142,251 dollars for a major ischemic stroke over a lifetime (2004 prices). The cost of a severe ischemic stroke may typically be 3-times that of mild stroke. However, cost-effectiveness models for anticoagulation in patients with AF have used average (not AF-specific) cost-of-stroke data, and most have used stroke severity distributions derived from clinical trials, which may differ from those in clinical practice.

CONCLUSIONS

Existing economic models underestimate the cost benefits of anticoagulation for stroke prevention because they do not adjust for poorer outcomes associated with cardioembolic strokes.

The burden of coronary, cerebrovascular and peripheral arterial disease

Atherothrombosis is a potentially life-threatening generalised disease process that affects the coronary, cerebral and peripheral vasculature, with clinical manifestations including myocardial infarction, ischaemic stroke and peripheral arterial disease. Atherothrombosis represents a massive clinical and economic burden to healthcare, annually accounting for at least 22% of all deaths globally. Moreover, the prevalence of atherothrombotic disease is increasing as a result of increased longevity resulting in a larger cohort of older individuals. Stroke in particular is a major burden, and is the primary cause of adult disability, the second most important cause of dementia, and the third leading cause of death in industrialised countries. Atherothrombosis is also associated with a poor prognosis, significantly reducing life expectancy in the 60-year-old patient by 8-12 years depending on the vascular event. Moreover, this already shortened life expectancy is further and substantially reduced in patients with more than one atherothrombotic event. The economic burden of atherothrombosis is significant, particularly given its increasing prevalence, with the United States spending over US dollars 300 billion on it. There is thus a need for effective intervention to prevent or reduce mortality and morbidity. Evidence-based medicine using economics, clinical trials data, outcomes research, epidemiology and risk stratification are necessary to target treatment effectively to patients at greatest risk, in an attempt to reduce the burden of atherothrombotic disease.

[Role of depression in the functional recovery and cost of stay in patients with acute cerebrovascular lesions]

BACKGROUND AND PURPOSE

The constant increase in health costs in recent years has led to the introduction of instruments such as DRG--diagnosis-related groups--with the declared aim of best rationalizing in-hospital costs. As part of this rationalisation it has become necessary to identify the causes of prolonged admissions in health-care structures. As far as concerns the rehabilitation of cerebrovascular diseases, attention has been centred on the presence of post-stroke depression. Our study was aimed at analysing the effect of depression on the time spent in hospital and whether the depression also affected on the patient's potential for functional recovery.

METHODS

Patients with acute cerebrovascular lesions admitted to our center for rehabilitation were enrolled in this study. Depressive syndromes and functional deficits were evaluated at admission and discharge.

RESULTS AND CONCLUSIONS

The most depressed patients were those who spent a longer time in hospital, but they were also those who had a greater functional deficit. The depression did not affect the efficacy and efficiency of the rehabilitation treatment. The time spent in hospital did, however, correlate with the clinical condition of the patient at admission and the age of the lesion.

[Studies on direct and indirect economic burden of disease and related factor in countryside of Qingdao city in 2001]

OBJECTIVE

To study the condition of economic burden of disease in the countryside and to explore the related factors.

METHODS

Human capital method and two-step method were used in the calculation of economic burden of disease.

RESULTS

The total economic burden of disease among 3359 persons was 3072 225 Yuan. Noncommunicable conditions were accounted for 62.95%, while communicable disease, maternal and perinatal conditions accounted for 24.25%, and injury accounted for 9.83% respectively. The direct economic burden of disease was 1,559,619 Yuan and the indirect economic burden of disease was 1,472,606 Yuan. The economic burden of disease for each person was 914 Yuan. The equal burden of disease among patients with disability and without disability were 3070 Yuan and 680 Yuan respectively (P < 0.001). There was significant difference among different age groups. The influencing factors were found to include having noncommunicable disease, age, disability and the condition of marriage.

CONCLUSION

Corresponding policy to cope with conditions of different age groups needs to be developed to reduce the economic burden of disease in the countryside.

Diagnostic pathway of syncope and analysis of the impact of guidelines in a district general hospital. The ECSIT study (epidemiology and costs of syncope in Trento)

BACKGROUND

The ECSIT study was aimed at evaluating the hospital management of syncope patients, at comparing the appropriateness and costs of the hospital diagnostic pathway before (phase 1) and after (phase 2) the introduction of new guidelines and at analyzing the physicians' compliance to the guidelines.

METHODS

All syncope patients admitted to the emergency room between August 1 and October 31, 1999 (phase 1) and between March 1 and May 31, 2000 (phase 2) were enrolled and their clinical records were analyzed in a blind fashion.

RESULTS

During the study 538 consecutive patients came to the emergency room for syncope with a hospitalization rate of 53% in phase 1 (n = 151) and of 42% in phase 2 (n = 107). The in-hospital stay increased from 9 days in phase 1 to 11.3 days in phase 2 and diagnostic tests from 2.6 per patient (phase 1) to 2.9 per patient (phase 2) with total costs that rose from [symbol: see text] 3,474 to [symbol: see text] 3,647. Patients with no diagnosis decreased from 51 to 45.8% and the principal causes were identified as vascular brain disease (36.1 vs 33.7%) and neurally-mediated mechanisms (35.3 vs 42.2%).

CONCLUSIONS

Despite the high costs of syncope management, the appropriateness and efficacy of the hospital diagnostic pathway remains far from ideal and simply introducing new guidelines seems unable to modify clinical practice.

Cerebrovascular disease in Italy and Europe: it is necessary to prevent a 'pandemia'

In Italy and Europe, strokes are the third most common cause of death and resulting invalidity. In the ever-increasing 80-years-old-and-over people, strokes become more serious due to the clinical presentation during the acute phase and the ten-times higher mortality, but also in relation to the twice as high resulting disability as for younger subjects. However, stroke prevention is possible both through correct behavioural habits and pharmacological means. Besides the well-known preventive effects of an adequate anti-hypertensive, anti-diabetic and/or anti-aggregant/anti-coagulant therapy, there are increasing evidences of the effectiveness of the anti-hypercholesterolemic therapy in stroke prevention. Moreover, a great part of the risk factors for the cerebrovascular disease coincides with those for cardiovascular disease, for which the correction of the former automatically involves a reduction in incidence of both pathologies. In this context, a statin's rational use can therefore represent an important tool for the combined prevention of the two pathologies. Finally, different hypotheses link the origin of Alzheimer's disease to that of progressive cerebrovascular dementia caused by cerebral microcirculation damage. It is plausible that the application of a suitable early prevention of the cerebrovascular pathology could bring to a more late slatentisation and less serious demonstrations of Alzheimer's disease, when this is destined to develop.

Societal costs of vascular cognitive impairment in older adults

BACKGROUND AND PURPOSE

The construct of vascular cognitive impairment (VCI) includes many whose care is or will be costly. Nevertheless, estimates of these costs are not well described. We therefore set out to estimate the societal costs of VCI in elderly people.

METHODS

In a secondary analysis of the Canadian Study of Health and Aging, a representative cohort study, Canadian dollar costs using a societal perspective were estimated by standard methods.

RESULTS

The total annual per-patient societal costs for VCI by severity were $15 022 for those with mild disease, $14 468 for those with mild to moderate disease, $20 063 for those with moderate disease, and $34 515 for those with severe disease. The most expensive component per individual was the cost of institutional long-term care. Although severe impairment was associated with higher costs, the extent of institutionalization at all levels of severity and less drug use among those more severely impaired mitigated a severity-cost gradient.

CONCLUSIONS

The societal costs of VCI are not inconsiderable. In contrast to Alzheimer disease, there is no clear gradient relating cost to severity. Unpaid caregiver costs are an important aspect of societal costs, even in those with only mild impairment.

[Incidence and cost estimation of diseases of the nervous system and the psyche. An evaluation of non-profit hospitals]

There were 273,722 hospitalizations due to neurological disorders reported in Austria's nonprofit hospitals in 1997, including the related operated cases (14.12% of all 1.9 million hospitalizations). The individual disease groups, e.g., cerebrovascular disorders (59,269 admissions or 3.06%), multiple sclerosis (3,920 admissions or 0.2%) are detailed and the cost resulting from these diseases were estimated according to the Austrian Diagnosis Related Groups. The number of hospitalizations due to psychiatric disorders was 99,346 (5.13%). According to our results, we were able to estimate that 6,492 beds (at the moment 2,053 beds) were required for inpatient treatment in the area of neurology and psychiatry, which means one bed per 1,260 inhabitants.

Inpatient costs, length of stay, and mortality for cerebrovascular events in community hospitals

BACKGROUND

Accurate estimates of inpatient cost, length of stay (LOS), and mortality are necessary for the development of economic models to estimate the cost-effectiveness of stroke-related treatments. Estimates based on data from academic institutions may not be generalizable to community hospitals. In this study, the authors estimated inpatient costs, LOS, and in-hospital mortality for patients with subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), ischemic cerebral infarction (ICI), and TIA who were treated in community hospitals.

METHODS

The authors selected patients using International Classification of Diseases-9-Clinical Modification primary diagnosis codes from the HBSI EXPLORE database. They analyzed patient-level data and inpatient costs, derived from detailed utilization data, for all patients admitted to 137 community hospitals in 1998. Multivariate statistical techniques were used to examine patient-, hospital-, and outcome-related factors associated with inpatient costs.

RESULTS

Patients with SAH incurred the highest average cost ($23,777, n = 1,124), followed by patients with ICH ($10,241, n = 3,139), ICI ($5,837, n = 18,740), and TIA ($3,350, n = 7,861). Patient subgroups ranked in the same order for average LOS at 11.5 days for SAH, 7.5 days for ICH, 5.9 days for ICI, and 3.4 days for TIA. Almost one third of patients with SAH (29.0%) and ICH (33.1%) died during hospitalization, whereas 7.0% with ICI and 0.2% with TIA died. For each event, as patient age increased, average costs consistently decreased. Also, average costs were higher among patients treated in community teaching hospitals compared to community nonteaching hospitals for each cerebrovascular event (10 to 29%).

CONCLUSIONS

Inpatient costs, LOS, and mortality for patients with cerebrovascular disease are dependent on patient and hospital characteristics.

The impact of cerebrovascular disease

Stroke may be affected by pathologic conditions such as atherosclerosis, vascular injury, coagulopathy, and increased platelet aggregability. Knowledge of the pathophysiology of stroke is critical in order to effectively prevent or treat this disabling state. Cerebrovascular disease is the third leading cause of death in the USA. It is also associated with significant morbidity, leading to extremely high health care costs and lost productivity. Total estimated costs of stroke are estimated to be more than $45 billion annually. This is an especially important issue for patients with diabetes, who are at higher risk for stroke and have a worse clinical outcome than non-diabetic patients. This review describes the impact of vascular disease, particularly cerebrovascular disease, and describes the pathophysiology of the disease. Interventions that result in reduction of stroke will likely result in decreased health care costs and improved clinical outcomes.

Lifetime health and economic benefits of weight loss among obese persons

OBJECTIVES

This study estimated the lifetime health and economic benefits of sustained modest weight loss among obese persons.

METHODS

We developed a dynamic model of the relationship between body mass index (BMI) and the risks and costs of 5 obesity-related diseases: hypertension, hypercholesterolemia, type 2 diabetes, coronary heart disease (CHD), and stroke. We then calculated the lifetime health and economic benefits of a sustained 10% reduction in body weight for men and women aged 35 to 64 years with mild, moderate, and severe obesity.

RESULTS

Depending on age, gender, and initial BMI, a sustained 10% weight loss would (1) reduce the expected number of years of life with hypertension, hypercholesterolemia, and type 2 diabetes by 1.2 to 2.9, 0.3 to 0.8, and 0.5 to 1.7, respectively; (2) reduce the expected lifetime incidence of CHD and stroke by 12 to 38 cases per 1000 and 1 to 13 cases per 1000, respectively; (3) increase life expectancy by 2 to 7 months; and (4) reduce expected lifetime medical care costs of these 5 diseases by $2200 to $5300.

CONCLUSIONS

Sustained modest weight loss among obese persons would yield substantial health and economic benefits.

Risk neutralization in cardiac operations: detection and treatment of associated carotid disease

BACKGROUND

A screening and treatment protocol was implemented to extend the benefit of prophylactic carotid endarterectomy to patients who had open heart operations.

METHODS

Patients aged 65 or older or who at any age had left main coronary disease, transient ischemic attack, or stroke were eligible for preoperative carotid duplex screening. Carotid endarterectomies and open heart operations were planned as a staged (n = 59) or combined procedure (n = 55) for angiographically confirmed carotid stenosis of at least 80%.

RESULTS

Duplex scans were obtained in 1,719 of 7,035 open heart surgical patients over 8 years. The overall stroke rate was 1.5% (108 of 7,035). Seven of these were strokes of carotid origin (0.1%). There were 129 patients with at least 80% stenosis. One hundred fourteen had carotid endarterectomy preceding open heart operation, and none had carotid artery stroke. Twelve patients with at least 80% carotid stenosis by duplex scan had open heart operations without prophylactic carotid endarterectomies. There were four carotid strokes in these 12 patients (p = 0.0001; odds ratio, 20.2). Stroke risk remained significantly elevated (16.8%, p = 0.005) in the 50% to 79% group. The changes associated with the reduced risk afforded by this screening and treatment strategy amounted to $346 for each patient in the study.

CONCLUSIONS

The risk of carotid stroke at the time of cardiac operation can be defined by duplex screening. Prophylactic carotid endarterectomy neutralizes the risk in those with at least 80% stenosis. Consideration for lowering the threshold for assessment and treatment of carotid stenoses appears warranted. The economic investment is recouped by the savings in system resources that would have been depleted through care for carotid stroke and its sequelae.

Costs of coronary heart disease and stroke: the case of Sweden

OBJECTIVES

To estimate the annual costs in Sweden of coronary heart disease (CHD) and stroke, and the potential cost savings if these clinical 'events' are avoided. The analysis is undertaken from a societal perspective, including both direct and indirect costs. Costs are calculated for five clinical conditions: (i) acute myocardial infarction (AMI), (ii) angina pectoris (AP), (iii) unstable angina (UA), (iv) congestive heart failure (CHF), and (v) stroke.

DESIGN

A retrospective study including patients admitted to the Department of Medicine at Södertälje Hospital during the period January 1993 to March 1995 with CHD or a stroke. Each patient was followed for 1 year after admission to the hospital. To estimate potential cost savings, the patient was used as his or her own control. The potential savings in direct costs if CHD or a stroke is avoided were estimated as the difference between costs for 1 year after and 1 year before the event. The indirect costs were calculated as the difference between the values of market production of goods and services the year before the event and the year after.

SETTING

The Department of Medicine at Södertälje Hospital, Södertälje, Sweden.

SUBJECTS

The patients included in the study were patients at the Department of Medicine at Södertälje Hospital in Sweden. The inclusion criterion was that the patients should have been admitted for the first time for CHD or stroke during the year 1994. To obtain 25 patients for each clinical category we first had to expand the inclusion period to cover January 1993 to March 1995. Secondly, we also had to include 36 patients with an earlier established uncomplicated CHD or stroke. Despite this, no more than 22 patients with UA were found.

INTERVENTIONS

Patients were followed in medical practice.

MAIN OUTCOME MEASURES

Costs, direct and indirect costs, and potential savings.

RESULTS

The mean direct costs during the year after a clinical event range between Swedish kronor (SEK) 41 000 for CHF and SEK 96 000 for stroke, whereas the mean potential savings in direct costs range from SEK 36 000 for CHF to SEK 91 000 for UA. The potential mean savings in indirect costs range between SEK 24 000 for CHF and SEK 102 000 for AMI. The direct costs for first-time patients are lower than those for patients with an earlier established CHD or stroke. No systematic differences have been found in potential direct cost savings and indirect costs between the two patient groups.

CONCLUSIONS

CHD and stroke are associated with high costs during the year after admission to the Department of Medicine. There are also large potential cost savings from the prevention of CHD and stroke. However, further studies, including more patients and costs arising in the municipality, are needed to establish more precise and complete estimates of the costs related to CHD and stroke.

An analysis of the costs of ischemic stroke in an Italian stroke unit

OBJECTIVE

To determine the direct costs of hospital care of acute ischemic stroke in a large Italian hospital, and to identify the main components of such costs.

BACKGROUND

Cost containment in stroke care requires an up-to-date assessment of expenditures in the different areas of stroke management. However, costs may vary among countries because of different health system organizations.

METHODS

All patients with ischemic stroke admitted during 1996 were considered. Total cost was the sum of a daily component, reflecting personnel wages and general care, and an ancillary component, reflecting mostly investigations and treatments. The real costs were used, not fixed charges.

RESULTS

We included 245 patients, with a mean length of stay (LOS) of 13.1+/-7.0 days, and an in-hospital case fatality rate of 8.2%. The mean total cost per patient was 5,087,000+/-2,536,000 Italian Lira (LIT; $3,289+/-$1,640), with a mean cost per day of 388,000 LIT ($251). Approximately 80% of total costs were due to the daily component and 20% to the ancillary component. A multiple linear regression model of length of stay, which determines the daily cost, showed that the Rankin score at entry, the clinical syndrome type, and the destination at discharge independently contributed to LOS. A second linear regression model showed that younger age and longer LOS significantly increased ancillary costs.

CONCLUSIONS

The containment of hospital costs of ischemic stroke may be achieved mostly through measures that reduce LOS, such as effective treatments and a quicker deployment.