Authors: Trung Quang Vo ( Department of Economic and
Administrative Pharmacy, Pham Ngoc Thach University of Medicine, Ho Chi
Minh City, Vietnam )
Phuong Hong Le ( Department of Pharmacy
Administration, Faculty of Pharmacy, University of Medicine and Pharmacy
at Ho Chi Minh City, Vietnam )
Abstract
Objective: After surviving from an acute
phase of stroke, it is essential for stroke survivors to continue
therapies to improve their function and quality of life. The aim of this
study was to assess the influence of rehabilitation treatment on the
society in economic aspect with evidence from a traditional hospital.
Methods: A prospective cohort study was carried out
with patients who were being treated at Traditional Medicine Hospital in
Ho Chi Minh City after experiencing a stroke. Patients' relevant
medical information was extracted from the hospital's database and
placed on a structured questionnaire.
Results: Among 103 eligible patients aged 60.3 } 11.4
years, 93.2% had experienced a stroke for the first time. Eighty-four
patients were diagnosed with ischaemic stroke, while the number of
haemorrhagic stroke patients was approximately 4.5 times lower (n = 19).
The mean total cost was $3,310.40 USD, which included $1,653.60 USD,
$539.90 USD and $1,117.00 USD for direct medical, direct non-medical and
indirect cost, respectively. Hospital bed costs accounted for a
considerable percentage of direct medical costs (41.0%).
Conclusion: Stroke was determined to be a significant
social burden, although patients in this study had already suffered from
the acute phase. This study gives decision makers a comparative view
about the economic view on the economic burden of the stroke
rehabilitation treatment between using traditional national Western and
Eastern therapy.
Keywords: Economic cost, Rehabilitation, Stroke, Traditional therapy, Vietnam. (JPMA 69: S-87 (Suppl. 2); 2019)
Introduction
Stroke was found to be the deadliest cardiovascular disease in Vietnam
during 2013 and the world's second biggest killer, accounting for more
than six million deaths in 2015.
1 Of the three types of
stroke such as - ischaemic heart disease stroke, haemorrhagic stroke and
transient ischaemic attack (TIA), the ischaemic stroke is the most
common at 87%.
2 In addition to its prevalence, stroke is
renowned for its abruptness, high mortality and serious sequelae.
Despite the fact that advances in the technological and medical
treatment of stroke, as well as in the systems for delivering care, have
improved stroke mortality rates,
3 many stroke survivors still experience relentless motor symptoms that affect their functional independence in daily life.
4
According to an observation from the Framingham Heart Study of the
National Heart, Lung, and Blood Institute in the United States of
America (NHLBI), 50% of ischaemic stroke patients who were at least 65
years old had some hemiparesis, 30% were unable to walk without some
assistance, 26% were dependent in activities of daily living, 19% had
aphasia, 35% had depressive symptoms and 26% were institutionalized in a
nursing home.
5 A 2011 study by Godwin et al. which
conducted with 54 patients in five hospitals in Southeast Texas found
that the average cost per case of outpatient stroke rehabilitation
services (included in physical therapy, occupational therapy, and speech
therapy that were delivered in outpatient facilities and in the home)
and medications for the first year after inpatient rehabilitation
discharge was $17,081 USD (United State Dollars), while the total cost
for outpatient expenses such as home healthcare, physician services,
drugs, and durable medical equipment in 2010 reached approximately $10.1
billion USD.
6 Since strokes affect the brain, it is
essential for stroke survivors to continue rehabilitation therapies
after treatment with the aim of boosting independent movement, because
these approaches can help them improve their muscle strength and
coordination. In a country like Vietnam with their reputation about
traditional therapy, rehabilitation phase using speech therapy,
occupational therapy, as well as other experimental therapies, namely
massage, acupuncture, herbal therapy, etc can teach patients how to use
mobility aids and promote mental and emotional adjustment through. To
provide accurate and timely information about the economic impacts of
stroke rehabilitation and to estimate the economic burden of stroke
recuperation with traditional therapy, this study presents the estimates
and determinants of specific costs using a societal perspective and
based on the findings from a crosssectional study.
Material/Subjects/Patients and Methods
This study was a prevalence-based cost-of-illness analysis in 2017 from
different perspectives. A cross-sectional approach was conducted to
estimate the cost per case and the total expense of stroke
rehabilitation in Traditional Medicine Hospital in Ho Chi Minh City,
which is one of the leading medical centres in using Eastern therapies
serving approximately 1,000 patients' visits every day in Ho Chi Minh
City and the surrounding provinces in the middle and south regions of
Vietnam. This study considered inpatients who had been admitted to Ho
Chi Minh City Traditional Medicine Hospital between Jan 2017 and
December 2017 for treatment of post-stroke, according to ICD-10
(International Classification of Diseases, Tenth Revision) with code
I69. All eligible participants voluntarily confirmed their consent and
agreement after being informed about the content and objective of the
research. All relevant patient data — comprising general information
(age, gender, weight, height, locality and health insurance), medical
services and medication used — were entered into the hospital database.
This research design and methodology was approved by the ethics
committee of the hospital, to allow researchers to access the necessary
materials. A questionnaire was constructed to accumulate details from
both patients and family members for the purpose of calculating the cost
that society incurred due to the direct effect of stroke
rehabilitation. The questionnaire consisted of two parts: one to record
sociodemographic characteristics (occupation, education, monthly income,
the number of strokes suffered and the number of caregivers) and one to
record direct non-medical component costs (meals, accommodation and
travel). Caregivers were divided into unpaid caregivers (who were family
members of the patients) and hired caregivers (who were employed to
take care of patients). Researchers also defined the amounts for salary
and pension in monthly income, to have an accurate appraisal of each
cost element. Economic burden was computed under patient, payer (health
insurance company), hospital and social perspective, respectively.
71
The total cost was sum of the direct medical costs, the direct
non-medical costs and indirect costs. All cost values were calculated in
Vietnamese Dong (VND) currency, then converted to U.S. dollars by using
the exchange rate 22,498 VND = $1 USD.
8 Direct cost
included in direct medical cost and direct nonmedical cost. Direct
medical cost was calculated from the intervention and unit cost which
were extracted from data resources to assess the payment required from
patients and health insurance companies. The results would measure cost
components by grouping them into imaging diagnosis, laboratory tests,
hospital beds, medication, herbal remedies, acupuncture, physical
therapy and other costs (oxygen, ambulance, etc.).
9
Regarding direct non-medical cost, based on the answers of patients or
their caregivers, accommodation and travelling cost were computed
(Figure-1).
This study calculated direct costs according to the following equation:
The variables n, m and p represented the number of patients, caregivers
and interventions. QI, UI, MP, LS and CD were abbreviations for
quantities ofinterventions, unit cost of intervention, meal cost per
day, length of stay and caregivers' nursing day, respectively. AC
represents the accommodation of caregivers, and TV represents the travel
costs for patients and caregivers.9 Absenteeism was defined as the
amount of salary missed because of patients' hospitalization, which was
calculated by multiplication between the length of stay (LS) and monthly
income (MI). Reduced productivity from nonsalary patients was estimated
based on expenses per month (EX). The population included retired
people and adults who were in the typical workforce age range but who
did not have a regular monthly income, such as unemployed workers,
housewives, etc. The caregiver burden was computed using a summary of
the hired caregivers' income lost because of dropping out of the
workforce to provide care. For unpaid caregivers it was calculated by
the amount of their salary missed from days off attributed to taking
care of post-stroke patients. The indirect cost was computed by the
formula below (Elliott & Payne, 2005)
9:
The variables n, m and q were the number of patients, paid caregivers
and unpaid caregivers. LS is an abbreviation for length of stay, MI
refers to monthly income and EX refers to expenses. PCD are PMI are
abbreviations for paid caregivers' nursing days and monthly income,
respectively; CD and CMI represent unpaid caregivers' nursing days and
monthly income, respectively.
Statistical Analysis: Data management and analysis was
completed using the statistical software R version 3.4.3. Descriptive
statistics handled the output of demographical characteristics.
Bootstrap method with 95% CI (confident intervals) was used to control
the natural skewness of cost data to increase the accuracy of the
average cost per patient. The study applied t-tests and ANOVA when
appropriate to evaluate the association between the mean cost and
general features (age range, gender, location, education, BMI range,
occupation, type of stroke, the number of strokes suffered and the
number of comorbidities), which were arranged as categorical variables.
Ethics Statement: The Ho Chi Minh City Traditional
Medicine Hospital Ethical Committee reviewed the study protocol, the
questionnaire and the information letter for participants, and approved
them in 2017 (No. 24/2017/YHCT). Data were analysed anonymously. Verbal
informed consent was obtained from all persons that complied with our
inclusion criteria and agreed via telephone to participate in the
survey. Verbal consent was considered sufficient, as the survey was
conducted without any physical or psychological intervention.
Results
Table-1 illustrates the demographic information of afterstroke
rehabilitation patients who took part in the survey. It is clearly shown
that more than half of the 103 participants were male (n = 61), with
the mean age of 60.3 } 11.4 years. In addition, 68% of patients (n =
70) came from urban areas, and most of them were sellers (n = 31,
30.1%). In terms of the clinical record, 93.2% of the patients had no
prior history of stroke, and 84 out of 103 people were diagnosed with
ischaemic stroke. Although all the recorded patients had health
insurance, the coverage percentages varied among them. It was recorded
that the mean length of stay was 137.0 } 94.6 days. Regarding patients'
comorbidity, the data depicts that most of the patients (n = 88) were
also treated for hypertension (Table-1). Our conducted survey also
collected data on the economic burden of post-stroke rehabilitation in
Traditional Medicine Hospital, which are shown in Table-2 and
illustrated within Figure-2.
The economic burden was computed as $342,303.50 USD, and the average
total expenditure per case was $3,310.40 USD. Economic burden of
post-stroke from social perspective [2017, USD, Arithmetic mean
(Bootstrap 95% CI) (Table-2).
Effect of Cost Components on Total Cost of
Stroke Rehabilitation Patients
Table-3 depicts the average expenditure according to the demographic figures mentioned in the Table-1,
Figure-3 describes the direct medical costs determined by the mentioned
social demographic characteristics (Table-3). Cost per case by
demographical characteristics [n=103, 2017, USD, Arithmetic mean
(Bootstrap 95% CI)] (Figure-3). Direct medical cost by demographic
characteristics is shown in Figure-4 which illustrates costs from
patient, payer, hospital and society perspectives. Society witnessed the
economic burden of post-stroke rehabilitation with the total recorded
cost of $342,303.00 USD, approximately two times higher than the
hospital's cost. Economic burden under distinguished perspective can be
seen in Figure-4.
Discussion
The mean age of patients in this study was 60.3 } 11.4 years, with
44.7% patients being younger than 60 years old, which is a lower age
range than in previous studies on this topic. For example, the age
ranges in Giovanni Fattore et al.,10 M van Eeden et al.11 and Charles
Ellis et al.12 were 69.0 } 12.9, 66.8 } 12.3 and 78.1 } 6.9,
respectively. In 2012, the AHA (American Heart Association) presented
statistics showing that stroke patients were often more than 80 years
old.13 The average length of stay of inpatient rehabilitation was 137.0
} 94.6 days. In other studies, patients were hospitalized from two to
seven weeks after a stroke.
6,10,12 The significant
difference could be explained by the fact that the populations of the
other studies were mostly outpatients or patients evaluated after
discharge, and this study was conducted in a traditional hospital. In
this study, 84% of the patients were diagnosed with ischaemic stroke,
and this percentage was at least 75% in a majority of stroke
publications.
6,10-12,14 Stroke rehabilitation had a direct
impact on society with a cost of $342,303.50 USD, or $3,310.40 USD per
patient. Because not only was there a variety of cost-analysis
methodology in the study design, but also this study was conducted in a
hospital that uses both Eastern and Western therapy, it was
incommensurable with the estimated values of the economic burden as
presented in other articles. Akhavan Hejazi SM et al.
14
showed that the direct cost for outpatient rehabilitation during the
first three months was $547.10 USD, corresponding with $548.38 USD in
our results (which consisted of $1,653.60 USD for direct medical and
$539.90 USD for direct nonmedical costs). Moreover, traditional therapy
mentioned as an additional treatment outside the hospital for 69.4%
patients amounted to $14.60 USD per session, which was more than double
the price of a treatment session in hospital ($5.67 USD), whereas, it
accounted for 45.9% direct medical cost in our assessment.
14
An Italian study10 computed a cost of €4,112 EUR (euro) ($4,701 USD) in
healthcare services for rehabilitation in the first twelve months. Some
publications considered indirect cost to summarize the society's
economic burden. M van Eeden et al. claimed that a post-stroke Dutch
patients had productivity losses of €3,003.10 EUR (3,434 USD) and
inability to do unpaid labour of €3,000.00 EUR (3,430 USD)11 while an
Italian patient lost €792 EUR (905.68 USD) per stroke survivor because
of the decrease of production,10 and the corresponding figure of
Vietnamese patients from our results was $874.80 USD. Although the
methodology was constructed carefully, there were some limitations in
this study. The cost calculated was based on the information supplied by
family members or patients, so some mistakes or missing values could be
identified in estimating the economic burden. In spite of being
cautious, the cost elements that belong to comorbidities could not be
eliminated completely. Moreover, traditional therapy is very common in
Vietnamese medical centres, but our study solely researched a small
population in one hospital, although it has a strong reputation for
Eastern treatment in Vietnam. An idea for future researchers is to
expand the sample size in multiple centres to more accurately appraise
economic burden. Another approach would be to assess the cost and
effectiveness of stroke rehabilitation and the quality of life for
patients in both modern and traditional hospitals to have a comparative
view for policymakers.
Conclusion
The study concluded that strokes had a significant effect on patients
and caregivers, although in this case patients had already overcome the
acute phase. Treatment and rehabilitation were a social burden not only
in terms of the reduction of human source, but also in terms of the
great amount of treatment cost. The method of this research was designed
in a traditional hospital, and it could give decision makers a new
perspective about economic burden of poststroke patients who followed
traditional regiments.
Acknowledgement The authors also acknowledge the
efforts of the research assistants at Ho Chi Minh city Traditional
Medicine Hospital for communicating with study participants and
collecting data. We are grateful to all study participants for giving us
time at their residence and for their cooperation.
Disclaimer: None to declare.
Conflict of Interest: The authors declare that they have no conflict of interests.
Funding Disclosure: None to declare.
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