Acute treatment costs of stroke in Brazil

Challenges in adapting a stroke unit in a middle-income country: warning about costs and underfunding to achieve the Brazilian Ministry of Health's benchmark

Background

Since the implementation of the stroke care line in Brazil, the relationship (adequacy) of costs spent during hospitalization with the Brazilian Ministry of Health indicators for a stroke unit have not yet been analyzed.

Aims

This study aimed to assess the adequacy of a comprehensive stroke center for key performance indicators and analyze the costs involved in hospitalization. We verified the association between stroke severity at admission and care costs during hospitalization.

Methods

A retrospective medical chart review of 451 patients was performed using semiautomatic electronic data from a single comprehensive stroke center in Brazil between July 2018 and January 2020. Clinical and resource utilization data were collected, and the mean acute treatment cost per person was calculated. The Kruskal-Wallis test with Dunn's post-test was used to compare the total costs between stroke types and reperfusion therapies. A robust linear regression test was used to verify the association between stroke severity at hospital admission and the total hospitalization costs. Good adequacy rates were observed for several indicators.

Results

Data from 451 patients were analyzed. The stroke unit had good adaptation to key performance indicators, but some critical points needed revision and improvement to adapt to the requirements of the Ministry of Health. The average total cost of the patient's stay was the USD 2,637.3, with the daily hospitalization, procedure, operating room, and materials/medication costs equating to USD 2,011.1, USD 220.7, USD 234.1, and USD 98.8, respectively. There was a positive association between the total cost and length of hospital stay (p < 0.001).

Conclusion

The stroke unit complied with most of the main performance indicators proposed by the Brazilian Ministry of Health. Underfunding of the costs involved in the hospitalization of patients was verified, and high costs were associated with the length of stay, stroke severity, and mechanical thrombectomy.

Functionality and quality of life in Brazilian patients 6 months post-stroke

Background

Surviving a stroke poses a social and economic impact that requires the care system to be reformulated and the patient to be addressed in a comprehensive approach.

Purpose

This study aims to investigate if there is a relationship between functional activities performed before the stroke, patients' clinical and hospitalization data, and functionality and quality of life measures in the first 6 months after the stroke.

Methods

This study used a prospective cohort of 92 patients. We investigated sociodemographic and clinical data, the modified Rankin Scale (mRS), and the Frenchay Activities Index (FAI) during hospitalization. The Barthel Index (BI) and EuroQol-5D (EQ-5D) were applied at the following time points: 30 days (T1), 90 days (T2), and 180 days (T3) following postictal state. Statistical analysis was conducted using Spearman's coefficient, Friedman's non-parametric test, and multiple linear regression models.

Results

No correlation was found between FAI, BI, and EQ-5D average scores. Severe patients, patients with comorbidities, and patients with extended hospital stays showed lower BI and EQ-5D scores □in the follow-up. BI and EQ-5D scores increased.

Conclusion

This research found no relationship between activities performed before the stroke and functionalities and quality of life after the stroke, but comorbidities and extended hospital stay were associated with worse outcomes.

Cost-utility and budget impact analysis of CPAP therapy compared to no treatment in the management of moderate to severe obstructive sleep apnea in Colombia from a third-party payer perspective

OBJECTIVES

To conduct cost-utility and budget impact analysis of providing Continuous Positive Airway Pressure (CPAP) therapy versus no treatment for moderate to severe obstructive sleep apnea (OSA) in Colombia from a third-party payer perspective.

METHODS

We used a Markov model to assess the cost-utility and budget impact analysis of CPAP in patients over 40 years old with moderate to severe OSA. Data on effectiveness and utility values were obtained from published literature. A discount rate of 5% was applied for outcomes and costs. ICER was calculated and compared against the threshold estimated for Colombia, which is 86% of the GDP per capita.

RESULTS

Over a lifetime horizon, the base case analysis showed the incremental cost per quality-adjusted life-years (QALYs) gained with CPAP therapy was COP$3,503,804 (USD$1,011 in 2020 prices). The budget impact analysis showed that the adoption of CPAP therapy in the target population would lead to a cumulative net budget impact of COP$411,722 million (USD$118,784,412 in, 2020 prices) over five years of time horizon.

CONCLUSIONS

CPAP was cost-effective compared to no-treatment in OSA. According to the budget impact analysis, adopting this technology would require a budget allocation that is partially offset by reduced number of strokes and traffic accident events.

Stroke in the state of Alagoas, Brazil: a descriptive analysis of a northeastern scenario

BACKGROUND

There is little information available on stroke epidemiology in the northeast of Brazil.

OBJECTIVE

Our objective was to investigate the prevalence of the stroke subtypes, prevalence of cerebrovascular risk factors and patterns of management in a public neurovascular outpatient referral service, in Alagoas.

METHODS

Data were prospectively collected from consecutive patients with stroke who were treated in a specialized neurovascular clinic between November 2016 and June 2018. Recurrence was evaluated by telephone 12 months after patients had been included in the study.

RESULTS

We evaluated 190 patients (mean age, 60.22 ( 13.29 years; 60.5% males). Ischemic stroke was the most frequent subtype (85.2%). Sedentary lifestyle was the most common risk factor (71.6%), followed by hypertension (62.6%) and stroke family history (41.1%). Only 21.5% of the patients were transported by ambulance to the hospital, and 42.6% received medical support in hospital units or emergency units with no imaging support. The median NIHSS was 2.5 (IQR, 1-5) and mRS was 2 (IQR, 1-3). We found a high rate of undetermined stroke (35.8%), and few patients completed the etiological investigation. One year after inclusion in the study, 12 patients (6.3%) had died and 14 (7.3%) had had another stroke.

CONCLUSIONS

The prevalence of cerebrovascular risk factors and clinical presentation were similar to what had been seen in previous series. A notable number of patients received medical support in institutions with no imaging equipment. The high number of cases of undetermined stroke etiology shows the difficulty in accessing healthcare services in Alagoas.

Systematic Review of Resource Use and Costs in the Hospital Management of Intracerebral Hemorrhage

BACKGROUND

While clinical guidelines provide a framework for hospital management of spontaneous intracerebral hemorrhage (ICH), variation in the resource use and costs of these services exists. We sought to perform a systematic literature review to assess the evidence on hospital resource use and costs associated with management of adult patients with ICH, as well as identify factors that impact variation in such hospital resource use and costs, regarding clinical characteristics and delivery of services.

METHODS

A systematic literature review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Ovid MEDLINE(R) 1946 to present. Articles were assessed against inclusion and exclusion criteria. Study design, ICH sample size, population, setting, objective, hospital characteristics, hospital resource use and cost data, and main study findings were abstracted.

RESULTS

In total, 43 studies met the inclusion criteria. Pertinent clinical characteristics that increased hospital resource use included presence of comorbidities and baseline ICH severity. Aspects of service delivery that greatly impacted hospital resource consumption included intensive care unit length of stay and performance of surgical procedures and intensive care procedures.

CONCLUSIONS

Hospital resource use and costs for patients with ICH were high and differed widely across studies. Making concrete conclusions on hospital resources and costs for ICH care was constrained, given methodologic and patient variation in the studies. Future research should evaluate the long-term cost-effectiveness of ICH treatment interventions and use specific economic evaluation guidelines and common data elements to mitigate study variation.

Healthcare costs of post-stroke oropharyngeal dysphagia and its complications: malnutrition and respiratory infections

BACKGROUND AND PURPOSE

The healthcare economic costs of post-stroke oropharyngeal dysphagia (OD) are not fully understood. The purpose of this study was to assess the acute, subacute and long-term costs related to post-stroke OD and its main complications (malnutrition and respiratory infections).

METHODS

A cost of illness study of patients admitted to Mataró Hospital (Catalonia, Spain) from May 2010 to September 2014 with a stroke diagnosis was performed. OD, malnutrition and respiratory infections were assessed during hospitalization and follow-up (3 and 12 months). Hospitalization and long-term costs were measured from hospital and healthcare system perspectives. Multivariate linear regression analysis was performed to assess the independent effect of OD, malnutrition and respiratory infections on healthcare costs during hospitalization, and at 3 and 12 months' follow-up.

RESULTS

In all, 395 patients were included of whom 178 had OD at admission. Patients with OD incurred major total in-hospital costs (€5357.67 ± €3391.62 vs. €3976.30 ± €1992.58, p < 0.0001), 3-month costs (€8242.0 ± €5376.0 vs. €5320.0 ± €4053.0, p < 0.0001) and 12-month costs (€11,617.58 ± €12,033.58 vs. €7242.78 ± €7402.55, p < 0.0001). OD was independently associated with a cost increase of €789.68 (p = 0.011) during hospitalization and of €873.5 (p = 0.084) at 3 months but not at 12 months. However, patients with OD who were at risk of malnutrition or malnourished and suffered respiratory infections incurred major mean costs compared with those patients without OD (€19,817.58 ± €13,724.83 vs. €7242.8 ± €7402.6, p < 0.0004) at 12 months' follow-up.

CONCLUSION

Oropharyngeal dysphagia causes significant high economic costs during hospitalization that strongly and significantly increase with the development of malnutrition and respiratory infections at long-term follow-up.

Big Data-Enabled Analysis of DRGs-Based Payment on Stroke Patients in Jiaozuo, China

Stroke is the first leading cause of mortality in China with annual 2 million deaths. According to the National Health Commission of the People's Republic of China, the annual in-hospital costs for the stroke patients in China reach ¥20.71 billion. Moreover, multivariate stepwise linear regression is a prevalent big data analysis tool employing the statistical significance to determine the explanatory variables. In light of this fact, this paper aims to analyze the pertinent influence factors of diagnosis related groups- (DRGs-) based stroke patients on the in-hospital costs in Jiaozuo city of Henan province, China, to provide the theoretical guidance for medical payment and medical resource allocation in Jiaozuo city of Henan province, China. All medical data records of 3,590 stroke patients were from the First Affiliated Hospital of Henan Polytechnic University between 1 January 2019 and 31 December 2019, which is a Class A tertiary comprehensive hospital in Jiaozuo city. By using the classical statistical and multivariate linear regression analysis of big data related algorithms, this study is conducted to investigate the influence factors of the stroke patients on in-hospital costs, such as age, gender, length of stay (LoS), and outcomes. The essential findings of this paper are shown as follows: (1) age, LoS, and outcomes have significant effects on the in-hospital costs of stroke patients; (2) gender is not a statistically significant influence factor on the in-hospital costs of the stroke patients; (3) DRGs classification of the stroke patients manifests not only a reduced mean LoS but also a peculiar shape of the distribution of LoS.

Anticoagulation Therapy in Patients with Non-valvular Atrial Fibrillation in a Private Setting in Brazil: A Real-World Study

Fundamento:

A segurança e a eficácia da varfarina dependem da qualidade do controle da anticoagulação. Estudos observacionais associam controle deficiente com aumento de morbidade, mortalidade e custos com saúde.

Objetivos:

Desenvolver um perfil de pacientes com fibrilação atrial não valvar (FANV) tratados com varfarina em ambiente ambulatorial e hospitalar privado brasileiro, avaliar a qualidade do controle da anticoagulação e sua associação com resultados clínicos e econômicos.

Métodos:

Este estudo retrospectivo, por meio de um conjunto de dados de seguros privados de saúde no Brasil, identificou pacientes com FANV tratados com varfarina entre 01 de maio de 2014 a 30 de abril de 2016, descreveu seu manejo da anticoagulação e quantificou os custos relacionados à doença. Foram recuperados dados demográficos, histórico clínico, medicação concomitante e tempo na faixa terapêutica (TTR) dos valores da razão normalizada internacional (RNI). Os pacientes foram agrupados em quartis de TTR, com um bom controle sendo definido como TTR ≥65% (método de Rosendaal). Sangramentos maiores e custos médicos diretos por todas as causas foram calculados e comparados entre subgrupos de controle bons e ruins. Valores de p < 0,05 foram considerados estatisticamente significantes.

Resultados:

A análise incluiu 1220 pacientes (mediana de seguimento: 1,5 anos; IIQ: 0,5–2,0). Em média, cada paciente recebeu 0,95 medidas mensais de RNI (RNI média: 2,60 ± 0,88, com 26,1% dos valores < 2 e 24,8% > 3), (mediana de TTR: 58%; IIQ: 47-68%), (TTR médio: 56,6% ± 18,9%). Apenas 31% dos pacientes estavam bem controlados (TTR médio: 78% ± 10%), com 1,6% apresentando grandes sangramentos na mediana do seguimento e custos médicos diretos por membro por ano (PMPY) de R$25.352 (± R$37.762). Pacientes com controle abaixo do ideal (69%) foram associados a 3,3 vezes mais sangramentos graves (5,3% vs. 1,6%; p <0,01) e custos 40% maiores (R$35.384 vs. R$25.352; p < 0,01).

Conclusões:

Mais de 60% dos pacientes estavam abaixo da meta desejada e os custos associados foram significativamente maiores nesta população.

Healthcare-related cost of oropharyngeal dysphagia and its complications pneumonia and malnutrition after stroke: a systematic review

OBJECTIVES

To assess the healthcare costs associated with poststroke oropharyngeal dysphagia (OD) and its complications (malnutrition, dehydration, pneumonia and death).

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

DATA SOURCES

MEDLINE, Embase and the National Health Service Economic Evaluation Database were searched up to 31 December 2019.

PARTICIPANTS

Patients with poststroke.

PRIMARY OUTCOME MEASURES

The costs associated to poststroke OD and its complications.

DATA ANALYSIS

Data were synthetised narratively, quality evaluation was done using an adaptation of Drummond's checklist and Grading of Recommendations Assessment, Development and Evaluation recommendations were used to assess strength of evidence.

RESULTS

A total of 166 articles were identified, of which 10 studies were included. The cost of OD during the hospitalisation was assessed in four studies. One prospective study showed an increase of US$6589 for patients requiring tube feeding. Two retrospective studies found higher costs for those patients who developed OD, (US$7329 vs US$5939) among patients with haemorrhagic stroke transferred to inpatient rehabilitation and an increase of €3000 (US$3950) and SFr14 000 (US$15 300) in hospitalisation costs. One study did not found OD as a predictor for total medical costs in the multivariate analysis. One retrospective study showed an increase of US$4510 during the first year after stroke for those patients with OD. For pneumonia, five retrospective studies showed an increase in hospitalisation costs after stroke of between US$1456 and US$27 633. One prospective study showed an increase in hospitalisation costs during 6 months after stroke in patients at high malnutrition risk. Strength of evidence was considered moderate for OD and pneumonia and low for malnutrition.

CONCLUSIONS

This systematic review shows moderate evidence towards higher costs for those patients who developed OD after stroke. The available literature is heterogeneous, and some important aspects have not been studied yet. Further studies are needed to define the specific cost of poststroke OD.

PROSPERO REGISTRATION NUMBER

CRD42018099977.

Cost of hospitalization for stroke in a low–middle-income country: Findings from a public tertiary hospital in the Philippines

Background

Determining the cost of hospitalization for acute stroke is important in the appropriate allocation of resources for public health facilities and in the cost effectiveness analysis of interventions. Despite being the second leading cause of mortality in the Philippines, there are no published data on the cost of stroke in the country.

Aim

The study aims to determine the in-hospitalization cost for stroke (IHCS) in a tertiary public hospital in the Philippines and identify the factors influencing IHCS.

Methods

The study was a retrospective review of the medical and billing records of the hospital. Adult patients admitted for acute stroke between 1 June 2017 and 31 May 2018 were included in the analysis. After the mean cost of stroke was determined, multivariate logistic regression analysis was done to determine demographic and clinical characteristics that were predictive of stroke cost.

Results

A total of 863 patient records were analyzed. The median in-hospitalization cost for stroke was PHP 17,141.50 or US$329.52. Independent determinants of higher cost include male sex (p = 0.021), stroke type (hemorrhagic stroke, p = 0.001; subarachnoid hemorrhage, p < 0.001), lower GCS on admission (p = 0.023), surgical intervention (p < 0.001), intravenous thrombolysis (p < 0.001), infection (p < 0.001), length of hospital stay (p < 0.001), and mechanical ventilation (p = 0.008).

Conclusion

The study provided current data on the in-hospitalization cost of acute stroke in a public tertiary hospital in the Philippines. Male sex, stroke type, lower GCS on admission, surgical intervention, intravenous thrombolysis, infection, length of hospital stay, and mechanical ventilation were independent predictors of cost.

The cost of stroke in private hospitals in Brazil: a one-year prospective study

OBJECTIVE

Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil.

METHODS

Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity.

RESULTS

We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001).

CONCLUSIONS

Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

The cost of stroke in a public hospital in Brazil: a one-year prospective study

OBJECTIVE

Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. To measure the costs of stroke care in a public hospital in Joinville, Brazil.

METHODS

We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement.

RESULTS

We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively.

CONCLUSIONS

Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

Direct Medical Cost of Hospitalization for Acute Stroke in Lebanon: A Prospective Incidence-Based Multicenter Cost-of-Illness Study

Stroke is a major social and health problem posing heavy burden on national economies. We provided detailed financial data on the direct in-hospital cost of acute stroke care in Lebanon and evaluated its drivers. This was an observational, quantitative, prospective, multicenter, incidence-based, bottom-up cost-of-illness study. Medical and billing records of stroke patients admitted to 8 hospitals in Beirut over 1 year were analyzed. Direct medical costs were calculated, and cost drivers were assessed using a multivariable linear regression analysis. In total, 203 stroke patients were included (male: 58%; mean age: 68.8 ± 12.9 years). The direct in-hospital cost for all cases was US$1 413 069 for 2626 days (US$538 per in-hospital day). The average in-hospital cost per stroke patient was US$6961 ± 15 663. Hemorrhagic strokes were the most costly, transient ischemic attack being the least costly. Cost drivers were hospital length of stay, intensive care unit length of stay, type of stroke, stroke severity, modified Rankin Scale, third party payer, surgery, and infectious complications. Direct medical cost of acute stroke care represents high financial burden to Lebanese health system. Development of targeted public health policies and primary prevention activities need to take priority to minimize stroke admission in future and to contain this cost.

Distribution and predictors of hospital charges for haemorrhagic stroke patients in Beijing, China, March 2012 to February 2015: a retrospective study

OBJECTIVES

The purpose of this study is to analyse hospital charges for patients with haemorrhagic stroke in China and investigate potential factors associated with inpatient charges.

METHODS

The study participants were in-hospital patients with a primary diagnosis of haemorrhagic stroke from all the secondary and tertiary hospitals in Beijing during the period from 1 March 2012 to 28 February 2015. Distribution characteristics of detailed hospital charges were analysed. The influence of potential factors on hospital charges was researched using a stepwise multiple regression model.

RESULTS

A total of 34 890 patients with haemorrhagic stroke of mean age 61.19±14.37 years were included in the study, of which 37.2% were female. Median length of hospital stay (LOHS) was 15 days (IQR 9-23) and median hospital cost was 18 577 Chinese yuan (CNY) (IQR 10 442-39 784). The hospital costs for patients in Western medicine hospitals (median 19 651 CNY) were significantly higher (P<0.01) than those in traditional Chinese medicine hospitals (median 14 560 CNY), and were significantly higher (P<0.01) for Level 3 hospitals (median 20 029 CNY) than for Level 2 hospitals (median 16 095 CNY). The proportion of medicine fees and bed fees within total hospital charges showed a decreasing trend during the study period. With stepwise multiple regression, the major factors associated with hospital charges were LOHS, surgery, pulmonary infection, ventilator usage, hospital level, occupation, hyperlipidaemia, hospital type, in-hospital death, sex and age.

CONCLUSION

We conclude that medicines form the largest part of hospital charges but are showing a decreasing trend, and LOHS is strongly associated with patient charges for haemorrhagic stroke in China. This implies that the cost structure is very unreasonable in China and medical technology costs fail to be fully manifested. A reasonable decrease in medicine charges and shortening LOHS may be effective ways to reduce hospital charges.

Analysis of Hospital Charges of Inpatients with Acute Ischemic Stroke in Beijing, China, 2012-2015

BACKGROUND

The study aimed to analyze the hospital charges of the inpatients with acute ischemic stroke in Beijing and determine the factors associated with hospital costs.

METHODS

Medical records of hospitalized patients with a primary diagnosis of ischemic stroke according to International Classification of Diseases 10th Revision codes were collected from 121 hospitals in Beijing from March 1, 2012, to February 28, 2015. Distribution characteristics of hospital charges for different hospital levels (level 2 hospitals and level 3 hospitals) and types (Western medicine hospitals and Chinese medicine hospitals) were studied. Linear regression analysis was used to examine the association among hospital costs and factors that influenced total hospital charges.

RESULTS

There were 158,781 admissions for ischemic stroke, 63.1% of the patients were male and their mean age was 67.7 ± 12.4 years, the median length of hospital stay (LOHS) was 13.5 days (interquartile range 9.9-18.1 days). The median hospital charge was 2,112 (1,436-3,147) US dollars. Of these, 46.7% were for medicine, 21.1% for laboratory and examination, and 16.3% for therapy. LOHS, hospital level, and pulmonary infection were key determinants of the hospital charges.

CONCLUSIONS

The proportion of medicine fees for the ischemic stroke inpatients showed a downward trend during the period from 2012 to 2015, but medicine fees still accounted for the largest percentage of hospital charges in China. LOHS emerged to be the main determinant of the cost. Decreasing medicine fees and LOHS might be strategies to decrease hospital charges and reduce economic burden of stroke in China.

A Systematic Review of Cardiovascular Outcomes-Based Cost-Effectiveness Analyses of Lipid-Lowering Therapies

BACKGROUND

Previous reviews have evaluated economic analyses of lipid-lowering therapies using lipid levels as surrogate markers for cardiovascular disease. However, drug approval and health technology assessment agencies have stressed that surrogates should only be used in the absence of clinical endpoints.

OBJECTIVE

The aim of this systematic review was to identify and summarise the methodologies, weaknesses and strengths of economic models based on atherosclerotic cardiovascular disease event rates.

METHODS

Cost-effectiveness evaluations of lipid-lowering therapies using cardiovascular event rates in adults with hyperlipidaemia were sought in Medline, Embase, Medline In-Process, PubMed and NHS EED and conference proceedings. Search results were independently screened, extracted and quality checked by two reviewers.

RESULTS

Searches until February 2016 retrieved 3443 records, from which 26 studies (29 publications) were selected. Twenty-two studies evaluated secondary prevention (four also assessed primary prevention), two considered only primary prevention and two included mixed primary and secondary prevention populations. Most studies (18) based treatment-effect estimates on single trials, although more recent evaluations deployed meta-analyses (5/10 over the last 10 years). Markov models (14 studies) were most commonly used and only one study employed discrete event simulation. Models varied particularly in terms of health states and treatment-effect duration. No studies used a systematic review to obtain utilities. Most studies took a healthcare perspective (21/26) and sourced resource use from key trials instead of local data. Overall, reporting quality was suboptimal.

CONCLUSIONS

This review reveals methodological changes over time, but reporting weaknesses remain, particularly with respect to transparency of model reporting.

The cost of warfarin treatment for stroke prevention in patients with non-valvular atrial fibrillation in Mexico from a collective perspective

AIMS

To describe the collective costs of vitamin K antagonist (VKA) treatment for stroke prevention in non-valvular atrial fibrillation (NVAF). VKA drug costs are relatively low, but they necessitate frequent international normalized ratio (INR) monitoring. There are currently minimal data describing the economic impact of this in Mexico.

MATERIALS AND METHODS

Cardiologists provided data on their NVAF patients (n = 400) to quantify direct medical costs (INR testing, appointments, drug costs). A sub-set of patients (n = 301) completed a patient questionnaire providing data to calculate direct non-medical costs (travel and other expenses for attendance at VKA-associated appointments) and indirect costs (opportunity cost and reduced work productivity associated with VKA treatment).

RESULTS

Estimated annual direct medical costs totaled $753.6 per patient. Annual direct non-medical and indirect costs were USD$149.8 and $132.1, respectively.

LIMITATIONS

Recruited patients were those who consulted with a cardiologist during the study period and selected due to inclusion criteria. All had received uninterrupted treatment for 12-24 months. Consequently, the results are not fully generalizable to all VKA treated NVAF patients.

CONCLUSIONS

The true cost of VKA treatment cannot be appreciated by a consideration of drug costs alone. Ongoing monitoring appointments incur additional expenses for both patients and the healthcare system.

Understanding the relationship between costs and the modified Rankin Scale: A systematic review, multidisciplinary consensus and recommendations for future studies

Background and purpose

Cost-of-illness studies often describe a single aggregate cost of a disease state. This approach is less helpful for a condition with a spectrum of outcomes like stroke. The modified Rankin Scale is the most commonly used outcome measure for stroke. We sought to describe the existing evidence on the costs of stroke according to individual modified Rankin Scale categories. This may be useful in future cost effectiveness modelling studies of interventions where cost data have not been collected, but disability outcome is known.

Methods

Systematic review of the published literature, searching electronic databases between 2004 and 2015 using validated search filters. Results were screened to identify studies presenting costs by individual modified Rankin Scale categories.

Results

Of 17,782 unique identified articles, 13 matched all inclusion criteria. In only four of these studies were costs reported by modified Rankin Scale categories. Most studies included direct medical costs only. Societal costs were assessed in two studies. Overall, studies had a high methodological and reporting quality. The heterogeneity in costing methods used in the identified studies prevented meaningful comparison of the reported cost data. Despite this limitation, the costs consistently increased with greater severity (increasing modified Rankin Scale score).

Conclusions

Few cost studies of stroke include information based on stroke recovery measured by individual modified Rankin Scale categories and the existing data are limited. To reliably capture this information, future studies are needed that preferably apply standardised costing methods to promote greater potential for use in cost-effectiveness analyses whereby direct collection of patient-level resource use has not been possible.

Difference of hospital charges for stroke inpatients between hospitals with different levels and therapeutic modes in Beijing, China

OBJECTIVES

The present study analyzed the hospital charges for stroke patients in China and determined the factors associated with hospital costs.

METHODS

Medical records of hospitalized patients with a primary diagnosis of acute stroke were collected from 121 hospitals in Beijing (2012). Distribution characteristics of hospital charges for different stroke types, hospital levels and types were studied. Factors influencing total hospital charges were analyzed.

RESULTS

60.8% of the 94 906 stroke patients were male and the mean age of these patients was 66.5 ± 13.2 years. The median length of hospital stay (LOHS) for these patients was 14 d (interquartile range, IQR 9-19). The mean hospital charge per patient was 19 270 Chinese Yuan. Forty-five percent of these charges were for medicine, 18% for laboratory and examination, 16% for material, 15% for therapy, 5% for service and 1% for blood product. The mean hospital charge for patients suffering from hemorrhagic stroke was significantly more than ischemic stroke (34 937 vs. 17 049, p < 0.001), and was significantly more for Level 3 than Level 2 hospitals (23 762 vs. 14 554, p < 0.001). LOHS, hospital level and stroke severity were key determinants of the hospital charge.

CONCLUSIONS

Though hospital charges for stroke patients in China were low, it brought a heavy economic burden for the larger stroke population. Medicine accounted for the largest percentage of hospital charges in China. LOHS emerged to be the main predictor of the cost. Decreasing medicine charge and LOHS might be strategies to decrease hospital charges and reduce economic burden of stroke in China.

Targeting stroke risk and improving outcomes in patients with atrial fibrillation in Latin America

CONTEXT AND OBJECTIVE:

To examine stroke risk factors, including atrial fibrillation, management and prevention, and stroke outcomes across Latin America.

DESIGN AND SETTING:

Narrative review conducted at Piedmont Heart Institute, United States.

METHODS:

The PubMed, Embase and Cochrane databases were searched for stroke AND "Latin America" AND epidemiology (between January 2009 and March 2015). Further studies in the SciELO, World Health Organization and Pan-American Health Organization databases were used to address specific points.

RESULTS:

Countries categorized as low or middle-income nations by the World Bank, which includes most of Latin America, account for two-thirds of all strokes. Globally, fewer than half of patients (median treatment level: 43.9%) with atrial fibrillation receive adequate anticoagulation to reduce stroke risk, which correlates with data from Latin America, where 46% of outpatients did not receive guideline-compliant anticoagulation, ranging from 41.8% in Brazil to 54.8% in Colombia.

CONCLUSIONS:

Atrial fibrillation-related stroke carries a heavy burden. Non-vitamin K antagonist oral anti-coagulants provide options for reducing the risk of atrial fibrillation-related stroke. However, cost-effectiveness comparisons with warfarin are warranted before observational health-economics study results can be applied clinically. Initiatives to remedy inequalities and improve access to care across Latin America should accompany risk factor modification and guideline-based prevention.

Patient-level costs of major cardiovascular conditions: a review of the international literature

OBJECTIVE

Robust cost estimates of cardiovascular (CV) events are required for assessing health care interventions aimed at reducing the economic burden of major adverse CV events. This review synthesizes international cost estimates of CV events.

METHODS

MEDLINE database was searched electronically for English language studies published during 2007-2012, with cost estimates for CV events of interest - unstable angina, myocardial infarction, heart failure, stroke, and CV revascularization. Included studies provided at least one estimate of patient-level direct costs in adults for any identified country. Information on study characteristics and cost estimates were collected. All costs were adjusted for inflation to 2013 values.

RESULTS

Across the 114 studies included, the average cost was US $6,466 for unstable angina, $11,664 for acute myocardial infarction, $11,686 for acute heart failure, $11,635 for acute ischemic stroke, $37,611 for coronary artery bypass graft, and $13,501 for percutaneous coronary intervention. The ranges for cost estimates varied widely across countries with US cost estimate being at least twice as high as European Union costs for some conditions. Few studies were found on populations outside the US and European Union.

CONCLUSION

This review showed wide variation in the cost of CV events within and across countries, while showcasing the continuing economic burden of CV disease. The variability in costs was primarily attributable to differences in study population, costing methodologies, and reporting differences. Reliable cost estimates for assessing economic value of interventions in CV disease are needed.

Initial blood pressure is associated with stroke severity and is predictive of admission cost and one-year outcome in different stroke subtypes: a SRICHS registry study

Background

To investigate if initial blood pressure (BP) on admission is associated with stroke severity and predictive of admission costs and one-year-outcome in acute ischemic (IS) and hemorrhagic stroke (HS).

Methods

This is a single-center retrospective cohort study. Stroke patients admitted within 3 days after onset between January 1^st and December 31^st in 2009 were recruited. The initial BP on admission was subdivided into high (systolic BP ≥ 211 mmHg or diastolic BP ≥ 111 mmHg), medium (systolic BP 111–210 mmHg or diastolic BP 71–110 mmHg), and low (systolic BP ≤ 110 mmHg or diastolic BP ≤ 70 mmHg) groups and further subgrouped with 25 mmHg difference in systole and 10 mmHg difference in diastole for the correlation analysis with demographics, admission cost and one-year modified Rankin scale (mRS).

Results

In 1173 IS patients (mean age: 67.8 ± 12.8 years old, 61.4 % male), low diastolic BP group had higher frequency of heart disease (p =0.001), dehydration (p =0.03) and lower hemoglobin level (p <0.001). The extremely high and low systolic BP subgroups had worse National Institutes of Health Stroke Scale (NIHSS) score (p =0.03), higher admission cost (p <0.001), and worse one-year mRS (p =0.03), while extremely high and low diastolic BP subgroups had higher admission cost (p <0.01). In 282 HS patients (mean age: 62.4 ± 15.4 years old, 60.6 % male), both low systolic and diastolic BP groups had lower hemoglobin level (systole: p =0.05; diastole: p <0.001). The extremely high and low BP subgroups had worse NIHSS score (p =0.01 and p <0.001, respectively), worse one-year mRS (p =0.002 and p =0.001, respectively), and higher admission cost (diastole: p <0.002).

Conclusions

Stroke patients with extremely high and low BP on admission have not only worse stroke severity but also higher admission cost and/or worse one-year outcome. In those patients with low BP, low admission hemoglobin might be a contributing factor.

Provider costs for prevention and treatment of cardiovascular and related conditions in low- and middle-income countries: a systematic review

BACKGROUND

The burden of cardiovascular disease (CVD) and CVD risk conditions is rapidly increasing in low- and middle-income countries, where health systems are generally ill-equipped to manage chronic disease. Policy makers need an understanding of the magnitude and drivers of the costs of cardiovascular disease related conditions to make decisions on how to allocate limited health resources.

METHODS

We undertook a systematic review of the published literature on provider-incurred costs of treatment for cardiovascular diseases and risk conditions in low- and middle-income countries. Total costs of treatment were inflated to 2012 US dollars for comparability across geographic settings and time periods.

RESULTS

This systematic review identified 60 articles and 143 unit costs for the following conditions: ischemic heart disease, non-ischemic heart diseases, stroke, heart failure, hypertension, diabetes, and chronic kidney disease. Cost data were most readily available in middle-income countries, especially China, India, Brazil, and South Africa. The most common conditions with cost studies were acute ischemic heart disease, type 2 diabetes mellitus, stroke, and hypertension.

CONCLUSIONS

Emerging economies are currently providing a base of cost evidence for NCD treatment that may prove useful to policy-makers in low-income countries. Initial steps to publicly finance disease interventions should take account of costs. The gaps and limitations in the current literature include a lack of standardized reporting as well as sparse evidence from low-income countries.

Predictors of pneumonia in acute stroke in patients in an emergency unit

OBJECTIVE

To evaluate the risk factors and comorbid conditions associated with the development of pneumonia in patients with acute stroke. To determine the independent predictors of pneumonia.

METHOD

Retrospective study from July to December 2011. We reviewed all medical charts with diagnosis of stroke.

RESULTS

159 patients (18-90 years) were admitted. Prevalence of pneumonia was 32%. Pneumonia was more frequent in patients with hemorrhagic stroke (OR: 4.36; 95%CI: 1.9-10.01, p < 0.001), higher National Institute of Health Stroke Scale (NIHSS) (p = 0.047) and, lower Glasgow Coma Score (GCS) (p < 0.0001). Patients with pneumonia had longer hospitalization (p < 0.0001). Multivariable logistic regression analysis identified NIHSS as an independent predictor of pneumonia (95%CI: 1.049-1.246, p = 0.002).

CONCLUSION

Pneumonia was associated with severity and type of stroke and length of hospital stay. The severity of the deficit as evaluated by the NIHSS was shown to be the only independent risk factor for pneumonia in acute stroke patients.

Validity of Diagnostic Codes for Acute Stroke in Administrative Databases: A Systematic Review

OBJECTIVE

To conduct a systematic review of studies reporting on the validity of International Classification of Diseases (ICD) codes for identifying stroke in administrative data.

METHODS

MEDLINE and EMBASE were searched (inception to February 2015) for studies: (a) Using administrative data to identify stroke; or (b) Evaluating the validity of stroke codes in administrative data; and (c) Reporting validation statistics (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), or Kappa scores) for stroke, or data sufficient for their calculation. Additional articles were located by hand search (up to February 2015) of original papers. Studies solely evaluating codes for transient ischaemic attack were excluded. Data were extracted by two independent reviewers; article quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool.

RESULTS

Seventy-seven studies published from 1976-2015 were included. The sensitivity of ICD-9 430-438/ICD-10 I60-I69 for any cerebrovascular disease was ≥ 82% in most [≥ 50%] studies, and specificity and NPV were both ≥ 95%. The PPV of these codes for any cerebrovascular disease was ≥ 81% in most studies, while the PPV specifically for acute stroke was ≤ 68%. In at least 50% of studies, PPVs were ≥ 93% for subarachnoid haemorrhage (ICD-9 430/ICD-10 I60), 89% for intracerebral haemorrhage (ICD-9 431/ICD-10 I61), and 82% for ischaemic stroke (ICD-9 434/ICD-10 I63 or ICD-9 434&436). For in-hospital deaths, sensitivity was 55%. For cerebrovascular disease or acute stroke as a cause-of-death on death certificates, sensitivity was ≤ 71% in most studies while PPV was ≥ 87%.

CONCLUSIONS

While most cases of prevalent cerebrovascular disease can be detected using 430-438/I60-I69 collectively, acute stroke must be defined using more specific codes. Most in-hospital deaths and death certificates with stroke as a cause-of-death correspond to true stroke deaths. Linking vital statistics and hospitalization data may improve the ascertainment of fatal stroke.

Predictors for total medical costs for acute hemorrhagic stroke patients transferred to the rehabilitation ward at a regional hospital in Taiwan

BACKGROUND

One-third of the acute stroke patients in Taiwan receive rehabilitation. It is imperative for clinicians who care for acute stroke patients undergoing inpatient rehabilitation to identify which medical factors could be the predictors of the total medical costs.

OBJECTIVES

The aim of this study was to identify the most important predictors of the total medical costs for first-time hemorrhagic stroke patients transferred to inpatient rehabilitation using a retrospective design.

METHODS

All data were retrospectively collected from July 2002 to June 2012 from a regional hospital in Taiwan. A stepwise multivariate linear regression analysis was used to identify the most important predictors for the total medical costs.

RESULTS

The medical records of 237 patients (137 males and 100 females) were reviewed. The mean total medical cost per patient was United States dollar (USD) 5939.5 ± 3578.5.The following were the significant predictors for the total medical costs: impaired consciousness [coefficient (B), 1075.7; 95% confidence interval (CI) = 138.5-2012.9], dysphagia [coefficient (B), 1025.8; 95% CI = 193.9-1857.8], number of surgeries [coefficient (B), 796.4; 95% CI = 316.0-1276.7], pneumonia in the neurosurgery ward [coefficient (B), 2330.1; 95% CI = 1339.5-3320.7], symptomatic urinary tract infection (UTI) in the rehabilitation ward [coefficient (B), 1138.7; 95% CI = 221.6-2055.7], and rehabilitation ward stay [coefficient (B), 64.9; 95% CI = 31.2-98.7] (R(2) = 0.387).

CONCLUSIONS

Our findings could help clinicians to understand that cost reduction may be achieved by minimizing complications (pneumonia and UTI) in these patients.

Cost of stroke in low and middle income countries: a systematic review

BACKGROUND

There is limited information available from low and middle-income countries regarding the cost of stroke treatment. Hence, we aimed to review the costs of stroke in low and middle-income countries.

SUMMARY OF REVIEW

The literature search was done using databases: PubMed/Medline, Ovid, EconLit and Google Scholar from 1966 until January 2014 using key words 'economic impact of stroke', 'cost of illness in low and middle income countries' and 'cost of stroke'. With these key words, 10/184 articles were retained for this review. The cost data were converted to 2013 currency values using a web-based tool (CCEMG-EPPI-centre cost converter). Most of the included studies were conducted in Asia. The design of these studies was retrospective and conducted predominantly in multicenter private hospitals. The highest mean direct medical cost of stroke was US$ 8424 in Nigeria. The lowest mean cost of stroke was in Senegal (US$ 416). The average length of hospital stay was longest (20 days) in China. The main predictors of higher costs appeared to be due to differences in length of stay and stroke severity.

CONCLUSION

Costs of stroke are variable because of heterogeneous healthcare systems prevailing in low and middle-income countries. Length of hospital stay and stroke severity appear to be the main predictors of cost. Understanding the costs of stroke in low and middle-income countries is important. However, the evidence remains limited because there is a lack of standardized research. Future research should focus on using a uniform method across low and middle-income countries for estimating the costs of stroke.

Impact of stroke unit in a public hospital on length of hospitalization and rate of early mortality of ischemic stroke patients

We ascertained whether a public health stroke unit reduces the length of hospitalization, the rate of inpatient fatality, and the mortality rate 30 days after the stroke.

METHODS

We compared a cohort of stroke patients managed on a general neurology/medical ward with a similar cohort of stroke patients managed in a stroke unit. The in-patient fatality rates and 30-day mortality rates were analyzed.

RESULTS

729 patients were managed in the general ward and 344 were treated at a comprehensive stroke unit. The in-patient fatality rates were 14.7% for the general ward group and 6.9% for the stroke unit group (p<0.001). The overall mortality rate 30 days after stroke was 20.9% for general ward patients and 14.2% for stroke unit patients (p=0.005).

CONCLUSIONS

We observed reduced in-patient fatalities and 30-day mortality rates in patients managed in the stroke unit. There was no impact on the length of hospitalization.

A pilot study of respiratory muscle training to improve cough effectiveness and reduce the incidence of pneumonia in acute stroke: study protocol for a randomized controlled trial

BACKGROUND

After stroke, pneumonia is a relevant medical complication that can be precipitated by aspiration of saliva, liquids, or solid food. Swallowing difficulty and aspiration occur in a significant proportion of stroke survivors. Cough, an important mechanism protecting the lungs from inhaled materials, can be impaired in stroke survivors, and the likely cause for this impairment is central weakness of the respiratory musculature. Thus, respiratory muscle training in acute stroke may be useful in the recovery of respiratory muscle and cough function, and may thereby reduce the risk of pneumonia. The present study is a pilot study, aimed at investigating the validity and feasibility of this approach by exploring effect size, safety, and patient acceptability of the intervention.

METHODS/DESIGN

Adults with moderate to severe stroke impairment (National Institutes of Health Stroke Scale (NIHSS) score 5 to 25 at the time of admission) are recruited within 2 weeks of stroke onset. Participants must be able to perform voluntary respiratory maneuvers. Excluded are patients with increased intracranial pressure, uncontrolled hypertension, neuromuscular conditions other than stroke, medical history of asthma or chronic obstructive pulmonary disease, and recent cardiac events. Participants are randomized to receive inspiratory, expiratory, or sham respiratory training over a 4-week period, by using commercially available threshold resistance devices. Participants and caregivers, but not study investigators, are blind to treatment allocation. All participants receive medical care and stroke rehabilitation according to the usual standard of care. The following assessments are conducted at baseline, 4 weeks, and 12 weeks: Voluntary and reflex cough flow measurements, forced spirometry, respiratory muscle strength tests, incidence of pneumonia, assessments of safety parameters, and self-reported activity of daily living. The primary outcome is peak expiratory cough flow of voluntary cough, a parameter indicating the effectiveness of cough. Secondary outcomes are incidence of pneumonia, peak expiratory cough flow of reflex cough, and maximum inspiratory and expiratory mouth pressures.

DISCUSSION

Various novel pharmacologic and nonpharmacologic approaches for preventing stroke-associated pneumonia are currently being researched. This study investigates a novel strategy based on an exercise intervention for cough rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN40298220.

The incidence, hospital expenditure, and, 30 day and 1 year mortality rates of spontaneous intracerebral hemorrhage in Taiwan

The risks of morbidity and mortality are high in patients with spontaneous intracerebral hemorrhage (sICH). The medical care resources associated with sICH are also substantial. This study aimed to evaluate the medical expenditure for sICH patients in Taiwan. We analyzed the National Health Insurance Research Database from 2005 to 2010. The inclusion criterion was first-event sICH; traumatic ICH patients were excluded. Student's t-test, multiple linear regression and the chi-squared test were employed as the statistical methods. Our results showed that the incidence of sICH was 40.77 patients per 100,000 of population per year in Taiwan. The incidence increased with age and was greater in men than women. The mean hospital length of stay (LOS) of first-event sICH patients was 31.8 days; the mean LOS in the intensive care unit was 7.9 days; and the mean survival time was 60.4 months. The mortality rate within 30 days and within 1 year was 19.8 and 29.6%, respectively. The mean hospital expenditure of first-event sICH patients was USD $7572, and was highly correlated with LOS. In conclusion, the incidence of sICH in Taiwan is higher than that in white and black populations of northern America and some European countries and lower than that in the Asian populations of Japan and China. The features of male and female sICH patients differ. Our findings suggest that the hospital expenditure and mortality rate of sICH patients in Taiwan are comparable with those of other countries.

Estudo de seguimento da função motora de indivíduos pós-acidente vascular encefálico

Objetivou-se caracterizar e analisar mudanças nas variáveis relacionadas à função motora de hemiparéticos crônicos após um período médio de sete anos. Coletaram-se via telefone dados demográficos e clínicos de hemiparéticos avaliados em 2003. Todos foram convidados a participar da reavaliação, em que se coletaram medidas de força da musculatura respiratória, desempenho funcional, capacidade física e nível de atividade física. Estatísticas descritivas, testes t pareado ou Wilcoxon foram utilizados para análise dos dados. Dos 101 hemiparéticos avaliados presencialmente em 2003, contataram-se por telefone 65 deles ou seus familiares, sendo que 35 (64,6±10,6 anos) responderam às questões por telefone, 22 (56,8±13,3 anos) foram avaliados presencialmente e 8 faleceram. Após uma média de sete anos de seguimento, em relação às medidas realizadas presencialmente, nenhuma variável apresentou diferença significativa entre as avaliações (0,08<p<0,96), exceto a força da musculatura inspiratória (p<0,05), que aumentou. Apesar de serem esperadas reduções nos valores das variáveis devido ao envelhecimento, evidenciou-se a sua manutenção ou aumento, ressaltando-se assim, a importância desta população manter-se ativa.

Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population

OBJECTIVE

Large vessel occlusion in acute ischemic stroke is associated with low recanalization rates under intravenous thrombolysis. We evaluated the safety and efficacy of the Solitaire AB stent in treating acute ischemic stroke.

METHODS

Patients presenting with acute ischemic stroke were prospectively evaluated. The neurological outcomes were assessed using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Time was recorded from the symptom onset to the recanalization and procedure time. Recanalization was assessed using the thrombolysis in cerebral infarction score.

RESULTS

Twenty-one patients were evaluated. The mean patient age was 65, and the National Institutes of Health Stroke Scale scores ranged from 7 to 28 (average 17 ± 6.36) at presentation. The vessel occlusions occurred in the middle cerebral artery (61.9%), distal internal carotid artery (14.3%), tandem carotid occlusion (14.3%), and basilarartery (9.5%). Primary thrombectomy, rescue treatment and a bridging approach represented 66.6%, 28.6%, and 4.8% of the performed procedures, respectively. The mean time from symptom onset to recanalization was 356.5 ± 107.8 minutes (range, 80-586 minutes). The mean procedure time was 60.4 ± 58.8 minutes (range, 14-240 minutes). The overall recanalization rate (thrombolysis in cerebral infarction scores of 3 or 2b) was 90.4%, and the symptomatic intracranial hemorrhage rate was 14.2%. The National Institutes of Health Stroke Scale scores at discharge ranged from 0 to 25 (average 6.9 ± 7). At three months, 61.9% of the patients had a modified Rankin Scale score of 0 to 2, with an overall mortality rate of 9.5%.

CONCLUSIONS

Intra-arterial thrombectomy with the Solitaire AB device appears to be safe and effective. Large randomized trials are necessary to confirm the benefits of this approach in acute ischemic stroke.

The costs of overweight and obesity-related diseases in the Brazilian public health system: cross-sectional study

BACKGROUND

Obesity is a major global epidemic and a burden to society and health systems. It is well known risk factor for a number of chronic medical conditions with high morbidity and mortality. This study aimed to provide an estimate of the direct costs associated to outpatient and inpatient care of overweight and obesity related diseases in the perspective of the Brazilian Health System (SUS).

METHODS

Population attributable risk (PAR) was calculated for selected diseases related to overweight and obesity and with the following parameters: Relative risk (RR) ≥ 1.20 or RR ≥ 1.10 and < 1.20, but important problem of public health due its high prevalence. After a broad search in the literature, two meta-analysis were selected to provide RR for PAR calculation. The prevalence rates of overweight and obesity in Brazilians with ≥ 18 years were obtained from large national survey. The national health database (DATASUS) was used to estimate the annual cost of the Brazilian Unified Health System (SUS) with the diseases included in the analysis. The extracted values were stratified by sex, type of service (inpatient or outpatient care) and year. Data were collected from 2008 to 2010 and the results reflect the average of 3 years. Brazilian costs were converted into US dollars during the analysis using a purchasing power parity basis (2010).

RESULTS

The estimated total costs in one year with all diseases related to overweight and obesity are US$ 2,1 billion; US$ 1,4 billion (68.4% of total costs) due to hospitalizations and US$ 679 million due to ambulatory procedures. Approximately 10% of these cost is attributable to overweight and obesity.

CONCLUSION

The results confirm that overweight and obesity carry a great economic burden for Brazilian health system and for the society. The knowledge of these costs will be useful for future economic analysis of preventive and treatment interventions.

Correlates of the incidence of disability and mortality among older adult Brazilians with and without diabetes mellitus and stroke

Background

The combined effect of diabetes and stroke on disability and mortality remains largely unexplored in Brazil and Latin America. Previous studies have been based primarily on data from developed countries. This study addresses the empirical gap by evaluating the combined impact of diabetes and stroke on disability and mortality in Brazil.

Methods

The sample was drawn from two waves of the Survey on Health and Well-being of the Elderly, which followed 2,143 older adults in São Paulo, Brazil, from 2000 to 2006. Disability was assessed via measures of activities of daily living (ADL) limitations, severe ADL limitations, and receiving assistance to perform these activities. Logistic and multinomial regression models controlling for sociodemographic and health conditions were used to address the influence of diabetes and stroke on disability and mortality.

Results

By itself, the presence of diabetes did not increase the risk of disability or the need for assistance; however, diabetes was related to increased risks when assessed in combination with stroke. After controlling for demographic, social and health conditions, individuals who had experienced stroke but not diabetes were 3.4 times more likely to have ADL limitations than those with neither condition (95% CI 2.26-5.04). This elevated risk more than doubled for those suffering from a combination of diabetes and stroke (OR 7.34, 95% CI 3.73-14.46). Similar effects from the combination of diabetes and stroke were observed for severe ADL limitations (OR 19.75, 95% CI 9.81- 39.76) and receiving ADL assistance (OR 16.57, 95% CI 8.39-32.73). Over time, older adults who had experienced a stroke were at higher risk of remaining disabled (RRR 4.28, 95% CI 1.53,11.95) and of mortality (RRR 3.42, 95% CI 1.65,7.09). However, risks were even higher for those who had experienced both diabetes and stroke. Diabetes was associated with higher mortality.

Conclusions

Findings indicate that a combined history of stroke and diabetes has a great impact on disability prevalence and mortality among older adults in São Paulo, Brazil.

[Analysis of cost-effectiveness of simvastatin versus atorvastatin in the secondary prevention of cardiovascular events within the Brazilian public healthcare system]

OBJECTIVE

The objective of this study is to perform an economic evaluation analyzing the treatment with atorvastatin and simvastatin in comparison to placebo treatment, within the Brazilian Public Healthcare System (SUS) scenario, for patients with high risk of cardiovascular disease; analyzing if the additional cost related to statin treatment is justified by the clinical benefits expected, in terms of cardiovascular event and mortality reduction.

METHODS

Cardiovascular event risk and mortality risk were used as outcomes. Statin efficacy at LDL-c and cardiovascular events levels lowering data was obtained from a systematic review of literature. A decision analytic model was developed to perform a cost-effectiveness analysis comparing atorvastatin 10mg/day and simvastatin 40 mg/day to placebo treatment in patients with dyslipidemia in Brazil. The target population of this study was a hypothetic cohort of men and women with a mean age of 50 years old and high risk of cardiovascular disease. The model includes only direct costs obtained from Ambulatory and Hospital Information System and Price Database of Brazilian Ministry of Health. The comparative cost-effectiveness analysis itself was done through Excel spreadsheets covering a 5 -years time horizon.

RESULTS

The result shows that atorvastatin 10mg/day in comparison to placebo has higher cost with higher effectiveness in the time horizon of 5 years (Incremental Cost Effectiveness Ratio of R$ 433.065,05 per life year gained). In this scenario atorvastatin is not cost effective in comparison to placebo. The simvastatin 40 mg/day appears to be a strategy with lower cost and higher effectiveness in comparison to placebo, in the time horizon analyzed (5 years). In the multivariate probabilistic sensitivity analysis, simvastatin showed 53% of the results in the quadrant with greater effectiveness and lower cost.

CONCLUSIONS

This study is an important tool for public decision makers. The study can be used in the decision process of increasing cardiovascular disease treatment access with budgetary sustainability for Ministry of Health. In comparison to placebo, the results show that sinvastatin is a cost saving strategy while atorvastatin is not cost effective.

Current management of intracerebral haemorrhage in China: a national, multi-centre, hospital register study

BACKGROUND

We aimed to examine current practice of the management and secondary prevention of intracerebral haemorrhage (ICH) in China where the disease is more common than in Western populations.

METHODS

Data on baseline characteristics, management in-hospital and post-stroke, and outcome of ICH patients are from the ChinaQUEST (QUality Evaluation of Stroke Care and Treatment) study, a multi-centre, prospective, 62 hospital registry in China during 2006-07.

RESULTS

Nearly all ICH patients (n = 1572) received an intravenous haemodiluting agent such as mannitol (96%) or a neuroprotectant (72%), and there was high use of intravenous traditional Chinese medicine (TCM) (42%). Neurosurgery was undertaken in 137 (9%) patients; being overweight, having a low Glasgow Coma Scale (GCS) score on admission, and Total Anterior Circulation Syndrome (TACS) clinical pattern on admission, were the only baseline factors associated with this intervention in multivariate analyses. Neurosurgery was associated with nearly three times higher risk of death/disability at 3 months post-stroke (odd ratio [OR] 2.60, p < 0.001). Continuation of antihypertensives in-hospital and at 3 and 12 months post-stroke was reported in 732/935 (78%), 775/935 (83%), and 752/935 (80%) living patients with hypertension, respectively.

CONCLUSIONS

The management of ICH in China is characterised by high rates of use of intravenous haemodiluting agents, neuroprotectants, and TCM, and of antihypertensives for secondary prevention. The controversial efficacy of these therapies, coupled with the current lack of treatments of proven benefit, is a call for action for more outcomes based research in ICH.

Alteration of thrombospondin-1 and -2 in rat brains following experimental intracerebral hemorrhage. Laboratory investigation

OBJECT

Spontaneous intracerebral hemorrhage (ICH) is among the most intractable forms of stroke. Angiogenesis, an orchestrated balance between proangiogenic and antiangiogenic factors, is a fundamental process to brain development and repair by new blood vessel formation from preexisting ones and can be induced by ICH. Thrombospondin (TSP)–1 and TSP-2 are naturally occurring antiangiogenic factors. The aim of this study was to observe their expression in rat brains with ICH.

METHODS

Intracerebral hemorrhage was induced in adult male Sprague-Dawley rats by stereotactic injection of collagenase VII or autologous blood into the right globus pallidus. The expression of TSP-1 and -2 was evaluated by immunohistochemistry and quantitative real-time reverse transcription–polymerase chain reaction analysis.

RESULTS

After the induction of ICH, some TSP1- or TSP2-immunoreactive microvessels resided around the hematoma for ~ 7 days and extended into a clot thereafter. Cerebral endothelial cells expressed the TSPs. The expression of TSP-1 and TSP-2 mRNA peaked at 4 and 14 days after collagenase-induced ICH, respectively.

CONCLUSIONS

Findings in this study suggest that ICH can alter the expression of TSP-1 and TSP-2, which may be involved in modulating angiogenesis in brains following ICH.

A Stepwise Approach to Stroke Surveillance in Brazil: the EMMA (Estudo de Mortalidade E Morbidade Do Acidente Vascular Cerebral) Study

Background:

Stroke mortality rates in Brazil are the highest in the Americas. Deaths from cerebrovascular disease surpass coronary heart disease.

Aim:

To verify stroke mortality rates and morbidity in an area of São Paulo, Brazil, using the World Health Organization Stepwise Approach to Stroke Surveillance.

Methods:

We used the World Health Organization Stepwise Approach to Stroke Surveillance structure of stroke surveillance. The hospital-based data comprised fatal and nonfatal stroke (Step 1). We gathered stroke-related mortality data in the community using World Health Organization questionnaires (Step 2). The questionnaire determining stroke prevalence was activated door to door in a family-health-programme neighbourhood (Step 3).

Results:

A total of 682 patients 18 years and above, including 472 incident cases, presented with cerebrovascular disease and were enrolled in Step 1 during April–May 2009. Cerebral infarction (84.3%) and first-ever stroke (85.2%) were the most frequent. In Step 2, 256 deaths from stroke were identified during 2006–2007. Forty-four per cent of deaths were classified as unspecified stroke, 1/3 as ischaemic stroke, and 1/4 due to haemorrhagic subtype. In Step 3, 577 subjects over 35 years old were evaluated at home, and 244 cases of stroke survival were diagnosed via a questionnaire, validated by a board-certified neurologist. The population demographic characteristics were similar in the three steps, except in terms of age and gender.

Conclusion:

By including data from all settings, World Health Organization stroke surveillance can provide data to help plan future resources that meet the needs of the public-health system.

Validation of a stroke symptom questionnaire for epidemiological surveys

CONTEXT AND OBJECTIVE

Stroke is a relevant issue within public health and requires epidemiological surveillance tools. The aim here was to validate a questionnaire for evaluating individuals with stroke symptoms in the Stroke Morbidity and Mortality Study (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral, EMMA), São Paulo, Brazil.

DESIGN AND SETTING

This was a cross-sectional study performed among a sample of the inhabitants of Butantã, an area in the western zone of the city of São Paulo.

METHODS

For all households in the coverage area of a primary healthcare unit, household members over the age of 35 years answered a stroke symptom questionnaire addressing limb weakness, facial weakness, speech problems, sensory disorders and impaired vision. Thirty-six participants were randomly selected for a complete neurological examination (gold standard).

RESULTS

Considering all the questions in the questionnaire, the sensitivity was 72.2%, specificity was 94.4%, positive predictive value was 92.9% and negative predictive value was 77.3%. The positive likelihood ratio was 12.9, the negative likelihood ratio was 0.29 and the kappa coefficient was 0.67. Limb weakness was the most sensitive symptom, and speech problems were the most specific.

CONCLUSIONS

The stroke symptom questionnaire is a useful tool and can be applied by trained interviewers with the aim of identifying community-dwelling stroke patients, through the structure of the Family Health Program.

Medical Complications Among Hospitalizations for Ischemic Stroke in the United States From 1998 to 2007

Background and Purpose— The common medical complications after ischemic stroke are associated with increased mortality and resource use.

Method— The study population consisted of 1 150 336 adult hospitalizations with ischemic stroke as a primary diagnosis included in the 1998 to 2007 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Multiple logistic regression analyses were used to examine changes between 1998 to 1999 and 2006 to 2007 in the prevalence of acute myocardial infarction, pneumonia, deep venous thrombosis, pulmonary embolism, or urinary tract infection, in-hospital mortality, and length of stay.

Results— In 2006 to 2007, the prevalence of hospitalizations with a secondary diagnosis of acute myocardial infarction, pneumonia, deep venous thrombosis, pulmonary embolism, and urinary tract infection was 1.6%, 2.9%, 0.8%, 0.3%, and 10.1%, respectively. The adjusted ORs for a hospitalization in 2006 to 2007 complicated by acute myocardial infarction, deep venous thrombosis, pulmonary embolism, or urinary tract infection, using 1998 to 1999 as the referent, were 1.39, 1.68, 2.39, and 1.18, respectively. The odds of pneumonia did not change significantly between 1998 to 1999 and 2006 to 2007. In-hospital mortality was significantly lower in 2006 to 2007 than in 1998 to 1999. Despite the overall length of stay decreasing significantly from 1998 to 1999 to 2006 to 2007, it remained the same for hospitalizations with acute myocardial infarction, pneumonia, deep vein thrombosis, and pulmonary embolism.

Conclusion— Although in-hospital mortality decreased over the study period, 4 of the 5 complications were more common in 2006 to 2007 than they were 8 years earlier with the largest increase observed for deep venous thrombosis and pulmonary embolism.