Long-Term Effect of Income Level on Mortality after Stroke: A Nationwide Cohort Study in South Korea

We investigated whether income level has long-term effects on mortality rate in stroke patients and whether this varies with time after the first stroke event, using the National Health Insurance Service National Sample Cohort data from 2002 to 2015 in South Korea. The study population was new-onset stroke patients ≥18 years of age. Patients were categorized into Category (1) insured employees and Category (2) insured self-employed/Medical Aid beneficiaries. Each category was divided into three and four income level groups, retrospectively. The study population comprised of 11,668 patients. Among the Category 1 patients (n = 7720), the low-income group's post-stroke mortality was 1.15-fold higher than the high-income group. Among the Category 2 patients (n = 3948), the lower income groups had higher post-stroke mortality than the high-income group (middle-income, aOR (adjusted odds ratio) 1.29; low-income, aOR 1.70; Medical Aid beneficiaries, aOR 2.19). In this category, the lower income groups' post-stroke mortality risks compared to the high-income group were highest at 13-36 months after the first stroke event(middle-income, aOR 1.52; low-income, aOR 2.31; Medical Aid beneficiaries, aOR 2.53). Medical Aid beneficiaries had a significantly higher post-stroke mortality risk than the high-income group at all time points.

Healthcare costs of NVAF patients treated with rivaroxaban and apixaban in the US

OBJECTIVES

To provide the most current assessment of real-world healthcare resource utilization (HRU) and costs among patients with non-valvular atrial fibrillation (NVAF) who newly initiated rivaroxaban and apixaban using a large US database.

MATERIAL AND METHODS

A retrospective weighted cohort design was used with healthcare insurance claims from the Optum Clinformatics Data Mart databases (January 2012-December 2018). The index date was defined as the first dispensing of rivaroxaban or apixaban. Adult NVAF patients with an index date on or after 1 January 2016, ≥ 12 months of continuous eligibility before the index date and ≥ 1 month after, and without prior use of oral anticoagulant were included. The observation period spanned from the index date to the earliest of the end of data availability, end of insurance coverage, or death. Inverse probability of treatment weighting (IPTW) was used to adjust for differences in baseline characteristics between cohorts. All-cause healthcare resource utilization (HRU), including hospitalization, emergency room, and outpatient visits, and healthcare costs, including medical and pharmacy costs, were evaluated from the payer's perspective during the observation period up to 18 and 24 months, separately.

RESULTS

In total, 23,822 rivaroxaban and 53,666 apixaban users were included. After weighting, all baseline characteristics were well balanced between cohorts (mean age: 73.8 years, female: 46.6% in both cohorts). Up to 18 months of follow-up, rivaroxaban users incurred significantly lower total healthcare costs compared to apixaban users (cost difference = -$1,121; p = 0.020), driven by significantly lower rates of outpatient hospital visits and associated costs (cost difference = -$1,579; p < 0.001). Similar results were found in the analysis conducted for up to 24 months of follow-up (total cost difference = ‒$1,111; p = 0.020).

CONCLUSIONS

In this large retrospective analysis, patients with NVAF initiated on rivaroxaban incurred significantly lower healthcare costs compared to those initiated on apixaban, which were primarily driven by significantly lower outpatient visits and costs during the 18- and 24-month follow-up periods.

Exploring the Economic Benefits of Modafinil for Post-Stroke Fatigue in Australia: A Cost-Effectiveness Evaluation

BACKGROUND

In stroke survivors, post-stroke fatigue predicts dependency in daily living and failure to return to work. Modafinil shows promise as a pharmacotherapy to reduce post-stroke fatigue and related sequelae, e.g., poorer functional and clinical outcomes.

AIMS

This study explored the cost-effectiveness of modafinil in treating post-stroke fatigue in the Australian context, by determining its incremental cost-effectiveness ratio (ICER) and by simulating the potential cost-savings on a national scale, through a re-analysis of MIDAS trial data.

METHODS

A post hoc cost-effectiveness analysis was undertaken. Part A: patient-level cost and health effect data (Multidimensional Fatigue Inventory (MFI) scores) were derived from the MIDAS trial and analysis undertaken from a health-system perspective. Part B: a secondary analysis simulated the societal impact of modafinil therapy in terms of national productivity costs.

RESULTS

Part A: Mean cost of modafinil treatment was AUD$3.60/day/patient for a minimally clinically important change (10 points) in total MFI fatigue score, i.e., AUD$0.36/day/unit change in fatigue score per patient. For the base case scenario, the ICER of using modafinil (versus placebo) was AUD$131.73 ($90.17 - 248.15, for minimum and maximum costs, respectively). Part B: The potential productivity cost-savings to society were calculated as nearly AUD$467 million over 1 year, and up to $383,471,991,248 over 10 years, from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors, representing a significant societal benefit.

CONCLUSIONS

Modafinil is a highly cost-effective treatment for post-stroke fatigue, offering significant productivity gains and potential cost-savings to society from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors.

Cost-effectiveness of antithrombotic agents for atrial fibrillation in older adults at risk for falls: a mathematical modelling study

BACKGROUND

Antithrombotic drugs decrease stroke risk in patients with atrial fibrillation, but they increase bleeding risk, particularly in older adults at high risk for falls. We aimed to determine the most cost-effective antithrombotic therapy in older adults with atrial fibrillation who are at high risk for falls.

METHODS

We conducted a mathematical modelling study from July 2019 to March 2020 based on the Ontario, Canada, health care system. We derived the base-case age, sex and fall risk distribution from a published cohort of older adults at risk for falls, and the bleeding and stroke risk parameters from an atrial fibrillation trial population. Using a probabilistic microsimulation Markov decision model, we calculated quality-adjusted life years (QALYs), total cost and incremental cost-effectiveness ratios (ICERs) for each of acetylsalicylic acid (ASA), warfarin, apixaban, dabigatran, rivaroxaban and edoxaban. Cost data were adjusted for inflation to 2018 values. The analysis used the Ontario public payer perspective with a lifetime horizon.

RESULTS

In our model, the most cost-effective antithrombotic therapy for atrial fibrillation in older patients at risk for falls was apixaban, with an ICER of $8517 per QALY gained (5.86 QALYs at $92 056) over ASA. It was a dominant strategy over warfarin and the other antithrombotic agents. There was moderate uncertainty in cost-effectiveness ranking, with apixaban as the preferred choice in 66% of model iterations (given willingness to pay of $50 000 per QALY gained); edoxaban, 30 mg, was preferred in 31% of iterations. Sensitivity analysis across ranges of age, bleeding risk and fall risk still favoured apixaban over the other medications.

INTERPRETATION

From a public payer perspective, apixaban is the most cost-effective antithrombotic agent in older adults at high risk for falls. Health care funders should implement strategies to encourage use of the most cost-effective medication in this population.

Does race matter in universal healthcare? Stroke cost and outcomes in US military health care

Introduction: It is well documented in the US civilian healthcare system that race is correlated with different outcomes for ischemic stroke patients. That healthcare system has wide variations in access to and quality of care. In contrast, the US military healthcare system (MHS) a universal healthcare system where every member has access to the same healthcare benefits. Do racial disparities evident in the civilian healthcare system transfer to the MHS? Methods: Data was collected from the MHS Military Mart (M2) database from calendar years 2010 through 2015. All adult patients with a primary diagnosis of ischemic stroke upon discharge were reviewed. Race was compared across primary outcomes of: (1) IV tPA administration and (2) Disposition destination 'poor disposition destination or in-hospital mortality'. And secondary outcomes of: (1) Total cost of hospitalization and (2) Length of hospital stay. Relevant demographic and co-morbidities were adjusted with regression analysis. Results: A total of 3623 patients met this study's parameters. Race was identified in 2661 (73.5%) admissions. Racial composition of this patient sample was: White 1767 (48.8%), African Americans 619 (17.1%), Asian 275 (7.6%), Other or Unknown 962 (26.5%). There was no correlation between race and administration of IV tPA, poor disposition destination or in-hospital mortality. There was a correlation between African Americans and increased cost of hospitalization. This finding was correlated with costs for radiological studies but was not correlated with any increase in the length of stay. Conclusion: Racial disparities evident in the civilian healthcare system do not appear to transfer the universal healthcare system represented by the MHS. Universal healthcare mitigates racial disparities in ischemic stroke admissions.

Health Care Costs Associated With Macrovascular, Microvascular, and Metabolic Complications of Type 2 Diabetes Across Time: Estimates From a Population-Based Cohort of More Than 0.8 Million Individuals With Up to 15 Years of Follow-up

OBJECTIVE

Developing country-specific unit-cost catalogs is a key area for advancing economic research to improve medical and policy decisions. However, little is known about how health care costs vary by type 2 diabetes (T2D) complications across time in Asian countries. We sought to quantify the economic burden of various T2D complications in Taiwan.

RESEARCH DESIGN AND METHODS

A nationwide, population-based, longitudinal study was conducted to analyze 802,429 adults with newly diagnosed T2D identified during 1999-2010 and followed up until death or 31 December 2013. Annual health care costs associated with T2D complications were estimated, with multivariable generalized estimating equation models adjusted for individual characteristics.

RESULTS

The mean annual health care cost was $281 and $298 (2017 U.S. dollars) for a male and female, respectively, diagnosed with T2D at age <50 years, with diabetes duration of <5 years, and without comorbidities, antidiabetic treatments, and complications. Depression was the costliest comorbidity, increasing costs by 64-82%. Antidiabetic treatments increased costs by 72-126%. For nonfatal complications, costs increased from 36% (retinopathy) to 202% (stroke) in the event year and from 13% (retinopathy or neuropathy) to 49% (heart failure) in subsequent years. Costs for the five leading costly nonfatal subtype complications increased by 201-599% (end-stage renal disease with dialysis), 37-376% (hemorrhagic/ischemic stroke), and 13-279% (upper-/lower-extremity amputation). For fatal complications, costs increased by 1,784-2,001% and 1,285-1,584% for cardiovascular and other-cause deaths, respectively.

CONCLUSIONS

The cost estimates from this study are crucial for parameterizing diabetes economic simulation models to quantify the economic impact of clinical outcomes and determine cost-effective interventions.

Social deprivation among socio-economic contrasted french areas: Using item response theory analysis to assess differential item functioning of the EPICES questionnaire in stroke patients

Background

Multiple approaches have been proposed to measure low socio-economic status. In France the concept of precariousness, akin to social deprivation, was developed and is widely used. EPICES is a short questionnaire that was developed to measure this concept. This study aimed to evaluate Differential Item Functioning (DIF) in the EPICES questionnaire between contrasted areas: mainland France, French West Indies (FWI) and French Guiana (FG).

Methods

The population was taken from the INDIA study, which aimed to evaluate the impact of social inequalities on stroke characteristics and prognosis. Eligible people were patients referred to neurology or emergency departments for a suspicion of stroke. We assessed the DIF using hybrid ordinal logistic regression method, derived from item response theory.

Results

We analysed 1 553 stroke patients, including 768 from FWI (49.5%), 289 from FG (18.6%) and 496 from mainland (31.9%). We identified five items with a moderate to large DIF in area comparisons: “meeting with a social worker”, “complementary health insurance”, “home-owning”, “financial difficulties” and “sport activities”. Correlation between EPICES score and the latent variable was strong (r = 0.84).

Conclusion

This is the first attempt to assess the DIF of the EPICES score between different French populations. We found several items with DIF, which can be explained by individual interpretation or local context. However, the DIFs did not lead to a large difference between the latent variable and the EPICES score, which indicates that it can be used to assess precariousness and social deprivation between contrasted areas.

A pragmatic, multi-centered, stepped wedge, cluster randomized controlled trial pilot of the clinical and cost effectiveness of a complex Stroke Oral healthCare intervention pLan Evaluation II (SOCLE II) compared with usual oral healthcare in stroke wards

BACKGROUND

Patients with stroke-associated pneumonia experience poorer outcomes (increased hospital stays, costs, discharge dependency, and risk of death). High-quality, organized oral healthcare may reduce the incidence of stroke-associated pneumonia and improve oral health and quality of life.

AIMS

We piloted a pragmatic, stepped-wedge, cluster randomized controlled trial of clinical and cost effectiveness of enhanced versus usual oral healthcare for people in stroke rehabilitation settings.

METHODS

Scottish stroke rehabilitation wards were randomly allocated to stepped time-points for conversion from usual to enhanced oral healthcare. All admissions and nursing staff were eligible for inclusion. We piloted the viability of randomization, intervention, data collection, record linkage procedures, our sample size, screening, and recruitment estimates. The stepped-wedge trial design prevented full blinding of outcome assessors and staff. Predetermined criteria for progression included the validity of enhanced oral healthcare intervention (training, oral healthcare protocol, assessment, equipment), data collection, and stroke-associated pneumonia event rate and relationship between stroke-associated pneumonia and plaque.

RESULTS

We screened 1548/2613 (59%) admissions to four wards, recruiting n = 325 patients and n = 112 nurses. We observed marked between-site diversity in admissions, recruitment populations, stroke-associated pneumonia events (0% to 21%), training, and resource use. No adverse events were reported. Oral healthcare documentation was poor. We found no evidence of a difference in stroke-associated pneumonia between enhanced versus usual oral healthcare (P = 0.62, odds ratio = 0.61, confidence interval: 0.08 to 4.42).

CONCLUSIONS

Our stepped-wedge cluster randomized control trial accommodated between-site diversity. The stroke-associated pneumonia event rate did not meet our predetermined progression criteria. We did not meet our predefined progression criteria including the SAP event rate and consequently were unable to establish whether there is a relationship between SAP and plaque. A wide confidence interval did not exclude the possibility that enhanced oral healthcare may result in a benefit or detrimental effect.

TRIAL REGISTRATION

NCT01954212.

Continual Long-Term Physiotherapy After Stroke: A Health Technology Assessment

BACKGROUND

Stroke is a serious health issue in which an interruption in blood flow to any part of the brain damages brain cells. About 83% of people survive with substantial morbidity after their first stroke. We conducted a health technology assessment of continual long-term physiotherapy for people with a diagnosis of stroke, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding continual long-term physiotherapy for people with a diagnosis of stroke, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence. We also performed a systematic literature search of the economic evidence. We did not conduct a primary economic evaluation because there was insufficient clinical evidence. We also analyzed the budget impact of publicly funding continual long-term physiotherapy after stroke in Ontario. To contextualize the potential value of continual long-term physiotherapy after stroke, we spoke with people who had been diagnosed with stroke, as well as their caregivers.

RESULTS

We did not find any published studies that met the specific clinical inclusion criteria. We did not identify any studies that compared the cost-effectiveness of continual long-term versus short-term physiotherapy after stroke. The budget impact of publicly funding continual long-term physiotherapy after stroke in Ontario over the next 5 years ranges from $445,000 in year 1 at an uptake rate of 8% to $888,000 in year 5 at an uptake rate of 16%. The people who had been diagnosed with stroke with whom we spoke reported that they had benefitted from continual long-term physiotherapy.

CONCLUSIONS

We did not identify studies that addressed the specific research question. Based on the clinical evidence review, we are unable to determine the benefits of continual long-term compared with short-term physiotherapy after stroke. The cost-effectiveness of continual long-term physiotherapy after stroke in Ontario is unknown. We estimate that publicly funding continual long-term physiotherapy after stroke in Ontario would result in additional costs of between $445,000 and $888,000 annually over the next 5 years. Patients and caregivers who we spoke with felt that patients who have experienced a stroke should be able to continue with physiotherapy.

Assessment of Differences in Inpatient Rehabilitation Services for Length of Stay and Health Outcomes Between US Medicare Advantage and Traditional Medicare Beneficiaries

IMPORTANCE

Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types.

OBJECTIVE

To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US.

DESIGN, SETTING, AND PARTICIPANTS

This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019.

EXPOSURES

Medicare insurance plan type, TM or MA.

MAIN OUTCOMES AND MEASURES

Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge.

RESULTS

The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, -0.15 to -0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, -0.21 to -0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs within an acute care hospital) and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types.

CONCLUSIONS AND RELEVANCE

This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics.

Economic burden associated with inadequate antidepressant medication management among patients with depression and known cardiovascular diseases: insights from a United States-based retrospective claims database analysis

Aims: The current study examined the association between insufficient major depressive disorder (MDD) care and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke.Methods: This was a retrospective study conducted using the MarketScan Claims Database (2010-2015). The date of the first MI/stroke diagnosis was defined as the cardiovascular disease (CVD) index date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90 days following the index MDD date (profiling period) using 2 measures: dosage adequacy (average fluoxetine equivalent dose of ≥20 mg/day for nonelderly and ≥10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Study outcomes included all-cause and CVD-related HCRU and costs which were determined from the end of the profiling period until the end of study follow-up. Propensity-score adjusted generalized linear models (GLMs) were used to compare patients receiving adequate versus inadequate MDD care in terms of study outcomes.Results: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Results from the GLMs suggested that patients receiving inadequate MDD care had 14% more all-cause hospitalizations, 4% more all-cause outpatient visits, 17% more CVD-related outpatient visits, 13% more CVD-related emergency room (ER) visits, higher per patient per year CVD-related hospitalization costs ($21,485 vs. $17,756), higher all-cause outpatient costs ($2,820 vs. $2,055), and higher CVD-related outpatient costs ($520 vs. $434) compared to patients receiving adequate MDD care.Limitations: Clinical information such as depression severity and frailty, which are potential predictors of adverse CVD outcomes, could not be ascertained using administrative claims data.Conclusions: Among post-MI and post-stroke patients, inadequate MDD care was associated with a significantly higher economic burden.

[Effectiveness, safety and costs of stroke prevention in non-valvular auricular fibrillation. Study of cohorts matched by Propensity score]

OBJECTIVE

To analyze the use, effectiveness, safety and costs of stroke prevention in non-valvular atrial fibrillation (AF) in patients initiating treatment with dabigatran or vitamin K antagonists (VKA).

SETTING

Primary Care (PC) at the Catalan Health Institute (ICS) in Catalonia, during 2011-2013.

PARTICIPANTS

Patients attended in ICS PC centres with a registered diagnosis of AF who initiate dabigatran or VKA.

INTERVENTIONS

Not applicable MAIN MEASUREMENTS: Number of prescriptions and reimbursements of dabigatran and VKA, incidence of stroke and haemorrhages, incidence of mortatlity, number of sickness leave, and costs associated to all the previous variables.

RESULTS

14,930 patients were included; 94.6% initiated VKA and 5.4%, dabigatran. Dabigatran patients were younger and with less comorbidity. There were no statistically significant differences between VKA and dabigatran in the risk of stroke, haemorrhages or death. The costs associated to AF management were higher for PC visits in the VKA group, and higher for laboratory and pharmacy in the dabigatran group, although overall costs were not statistically different.

CONCLUSIONS

Most patients initiated VKA. We found no differences between VKA and dabigatran in the risk of stroke, haemorrhages or mortality.

Fighting healthcare rocketing costs with value-based medicine: the case of stroke management

Value-Based Medicine (VBM) is imposing itself as 'a new paradigm in healthcare management and medical practice.In this perspective paper, we discuss the role of VBM in dealing with the large productivity issue of the healthcare industry and examine some of the worldwide industrial and technological trends linked with VBM introduction. To clarify the points, we discuss examples of VBM management of stroke patients.In our conclusions, we support the idea of VBM as a strategic aid to manage rising costs in healthcare, and we explore the idea that VBM, by establishing value-generating networks among different healthcare stakeholders, can serve as the long sought-after redistributive mechanism that compensate patients for the industrial exploitation of their personal medical records.

Four-year trends in oral anticoagulant use and declining rates of ischemic stroke among 194,030 atrial fibrillation patients drawn from a sample of 12 million people

BACKGROUND

Administrative data were used to investigate changes in hospitalizations for atrial fibrillation (AF), AF-related stroke, and treatment patterns between 2012 and 2016.

METHODS

From the 'Ricerca e Salute' database, a population- and patient-based repository involving >12 million inhabitants and linking demographics, prescriptions, and hospital discharge records, all patients discharged alive with a diagnosis of AF between 2012 and 2015 were followed for 1 year.

RESULTS

A total of 194,030 AF patients were included. The number of AF cases increased ~10% over time, from 4.0 per 1,000 inhabitants in 2012 to 4.4 per 1,000 in 2015. At 1 year, hospitalizations for ischemic stroke decreased from 21.3 per 1,000 patients with AF in 2012-2013 to 14.7 per 1,000 in 2015-2016 (-31%, 95% CI -18 to -41). Over the same period, oral anticoagulant (OAC) use increased from 56.7% to 64.4% (+14%, 95% CI +8 to +26), vitamin K antagonist use decreased (from 55.9 to 36.7%; -34%, 95% CI -21 to -44), whereas direct OACs (DOACs) increased (from <1% in 2012 to 27.7% in 2015). Antiplatelet prescriptions fell from 42.6% in 2012 to 28.1% in 2015. Hospitalizations for major bleeds, mainly gastrointestinal, increased from 1.5‰ in 2012-2013 to 2.3‰ in 2015-2016, whereas hemorrhagic stroke admissions decreased from 6.5‰ to 4.1‰.

CONCLUSIONS

There was a slight increase in the prevalence of AF between 2012 and 2015, whereas the overall use of antiplatelet agents decreased and that of OAC, particularly DOACs, increased. Over the same period, 1-year hospitalizations for ischemic stroke declined substantially, with a declining rate of hemorrhagic strokes.

Financial Burden of Stroke Reflected in a Pilot Center for the Implementation of Thrombolysis

Stroke represents a serious illness and is extremely relevant from the public health point of view, implying important social and economic burdens. Introducing new procedures or therapies that reduce the costs both in the acute phase of the disease and in the long term becomes a priority for health systems worldwide. The present study quantifies and compares the direct costs for ischemic stroke in patients with thrombolysis treatment versus conservative treatment over a 24-month period from the initial diagnosis, in one of the 7 national pilot centres for the implementation of thrombolytic treatment. The significant reduction (p < 0.001) of the hospitalization period, especially of the days in the intensive care unit (ICU) for stroke, resulted in a significant reduction (p < 0.001) of the total average costs in the patients with thrombolysis, both at the first hospitalization and for the subsequent hospitalizations, during the period followed in the study. It was also found that the percentage of patients who were re-hospitalized within the first 24-months after stroke was significantly lower (p < 0.001) among thrombolyzed patients. The present study demonstrates that the quick intervention in cases of stroke is an efficient policy regarding costs, of Romanian Public Health System, Romania being the country with the highest rates of new strokes and deaths due to stroke in Europe.

Real-world cost-effectiveness of rivaroxaban compared with vitamin K antagonists in the context of stroke prevention in atrial fibrillation in France

Objective

The objective was to assess the real-world cost-effectiveness of rivaroxaban, versus vitamin K antagonists (VKAs), for stroke prevention in patients with atrial fibrillation (AF) from a French national health insurance perspective.

Methods

A Markov model was developed with a lifetime horizon and cycle length of 3 months. All inputs were drawn from real-world evidence (RWE) studies: data on baseline patient characteristics at model entry were obtained from a French RWE study, clinical event rates as well as persistence rates for the VKA treatment arm were estimated from a variety of RWE studies, and a meta-analysis provided comparative effectiveness for rivaroxaban compared to VKA. Model outcomes included costs (drug costs, clinical event costs, and VKA monitoring costs), quality-adjusted life-years (QALY) and life-years (LY) gained, incremental cost per QALY, and incremental cost per LY. Sensitivity analyses were performed to test the robustness of the model and to better understand the results drivers.

Results

In the base-case analysis, the incremental total cost was €714 and the total incremental QALYs and LYs were 0.12 and 0.16, respectively. The resulting incremental cost/QALY and incremental cost/LY were €6,006 and €4,586, respectively. The results were more sensitive to the inclusion of treatment-specific utility decrements and clinical event rates.

Conclusions

Although there is no official willingness-to-pay threshold in France, these results suggest that rivaroxaban is likely to be cost-effective compared to VKA in French patients with AF from a national insurance perspective.

Income inequalities in stroke incidence and mortality: Trends in stroke-free and stroke-affected life years based on German health insurance data

Background

Due to substantial improvements in prevention and therapy, stroke incidence and mortality rates have decreased during the last decades, but evidence is still lacking on whether all socioeconomic groups benefited equally and how the length of life affected by stroke developed over time. Our study investigates time trends in stroke-free life years and life years affected by stroke. Special emphasis is given to the question whether trends differ between income groups, leading to decreasing or increasing social inequalities.

Methods

The analyses are based on claims data of a German statutory health insurance company of the two time periods 2006–2008 and 2014–2016. Income inequalities and time trends in incidence and mortality risks were estimated using multistate survival models. Trends in stroke-free life years and life years affected by stroke are analysed separately for income groups by applying multistate life table analyses.

Results

Stroke incidence and mortality risks decreased in men and women in all income groups. While stroke-free lifetime could be gained in men having higher incomes, improvements in mortality counterbalanced decreasing incidences, leading to increases in life years affected by stroke among men of the lower and higher income group. Among women, no significant changes in life years could be observed.

Conclusions

Changes in stroke-affected life years occur among men in all income groups, but are more pronounced in the higher income group. However, irrespective of the income group the proportion of stroke-affected life years remains quite stable over time, pointing towards constant inequalities. Further research is needed on whether impairments due to stroke reduced over time and whether all socioeconomic groups are affected equally.

A Long-Term Cost-Effectiveness Analysis Comparing Radiofrequency Catheter Ablation with Antiarrhythmic Drugs in Treatment of Chinese Patients with Atrial Fibrillation

INTRODUCTION

Radiofrequency catheter ablation (RFCA) is widely used to treat atrial fibrillation (AF) in China.

OBJECTIVE

We aimed to determine the long-term cost effectiveness of RFCA versus antiarrhythmic drugs (AADs) in treating AF from the perspective of third-party payers.

METHODS

The model was structured as a 12-month decision tree leading to a Markov model that simulated the follow-up treatment outcomes and costs with time horizons of 8, 15, and 20 years. Comparators were standard-of-care AADs. Clinical parameters captured normal sinus rhythm, AF, stroke, post-stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding, post-ICH, and death. The risk of operative death, procedural complications, and adverse drug toxicity were also considered. The model output was quality-adjusted life-years (QALYs) and incremental cost per QALY gained.

RESULTS

RFCA incurred more costs than the AADs but resulted in more QALYs gained than did AADs. The incremental cost per QALY gained with RFCA versus AADs was ¥66,764, ¥36,280, and ¥29,359 at 8, 15, and 20 years, respectively. The sensitivity analyses showed that the results were most sensitive to the changes in RFCA cost and CHADS₂ score (clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic AF).

CONCLUSION

Compared with AADs, RFCA significantly improves clinical outcomes and QALYs among patients with paroxysmal or persistent AF. From the Chinese payer's perspective, RFCA is a cost-effective therapy over long-term horizons.

Performance of the UKPDS Outcomes Model 2 for Predicting Death and Cardiovascular Events in Patients with Type 2 Diabetes Mellitus from a German Population-Based Cohort

BACKGROUND AND OBJECTIVE

Accurate prediction of relevant outcomes is important for targeting therapies and to support health economic evaluations of healthcare interventions in patients with diabetes. The United Kingdom Prospective Diabetes Study (UKPDS) risk equations are some of the most frequently used risk equations. This study aims to analyze the calibration and discrimination of the updated UKPDS risk equations as implemented in the UKPDS Outcomes Model 2 (UKPDS-OM2) for predicting cardiovascular (CV) events and death in patients with type 2 diabetes mellitus (T2DM) from population-based German samples.

METHODS

Analyses are based on data of 456 individuals diagnosed with T2DM who participated in two population-based studies in southern Germany (KORA (Cooperative Health Research in the Region of Augsburg)-A: 1997/1998, n = 178; KORA-S4: 1999-2001, n = 278). We compared the participants' 10-year observed incidence of mortality, CV mortality, myocardial infarction (MI), and stroke with the predicted event rate of the UKPDS-OM2. The model's calibration was evaluated by Greenwood-Nam-D'Agostino tests and discrimination was evaluated by C-statistics.

RESULTS

Of the 456 participants with T2DM (mean age 65 years, mean diabetes duration 8 years, 56% male), over the 10-year follow-up time 129 died (61 due to CV events), 64 experienced an MI, and 46 a stroke. The UKPDS-OM2 significantly over-predicted mortality and CV mortality by 25% and 28%, respectively (Greenwood-Nam-D'Agostino tests: p < 0.01), but there was no significant difference between predicted and observed MI and stroke risk. The model poorly discriminated for death (C-statistic [95% confidence interval] = 0.64 [0.60-0.69]), CV death (0.64 [0.58-0.71]), and MI (0.58 [0.52-0.66]), and failed to discriminate for stroke (0.57 [0.47-0.66]).

CONCLUSIONS

The study results demonstrate acceptable calibration and poor discrimination of the UKPDS-OM2 for predicting death and CV events in this population-based German sample. Those limitations should be considered when using the UKPDS-OM2 for economic evaluations of healthcare strategies or using the risk equations for clinical decision-making.

Healthcare resource utilization and expenditures among newly-diagnosed elderly non-valvular atrial fibrillation patients initiating oral anticoagulants

Aims: Non-valvular atrial fibrillation (NVAF) prevalence increases with age. Hence, evaluating the economic burden among older-aged patients is vital. This study aimed to compare healthcare resource utilization (HRU) and costs among newly-diagnosed older-aged NVAF patients treated with warfarin, rivaroxaban, or apixaban vs. dabigatran.Materials and Methods: Newly-diagnosed older-aged (aged ≥65 years) NVAF patients initiating dabigatran, warfarin, rivaroxaban, or apixaban (first prescription date = index date) from 01JAN2010-31DEC2015 and with continuous enrollment for ≥12 months pre-index date were included from 100% Medicare database. Patient data were assessed until drug discontinuation/switch/dose change/death/disenrollment/study end (up to 12 months). Dabigatran initiators were 1:1 propensity score-matched (PSM) with warfarin, rivaroxaban, or apixaban initiators. Generalized linear models were used to compare all-cause HRU and costs per-patient-per-month (PPPM) between the matched cohorts.Results: After PSM with dabigatran, 70,531 warfarin, 51,673 rivaroxaban, and 25,209 apixaban patients were identified. Dabigatran patients had significantly fewer generalized-linear-model-adjusted PPPM hospitalizations (0.114 vs. 0.123; 0.111 vs. 0.121), and outpatient visits (2.864 vs. 4.201; 2.839 vs. 2.949) than warfarin and rivaroxaban patients, respectively, but had significantly more PPPM hospitalizations (0.103 vs. 0.090) and outpatient visits (2.780 vs. 2.673) than apixaban patients (all p < .0001). Dabigatran patients incurred significantly lower adjusted total PPPM costs ($3,309 vs. $3,362; $3,285 vs. $3,474) than warfarin and rivaroxaban patients, respectively (all p < .01) but higher total PPPM costs ($3,192 vs. $2,986) than apixaban patients (all p < .0001).Limitations: This study is subject to the inherent limitations of any claims dataset, including potential bias from coding errors and identification of medical conditions using diagnosis codes as opposed to clinical evidence. Medications filled over-the-counter or provided as samples by the physician are never captured in claims data.Conclusions: Newly-diagnosed older-aged NVAF patients initiating dabigatran incurred significantly lower adjusted all-cause HRU and costs than warfarin and rivaroxaban patients but higher adjusted HRU and costs than apixaban patients.

Omega-3 Polyunsaturated Fatty Acids and Stroke Burden

Stroke is a major leading cause of death and disability worldwide. N-3 polyunsaturated fatty acids (PUFAs) including eicosapentaenoic acid and docosahexaenoic acid have potent anti-inflammatory effects, reduce platelet aggregation, and regress atherosclerotic plaques. Since the discovery that the Greenland Eskimo population, whose diet is high in marine n-3 PUFAs, have a lower incidence of coronary heart disease than Western populations, numerous epidemiological studies to explore the associations of dietary intakes of fish and n-3 PUFAs with cardiovascular diseases, and large-scale clinical trials to identify the benefits of treatment with n-3 PUFAs have been conducted. In most of these studies the incidence and mortality of stroke were also evaluated mainly as secondary endpoints. Thus, a systematic literature review regarding the association of dietary intake of n-3 PUFAs with stroke in the epidemiological studies and the treatment effects of n-3 PUFAs in the clinical trials was conducted. Moreover, recent experimental studies were also reviewed to explore the molecular mechanisms of the neuroprotective effects of n-3 PUFAs after stroke.

Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention

BACKGROUND

Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window.

OBJECTIVE

We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times.

METHODS

Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%.

RESULTS

The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY.

CONCLUSION

II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.

Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization

OBJECTIVES

To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications.

STUDY DESIGN

Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges.

RESULTS

We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke).

CONCLUSIONS

Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

Continuation with apixaban treatment is associated with lower risk for hospitalization and medical costs among elderly patients

Objective: To compare the risk of hospitalization and costs associated with major bleeding (MB) or stroke/systemic embolism (SE) among elderly patients with nonvalvular atrial fibrillation (NVAF) who initiated apixaban then switched to another oral anticoagulant (OAC) vs. those who continued with apixaban treatment. Methods: NVAF patients (≥65 years) initiating apixaban were identified from the Humana database (1 January 2013-30 September 2017) and grouped into switcher and continuer cohorts. For switchers, the earliest switch from apixaban to another OAC was defined as the index event/date. A random date during apixaban treatment was selected as the index date for continuers. Patients were followed from index date to health plan disenrollment or 31 December 2017, whichever was earlier. Multivariable regression analyses were used to examine the association of switchers vs. continuers with risk of MB-related or stroke/SE-related hospitalization and healthcare costs during follow-up. Results: Of 7858 elderly NVAF patients included in the study, 14% (N = 1110; mean age: 78 years) were switchers; 86% (N = 6748; mean age: 79 years) were continuers. Apixaban switchers vs. continuers had significantly greater risk of MB-related hospitalization (hazard ratio [HR]: 2.00; 95% CI: 1.52-2.64; p < .001) during follow-up; risk of stroke/SE hospitalization did not differ significantly (HR: 1.36, 95% CI: 0.89-2.06, p = .154). MB- and stroke/SE-related medical costs were higher for switchers vs. continuers, although total all-cause healthcare costs were similar. Conclusion: Elderly patients with NVAF in the US who continued with apixaban treatment had a lower risk of MB-related hospitalization and lower MB- and stroke/SE-related medical costs compared to patients who switched to another OAC.

Incidence of stroke and traumatic brain injury in New Zealand: contrasting the BIONIC and ARCOS-IV studies

AIMS

Traumatic Brain Injury (TBI) and stroke are the main causes of acquired brain injury. The differences in demographic profiles of stroke and TBI suggest that high-quality epidemiological studies of the two be compared. This study examined incidence of stroke and TBI by age and ethnicity in New Zealand.

METHODS

Incidence rates are presented by age and ethnicity from two New Zealand population-based epidemiological studies (Brain Injury Outcomes New Zealand In the Community (BIONIC); and Auckland Regional Outcomes of Stroke Studies (ARCOS-IV)).

RESULTS

Males and females had similar stroke risk, while males had 2x relative risk of mild TBI and 3x the relative risk of moderate/severe TBI compared to females. More TBI cases (35.6%) were identified through non-medical sources compared to stroke (3%). Incidence of TBI was greater than 5 times that of stroke. New Zealand European/Pākehā had the highest TBI incidence when less than 5 years of age, while Māori had the highest incidence after five years of age. For stroke, Pacific people and Māori had higher incidences until 75-84 years, after which Europeans had higher incidence.

CONCLUSIONS

Differences in TBI and stroke incidence suggest targeting prevention very differently for the two groups. Incidence profiles suggest TBI is much more common; and a need to target males and those of Māori ethnicity for TBI prevention.