http://jama.jamanetwork.com/article.aspx?articleid=1983677
The long-term cost of treating stroke adds up to more than previous shorter-term estimates suggested, a recent study of Australian patients found.
Stroke
experts say they expect the cost would be even higher in the United
States than in Australia, highlighting the importance of early treatment
and prevention.
The study in Australia is thought to be the first to look at the cost of care for 10 years after a stroke (Gloede TD et al. Stroke.
2014;45[11]:3389-3394). Researchers interviewed 286 patients who had a
stroke and survived for at least a decade. Of that total, 243 had an
ischemic stroke, while 43 had an intracerebral hemorrhage (ICH).
Previous research estimated lifetime costs in Australia using data from 5 years after a stroke (Cadilhac DA et al. Stroke.
2009;40:915-921). It suggested that costs peaked in the first year and
then declined in the following years. But the new study found that the
annual direct cost of care for a patient after an ischemic stroke was
$5207 10 years out, only slightly lower than the annual cost between
years 3 and 5, which was $5438. For patients who had an ICH, the annual
cost at 10 years was $7607, considerably higher than the annual cost at 3
to 5 years, which was $5807. (Although the study was conducted in
Australia, the costs were reported in US dollars.)
The
authors of the Australian study estimated the lifetime costs of direct
care at $68 769 for a patient after an ischemic stroke and $54 956 for a
patient after an ICH. Those amounts are about 50% higher than lifetime
estimates they had published previously based on 5-year data, which were
$47 354 for ischemic stroke care and $39 628 for ICH care.
Even
so, “the (Australian) numbers are considerably less than the current
estimate of direct lifetime cost of ischemic stroke in the US,” which is
$140 048, Larry Goldstein, MD, director of the Duke Stroke Center, said
in an e-mail (Go AS et al. Circulation. 2014;129[3]:e28-e292).
“The
way health care is delivered and priced may influence cost differences
between the two health systems,” Dominique Cadilhac, PhD, MPH, senior
author of the study of Australian patients, said in an e-mail. Australia
has publicly funded universal health care, which coexists with private
health care, said Cadilhac, who heads up the translational public health
and evaluation division at the Monash University Stroke and Ageing
Research Group in Melbourne.
“It
is clear that overall, our system is more cost-effective, as the vast
majority of stroke care is delivered under the public health system,
which has a capitated budget and cost-control measures,” neurologist
Christopher Levi, MD, director of the Stroke Research Program at the
Hunter Medical Research Institute in Newcastle, Australia, said in an
e-mail. Levi formerly served as medical director of Australia’s National
Stroke Foundation.
Compared
with Australia, “our skilled nursing facilities, our medication costs,
our health care system—everything tends to cost more” in the United
States, said Ralph Sacco, MD, MS, chairman of neurology at the
University of Miami’s Miller School of Medicine.
In
fact, across the board, the price of medications, medical technology,
and other components of health care is about twice as much in the United
States as in Australia, said Gerard Anderson, PhD, director of the
Center for Hospital Finance and Management at the Johns Hopkins
Bloomberg School of Public Health.
“All
countries negotiate much more effectively for price than the United
States does,” Anderson said. “We just pay a lot more for the same
things.”
But
price alone probably doesn’t explain the higher cost of stroke care in
the United States, he said. “It’s certainly a reasonable hypothesis”
that US stroke patients have more comorbidities that add to the cost of
their care, he said. In addition, Anderson said, “we tend to use a
little more technology and a little more expensive technology.”
The
cost of care in the United States is not only more expensive item by
item, but the country’s population is more heterogeneous than
Australia’s, leading to greater overall costs for stroke care, said
Bruce Ovbiagele, MD, co-chair of the neurosciences department at the
Medical University of South Carolina.
Ovbiagele
chaired an American Heart Association/American Stroke Association
(AHA/ASA) committee that in 2013 published a policy statement
forecasting the future of stroke in the United States (Ovbiagele B et
al. Stroke. 2013;44[8]:2361-2375). The statement, coauthored by
Goldstein and Sacco among others, projected that between 2012 and 2030,
total direct medical costs for stroke in the United States will have
nearly tripled, from $71.55 billion to $184.13 billion, with aging of
the population and growth in per capita medical spending the primary
drivers.
The
AHA/ASA committee predicted that by 2030, 3.9% of US individuals older
than 18 years will have had a stroke, with the greatest increases seen
among white Hispanic men, followed by other races and ethnicities and
black men and women. By comparison, a 2012 report prepared for
Australia’s National Stroke Foundation projected that by 2032, 2.4% of
that country’s population will have had a stroke (http://bit.ly/1wcXXcL).
“We
are concerned that stroke is becoming increasingly costly as the
population ages,” Sacco said. “One, we’re seeing more strokes, and two,
people are living longer, which means there’s going to be greater costs.
When people die, they don’t cost as much,” he said. In 2008, stroke
dropped from third place—a spot it had held for 50 years—to fourth among
the leading killers of people in the United States, according to the
National Center for Health Statistics (http://1.usa.gov/1rB02Zt).
Sacco
praised the Australian study for helping to fill in some of the many
blanks about the cost of strokes. “They’re adding to the literature by
giving us a 10-year estimate,” Sacco said. “People with stroke survive
longer, so we need a better handle on what the full costs are for a
stroke for longer periods.”
Indeed,
the Australian study’s estimates of survival based on 10-year data are
higher than those based on 5-year data. The researchers now estimate
that, on average, 31% of patients who had an ischemic stroke and 27% of
patients who had an ICH live for at least a decade after their stroke.
Their earlier model, based on 5-year data, estimated that only 21% of
both ischemic stroke and ICH patients survived 10 years.
Although
ICH occurs less frequently than ischemic strokes, “they tend to be more
severe,” with greater neurological deficits and disabilities, which
helps explain the greater annual cost of their care and their lower
survival rate, said Sacco, who was not involved in the study of
Australian patients.
The
increase seen in the cost of care over time for ICH “was mainly driven
by a greater need for aged care (nursing home) services,” Cadilhac said.
For patients who’ve had ischemic stroke, “nursing home utilization was
more consistent” from 5 years to 10 years, first author Tristan Gloede
said in an e-mail. Gloede is a PhD candidate at the University of
Cologne’s Institute for Medical Sociology, Health Services Research, and
Rehabilitation Science. A possible limitation of the study was the
small number of patients who had an ICH, Gloede said. “In the future, we
should replicate the study to see whether we will yield similar
findings.”
After
ischemic stroke, average annual medication costs were slightly greater
at 10 years than at years 3 to 5, while inpatient rehabilitation costs
were lower, Cadilhac’s team found. After ICH, the average annual cost of
nursing home care was 64% greater at 10 years than at 3 to 5 years,
while the average annual medication cost was 70% higher than the earlier
years.
“A
stroke survivor, even after 5 years, still requires a certain amount of
care with medications, with placement, with rehabilitation, and these
do become additive,” Sacco said. “It’s possible that the improved
survival is driving up costs, but we do have cost-effective medications
that can reduce costs.”
The
problem, he said, is that tissue plasminogen activator (tPA), the only
treatment approved by the US Food and Drug Administration for ischemic
strokes, is greatly underused, Sacco said. If given within 4.5 hours of a
stroke, tPA can dissolve a clot and improve blood flow in the brain,
thereby minimizing the long-term effects of a stroke and preventing
death.
But
even in the parts of the United States that tend to provide the most
aggressive stroke care, such as New York City, Houston, and Miami, only
10% to 15% of stroke patients are treated with tPA, Sacco said. The
percentage of patients having an ischemic stroke who received tPA within
3 hours of onset did nearly double from 2003-2005 to 2010-2011, but the
increase was only from 4% to 7% (Schwamm LH et al. Circ Cardiovasc Qual Outcomes. 2013;6[5]:543-549).
“It’s
not the system. Now we have plenty of stroke centers,” Sacco said,
referring to the more than 1000 US hospitals that have been certified as
primary stroke centers by the AHA/ASA and the Joint Commission. “The
majority of strokes don’t come in in time. That is the main reason tPA
is not given.” Levi said the situation isn’t much different in
Australia, where the national tPA rate is about 7%. “I don’t think there
is any evidence that Australians access acute stroke care any earlier
than others,” Levi said.
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