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US Cost Burden of Ischemic Stroke: A Systematic Literature Review
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US Cost Burden of Ischemic Stroke: A Systematic Literature Review

Bart M. Demaerschalk, MD, MSc, FRCP(C); Ha-Mill Hwang, PharmD; and Grace Leung, MPH

Effective preventive treatments, early critical care, and multi-disciplinary rehabilitative strategies for stroke will reduce the national expenditure for stroke-related healthcare services.

In the study by Leibson and colleagues,20 total inpatient and outpatient charges during the 12-month poststroke period were reported to be 3.4 times higher than those in the 12-month prestroke period. The analyses by Samsa and colleagues,14 Lipscomb and colleagues,26 and Sloss and colleagues25 have shown that the total stroke-related costs are highest during months 1 to 3 after a stroke. Taylor and colleagues7 reported direct cost of ischemic stroke per person during the first year in 1990 of approximately $15,102 to $20,574, depending on age. Fagan and colleagues16 estimated a mean cost (converted to 1996 dollars) nearing $30,000 for year 1 and approximately $60,000 as total cost (ie, short-term plus long-term care for the treatment of patients with acute ischemic stroke). Lee and colleagues8 reported an average Medicare expenditure of $39,396 (in 1997 dollars) from the initial event through 4 years in patients identified as having acute ischemic stroke. These data emphasize the need for effective preventive and early critical care.8

Indirect Costs. The majority of lifetime costs for each type of stroke results from indirect costs. Indirectcosts are a result of premature mortalityand reduced productivity for stroke survivors.7 In the study by Taylor and colleagues,7 indirect costs accounted for 58% ($23.6 billion) of lifetime stroke costs in the United States. Lost earnings owing to premature mortality accountedfor 56% of total indirect costs, and the remainder was a result of lost earnings for stroke survivors.7A cost analysis study by Brown and colleagues27 provided a projected breakdown of indirect costs (lost earnings and informal care) as well as direct costs caused by ischemic stroke (from 2005 to 2050) in non-Hispanic whites, African Americans, and Hispanics. Informal care refers to in-home assistance with activities of daily living as provided by a relative or unpaid nonrelative not associated with an organization.28 The single largest contributor to overall costs in all race/ethnic groups was lost earnings (33%, 43%, and 30%, respectively), and the second largest contributor to overall costs was informal caregiving (19%, 16%, and 19%).27

Aggregate Lifetime Costs. The US aggregate lifetime cost of first strokes was estimated to be $40.6 billion by Taylor and colleagues in 1990,7 with ischemic stroke accounting for $29 billion. Short-term care costs incurred in the first 2 years after a stroke (45%), long-term ambulatory care (35%), and nursing home costs (17.5%) constituted the major expenditure groups.7 The mean lifetime cost of ischemic stroke was estimated at nearly $91,000 in 1990 dollars.7 Lifetime cost of stroke per person was calculated as thesum of direct and indirect costs, while aggregate lifetime cost of strokewas calculated by multiplying the per personlifetime cost by the estimated incidence of first strokes in 1990.7 TheAmerican Heart Association estimated the direct medical and indirect expenditures attributable to stroke in 2008 as $65.5 billion and the mean lifetime cost of ischemic stroke, which included inpatient care, rehabilitation, and follow-up care, as $140,048 (converted to 1999 dollars).1 Brown and colleagues27 projected the US costs of ischemic stroke from 2005 to 2050 (in 2005 dollars) to be approximately $2.2 trillion; $1.52 trillion for non-Hispanic whites, $313 billion for Hispanics, and $379 billion for African Americans. The projected proportion of indirect and direct costs of ischemic stroke by ethnic group is presented the eAppendix B, available at www.ajmc.com.27The proposed figures likely underestimate the true burden of stroke, because the estimates do not take into account the rise in salaries and treatment costs, growth among minority populations, and the increase in risk factors for stroke such as obesity, diabetes, and heart disease.



DISCUSSION
It should be noted that the SIGN grading system was used in this literature review to rank economic studies, although it was designed to grade levels of evidence and evidence-based clinical studies and as such may not be a reliable instrument for assessing economic studies. Nonetheless, stroke presents a substantial burden on the healthcare system as well as on patients, family, and society.7 The majority of the literature addressing stroke-related costs focuses on short-term, in-hospital expenditures, with costs ranging from approximately $8000 to $23,000 (adjusted to 2008 dollars), depending on the length of hospital stay. Also, the literature search did not identify studies that determined the cost of stroke rehabilitation care. In contrast, there is a relative scarcity of quality studies focusing on the long-term components of direct stroke-related medical expenses, which are substantial. For example, in the study by Taylor and colleagues,7 long-term ambulatory care accounted for 35% and nursing homecosts accounted for 17.5% of total direct costs of stroke. In 1990 alone, there were more than 100,000 stroke-related nursing home admissions with a mean length of stay of 432 days,7 and in 1993 the annual cost for nursing home care based on a study of long-term care US insurers was $20,000 to $50,000.16These data emphasize the need for further studies that would examine the long-term components of stroke-related medical costs. Additionally, almost all of the studies citing short-term and long-term costs were from the 1990s, highlighting the need for more current data on the costs of stroke.

Those long-term expenses are estimated to be substantial. Assuming 3% yearly inflation from 2008, total direct and indirect costs of stroke in the United States would be $108 billion in 2025,1 and per the cost-analyses study by Brown and colleagues,27 the total cost of stroke from 2005 to 2050 is projected to be $2.2 trillion. These cost projections for stroke are comparable to those for other high-impact chronic diseases such as cancer and cardiovascular disease. The annual productivity loss from cancer mortality is projected to be $308 billion in 2020, while the cost associated with cancer-related deaths is expected to be $1.47 trillion in 2020.29,30The total cost of heart disease is projected to be $149 billion in 2025.31

Direct and indirect costs associated with stroke can be reduced by wider utilization of improved strategies for stroke care. rt-PA (Activase), approved in 1996 by the US Food and Drug Administration (FDA), has remained the only FDA-approved drug that is indicated for improving neurologic recovery and reducing the incidence of disability in adults with acute ischemic stroke.32 Additionally, there have been numerous cost-effectiveness studies of rt-PA, including that by Fagan and colleagues,16 which showed a decrease in rehabilitation costs of $1.4 million and nursing home costs of $4.8 million per 1000 eligible rt-PA–treated patients. More recently, other improved treatment strategies include the establishment of primary stroke centers and stroke center matrices that encompass multidisciplinary specialized stroke teams,33-35 stroke telemedicine via state-of-the-art video telecommunications and Internet-based consultative modalities for healthcare professionals and patients mainly in underserved urban and rural areas,36-39 and expansion of the rt-PA treatment time window.40 However, further studies are required to quantify the cost-effectiveness or cost savings of these interventions independently, and when combined in regional strategies and community networks of stroke care.

Acknowledgments We gratefully acknowledge Shilpa Lalchandani, PhD, Embryon, for assistance with the revisions and further development of the manuscript based on critical comments and direction from all authors; Susan Hogan, PhD, Embryon, for reviewing the manuscript for scientific accuracy; and Vicki Blasberg, Embryon, for managing the coordination of manuscript development and submission.

 

Author Affiliations: From the Department of Neurology (BMD), Mayo Clinic Hospital, Phoenix, AZ; and Genentech, Inc (HMH, GL), South San Francisco, CA.

 

Funding Source: Genentech, Inc, South San Francisco, CA, provided funding for editorial assistance to Embryon for editing, proofreading, and reference verification.

 

Author Disclosure: Dr Demaerschalk is the principal investigator (PI) for STRokE DOC AZ TIME (Arizona Department of Health Service [ADHS]) and Stroke Telemedicine for Arizona Rural Residents (ADHS); the site PI for Interventional Management of Stroke III (IMS III; National Institutes of Health [NIH]), Stenting and Aggressive Medical Management for Preventing Recurrent Stroke (SAMMPRIS; NIH), Secondary Pre-vention of Small Subcortical Strokes (SPS3; NIH), Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST; NIH), Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment (RESPECT; AGA Medical Corpora-tion), V10153 Acute Stroke Thrombolysis Trial (VASTT; Vernalis), Ancrod Stroke Program (ASP, Neurobiological Technology), and MP-124-A07 Trial (Mitsubishi Pharma); a co-investigator for ALbumin In Acute Stroke (ALIAS; NIH), CHOICE (Abbott), and ACT I (Abbott); a steering commit-tee member for SPS3, ASP, and VASTT; a Data Safety Monitoring Board member for IN-STEP (Vernalis); medical monitor for Neuralieve; and an event adjudicator for Axio Research. He reports no other consultancies, honoraria, speaker bureau memberships, employment relationships, or stocks. Ms Leung is an employee of Genentech, the company that funded this work. Dr Hwang was an employee of Genentech at the time this study was developed. She is now with the University of California San Francisco, San Francisco, CA. The opinions expressed in the current article are those of the authors. The authors received no honoraria or other form of financial support re-lated to the development of this manuscript.

 

Authorship Information: Concept and design (BMD, HMH, GL); acquisition of data (BMD, HMH, GL); analysis and interpretation of data (BMD, HMH, GL); drafting of the manuscript (BMD, GL); and critical revision of the manuscript for important intellectual content (BMD, HMH, GL).

 

Address correspondence to: Bart M. Demaerschalk, MD, MSc, FRCP(C), Department of Neurology, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054. E-mail: demaerschalk.bart@mayo.edu.

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