Predictors of hospital length of stay and cost in patients with intracerebral hemorrhage

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.

Short- and Long-term Health Care Resource Utilization and Costs Following Intracerebral Hemorrhage

OBJECTIVE

We sought to evaluate the short- and long-term resource use and costs associated with intracerebral hemorrhage (ICH) taken from an entire population. We in addition sought to evaluate the association of oral anticoagulation (OAC) and health care costs.

METHODS

This was a retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (2009-2017). We captured outcomes through linkage to health administrative databases. We used generalized linear models to identify factors associated with total cost. Analysis of OAC use was limited to patients ≥66 years of age. The primary outcome was total 1-year direct health care costs in 2020 US dollars.

RESULTS

Among 16,248 individuals with ICH (mean age 71.2 years, male 52.3%), 1-year mortality was 46.0%, and 24.2% required mechanical ventilation. The median total 1-year cost was $26,886 (interquartile range [IQR] $9,641-$62,907) with costs for those who died in hospital of $7,268 (IQR $4,031-$14,966) vs $44,969 (IQR $20,264-$82,414, p < 0.001) for survivors to discharge. OAC use (analysis limited to individuals ≥66 years old) was associated with higher total 1-year costs (cost ratio 1.06 [95% confidence interval 1.01-1.11]). Total 1-year costs for the entire cohort exceeded $120 million per year over the study period.

CONCLUSIONS

ICH is associated with significant health care costs, and the median cost of a patient with ICH is roughly 10 times the median inpatient cost in Ontario. Costs were higher among survivors than deceased patients. OAC use is independently associated with increased costs. To maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, not only improve mortality.

Early Determinants of Neurocritical Care Unit Length of Stay in Patients with Spontaneous Intracerebral Hemorrhage

BACKGROUND

The present study considers patients with spontaneous intracerebral hemorrhage (ICH) admitted to the neurocritical care unit (NCCU) through the Emergency Department (ED). It aims to identify patient-specific clinical variables that can be assessed on presentation and that are associated with prolonged NCCU length of stay (LOS).

METHODS

A cross-sectional, single-center, retrospective analysis of ICH patients directly admitted from the ED to the NCCU over an 8-year period was performed. Patients' demographics, clinical exam characteristics, serum laboratory values, intubation status, and neurosurgical procedures at presentation were recorded. Head computed tomography scans obtained on presentation were reviewed. LOS was calculated based on the number of midnights spent in the NCCU. Prolonged LOS was determined using a change point analysis, adopting the method of Taylor which utilizes CUMSUM charts and bootstrap analysis. A decision tree model was trained and validated to identify reliable variables associated with prolonged LOS.

RESULTS

Two hundred and five patients with ICH were analyzed. Prolonged LOS was calculated to be a stay that exceeds 8 days; 68 patients (33%) had a prolonged LOS in NCCU. Median LOS did not differ between survivors and patients who died in hospital. Clinical variables explored through the decision tree model were intubation status, neurosurgical intervention (EVD, decompression or evacuation within 24 h from presentation), and components of the ICH score: age, GCS, hematoma volume, the presence of intraventricular hemorrhage (IVH), and infratentorial location. The model accuracy was 0.8 and AUC was 0.83 (95% CI 0.78-0.89).

CONCLUSION

We propose an ICH-LOS model based on neurosurgical intervention, intubation status and GCS at presentation to predict prolonged LOS in the NCCU in patients with ICH. This simple clinical tool, if prospectively validated, could help with medical planning, contribute to patient care-directed conversations, assist in optimizing hospital resource utilization, and, more importantly, motivating patient-specific interventions aimed at optimizing outcomes and decreasing LOS.

The intra-neuroendoscopic technique (INET): a modified minimally invasive technique for evacuation of brain parenchyma hematomas

Background

Minimally invasive endoscopic hematoma evacuation is widely used in the treatment of intracerebral hemorrhage. However, this technique still has room for improvement. The intra-neuroendoscopic technique (INET) is a modified minimally invasive technique, and we report its safety and efficacy in evacuating brain parenchyma hematomas by comparing it with cranial puncture and drainage operation (CPDO).

Methods

The frontal, temporal, or occipital approaches were used according to the site of bleeding. The preoperative and postoperative hematoma volumes, Glasgow Coma Scale (GCS) score, Cerebral State Index (CSI), hematoma evacuation rate, operation time, complications, and 30-day mortality and Glasgow Outcome Scale (GOS) were retrospectively compared between the two groups.

Results

A total of 98 patients were enrolled. The evacuation rate (84 ± 7.1% versus 51.0 ± 8.4%, p = 0.00), 7-day GCS (11.8 ± 1.2 versus 10.4 ± 1.5, p = 0.01), and CSI (87.1 ± 8.7 versus 80.6 ± 10.2, p = 0.02) were higher, and the 30-day mortality rate (1.9% versus 15.6%, p = 0.036) was lower in the INET group. However, the operation time was longer in the INET group than in the control group (65.2 ± 12.5 min versus 45.6 ± 10.9 min, p = 0.000). Multivariable logistic regression showed that a good medium-term outcome (GOS scores 4–5) was significantly associated with INET (odds ratio (OR) 3.514, 95% confidence interval (CI) 1.463–8.440, p = 0.005), age under 65 years (OR 1.402, 95% CI, 1.041–1.888, p = 0.026), and hematoma volume less than 50 ml (OR 1.974, 95% CI 1.302–2.993, p = 0.001).

Conclusions

INET surgery for brain parenchyma hematoma evacuation is a safe and efficient modified technique. This technique is minimally invasive, has less complications, and may be helpful in providing optimal outcomes for selected patients.

Trial registration

ClinicalTrials.gov, NCT02515903. Registered on 5 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s13017-019-0239-0) contains supplementary material, which is available to authorized users.

Predicting Intracerebral Hemorrhage Patients' Length-of-Stay Probability Distribution Based on Demographic, Clinical, Admission Diagnosis, and Surgery Information

The vast majority of patients with intracerebral hemorrhage (ICH) suffer from long and uncertain length of stay (LOS). The aim of our study was to provide decision support for discharge and admission plans by predicting ICH patients' LOS probability distribution. The demographics, clinical predictors, admission diagnosis, and surgery information from 3,600 ICH patients were used in this study. We used univariable Cox analysis, multivariable Cox analysis, Cox-variable of importance (Cox-VIMP) analysis, and an intersection analysis to select predictors and used random survival forests (RSF)—a method in survival analysis—to predict LOS probability distribution. The Cox-VIMP method constructed by us effectively selected significant correlation predictors. The Cox-VIMP RSF model can improve prediction performance and is significantly different from the other models. The Cox-VIMP can contribute to the screening of predictors, and the RSF model can be established through those predictors to predict the probability distribution of LOS in each patient.

Hospital treatment costs and length of stay associated with hypertension and multimorbidity after hemorrhagic stroke

Background

Previous studies have identified various treatment and patient characteristics that may be associated with higher hospital cost after spontaneous intracerebral hemorrhage (ICH); a devastating type of stroke. Patient morbidity is perhaps the least understood of these cost-driving factors. We describe how hypertension and other patient morbidities affect length of stay, and hospital treatment costs after ICH using primary and simulated data. We also describe the relationship between cost and length of stay within these patients.

Methods

We used a cohort design; evaluating 987 consecutive ICH patients across one decade in a Canadian center. Economic, treatment, and patient data were obtained from clinical and administrative sources. Multimorbidity was defined as the presence of one or more diagnoses at hospital admission in addition to a primary diagnosis of ICH.

Results

Hypertension was the most frequent (67%) morbidity within these patients, as well as the strongest predictor of longer stay (adjusted RR for >7 days: 1.31, 95% CI: 1.07-1.60), and was significantly associated with higher cost per visit when accounting for other morbidities (adjusted cost increase for hypertension $8123.51, 95% CI: $4088.47 to $12,856.72 USD). A Monte Carlo simulation drawing one million samples of patients estimated for a generation (100 years) assuming 0.94% population growth per year, and a hospitalization rate of 12 per 100,000 inhabitants, supported these findings (p = 0.516 for the difference in unadjusted cost: simulated vs primary). Using a restricted cubic spline, we observed that the rate of change in overall cost for all patients was greatest for the first 3 weeks (p < 0.001) compared to subsequent weeks.

Conclusion

Patient multimorbidity, specifically hypertension, is a strong predictor of longer stay and cost after ICH. The non-linear relationship between cost and time should also be considered when forecasting healthcare spending in these patients.

Endoscopic Evacuation of Basal Ganglia Hematoma: Surgical Technique, Outcome, and Learning Curve

BACKGROUND

Minimally invasive endoscopic hematoma evacuation is a promising treatment option for intracerebral hemorrhage. However, the technique still needs improvement. We report our clinical experience of using this technique to evacuate deep-seated basal ganglia hematomas.

METHODS

The frontal approach was used in most patients. The preoperative and postoperative hematoma volumes, Glasgow Coma Scale, hematoma evacuation rate, 30-day mortality, and long-term outcome defined by the modified Rankin Scale were analyzed retrospectively. The surgical duration per milliliter of clot (DPM) was calculated. The learning curve for this technique was determined based on the relation between the DPM and evacuation rate per the number of cases experienced.

RESULTS

A total of 24 patients were enrolled. The evacuation rate was 87% ± 10%. The average Glasgow Coma Scale score recovered from 8 to 13 after surgery. Twenty-one patients had follow-up data. The follow-up time was 13 ± 6 months. The 30-day mortality after surgery was zero. Forty-eight percent of patients (10/21) achieved a favorable outcome. The DPM (P = 0.92) and evacuation rate (P = 0.64) did not change substantially with the number of cases experienced.

CONCLUSIONS

Endoscopic port surgery for hematoma evacuation via the frontal approach is a safe surgical option for deep-seated basal ganglia hematomas. This technique is minimally invasive and may be helpful to provide better long-term outcomes for selected patients. For neurosurgeons, the learning curve for this technique is steep, which implies that the skills needed for our technique can be easily acquired.

Negative spot sign in primary intracerebral hemorrhage: potential impact in reducing imaging

Intracerebral hemorrhage (ICH) is one of the most devastating and costly diagnoses in the USA. ICH is a common diagnosis, accounting for 10-15 % of all strokes and affecting 20 out of 100,000 people. The CT angiography (CTA) spot sign, or contrast extravasation into the hematoma, is a reliable predictor of hematoma expansion, clinical deterioration, and increased mortality. Multiple studies have demonstrated a high negative predictive value (NPV) for ICH expansion in patients without spot sign. Our aim is to determine the absolute NPV of the spot sign and clinical characteristics of patients who had ICH expansion despite the absence of a spot sign. This information may be helpful in the development of a cost effective imaging protocol of patients with ICH. During a 3-year period, 204 patients with a CTA with primary intracerebral hemorrhage were evaluated for subsequent hematoma expansion during their hospitalization. Patients with intraventricular hemorrhage were excluded. Clinical characteristics and antithrombotic treatment on admission were noted. The number of follow-up NCCT was recorded. Of the resulting 123 patients, 108 had a negative spot sign and 7 of those patients subsequently had significant hematoma expansion, 6 of which were on antithrombotic therapy. The NPV of the CTA spot sign was calculated at 0.93. In patients without antithrombotic therapy, the NPV was 0.98. In summary, the negative predictive value of the CTA spot sign for expansion of ICH, in the absence of antithrombotic therapy and intraventricular hemorrhage (IVH) on admission, is very high. These results have the potential to redirect follow-up imaging protocols and reduce cost.

Intracerebral Hemorrhage: A Common and Devastating Disease in Need of Better Treatment

OBJECTIVE

To review the poor natural history of intracerebral hemorrhage (ICH), current treatment options for ICH, discuss ongoing trials evaluating minimally invasive techniques for clot evacuation, and offer future directions of investigation for the management of this devastating disease.

METHODS

A selective review of recent trials regarding treatment of ICH was performed.

RESULTS

Completed trials of medical and surgical management are reviewed. The supportive research for clot evacuation to limit secondary injury is surveyed. We also provide a comprehensive discussion of current data evaluating minimally invasive techniques to achieve clot removal, including Minimally Invasive Surgery plus tPA for ICH Evacuation (MISTIE), Clot Lysis: Evaluating Accelerated Resolution (CLEAR), and endoscopic evacuation.

CONCLUSION

We encourage the neurosurgical community to pursue improved therapies for ICH.

PRACTICE

New minimally invasive treatments for ICH are being developed.

IMPLICATIONS

Treatment of ICH is an important area of research and should continue to be aggressively pursued because of the significant societal burden and poor outcomes associated with ICH.

The Safety and Feasibility of Admitting Patients With Intracerebral Hemorrhage to the Step-Down Unit

BACKGROUND

Intracerebral hemorrhage (ICH) is a devastating and costly condition. Although the American Heart Association/American Stroke Association recommends admitting patients with ICH to a neurocritical care unit (NCCU), this strategy may accrue unnecessary cost for patients with relatively milder presentation. We conducted a prospective observational study to determine the safety and feasibility of admitting patients with mild ICH directly to a step-down unit (SDU) instead of an NCCU.

METHODS

Consecutive patients with "mild presentation," defined as a combination of ICH score ≤2, National Institutes of Health Stroke Scale (NIHSS) ≤ 15, and Graeb score ≤2 (if intraventricular hemorrhage was present), were admitted to the SDU. Data were collected on age, gender as well as the initial NIHSS, Glasgow Coma Scale (GCS), ICH, and Graeb scores. Primary end point was any complication or death during hospital stay.

RESULTS

Twenty patients were admitted to the SDU. No patient was transferred to the NCCU from the SDU. One patient, who eventually died, had respiratory insufficiency due to hospital-acquired pneumonia.

CONCLUSION

Admission of ICH patients with mild symptoms to the SDU is safe and feasible. Larger prospective studies are needed to define the specific criteria for admission.

Does warfarin-related intracerebral haemorrhage lead to higher costs of management?

BACKGROUND AND PURPOSE

Warfarin-related intracerebral haemorrhage is associated with significant morbidity but long term treatment costs are unknown. Our study aimed to assess the cost of warfarin-related intracerebral haemorrhage.

METHODS

We included all patients with intracerebral haemorrhage between July 2006 and December 2011 at a single centre. We collected data on anticoagulant use, baseline clinical variables, discharge destinations, modified Rankin Scale at discharge and in-hospital costings. First year costings were extracted from previous studies. Multiple linear regression for treatment cost was performed with stratified analysis to assess for effect modification.

RESULTS

There were 694 intracerebral haemorrhage patients, with 108 (15.6%) previously on warfarin. Mean age (SD) of participants was 70.3 (13.6) and 58.5% were male. Patients on warfarin compared to those not on warfarin had significantly lower rates of discharge home (12.0% versus 18.9%, p=0.013). Overall total costs between groups were similar, $AUD 25,767 for warfarin-related intracerebral haemorrhage and $AUD 27,388 for non-warfarin intracerebral haemorrhage (p=0.353). Stratified analysis showed survivors of warfarin-related intracerebral haemorrhage had higher costs compared to those without warfarin ($AUD 33,419 versus $AUD 30,193, p<0.001) as well as increased length of stay (12 days versus 8 days, p<0.001). Inpatient mortality of patients on warfarin was associated with a shorter length of stay (p=0.001) and lower costs.

CONCLUSION

Survival of initial haemorrhage on warfarin was associated with increased treatment cost and length of stay but this was discounted by higher rates and earlier nature of mortality in warfarinised patients.

High dose deferoxamine in intracerebral hemorrhage (HI-DEF) trial: rationale, design, and methods

BACKGROUND

Hemoglobin degradation products, in particular iron, have been implicated in secondary neuronal injury following intracerebral hemorrhage (ICH). The iron chelator Deferoxamine Mesylate (DFO) exerts diverse neuroprotective effects, reduces perihematoma edema (PHE) and neuronal damage, and improves functional recovery after experimental ICH. We hypothesize that treatment with DFO could minimize neuronal injury and improve outcome in ICH patients. As a prelude to test this hypothesis, we conducted a Phase I, open-label study to determine the tolerability, safety, and maximum tolerated dose (MTD) of DFO in patients with ICH. Intravenous infusions of DFO in doses up to 62 mg/kg/day (up to a maximum of 6000 mg/day) were well-tolerated and did not seem to increase serious adverse events (SAEs) or mortality. We have initiated a multi-center, double-blind, randomized, placebo-controlled, Phase II clinical trial (High Dose Deferoxamine [HI-DEF] in Intracerebral Hemorrhage) to determine if it is futile to move DFO forward to Phase III efficacy evaluation.

METHODS

We will randomize 324 subjects with spontaneous ICH to either DFO at 62 mg/kg/day (up to a maximum daily dose of 6000 mg/day) or saline placebo, given by intravenous infusion for 5 consecutive days. Treatment will be initiated within 24 hours after ICH symptom onset. All subjects will be followed for 3 months and will receive standard of care therapy while participating in the study. At 3 months, the proportion of DFO-treated subjects with a good clinical outcome, assessed by modified Rankin Scale, will be compared to the placebo proportion in a futility analysis.

CONCLUSIONS

The Hi-Def trial is expected to advance our understanding of the pathopgysiology of secondary neuronal injury in ICH and will provide a crucial "Go/No Go" signal as to whether a Phase III trial to investigate the efficacy of DFO is warranted.

Spontaneous intracerebral hemorrhage and the challenge of surgical decision making: a review

Decision making for patients with spontaneous intracerebral hemorrhage (ICH) poses several challenges. Outcomes in this patient population are generally poor, prognostication is often uncertain, and treatment strategies offer limited benefits. Studies demonstrate variability in the type and intensity of treatment offered, which is attributed to clinical uncertainty and habits of training. Research has focused on new techniques and more stringent evidence-based selection criteria to improve outcomes and produce consensus around treatment strategies for patients with ICH. Such focus, however, offers little description of how ICH treatment decisions are made and how such decisions reflect patient preferences regarding medical care. A growing body of literature suggests that the process of decision making in ICH is laden with bias, value assumptions, and subjective impressions. Factors such as geography, cognitive biases, patient perceptions, and physician characteristics can all shape decision making and the selection of treatment. Such factors often serve as a barrier to providing patient-centered medical care. In this article, the authors review how surgical decision making for patients with ICH is shaped by these decisional factors and suggest future research pathways to study decision making in ICH. Such research efforts are important for establishing quality guidelines and pay-for-performance measures that reflect the preferences of individual patients and the contextual nature of medical decision making.

CT perfusion spot sign improves sensitivity for prediction of outcome compared with CTA and postcontrast CT

BACKGROUND AND PURPOSE

Recent studies have recommended both early and late imaging to increase spot sign detection. However optimal acquisition timing for spot detection and impact on outcome prediction is uncertain. Our aim was to assess the utility of CTP in spot sign detection and characterization with emphasis on its impact on the prediction of outcome in patients with acute primary ICH.

MATERIALS AND METHODS

A retrospective review of 28 patients presenting within 6 hours of ICH, studied with CTA, CTP, and postcontrast CT, was performed. CTA, CTP, and postcontrast CT spot sign characteristics were recorded according to predefined radiologic criteria. A combined primary outcome of hematoma expansion or poor clinical outcome was used and defined as hematoma expansion ≥6 mL or ≥30%, need for surgical drainage, or in-hospital mortality. Associations with the primary outcome and spot sign presence were examined against baseline clinical, laboratory, and radiographic variables. Predictive ability of CTA, CTP, and postcontrast CT spot characteristics were compared among modalities.

RESULTS

Primary outcome criteria were met in 18 patients (61%). CTP spot sign presence was an independent predictor of hematoma expansion or poor outcome (P = .040) and demonstrated greater sensitivity (78%) than spots detected on CTA (44%, P = .034) and postcontrast CT (50%, P = .025). Specificity and positive predictive value of the spot sign was high (100%) on all modalities. CTP detected the greatest number of spots (80%) with peak spot attenuation demonstrated at a median (interquartile range) time of 50 seconds (range, 34-63 seconds) after contrast bolus injection. CTP spot appearance was later than CTA-detected spots (P = .002) and earlier than postcontrast CT spots (P < .001).

CONCLUSIONS

CTP spot sign detection improves the sensitivity for prediction of outcome compared with CTA or postcontrast CT-detected spots.

Factors associated with failure to correct the international normalised ratio following fresh frozen plasma administration among patients treated for warfarin-related major bleeding. An analysis of electronic health records

This study assessed the frequency and factors associated with failure to correct international normalised ratio (INR) in patients administered fresh frozen plasma (FFP) for warfarin-related major bleeding. This retrospective database analysis used electronic health records from an integrated health system. Patients who received FFP between 01/01/2004 and 01/31/2010, and who met the following criteria were selected: major haemorrhage diagnosis the day before to the day after initial FFP administration; INR ≥2 on the day before or the day of FFP and another INR result available; warfarin prescription within 90 days. INR correction (defined as INR ≤1.3) was evaluated at the last available test up to one day following FFP. A total of 414 patients met selection criteria (mean age 75 years, 53% male, mean Charlson score 2.5). Patients presented with gastrointestinal bleeding (58%), intracranial haemorrhage (38%) and other bleed types (4%). The INR of 67% of patients remained uncorrected at the last available test up to one day following receipt of FFP. In logistic regression analysis, the INR of patients who were older, those with a Charlson score of 4 or greater, and those with non-ICH bleeds (odds ratio vs. intracranial bleeding 0.48; 95% confidence interval 0.31-0.76) were more likely to remain uncorrected within one day following FFP administration. In an alternative definition of correction, (INR ≤1.5), 39% of patients' INRs remained uncorrected. For a substantial proportion of patients, the INRs remain inadequately or uncorrected following FFP administration, with estimates varying depending on the INR threshold used.

A population-based study of inpatient outcomes after operative management of nontraumatic intracerebral hemorrhage in the United States

BACKGROUND

In the United States, data on patient outcomes after operative management of nontraumatic intracerebral hemorrhage (ICH) have been largely derived from tertiary care academic institutions. Given that outcomes of patients treated at these specialized centers may differ from those treated at community hospitals, our aim was to report patient outcomes on a population-based, national level.

METHODS

The Nationwide Inpatient Sample (NIS) was utilized to identify all patients with a primary diagnosis of nontraumatic ICH (431.xx) who underwent a craniotomy or craniectomy (ICD-9 CCS code 1). Univariate and multivariate analyses were performed to analyze the effects of patient and hospital characteristics on outcome measures.

RESULTS

NIS estimated that 657,428 patients with a primary diagnosis of nontraumatic ICH were admitted between 1993 and 2003 in the United States, 45,159 (6.9%) of whom underwent surgical treatment. The in-hospital mortality rate for surgically treated patients was 27.2%, and the complication rate was 41.2%. The most common complications reported were pulmonary (30.4%), renal (3.2%), and thromboembolic (2.9%). A single postoperative complication increased the mortality rate by 29% and lengthened the hospital stay by 5 days. Multivariate logistic regression demonstrated that complications and mortality were more likely in patients of African-American descent, and in subjects with 1 or more pre-existing comorbidity. Additionally, the mortality rate was lowest in hospitals that performed the highest volume of operations for nontraumatic ICH (odds ratio = 0.8; 95% confidence interval 0.68 to 0.99).

CONCLUSIONS

Patients with intracerebral hemorrhage who undergo craniotomy or craniectomy have a high morbidity and mortality. Male gender, preoperative comorbidities, complications, and low hospital volume were associated with an increased risk of in-hospital mortality.

Acute pediatric stroke: contributors to institutional cost

BACKGROUND AND PURPOSE

Recent studies examined the overall cost of pediatric stroke, but there are little data regarding the sources of these costs. We examined an administrative database that collected charges from 24 US children's hospitals to determine the sources of costs for acute hospital care of stroke.

METHODS

We used International Classification of Diseases, 9th Revision codes to search the Pediatric Health Information System. From 2003 to 2009 there were 1667 patients who had a primary diagnosis of stroke, 703 of which were hemorrhagic and 964 were ischemic. Individual costs, excluding physician charges, were gathered under 7 categories that were ranked to determine which contributed the most to total cost. Individual costs were ranked within their categories. We analyzed costs based on stroke type. Total costs were adjusted using the US Consumer Price Index to compare increases with the rate of inflation.

RESULTS

Median total cost for any stroke was $19,548 (interquartile range, $10,764-$40,721). The category "other/nursing" contributed the most to hospital costs followed by imaging, laboratory, and pharmacy. Brain MRI and CT contributed the most to imaging costs. Hemorrhagic strokes (median $24,843) were more expensive than ischemic strokes (median $16,954). Total cost increased from 2003 to 2009, but no overall annual trend emerged after controlling for gender, age, race, and hospital.

CONCLUSIONS

This is the first in-depth analysis of cost for pediatric stroke care. The highest cost categories are potential targets for cost containment but are also crucial for effective diagnosis and treatment. Necessary yet prudent use of imaging technologies and inpatient stays may be strategies for cost containment.

Critical care management of acute intracerebral hemorrhage

OPINION STATEMENT

Intracerebral hemorrhage is a medical emergency. It is the most deadly and disabling form of stroke, and no individual therapy has been demonstrated to improve outcome. However, it appears that aggressive medical care in general, and management by neuroscience specialists in particular, offers substantial benefit. Therefore, providing the best supportive care based on currently available evidence may well improve outcomes. Airway management and management of blood pressure aimed at maximizing cerebral perfusion while minimizing ongoing bleeding, as well as rapid reversal of anticoagulation, are likely to be important in the early phase. Additionally, efforts should be undertaken to provide careful glucose management and temperature management and to maximize cerebral perfusion pressure. Selected patients are likely to benefit from external ventricular drainage or even hematoma evacuation. Except in rare circumstances, most patients should be managed in a neuroscience intensive care unit during the acute phase. Some patients appear to have no reasonable likelihood of recovery and can be considered for limitations of care such as Do Not Resuscitate orders or Comfort Measures Only orders. However, it can be difficult to accurately predict long-term outcome in the acute phase; formal prognostic tools should be used to offer information to patients and their families. After the hemorrhage has stabilized, efforts to minimize complications include thromboembolism prophylaxis, physical therapy, and acute rehabilitation.

The cost of pediatric stroke acute care in the United States

BACKGROUND AND PURPOSE

The cost of pediatric stroke care has received little attention, but the available data suggest it is expensive. To determine the cost of acute stroke, we analyzed a US national database. Method- We used the Kids' Inpatient Database (KID2003) to determine the hospital-based costs of acute stroke in children ages 3 months to 20 years. Discharges were selected if the first diagnostic position contained an International Classification of Diseases, 9th Revision code pertaining to ischemic or hemorrhagic stroke. We examined the relationship between cost and stroke type by adjusting for variables that predict the cost of adult stroke.

RESULTS

There were 2224 pediatric cases, after statistical weighting, discharged with a diagnosis of hemorrhagic or ischemic stroke in KID2003. The estimated cost of acute pediatric stroke in the United States was $42 million in 2003. For the entire cohort, the mean cost of acute hospital care was $20 927 per discharge. The mean cost for ischemic stroke was $15 003, for intracerebral hemorrhage $24 117, and for subarachnoid hemorrhage $31 653. Stroke diagnosis, length of stay, hospital ownership, rural/urban teaching status, US geographical region, and discharge disposition were significantly associated with cost. Cost remained significantly associated with stroke diagnosis after adjusting for other predictors in the final multivariable regression model.

CONCLUSIONS

Pediatric stroke is expensive, and the lifetime cost of care is likely greater for a child than an adult. The cost to the family and the larger society underscore the importance of pediatric stroke treatment and prevention.

Costs of stroke using patient-level data: a critical review of the literature

BACKGROUND AND PURPOSE

With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.

METHODS

A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.

RESULTS

A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.

CONCLUSIONS

This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.

Hemostatic therapy for the treatment of intracranial hemorrhage

Intracranial hemorrhage results in poor neurologic outcomes and high mortality. Current management is limited to supportive care. In addition to the initial bleeding event, rebleeding and hematoma expansion have been identified as major risk factors for poor outcomes in these patients. The antifibrinolytic agents tranexamic acid, aminocaproic acid, and recombinant activated factor VII (rFVIIa) have been studied with the hopes of achieving early hemostasis and improving outcomes. Available data suggest that tranexamic acid and aminocaproic acid are more harmful than beneficial for this indication; therefore, they have no role in the treatment of intracranial bleeding. Alternatively, rFVIIa, has shown promising results in the management of spontaneous intracerebral hemorrhage. Clinicians should be aware of the available evidence regarding the use of these hemostatic agents in the management of intracranial hemorrhage, including traumatic brain injury, intracerebral hemorrhage, and subarachnoid hemorrhage.

Cost-effectiveness of recombinant activated factor VII in the treatment of intracerebral hemorrhage

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) is among the most costly and debilitating forms of stroke. Results from a recent Phase IIb clinical trial demonstrate that administration of recombinant activated factor VII (rFVIIa) reduces ICH mortality and improves functional outcome. In the current analysis, we examine the cost-effectiveness of early treatment with rFVIIa for ICH in the United States.

METHODS

A decision-analytic model was developed to estimate the lifetime costs and outcomes associated with rFVIIa treatment at doses of 40, 80 and 160 microg/kg compared with current standard of care in treating ICH, from a US third-party payer perspective. The patient population was similar to that of the Phase IIb clinical trial. Model structure and inputs were obtained from published literature, clinical trial data, claims databases, and expert opinion. All costs are presented in 2005 US dollars. Outcomes included incremental cost per life-year (LY) saved and incremental cost per quality-adjusted life-year (QALY) gained. Costs and outcomes were discounted at 3% annually. Univariate and multivariate sensitivity analyses were conducted to assess model robustness.

RESULTS

Compared with standard care, treatment with rFVIIa 40 microg/kg, and 160 microg/kg results in total lifetime cost-effectiveness ratios of 6308 dollars/QALY and 3152 dollars/QALY, respectively. Treatment with rFVIIa 80 microg/kg was found to be cost saving and a gain of 1.67 QALYs is achieved over a patient's lifetime. These results are robust to changes in input parameters.

CONCLUSIONS

Treatment of ICH with rFVIIa 40 microg/kg and 160 microg/kg appears to be cost-effective (<or=50,000 dollars/QALY). At the 80 microg/kg dose, rFVIIa was not only cost-effective, but also cost saving.