Stroke: Optimal care could lop millions from costs annually
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Hans Krueger, PhD, from the School of Population and Public Health at the University of British Columbia in Canada, and colleagues noted that several evidence-based stroke initiatives have been shown to improve patient outcomes, with some results pointing to cost savings as well. They assessed four aspects of care—rapid assessment and treatment services, thrombolytic therapy, organized stroke units and early home-supported discharge—and the estimated costs that would be avoided if these care programs were offered in a comprehensive way.
As an overview, they determined the current status of stroke care in Canada using the Canadian Institute for Health Information Discharge Abstract Database, the 2008–2009 National Stroke Audit and the Acute Cerebrovascular Syndrome Registry in the province of British Columbia. They estimated the effect of providing optimal stroke care on rates of acute care hospitalization, length of stay in hospital, discharge disposition (including death), changes in quality of life and costs avoided based on current literature.
They calculated costs, which were adjusted to 2010 Canadian dollars, using data from the Ontario Case Costing Initiative and Statistics Canada. Projected costs between 2010 and 2030 were based on current age-specific rates for ischemic and hemorrhagic hospital episodes combined with age-specific population projections. They then conducted sensitivity analyses to look at best and worst case scenarios.
Among findings on Canada’s current status of stroke care from 2004 to 2005 and 2008 to 2009, they found an annual occurrence of:
- 32,081 hospital episodes for stroke care (excluding transient ischemic attacks [TIA]);
- 7,111 deaths in hospital;
- 286,000 quality-adjusted life years (QALYs) lost; and
- 29,300 TIAs and nonhospitalized strokes.
Stroke admissions accounted for 639,000 acute care days and 4.5 million residential care days annually. Stroke patients had a one-year risk of recurrence of 3.64 percent and 4.14 percent of patients with an incident TIA or nonhospitalized stroke had a hospitalized stroke within a year.
Under their modeled comprehensive system with optimal care in each of the four categories, they calculated an annual occurrence of:
- 3.3 percent decrease in hospital episodes;
- 25.9 percent decrease in acute care days;
- 12.8 percent decrease in residential care days;
- 14.9 percent decrease in in-hospital deaths; and a
- 3.7 percent decrease in lost QALYs.
“The most significant contributions to the direct cost avoidance were generated by optimized access to early supported discharge services ($132.9 million CAD [$129 million USD]) and organized stroke units ($116.8 million CAD [$113.4 million USD]),” they wrote. “Both of these areas reduce length of stay in the hospital and reduce the risk of admission to a residential care facility after a stroke.”
For indirect costs avoided, they cited optimized TIA rapid assessment and treatment, at $269.2 million CAD ($261.4 million USD) in avoided costs. “Preventing the risk of progression from a TIA/minor stroke to a major stroke requiring hospitalization has a significant impact on the number of QALYs lost,” Krueger and colleagues wrote.
The average stroke patient in the optimized care system would see a 3.3 percent reduced risk of acute hospitalization, they claimed, and the rate of death for hospitalized stroke patients would fall from 22.5 percent to 19.8 percent. Per patient costs avoided for hospitalized patients included $8,191 CAD ($7,955 USD) in hospital and residential care services (direct costs) and $3,277 CAD ($3,183 USD) in additional indirect costs.
The best case scenario showed a 30.9 percent increase in overall annual costs avoided and the worst case scenario came in at decrease of 28.4 percent.
The study did not use a cost-effectiveness approach, which could be considered a limitation. Instead, “we have placed a value on QALYs lost, a usual output measure in most cost-effectiveness analyses,” authors acknowledged.
The authors argued that increasing the availability of stroke units in Canada would help avoid costs and that while the push for more units has begun in Canada, the effort should be accelerated. “The magnitude of potential cost savings over two decades could be substantial,” they concluded. “Healthcare decision makers could use these data to better plan investment in stroke systems of care over the next decade.”