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Becker CJ, Sucharew H, Robinson D, Stamm B, Royan R, Nobel L, Stanton RJ, Jasne AS, Woo D, De Los Rios La Rosa F, Mackey J, Ferioli S, Mistry EA, Demel S, Haverbusch M, Coleman E, Slavin S, Walsh KB, Star M, Flaherty ML, Martini SR, Kissela B, Kleindorfer D. Impact of Poverty on Stroke Recurrence: A Population-Based Study. Neurology 2024; 102:e209423. [PMID: 38759136 DOI: 10.1212/wnl.0000000000209423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Poverty is associated with greater stroke incidence. The relationship between poverty and stroke recurrence is less clear. METHODS In this population-based study, incident strokes within the Greater Cincinnati/Northern Kentucky region were ascertained during the 2015 study period and followed up for recurrence until December 31, 2018. The primary exposure was neighborhood socioeconomic status (nSES), defined by the percentage of households below the federal poverty line in each census tract in 4 categories (≤5%, >5%-10%, >10%-25%, >25%). Poisson regression models provided recurrence rate estimates per 100,000 residents using population data from the 2015 5-year American Community Survey, adjusting for age, sex, and race. In a secondary analysis, Cox models allowed for the inclusion of vascular risk factors in the assessment of recurrence risk by nSES among those with incident stroke. RESULTS Of 2,125 patients with incident stroke, 245 had a recurrent stroke during the study period. Poorer nSES was associated with increased stroke recurrence, with rates of 12.5, 17.5, 25.4, and 29.9 per 100,000 in census tracts with ≤5%, >5%-10%, >10%-25%, and >25% below the poverty line, respectively (p < 0.01). The relative risk (95% CI) for recurrent stroke among Black vs White individuals was 2.54 (1.91-3.37) before adjusting for nSES, and 2.00 (1.47-2.74) after adjusting for nSES, a 35.1% decrease. In the secondary analysis, poorer nSES (HR 1.74, 95% CI 1.10-2.76 for lowest vs highest category) and Black race (HR 1.31, 95% CI 1.01-1.70) were both independently associated with recurrence risk, though neither retained significance after full adjustment. Age, diabetes, and left ventricular hypertrophy were associated with increased recurrence risk in fully adjusted models. DISCUSSION Residents of poorer neighborhoods had a dose-dependent increase in stroke recurrence risk, and neighborhood poverty accounted for approximately one-third of the excess risk among Black individuals. These results highlight the importance of poverty, race, and the intersection of the 2 as potent drivers of stroke recurrence.
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Affiliation(s)
- Christopher J Becker
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Heidi Sucharew
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - David Robinson
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Brian Stamm
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Regina Royan
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Lisa Nobel
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Robert J Stanton
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Adam S Jasne
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Daniel Woo
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Felipe De Los Rios La Rosa
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Jason Mackey
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Simona Ferioli
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Eva A Mistry
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Stacie Demel
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Mary Haverbusch
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Elisheva Coleman
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Sabreena Slavin
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Kyle B Walsh
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Michael Star
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Matthew L Flaherty
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Sharyl R Martini
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Brett Kissela
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Dawn Kleindorfer
- From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX
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Hum B, Taneja K, Bunachita S, Ashor H, Shin J, Bright A, Wang R, Patel K. Unveiling the evolving landscape of stroke care costs: A time-driven analysis. J Stroke Cerebrovasc Dis 2024; 33:107663. [PMID: 38432489 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/26/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Stroke is a common cause of mortality in the United States. However, the economic burden of stroke on the healthcare system is not well known. In this study, we aim to calculate the annual cumulative and per-patient cost of stroke. METHODS We conducted a retrospective analysis of Nationwide Emergency Department Sample (NEDS). We calculate annual trends in cost for stroke patients from 2006 to 2019. A multivariate linear regression with patient characteristics (e.g. age, sex, Charlson Comorbidity Index) as covariates was used to identify factors for higher costs. RESULTS In this study time-period, 2,998,237 stroke patients presented to the ED and 2,481,171 (83 %) were admitted. From 2006 to 2019, the cumulative ED cost increased by a factor of 7.0 from 0.49 ± 0.03 to 3.91 ± 0.16 billion dollars (p < 0.001). The cumulative inpatient (IP) cost increased by a factor of 2.7 from 14.42 ± 0.78 to 37.06 ± 2.26 billion dollars (p < 0.001. Per-patient ED charges increased by a factor of 3.0 from 1950 ± 64 to 7818 ± 260 dollars (p < 0.001). Per-patient IP charges increased by 89 % from 40.22 +/- 1.12 to 76.06 ± 3.18 thousand dollars (p < 0.001). CONCLUSION Strokes place an increasing financial burden on the US healthcare system. Certain patient demographics including age, male gender, more comorbidities, and insurance type were significantly associated with increased cost of care.
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Affiliation(s)
- Bill Hum
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Sean Bunachita
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Hadi Ashor
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Jeeyong Shin
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Anshel Bright
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Ryan Wang
- Independent, Bethesda, MD,United States
| | - Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States.
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Babela R, Baráková A, Hatala R. Epidemiology and comprehensive economic impact of atrial fibrillation and associated stroke in Slovakia. BMC Health Serv Res 2024; 24:637. [PMID: 38760673 PMCID: PMC11100086 DOI: 10.1186/s12913-024-11100-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 05/10/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is also a major risk factor for ischemic stroke. The main objective of our study was to identify direct and indirect costs of AF and AF-related stroke in Slovakia. METHODS We conducted a retrospective population-based study of AF and stroke related costs both from the third-party healthcare payers and societal perspective. The prevalence and incidence of AF and stroke were determined from central government run healthcare database. Further we estimated both indirect and direct costs of AF and stroke. All costs and healthcare resources were assessed from 2015 through 2019 and were expressed in the respective year. RESULTS Over the 5-year study period, the prevalence of AF increased by 26% to a total of 149,198 AF cases in 2019, with an estimated total annual economic burden of €66,242,359. Direct medical costs accounted for 94% of the total cost of AF. The total cost of treating patients with stroke in 2019 was estimated at €89,505,669. As a result, the medical costs of stroke that develops as a complication of AF have been estimated to be €25,734,080 in 2019. CONCLUSIONS Our study shows a substantial economic burden of AF and AF-related stroke in Slovakia. In view of the above, both screening for asymptomatic AF in high-risk populations and effective early management of AF with a focused on thromboprophylaxis rhythm control should be implemented.
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Affiliation(s)
- Robert Babela
- Slovak Medical University, Bratislava, Slovakia.
- PHC, Project HealthCare, Bratislava, Slovakia.
| | - Anna Baráková
- Slovak Heart Rhythm Association (SASA), Bratislava, Slovakia
| | - Robert Hatala
- Slovak Medical University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
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van Voorst H, Hoving JW, Koopman MS, Daems JD, Peerlings D, Buskens E, Lingsma H, Marquering HA, de Jong HWAM, Berkhemer OA, van Zwam WH, van Walderveen MAA, van den Wijngaard IR, Dippel DWJ, Yoo AJ, Campbell B, Kunz WG, Majoie CB, Emmer BJ. Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation. J Neurol Neurosurg Psychiatry 2024; 95:515-527. [PMID: 38124162 DOI: 10.1136/jnnp-2023-331862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion. METHODS Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes. RESULTS Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR≤1.4: 0.0 (IQR: -1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years CONCLUSION: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Jasper D Daems
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daan Peerlings
- Department of Radiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Erik Buskens
- Epidemiology, University Medical Centre Groningen, Groningen, Groningen, The Netherlands
| | - Hester Lingsma
- Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
- Biomedical Engineering and Physics, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | | | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Ido R van den Wijngaard
- Neurology, HMC Westeinde, The Hague, Zuid-Holland, The Netherlands
- Neurology, Leiden University, Leiden, The Netherlands
| | | | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Bruce Campbell
- The Royal Melbourne Hospital, Parkville, Melbourne, Australia
| | | | - Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
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Benmalek M, Connock M, Savio L, Obadia JF, Armoiry X. Cost-effectiveness of left atrial appendage occlusion during cardiac surgery in France: An economic evaluation based on the LAAOS III study. PLoS One 2024; 19:e0302517. [PMID: 38722976 PMCID: PMC11081221 DOI: 10.1371/journal.pone.0302517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/04/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVES Left atrial appendage occlusion during cardiac surgery is a therapeutic option for stroke prevention in patients with atrial fibrillation. The effectiveness and safety of left atrial appendage occlusion have been evaluated in several studies, including the LAAOS-III trial. While these studies have demonstrated efficacy and safety, the long-term economic impact of this surgical technique has not yet been assessed. Here, we aimed to evaluate the cost-effectiveness and cost-utility of left atrial appendage occlusion during cardiac surgery over a long-term time horizon. METHODS Our study was based on a model representing an hypothetical cohort with the same characteristics as LAAOS-III trial patients. We modelled the incidence of ischemic strokes and systemic embolisms in each intervention arm: "occlusion" and "no-occlusion," using a one-month cycle length with a 20-year time horizon. Regarding occlusion devices, sutures, staples, or an approved surgical occlusion device (AtriClip™-AtriCure, Ohio, USA) could be used. RESULTS Our model generated an average cost savings of 607 euros per patient and an incremental gain of 0.062 quality-adjusted life years (QALYs), resulting an incremental cost-utility ratio (ICUR) of €-9,775/QALY. The scenario analysis in which occlusion was systematically performed using the AtriClip™ device generated an ICUR of €3,952/QALY gained. CONCLUSIONS In the base-case analysis, the strategy proved to be more effective and less costly, confirming left atrial appendage occlusion during cardiac surgery as an economically dominant strategy. The scenario analysis also appeared cost-effective, although it did not result in cost savings. This study provides a new perspective on the assessment of the cost-effectiveness of these techniques.
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Affiliation(s)
- Manon Benmalek
- Pharmacy Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Martin Connock
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Léa Savio
- Pharmacy Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jean-François Obadia
- Hôpital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque, Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | - Xavier Armoiry
- Pharmacy Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- School of Pharmacy (ISPB), UMR CNRS 5510 MATEIS, University of Lyon, Lyon, France
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Barbosa PM, Szrek H, Ferreira LN, Cruz VT, Firmino-Machado J. Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals. Ann Phys Rehabil Med 2024; 67:101824. [PMID: 38518399 DOI: 10.1016/j.rehab.2024.101824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Stroke burden challenges global health, and social and economic policies. Although stroke recovery encompasses a wide range of care, including in-hospital, outpatient, and community-based rehabilitation, there are no published cost-effectiveness studies of integrated post-stroke pathways. OBJECTIVE To determine the most cost-effective rehabilitation pathway during the first 12 months after a first-ever stroke. METHODS A cohort of people in the acute phase of a first stroke was followed after hospital discharge; 51 % women, mean (SD) age 74.4 (12.9) years, mean National Institute of Health Stroke Scale score 11.7 (8.5) points, and mode modified Rankin Scale score 3 points. We developed a decision tree model of 9 sequences of rehabilitation care organised in 3 stages (3, 6 and 12 months) through a combination of public, semi-public and private entities, considering both the individual and healthcare service perspectives. Health outcomes were expressed as quality-adjusted life years (QALY) over a 1-year time horizon. Costs included healthcare, social care, and productivity losses. Sensitivity analyses were conducted on model input values. RESULTS From the individual perspective, pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective, followed by pathway 1 (Rehabilitation Centre » Community Clinic). From the healthcare service perspective, pathway 3 was the most cost-effective followed by pathway 7 (Outpatient Hospital » Private Clinic). All other pathways were considered strongly dominated and excluded from the analysis. The total 1-year mean cost ranged between €12104 and €23024 from the individual's perspective and between €10992 and €31319 from the healthcare service perspective. CONCLUSION Assuming a willingness-to-pay threshold of one times the national gross domestic product (€20633/QALY), pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective strategy from both the individual and healthcare service perspectives. Rehabilitation pathway data contribute to the development of a future integrated care system adapted to different stroke profiles.
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Affiliation(s)
- Pedro Maciel Barbosa
- Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Hospital Pedro Hispano, Unidade Local de Saúde, EPE, Rua de Alfredo Cunha 365, 4450-021 Matosinhos, Portugal; Centro de Investigação em Reabilitação, Escola Superior de Saúde, Instituto Politécnico do Porto, R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
| | - Helena Szrek
- Centre for Economics and Finance, University of Porto, R. Dr. Roberto Frias, 4200-464 Porto, Portugal
| | - Lara Noronha Ferreira
- ESGHT, Universidade do Algarve, Estr. da Penha 139, 8005-246 Faro, Portugal; Centre for Health Studies and Research of the University of Coimbra, Avenida Dias da Silva 165, 3004-512 Coimbra, Portugal; Research Centre for Tourism, Sustainability and Well-Being (CinTurs), Portugal.
| | - Vitor Tedim Cruz
- Hospital Pedro Hispano, Unidade Local de Saúde, EPE, Rua de Alfredo Cunha 365, 4450-021 Matosinhos, Portugal; EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal
| | - João Firmino-Machado
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Centro Académico Clínico Egas Moniz, 810-193 Aveiro, Portugal; Centro Hospitalar Vila Nova de Gaia/Espinho, R. Conceição Fernandes S/N, 4434-502 Vila Nova de Gaia, Portugal
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Blue L, Kranker K, Markovitz AR, Powell RE, Williams MV, Pu J, Magid DJ, McCall N, Steiner A, Stewart KA, Rollison JM, Markovich P, Peterson GG. Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical Trial. JAMA 2023; 330:1437-1447. [PMID: 37847273 PMCID: PMC10582785 DOI: 10.1001/jama.2023.19597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/12/2023] [Indexed: 10/18/2023]
Abstract
Importance The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. Objective To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. Design, Setting, and Participants This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Intervention Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Main Outcomes and Measures Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. Results High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). Conclusions and Relevance The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. Trial Registration ClinicalTrials.gov Identifier: NCT04047147.
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Affiliation(s)
| | | | | | - Rhea E. Powell
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Jia Pu
- Mathematica, Oakland, California
| | | | | | | | | | | | - Patricia Markovich
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
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Wagner TH, Schoemaker L, Gehlert E, Nelson RE, Murphy K, Martini S, Graham GD, Govindarajan P, Williams LS. One-Year Costs Associated With the Veterans Affairs National TeleStroke Program. Value Health 2022; 25:937-943. [PMID: 35346590 DOI: 10.1016/j.jval.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP). METHODS We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect. RESULTS NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care. CONCLUSIONS Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.
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Affiliation(s)
- Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Surgery, Stanford University, Stanford, CA, USA.
| | - Lena Schoemaker
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Elizabeth Gehlert
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Richard E Nelson
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Sharyl Martini
- VA National TeleStroke Program and VA Office of Specialty Care Services, Washington, DC, USA; Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Glenn D Graham
- VA National TeleStroke Program and VA Office of Specialty Care Services, Washington, DC, USA; Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Linda S Williams
- VA HSR&D EXTEND QUERI and the Center for Health Information and Communication, Indianapolis VA Medical Center, Indianapolis, IN, USA; Department of Neurology, Indiana University, Indianapolis, IN, USA; Regenstrief Institute, Inc, Indianapolis, IN, USA
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Munir MB, Hlavacek P, Keshishian A, Guo JD, Mallampati R, Ferri M, Russ C, Emir B, Cato M, Yuce H, Hsu JC. Contemporary clinical and economic outcomes among oral anticoagulant treated and untreated elderly patients with atrial fibrillation: Insights from the United States Medicare database. PLoS One 2022; 17:e0263903. [PMID: 35176074 PMCID: PMC8853505 DOI: 10.1371/journal.pone.0263903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Oral anticoagulants (OACs) mitigate the risk of stroke in atrial fibrillation (AF) patients. Objective Elderly AF patients who were treated with OACs (apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) were compared against AF patients who were not treated with OACs with respect to their clinical and economic outcomes. Methods Newly diagnosed AF patients were identified between January 2013 and December 2017 in the Medicare database. Evidence of an OAC treatment claim on or after the first AF diagnosis was used to classify patients into treatment-defined cohorts, and these cohorts were further stratified based on the initial OAC prescribed. The risks of stroke/systemic embolism (SE), major bleeding (MB), and death were analyzed using inverse probability treatment weighted time-dependent Cox regression models, and costs were compared with marginal structural models. Results The two treatment groups were composed of 1,421,187 AF patients: OAC treated (N = 583,350, 41.0% [36.4% apixaban, 4.9% dabigatran, 0.1% edoxaban, 26.7% rivaroxaban, and 31.9% warfarin patients]) and untreated (N = 837,837, 59.0%). OAC-treated patients had a lower adjusted risk of stroke/SE compared to untreated patients (hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.68–0.72). Additionally patients receiving OACs had a lower adjusted risk of death (HR: 0.56; 95% CI: 0.55–0.56) and a higher risk of MB (HR: 1.57; 95% CI: 1.54–1.59) and this trend was consistent across each OAC sub-group. The OAC-treated cohort had lower adjusted total healthcare costs per patient per month ($4,381 vs $7,172; p < .0001). Conclusion For the OAC-treated cohort in this elderly US population, stroke/SE and all-cause death were lower, while risk of MB was higher. Among OAC treated patients, total healthcare costs were lower than those of the untreated cohort.
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Affiliation(s)
- Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California San Diego School of Medicine, La Jolla, CA, United States of America
| | | | | | - Jennifer D. Guo
- Bristol-Myers Squibb, Lawrenceville, NJ, United States of America
| | | | - Mauricio Ferri
- Bristol-Myers Squibb, Lawrenceville, NJ, United States of America
| | | | - Birol Emir
- Pfizer, New York, NY, United States of America
| | | | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, United States of America
| | - Jonathan C. Hsu
- Section of Electrophysiology, Division of Cardiology, University of California San Diego School of Medicine, La Jolla, CA, United States of America
- * E-mail:
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10
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Yeh HJ, Chen TA, Cheng HC, Chou YJ, Huang N. Long-Term Rehabilitation Utilization Pattern Among Stroke Patients Under the National Health Insurance Program. Am J Phys Med Rehabil 2022; 101:129-134. [PMID: 33782272 DOI: 10.1097/phm.0000000000001747] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to understand the frequency of patients receiving rehabilitation services at various periods after stroke and the possible medical barriers to receiving rehabilitation. DESIGN A retrospective cohort study was conducted using a nationally representative sample in Taiwan. A total of 14,600 stroke patients between 2005 and 2011 were included. Utilization of physical therapy or occupational therapy at different periods after stroke onset was the outcome variable. Individual and geographic characteristics were investigated to determine their effect on patients' probability of receiving rehabilitation. RESULTS More severe stroke or more comorbid diseases increased the odds of receiving physical therapy and occupational therapy; older age was associated with decreased odds. Notably, sex and stroke type influenced the odds of rehabilitation only in the early period. Copayment exemption lowered the odds of rehabilitation in the first 6 mos but increased the odds in later periods. Rural and suburban patients had significantly lower odds of receiving physical therapy and occupational therapy, as did patients living in areas with fewer rehabilitation therapists. CONCLUSIONS Besides personal factors, geographic factors such as urban-rural gaps and number of therapists were significantly associated with the utilization of post-stroke rehabilitation care. Furthermore, the influence of certain factors, such as sex, stroke type, and copayment exemption type, changed over time.
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Affiliation(s)
- Huan-Jui Yeh
- From the Department of Physical Medicine and Rehabilitation, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan (H-JY, T-AC); Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan (H-JY, Y-JC); Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan (H-CC); Department of Ophthalmology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan (H-CC); Program in Molecular Medicine, School of Life Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan (H-CC); Department of Life Sciences and Institute of Genome Sciences, School of Life Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan (H-CC); and Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan (NH)
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Owolabi MO, Thrift AG, Mahal A, Ishida M, Martins S, Johnson WD, Pandian J, Abd-Allah F, Yaria J, Phan HT, Roth G, Gall SL, Beare R, Phan TG, Mikulik R, Akinyemi RO, Norrving B, Brainin M, Feigin VL. Primary stroke prevention worldwide: translating evidence into action. Lancet Public Health 2022; 7:e74-e85. [PMID: 34756176 PMCID: PMC8727355 DOI: 10.1016/s2468-2667(21)00230-9] [Citation(s) in RCA: 136] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 02/05/2023]
Abstract
Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.
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Affiliation(s)
- Mayowa O Owolabi
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Ajay Mahal
- Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Marie Ishida
- Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sheila Martins
- Department of Neurology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Department of Neurology, Universidade Federal do Rio Grande do Sul, Rio Grande do Sul, Brazil; Department of Neurology, Hospital Moinhos de Vento, Porto Alegre, Brazil; Brazilian Stroke Network, São Paulo, Brazil
| | - Walter D Johnson
- School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | - Jeyaraj Pandian
- School of Public Health, Christian Medical College, Ludhiana, Punjab, India
| | - Foad Abd-Allah
- Department of Neurology, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Joseph Yaria
- Department of Neurology, University College Hospital, Ibadan, Nigeria
| | - Hoang T Phan
- Department of Neurology, Monash University, Melbourne, VIC, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Greg Roth
- Institute for Health Metrics Evaluation, University of Washington, Seattle, WA, USA
| | - Seana L Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Richard Beare
- Monash Health, and Peninsula Clinical School, Monash University, Melbourne, VIC, Australia; Developmental Imaging Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Thanh G Phan
- Department of Neurology, Monash University, Melbourne, VIC, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Robert Mikulik
- International Clinical Research Center, Neurology Department, St Anne's University Hospital, Masaryk University, Brno, Czech Republic
| | - Rufus O Akinyemi
- Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Bo Norrving
- Department of Clinical Sciences, and Department of Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Michael Brainin
- Department of Neuroscience and Preventive Medicine, Danube University Krems, Krems an der Donau, Austria
| | - Valery L Feigin
- Institute for Health Metrics Evaluation, University of Washington, Seattle, WA, USA; National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand; Scientific and Educational Department, Research Centre of Neurology, Moscow, Russia.
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Lo CT, Niu F, Fredriks DA, Hui RL. Evaluation of the Effectiveness and Safety of Direct Oral Anticoagulants in Elderly Patients With Nonvalvular Atrial Fibrillation Who Are Not Candidates for Warfarin in Real-World Setting. J Cardiovasc Pharmacol 2022; 79:e138-e143. [PMID: 34740212 DOI: 10.1097/fjc.0000000000001168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Limited literature has established the role of direct oral anticoagulants (DOAC) for elderly patients with nonvalvular atrial fibrillation who are unsuited for warfarin. Therefore, the objectives of this study were to assess the effectiveness and safety of DOAC use in this vulnerable patient population. This was a retrospective propensity score matching cohort study. Among all patients aged 75+ years who were not candidates for warfarin, we matched those who initiated DOAC between September 2017 and September 2018 with those who did not receive DOAC or warfarin in a 1:1 ratio. Effectiveness outcome was a composite measure of stroke, transient ischemic attack, and pulmonary embolism. Safety outcome was a composite measure of non-trauma-related intracranial hemorrhage and gastrointestinal bleed. Unless patients died or lost membership, follow-up period for the effectiveness outcome was until the end of 2019, whereas the safety outcome was for a period up to 1 year. Conditional logistic regression was used to analyze both outcomes. We identified 7818 patients who met the inclusion criteria and started DOAC, which matched to 7818 patients who did not receive anticoagulants. The mean age was 82.3 ± 5.1 years, and 51.5% male. The DOAC group had a lower hazard ratio of 0.37 (confidence interval, 0.24-0.57; P < 0.01) for composite effectiveness outcomes, whereas no difference in the composite safety outcome (hazard ratio, 0.91; confidence interval, 0.65-1.25; P = 0.55) when compared with matched control. In conclusion, DOAC was found to be effective in preventing thromboembolic events in patients aged 75+ years with nonvalvular atrial fibrillation who were not eligible for warfarin.
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Affiliation(s)
- Catherine T Lo
- Ambulatory Care, Central Valley Service Area, Kaiser Permanente, Modesto, CA
| | - Fang Niu
- Pharmacy Outcomes Research Group, Kaiser Permanente, Downey, CA
| | - Dean A Fredriks
- Northern California Drug Use Management, Kaiser Permanente, Oakland, CA; and
| | - Rita L Hui
- Pharmacy Outcomes Research Group, Kaiser Permanente, Oakland, CA
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13
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Kass B, Dornquast C, Meisel A, Holmberg C, Rieckmann N, Reinhold T. Cost-effectiveness of patient navigation programs for stroke patients-A systematic review. PLoS One 2021; 16:e0258582. [PMID: 34653188 PMCID: PMC8519430 DOI: 10.1371/journal.pone.0258582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 09/30/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Stroke remains a leading cause of premature death, impairment and reduced quality of life. Its aftercare is performed by numerous different health care service providers, resulting in a high need for coordination. Personally delivered patient navigation (PN) is a promising approach for managing pathways through health care systems and for improving patient outcomes. Although PN in stroke care is evolving, no summarized information on its cost-effectiveness in stroke survivors is available. Hence, the aim of this systematic review is to analyze the level of evidence on the cost-effectiveness of PN for stroke survivors. Methods A systematic literature search without time limitations was carried out in PubMed, EMBASE, CENTRAL, CINAHL as well as PsycINFO and supplemented by a manual search. Randomized controlled trials published prior to April 2020 in English or German were considered eligible if any results regarding the cost-effectiveness of PN for stroke survivors were reported. The review was conducted according to PRISMA guidelines. Quality of included studies was assessed with the RoB2 tool. Main study characteristics and cost-effectiveness results were summarized and discussed. Results The search identified 1442 records, and two studies met the inclusion criteria. Quality of included studies was rated moderate and high. Programs, settings and cost-effectiveness results were heterogeneous, with one study showing a 90% probability of being cost-effective at a willingness to pay of $25600 per QALY (health/social care perspective) and the other showing similar QALYs and higher costs. Conclusions Since only two studies were eligible, this review reveals a large gap in knowledge regarding the cost-effectiveness of PN for stroke survivors. Furthermore, no conclusive statement about the cost-effectiveness can be made. Future attempts to evaluate PN for stroke survivors are necessary and should also involve cost-effectiveness issues.
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Affiliation(s)
- Benjamin Kass
- Institute for Social Medicine, Epidemiology and Health Economics, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- * E-mail:
| | - Christina Dornquast
- Institute for Social Medicine, Epidemiology and Health Economics, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Neurocure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Holmberg
- Institute of Public Health, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Institute of Social Medicine and Epidemiology, Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Nina Rieckmann
- Institute of Public Health, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Reinhold
- Institute for Social Medicine, Epidemiology and Health Economics, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Kim Y, Twardzik E, Judd SE, Colabianchi N. Neighborhood Socioeconomic Status and Stroke Incidence: A Systematic Review. Neurology 2021; 96:897-907. [PMID: 33766995 PMCID: PMC8166445 DOI: 10.1212/wnl.0000000000011892] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/02/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To summarize overall patterns of the impact of neighborhood socioeconomic status (nSES) on stroke incidence and uncover potential gaps in the literature, we conducted a systematic review of studies examining the association between nSES and stroke incidence, independent of individual SES. METHODS Four electronic databases and reference lists of included articles were searched, and corresponding authors were contacted to locate additional studies. A keyword search strategy included the 3 broad domains of neighborhood, SES, and stroke. Eight studies met our inclusion criteria (e.g., nSES as an exposure, individual SES as a covariate, and stroke incidence as an outcome). We coded study methodology and findings across the 8 studies. RESULTS The results provide evidence for the overall nSES and stroke incidence association in Sweden and Japan, but not within the United States. Findings were inconclusive when examining the nSES-stroke incidence association stratified by race. We found evidence for the mediating role of biological factors in the nSES-stroke incidence association. CONCLUSIONS Higher neighborhood disadvantage was found to be associated with higher stroke risk, but it was not significant in all the studies. The relationship between nSES and stroke risk within different racial groups in the United States was inconclusive. Inconsistencies may be driven by differences in covariate adjustment (e.g., individual-level sociodemographic characteristics and neighborhood-level racial composition). Additional research is needed to investigate potential intermediate and modifiable factors of the association between nSES and stroke incidence, which could serve as intervention points.
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Affiliation(s)
- Yeonwoo Kim
- From the Department of Kinesiology (Y.K.), University of Texas at Arlington, TX; School of Kinesiology (E.T.), University of Michigan, MI; Department of Biostatistics (S.E.J.), University of Alabama at Birmingham, AL; School of Kinesiology (N.C.), University of Michigan, MI
| | - Erica Twardzik
- From the Department of Kinesiology (Y.K.), University of Texas at Arlington, TX; School of Kinesiology (E.T.), University of Michigan, MI; Department of Biostatistics (S.E.J.), University of Alabama at Birmingham, AL; School of Kinesiology (N.C.), University of Michigan, MI
| | - Suzanne E Judd
- From the Department of Kinesiology (Y.K.), University of Texas at Arlington, TX; School of Kinesiology (E.T.), University of Michigan, MI; Department of Biostatistics (S.E.J.), University of Alabama at Birmingham, AL; School of Kinesiology (N.C.), University of Michigan, MI
| | - Natalie Colabianchi
- From the Department of Kinesiology (Y.K.), University of Texas at Arlington, TX; School of Kinesiology (E.T.), University of Michigan, MI; Department of Biostatistics (S.E.J.), University of Alabama at Birmingham, AL; School of Kinesiology (N.C.), University of Michigan, MI.
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15
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 2900] [Impact Index Per Article: 966.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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16
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Waqas M, Gong AD, Levy BR, Dossani RH, Vakharia K, Cappuzzo JM, Becker A, Sonig A, Tutino VM, Almayman F, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:105557. [PMID: 33556672 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Bennett R Levy
- George Washington School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Alexander Becker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA; Department of Pathology and Anatomical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
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Bayliss WS, Bushnell CD, Halladay JR, Duncan PW, Freburger JK, Kucharska-Newton AM, Trogdon JG. The Cost of Implementing and Sustaining the COMprehensive Post-Acute Stroke Services Model. Med Care 2021; 59:163-168. [PMID: 33273292 PMCID: PMC8594619 DOI: 10.1097/mlr.0000000000001462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COMprehensive Post-Acute Stroke Services (COMPASS) model, a transitional care intervention for stroke patients discharged home, was tested against status quo postacute stroke care in a cluster-randomized trial in 40 hospitals in North Carolina. This study examined the hospital-level costs associated with implementing and sustaining COMPASS. METHODS Using an activity-based costing survey, we estimated hospital-level resource costs spent on COMPASS-related activities during approximately 1 year. We identified hospitals that were actively engaged in COMPASS during the year before the survey and collected resource cost estimates from 22 hospitals. We used median wage data from the Bureau of Labor Statistics and COMPASS enrollment data to estimate the hospital-level costs per COMPASS enrollee. RESULTS Between November 2017 and March 2019, 1582 patients received the COMPASS intervention across the 22 hospitals included in this analysis. Average annual hospital-level COMPASS costs were $2861 per patient (25th percentile: $735; 75th percentile: $3,475). Having 10% higher stroke patient volume was associated with 5.1% lower COMPASS costs per patient (P=0.016). About half (N=10) of hospitals reported postacute clinic visits as their highest-cost activity, while a third (N=7) reported case ascertainment (ie, identifying eligible patients) as their highest-cost activity. CONCLUSIONS We found that the costs of implementing COMPASS varied across hospitals. On average, hospitals with higher stroke volume and higher enrollment reported lower costs per patient. Based on average costs of COMPASS and readmissions for stroke patients, COMPASS could lower net costs if the model is able to prevent about 6 readmissions per year.
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Affiliation(s)
- William S Bayliss
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pamela W Duncan
- Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, Pittsburgh, PA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
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18
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Tsou C, Robinson S, Boyd J, Kamath S, Yeung J, Waters S, Gifford K, Jamieson A, Hendrie D. Effectiveness and cost-effectiveness of TeleStroke consultations to support the care of patients who had a stroke presenting to regional emergency departments in Western Australia: an economic evaluation case study protocol. BMJ Open 2021; 11:e043836. [PMID: 33408213 PMCID: PMC7789446 DOI: 10.1136/bmjopen-2020-043836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The Western Australia (WA) Acute TeleStroke Programme commenced incrementally across regional WA during 2016-2017. Since the introduction of the TeleStroke Programme, there has been monitoring of service outputs, including regional patient access to tertiary stroke specialist advice and reperfusion treatment; however, the impact of consultation with a stroke specialist via telehealth (videoconferencing or telephone) on the effectiveness and cost-effectiveness of stroke care and the drivers of cost-effectiveness has not been systematically evaluated. METHODS AND ANALYSIS The aim of the case study was to examine the impact of consultation with a stroke specialist via telehealth on the effectiveness and cost-effectiveness of stroke and transient ischaemic attack care using a mixed methods approach. A categorical decision tree model will be constructed in collaboration with clinicians and programme managers. A before and after comparison using state-wide administrative datasets will be used to run the base model. If sample size and statistical power permits, the cases and comparators will be matched by stroke type and presence of CT scan at the initial site of presentation, age category and presenting hospital. The drivers of cost-effectiveness will be explored through stakeholder interviews. Data from the qualitative analysis will be cross-referenced with trends emerging from the quantitative dataset and used to guide the factors to be involved in subgroup and sensitivity analysis. ETHICS AND DISSEMINATION Ethics approval for this case study has been granted from the Western Australian Country Health Service Human Research and Ethics Committee (RGS3076). Reciprocal approval has been granted from Curtin University Human Research Ethics Office (HRE2019-0740). Findings will be disseminated publicly through conference presentation and peer-review publications. Interim findings will be released as internal reports to inform the service development.
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Affiliation(s)
- Christina Tsou
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - Suzanne Robinson
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - James Boyd
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Shruthi Kamath
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Justin Yeung
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Stephanie Waters
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Karen Gifford
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Andrew Jamieson
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Delia Hendrie
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
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19
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Orlowski A, Gale CP, Ashton R, Petrungaro B, Slater R, Nadarajah R, Cowan JC, Buck J, Smith W, Wu J. Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation. Heart 2021; 107:47-53. [PMID: 33122302 PMCID: PMC7788263 DOI: 10.1136/heartjnl-2020-317006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/13/2020] [Accepted: 08/18/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To assess temporal clinical and budget impacts of changes in atrial fibrillation (AF)-related prescribing in England. METHODS Data on AF prevalence, AF-related stroke incidence and prescribing for all National Health Service general practices, hospitals and registered patients with hospitalised AF-related stroke in England were obtained from national databases. Stroke care costs were based on published data. We compared changes in oral anticoagulation prescribing (warfarin or direct oral anticoagulants (DOACs)), incidence of hospitalised AF-related stroke, and associated overall and per-patient costs in the periods January 2011-June 2014 and July 2014-December 2017. RESULTS Between 2011-2014 and 2014-2017, recipients of oral anticoagulation for AF increased by 86.5% from 1 381 170 to 2 575 669. The number of patients prescribed warfarin grew by 16.1% from 1 313 544 to 1 525 674 and those taking DOACs by 1452.7% from 67 626 to 1 049 995. Prescribed items increased by 5.9% for warfarin (95% CI 2.9% to 8.9%) but by 2004.8% for DOACs (95% CI 1848.8% to 2160.7%). Oral anticoagulation prescription cost rose overall by 781.2%, from £87 313 310 to £769 444 028, (£733,466,204 with warfarin monitoring) and per patient by 50.7%, from £293 to £442, giving an incremental cost of £149. Nevertheless, as AF-related stroke incidence fell by 11.3% (95% CI -11.5% to -11.1%) from 86 467 in 2011-2014 to 76 730 in 2014-2017 with adjustment for AF prevalence, the overall per-patient cost reduced from £1129 to £840, giving an incremental per-patient saving of £289. CONCLUSIONS Despite nearly one million additional DOAC prescriptions and substantial associated spending in the latter part of this study, the decline in AF-related stroke led to incremental savings at the national level.
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Affiliation(s)
- Andi Orlowski
- The Health Econimics Unit, West Bromwich, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Rachel Ashton
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Bruno Petrungaro
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Ruth Slater
- Business Intelligence, Imperial College Health Partners, London, UK
| | | | | | - Jackie Buck
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Wayne Smith
- The Health Econimics Unit, West Bromwich, UK
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Division of Clinical and Translational Research, School of Dentistry, University of Leeds, Leeds, UK
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Nguyen C, Luthra R, Kuti E, Willey VJ. Assessing risk of future cardiovascular events, healthcare resource utilization and costs in patients with type 2 diabetes, prior cardiovascular disease and both. Curr Med Res Opin 2020; 36:1927-1938. [PMID: 33023310 DOI: 10.1080/03007995.2020.1832455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Description of risk of cardiovascular (CV) events associated with diabetes is evolving. This US-based real-world study estimated risk of future CV events and heart failure (HF) from type 2 diabetes (T2DM) only, prior CV events only or T2DM plus prior CV events, versus controls, and evaluated healthcare resource utilization (HCRU) and costs. METHODS AND MATERIALS This retrospective cohort study queried claims and mortality data for 638,301 patients: T2DM only (377,205); prior CV events only (130,964); both T2DM and prior CV events (130,132); and matched (1:1) controls, during 1 January 2012-31 December 2012. Cardiovascular diagnoses/events and death were assessed individually, and as composite endpoint (myocardial infarction [MI], stroke, transient ischemic attack [TIA], peripheral artery disease [PAD]), during follow-up, ending 31 July 2018. RESULTS Adjusting for age and gender, patients with T2DM only were 1.6, prior CV events only 2.5 and T2DM plus prior CV events 3.8 times likelier to have primary composite CV events relative to controls, p < .001. HF development was elevated across all three cohorts. Adjusted results showed inpatient admissions for T2DM only, CV events only and T2DM plus prior CV events were 1.37, 2.76 and 3.63 times greater than controls, respectively. All-cause healthcare costs were highest in the T2DM plus prior CV events cohort ($2783 per patient per month [PPPM]) followed by the prior CV events only ($1910 PPPM) and T2DM only cohorts ($1343 PPPM), and controls ($825 PPPM). Adjusted all-cause total costs were 1.48 for T2DM only, 1.49 for prior CV events only and 1.93 for T2DM plus prior CV events times higher compared to controls. CONCLUSION In this large and geographically broad US based cohort, CV risk for T2DM patients was elevated, as was the risk for patients with prior CV events, while patients with T2DM plus prior CV events had the highest risk of future CV events. The substantial clinical and economic burden of CV events and HF in patients with both T2DM and prior CV events suggest a need for an integrated treatment and targeted intervention across both conditions.
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Affiliation(s)
- Chi Nguyen
- Health Economics and Outcomes Research, HealthCore Inc., Wilmington, NC, USA
| | - Rakesh Luthra
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Effie Kuti
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Vincent J Willey
- Health Economics and Outcomes Research, HealthCore Inc., Wilmington, NC, USA
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Jeong S, Cho SI, Kong SY. Long-Term Effect of Income Level on Mortality after Stroke: A Nationwide Cohort Study in South Korea. Int J Environ Res Public Health 2020; 17:ijerph17228348. [PMID: 33187353 PMCID: PMC7697688 DOI: 10.3390/ijerph17228348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 11/16/2022]
Abstract
We investigated whether income level has long-term effects on mortality rate in stroke patients and whether this varies with time after the first stroke event, using the National Health Insurance Service National Sample Cohort data from 2002 to 2015 in South Korea. The study population was new-onset stroke patients ≥18 years of age. Patients were categorized into Category (1) insured employees and Category (2) insured self-employed/Medical Aid beneficiaries. Each category was divided into three and four income level groups, retrospectively. The study population comprised of 11,668 patients. Among the Category 1 patients (n = 7720), the low-income group's post-stroke mortality was 1.15-fold higher than the high-income group. Among the Category 2 patients (n = 3948), the lower income groups had higher post-stroke mortality than the high-income group (middle-income, aOR (adjusted odds ratio) 1.29; low-income, aOR 1.70; Medical Aid beneficiaries, aOR 2.19). In this category, the lower income groups' post-stroke mortality risks compared to the high-income group were highest at 13-36 months after the first stroke event(middle-income, aOR 1.52; low-income, aOR 2.31; Medical Aid beneficiaries, aOR 2.53). Medical Aid beneficiaries had a significantly higher post-stroke mortality risk than the high-income group at all time points.
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Affiliation(s)
- Seungmin Jeong
- Department of Preventive Medicine, Kangwon National University Hospital, Chuncheon-si, Gangwon-do 24289, Korea;
- Department of Public Health Science, Graduate School of Public Health, and Institute of Health and Environment, Seoul National University, Seoul 08826, Korea
| | - Sung-il Cho
- Department of Public Health Science, Graduate School of Public Health, and Institute of Health and Environment, Seoul National University, Seoul 08826, Korea
- Correspondence:
| | - So Yeon Kong
- Strategic Research, Laerdal Medical, 4002 Stavanger, Norway;
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Abstract
OBJECTIVES To provide the most current assessment of real-world healthcare resource utilization (HRU) and costs among patients with non-valvular atrial fibrillation (NVAF) who newly initiated rivaroxaban and apixaban using a large US database. MATERIAL AND METHODS A retrospective weighted cohort design was used with healthcare insurance claims from the Optum Clinformatics Data Mart databases (January 2012-December 2018). The index date was defined as the first dispensing of rivaroxaban or apixaban. Adult NVAF patients with an index date on or after 1 January 2016, ≥ 12 months of continuous eligibility before the index date and ≥ 1 month after, and without prior use of oral anticoagulant were included. The observation period spanned from the index date to the earliest of the end of data availability, end of insurance coverage, or death. Inverse probability of treatment weighting (IPTW) was used to adjust for differences in baseline characteristics between cohorts. All-cause healthcare resource utilization (HRU), including hospitalization, emergency room, and outpatient visits, and healthcare costs, including medical and pharmacy costs, were evaluated from the payer's perspective during the observation period up to 18 and 24 months, separately. RESULTS In total, 23,822 rivaroxaban and 53,666 apixaban users were included. After weighting, all baseline characteristics were well balanced between cohorts (mean age: 73.8 years, female: 46.6% in both cohorts). Up to 18 months of follow-up, rivaroxaban users incurred significantly lower total healthcare costs compared to apixaban users (cost difference = -$1,121; p = 0.020), driven by significantly lower rates of outpatient hospital visits and associated costs (cost difference = -$1,579; p < 0.001). Similar results were found in the analysis conducted for up to 24 months of follow-up (total cost difference = ‒$1,111; p = 0.020). CONCLUSIONS In this large retrospective analysis, patients with NVAF initiated on rivaroxaban incurred significantly lower healthcare costs compared to those initiated on apixaban, which were primarily driven by significantly lower outpatient visits and costs during the 18- and 24-month follow-up periods.
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Affiliation(s)
- Dejan Milentijevic
- Real World Value & Evidence, Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | | | - Brahim K Bookhart
- Real World Value & Evidence, Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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Bajorek B, Gao L, Lillicrap T, Bivard A, Garcia-Esperon C, Parsons M, Spratt N, Holliday E, Levi C. Exploring the Economic Benefits of Modafinil for Post-Stroke Fatigue in Australia: A Cost-Effectiveness Evaluation. J Stroke Cerebrovasc Dis 2020; 29:105213. [PMID: 33066879 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 07/26/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In stroke survivors, post-stroke fatigue predicts dependency in daily living and failure to return to work. Modafinil shows promise as a pharmacotherapy to reduce post-stroke fatigue and related sequelae, e.g., poorer functional and clinical outcomes. AIMS This study explored the cost-effectiveness of modafinil in treating post-stroke fatigue in the Australian context, by determining its incremental cost-effectiveness ratio (ICER) and by simulating the potential cost-savings on a national scale, through a re-analysis of MIDAS trial data. METHODS A post hoc cost-effectiveness analysis was undertaken. Part A: patient-level cost and health effect data (Multidimensional Fatigue Inventory (MFI) scores) were derived from the MIDAS trial and analysis undertaken from a health-system perspective. Part B: a secondary analysis simulated the societal impact of modafinil therapy in terms of national productivity costs. RESULTS Part A: Mean cost of modafinil treatment was AUD$3.60/day/patient for a minimally clinically important change (10 points) in total MFI fatigue score, i.e., AUD$0.36/day/unit change in fatigue score per patient. For the base case scenario, the ICER of using modafinil (versus placebo) was AUD$131.73 ($90.17 - 248.15, for minimum and maximum costs, respectively). Part B: The potential productivity cost-savings to society were calculated as nearly AUD$467 million over 1 year, and up to $383,471,991,248 over 10 years, from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors, representing a significant societal benefit. CONCLUSIONS Modafinil is a highly cost-effective treatment for post-stroke fatigue, offering significant productivity gains and potential cost-savings to society from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors.
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Affiliation(s)
- Beata Bajorek
- Academic Pharmacist - Graduate School of Health, University of Technology Sydney, Broadway, New South Wales 2007, Australia; Research Affiliate - Hunter Medical Research Institute, New South Wales, Australia.
| | - Lan Gao
- Senior Lecturer - Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Victoria 3127, Australia.
| | - Tom Lillicrap
- Academic Pharmacist - Graduate School of Health, University of Technology Sydney, Broadway, New South Wales 2007, Australia; Clinical Scientist - Neurology Department, John Hunter Hospital, New Lambton Heights, New South Wales 2305, Australia.
| | - Andrew Bivard
- Research Affiliate - Hunter Medical Research Institute, New South Wales, Australia; Principle Research Fellow - Melbourne School of Health Sciences - Faculty of Medicine, Dentistry and Health Sciences, Victoria, Australia.
| | - Carlos Garcia-Esperon
- Research Affiliate - Hunter Medical Research Institute, New South Wales, Australia; Stroke Neurologist - Department of Neurology, John Hunter Hospital, New Lambton Heights, New South Wales 2305, Australia.
| | - Mark Parsons
- Research Affiliate - Hunter Medical Research Institute, New South Wales, Australia; Director of Neurology - Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria 3052, Australia.
| | - Neil Spratt
- Research Affiliate - Hunter Medical Research Institute, New South Wales, Australia; Stroke Neurologist - Department of Neurology, John Hunter Hospital, New Lambton Heights, New South Wales 2305, Australia; School of Biomedical Sciences, University of Newcastle, Australia.
| | - Elizabeth Holliday
- Research Affiliate - Hunter Medical Research Institute, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales 2308, Australia.
| | - Chris Levi
- Research Affiliate - Hunter Medical Research Institute, New South Wales, Australia; The Sydney Partnership for Health, Education, Research, and Enterprise (SPHERE), Liverpool, New South Wales 2170, Australia.
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Wong EKC, Belza C, Naimark DMJ, Straus SE, Wijeysundera HC. Cost-effectiveness of antithrombotic agents for atrial fibrillation in older adults at risk for falls: a mathematical modelling study. CMAJ Open 2020; 8:E706-E714. [PMID: 33158928 PMCID: PMC7661050 DOI: 10.9778/cmajo.20200107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antithrombotic drugs decrease stroke risk in patients with atrial fibrillation, but they increase bleeding risk, particularly in older adults at high risk for falls. We aimed to determine the most cost-effective antithrombotic therapy in older adults with atrial fibrillation who are at high risk for falls. METHODS We conducted a mathematical modelling study from July 2019 to March 2020 based on the Ontario, Canada, health care system. We derived the base-case age, sex and fall risk distribution from a published cohort of older adults at risk for falls, and the bleeding and stroke risk parameters from an atrial fibrillation trial population. Using a probabilistic microsimulation Markov decision model, we calculated quality-adjusted life years (QALYs), total cost and incremental cost-effectiveness ratios (ICERs) for each of acetylsalicylic acid (ASA), warfarin, apixaban, dabigatran, rivaroxaban and edoxaban. Cost data were adjusted for inflation to 2018 values. The analysis used the Ontario public payer perspective with a lifetime horizon. RESULTS In our model, the most cost-effective antithrombotic therapy for atrial fibrillation in older patients at risk for falls was apixaban, with an ICER of $8517 per QALY gained (5.86 QALYs at $92 056) over ASA. It was a dominant strategy over warfarin and the other antithrombotic agents. There was moderate uncertainty in cost-effectiveness ranking, with apixaban as the preferred choice in 66% of model iterations (given willingness to pay of $50 000 per QALY gained); edoxaban, 30 mg, was preferred in 31% of iterations. Sensitivity analysis across ranges of age, bleeding risk and fall risk still favoured apixaban over the other medications. INTERPRETATION From a public payer perspective, apixaban is the most cost-effective antithrombotic agent in older adults at high risk for falls. Health care funders should implement strategies to encourage use of the most cost-effective medication in this population.
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Affiliation(s)
- Eric K C Wong
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.
| | - Christina Belza
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | - David M J Naimark
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | - Sharon E Straus
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | - Harindra C Wijeysundera
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
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Holtkamp MD. Does race matter in universal healthcare? Stroke cost and outcomes in US military health care. Ethn Health 2020; 25:888-896. [PMID: 29724114 DOI: 10.1080/13557858.2018.1455810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 03/19/2018] [Indexed: 06/08/2023]
Abstract
Introduction: It is well documented in the US civilian healthcare system that race is correlated with different outcomes for ischemic stroke patients. That healthcare system has wide variations in access to and quality of care. In contrast, the US military healthcare system (MHS) a universal healthcare system where every member has access to the same healthcare benefits. Do racial disparities evident in the civilian healthcare system transfer to the MHS? Methods: Data was collected from the MHS Military Mart (M2) database from calendar years 2010 through 2015. All adult patients with a primary diagnosis of ischemic stroke upon discharge were reviewed. Race was compared across primary outcomes of: (1) IV tPA administration and (2) Disposition destination 'poor disposition destination or in-hospital mortality'. And secondary outcomes of: (1) Total cost of hospitalization and (2) Length of hospital stay. Relevant demographic and co-morbidities were adjusted with regression analysis. Results: A total of 3623 patients met this study's parameters. Race was identified in 2661 (73.5%) admissions. Racial composition of this patient sample was: White 1767 (48.8%), African Americans 619 (17.1%), Asian 275 (7.6%), Other or Unknown 962 (26.5%). There was no correlation between race and administration of IV tPA, poor disposition destination or in-hospital mortality. There was a correlation between African Americans and increased cost of hospitalization. This finding was correlated with costs for radiological studies but was not correlated with any increase in the length of stay. Conclusion: Racial disparities evident in the civilian healthcare system do not appear to transfer the universal healthcare system represented by the MHS. Universal healthcare mitigates racial disparities in ischemic stroke admissions.
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Affiliation(s)
- Matthew D Holtkamp
- Department of Medicine, Intrepid Spirit, Traumatic Brain Injury Clinic, Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
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Chen HY, Kuo S, Su PF, Wu JS, Ou HT. Health Care Costs Associated With Macrovascular, Microvascular, and Metabolic Complications of Type 2 Diabetes Across Time: Estimates From a Population-Based Cohort of More Than 0.8 Million Individuals With Up to 15 Years of Follow-up. Diabetes Care 2020; 43:1732-1740. [PMID: 32444454 PMCID: PMC7372047 DOI: 10.2337/dc20-0072] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Developing country-specific unit-cost catalogs is a key area for advancing economic research to improve medical and policy decisions. However, little is known about how health care costs vary by type 2 diabetes (T2D) complications across time in Asian countries. We sought to quantify the economic burden of various T2D complications in Taiwan. RESEARCH DESIGN AND METHODS A nationwide, population-based, longitudinal study was conducted to analyze 802,429 adults with newly diagnosed T2D identified during 1999-2010 and followed up until death or 31 December 2013. Annual health care costs associated with T2D complications were estimated, with multivariable generalized estimating equation models adjusted for individual characteristics. RESULTS The mean annual health care cost was $281 and $298 (2017 U.S. dollars) for a male and female, respectively, diagnosed with T2D at age <50 years, with diabetes duration of <5 years, and without comorbidities, antidiabetic treatments, and complications. Depression was the costliest comorbidity, increasing costs by 64-82%. Antidiabetic treatments increased costs by 72-126%. For nonfatal complications, costs increased from 36% (retinopathy) to 202% (stroke) in the event year and from 13% (retinopathy or neuropathy) to 49% (heart failure) in subsequent years. Costs for the five leading costly nonfatal subtype complications increased by 201-599% (end-stage renal disease with dialysis), 37-376% (hemorrhagic/ischemic stroke), and 13-279% (upper-/lower-extremity amputation). For fatal complications, costs increased by 1,784-2,001% and 1,285-1,584% for cardiovascular and other-cause deaths, respectively. CONCLUSIONS The cost estimates from this study are crucial for parameterizing diabetes economic simulation models to quantify the economic impact of clinical outcomes and determine cost-effective interventions.
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Affiliation(s)
- Hsuan-Ying Chen
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shihchen Kuo
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Pei-Fang Su
- Department of Statistics, College of Management, National Cheng Kung University, Tainan, Taiwan
| | - Jin-Shang Wu
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Division of Family Medicine, National Cheng Kung University Hospital, Dou-Liu Branch, Douliu, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
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Guilloteau A, Binquet C, Bourredjem A, Fournel I, Lalanne-Mistrih ML, Nacher M, Rochemont D, Cabie A, Mimeau E, Mislin-Tritsch C, Joux J, Lannuzel A, Bonithon-Kopp C, Béjot Y, Devilliers H. Social deprivation among socio-economic contrasted french areas: Using item response theory analysis to assess differential item functioning of the EPICES questionnaire in stroke patients. PLoS One 2020; 15:e0230661. [PMID: 32240217 PMCID: PMC7117693 DOI: 10.1371/journal.pone.0230661] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 03/05/2020] [Indexed: 11/19/2022] Open
Abstract
Background Multiple approaches have been proposed to measure low socio-economic status. In France the concept of precariousness, akin to social deprivation, was developed and is widely used. EPICES is a short questionnaire that was developed to measure this concept. This study aimed to evaluate Differential Item Functioning (DIF) in the EPICES questionnaire between contrasted areas: mainland France, French West Indies (FWI) and French Guiana (FG). Methods The population was taken from the INDIA study, which aimed to evaluate the impact of social inequalities on stroke characteristics and prognosis. Eligible people were patients referred to neurology or emergency departments for a suspicion of stroke. We assessed the DIF using hybrid ordinal logistic regression method, derived from item response theory. Results We analysed 1 553 stroke patients, including 768 from FWI (49.5%), 289 from FG (18.6%) and 496 from mainland (31.9%). We identified five items with a moderate to large DIF in area comparisons: “meeting with a social worker”, “complementary health insurance”, “home-owning”, “financial difficulties” and “sport activities”. Correlation between EPICES score and the latent variable was strong (r = 0.84). Conclusion This is the first attempt to assess the DIF of the EPICES score between different French populations. We found several items with DIF, which can be explained by individual interpretation or local context. However, the DIFs did not lead to a large difference between the latent variable and the EPICES score, which indicates that it can be used to assess precariousness and social deprivation between contrasted areas.
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Affiliation(s)
- Adrien Guilloteau
- Clinical Epidemiology Unit, INSERM, CIC 1432, University Hospital of Dijon, Epidemiology and infection control unit, Bourgogne-Franche-Comté University, Dijon, France
- * E-mail:
| | - Christine Binquet
- Clinical Epidemiology Unit, INSERM, CIC 1432, University Hospital of Dijon, Epidemiology and infection control unit, Bourgogne-Franche-Comté University, Dijon, France
| | - Abderrahmane Bourredjem
- Clinical Epidemiology Unit, INSERM, CIC 1432, University Hospital of Dijon, Epidemiology and infection control unit, Bourgogne-Franche-Comté University, Dijon, France
| | - Isabelle Fournel
- Clinical Epidemiology Unit, INSERM, CIC 1432, University Hospital of Dijon, Epidemiology and infection control unit, Bourgogne-Franche-Comté University, Dijon, France
| | - Marie Laure Lalanne-Mistrih
- INSERM, CIC 1424, Clinical Epidemiology Unit – Pointe-à-Pitre, University Hospital of Pointe-à-Pitre – Pointe-à-Pitre, University of West Indies – Pointe-à-Pitre, Guadeloupe, France
| | - Mathieu Nacher
- INSERM, CIC 1424, Clinical Epidemiology Unit, Hospital Andrée Rosemon, CIC 1424, Clinical Epidemiology Unit, University of French Guiana – Cayenne, Guyane, France
| | - Devi Rochemont
- INSERM, CIC 1424, Clinical Epidemiology Unit, Hospital Andrée Rosemon, CIC 1424, Clinical Epidemiology Unit, University of French Guiana – Cayenne, Guyane, France
| | - André Cabie
- INSERM, CIC 1424, Clinical Epidemiology Unit – Fort-de-France, University of West Indies, EA4537 – Fort-de-France, University Hospital of Martinique – Fort-de-France, Martinique, France
| | | | | | - Julien Joux
- University Hospital of Martinique – Fort-de-France, Martinique, France
| | - Annie Lannuzel
- INSERM, CIC 1424, Clinical Epidemiology Unit – Pointe-à-Pitre, University Hospital of Pointe-à-Pitre – Pointe-à-Pitre, University of West Indies – Pointe-à-Pitre, Institute for Brain and Spinal Cord Disorders, ICM, UMR 1127, Paris, France
| | - Claire Bonithon-Kopp
- Clinical Epidemiology Unit, INSERM, CIC 1432, University Hospital of Dijon, Epidemiology and infection control unit, Bourgogne-Franche-Comté University, Dijon, France
| | - Yannick Béjot
- Neurology Department and Dijon Stroke Registry, University Hospital of Dijon, Dijon, France
| | - Hervé Devilliers
- Clinical Epidemiology Unit, INSERM, CIC 1432, University Hospital of Dijon, Epidemiology and infection control unit, Bourgogne-Franche-Comté University, Dijon, France
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Brady MC, Stott DJ, Weir CJ, Chalmers C, Sweeney P, Barr J, Pollock A, Bowers N, Gray H, Bain BJ, Collins M, Keerie C, Langhorne P. A pragmatic, multi-centered, stepped wedge, cluster randomized controlled trial pilot of the clinical and cost effectiveness of a complex Stroke Oral healthCare intervention pLan Evaluation II (SOCLE II) compared with usual oral healthcare in stroke wards. Int J Stroke 2020; 15:318-323. [PMID: 31564241 PMCID: PMC7153219 DOI: 10.1177/1747493019871824] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 06/06/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with stroke-associated pneumonia experience poorer outcomes (increased hospital stays, costs, discharge dependency, and risk of death). High-quality, organized oral healthcare may reduce the incidence of stroke-associated pneumonia and improve oral health and quality of life. AIMS We piloted a pragmatic, stepped-wedge, cluster randomized controlled trial of clinical and cost effectiveness of enhanced versus usual oral healthcare for people in stroke rehabilitation settings. METHODS Scottish stroke rehabilitation wards were randomly allocated to stepped time-points for conversion from usual to enhanced oral healthcare. All admissions and nursing staff were eligible for inclusion. We piloted the viability of randomization, intervention, data collection, record linkage procedures, our sample size, screening, and recruitment estimates. The stepped-wedge trial design prevented full blinding of outcome assessors and staff. Predetermined criteria for progression included the validity of enhanced oral healthcare intervention (training, oral healthcare protocol, assessment, equipment), data collection, and stroke-associated pneumonia event rate and relationship between stroke-associated pneumonia and plaque. RESULTS We screened 1548/2613 (59%) admissions to four wards, recruiting n = 325 patients and n = 112 nurses. We observed marked between-site diversity in admissions, recruitment populations, stroke-associated pneumonia events (0% to 21%), training, and resource use. No adverse events were reported. Oral healthcare documentation was poor. We found no evidence of a difference in stroke-associated pneumonia between enhanced versus usual oral healthcare (P = 0.62, odds ratio = 0.61, confidence interval: 0.08 to 4.42). CONCLUSIONS Our stepped-wedge cluster randomized control trial accommodated between-site diversity. The stroke-associated pneumonia event rate did not meet our predetermined progression criteria. We did not meet our predefined progression criteria including the SAP event rate and consequently were unable to establish whether there is a relationship between SAP and plaque. A wide confidence interval did not exclude the possibility that enhanced oral healthcare may result in a benefit or detrimental effect. TRIAL REGISTRATION NCT01954212.
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Affiliation(s)
- Marian C Brady
- NMAHP Research Unit, Glasgow Caledonian
University, Glasgow, UK
| | - David J Stott
- Institute of Health and Wellbeing,
University of Glasgow, Glasgow, UK
| | - Christopher J Weir
- Centre for Population Health Sciences,
The University of Edinburgh, Edinburgh, UK
| | | | - Petrina Sweeney
- NMAHP Research Unit, Glasgow Caledonian
University, Glasgow, UK
| | - John Barr
- NMAHP Research Unit, Glasgow Caledonian
University, Glasgow, UK
| | - Alex Pollock
- NMAHP Research Unit, Glasgow Caledonian
University, Glasgow, UK
| | - Naomi Bowers
- NMAHP Research Unit, Glasgow Caledonian
University, Glasgow, UK
| | - Heather Gray
- NMAHP Research Unit, Glasgow Caledonian
University, Glasgow, UK
| | | | - Marissa Collins
- NMAHP Research Unit, Glasgow Caledonian
University, Glasgow, UK
| | | | - Peter Langhorne
- Institute of Health and Wellbeing,
University of Glasgow, Glasgow, UK
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Ontario Health (Quality). Continual Long-Term Physiotherapy After Stroke: A Health Technology Assessment. Ont Health Technol Assess Ser 2020; 20:1-70. [PMID: 32194882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Stroke is a serious health issue in which an interruption in blood flow to any part of the brain damages brain cells. About 83% of people survive with substantial morbidity after their first stroke. We conducted a health technology assessment of continual long-term physiotherapy for people with a diagnosis of stroke, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding continual long-term physiotherapy for people with a diagnosis of stroke, and patient preferences and values. METHODS We performed a systematic literature search of the clinical evidence. We also performed a systematic literature search of the economic evidence. We did not conduct a primary economic evaluation because there was insufficient clinical evidence. We also analyzed the budget impact of publicly funding continual long-term physiotherapy after stroke in Ontario. To contextualize the potential value of continual long-term physiotherapy after stroke, we spoke with people who had been diagnosed with stroke, as well as their caregivers. RESULTS We did not find any published studies that met the specific clinical inclusion criteria. We did not identify any studies that compared the cost-effectiveness of continual long-term versus short-term physiotherapy after stroke. The budget impact of publicly funding continual long-term physiotherapy after stroke in Ontario over the next 5 years ranges from $445,000 in year 1 at an uptake rate of 8% to $888,000 in year 5 at an uptake rate of 16%. The people who had been diagnosed with stroke with whom we spoke reported that they had benefitted from continual long-term physiotherapy. CONCLUSIONS We did not identify studies that addressed the specific research question. Based on the clinical evidence review, we are unable to determine the benefits of continual long-term compared with short-term physiotherapy after stroke. The cost-effectiveness of continual long-term physiotherapy after stroke in Ontario is unknown. We estimate that publicly funding continual long-term physiotherapy after stroke in Ontario would result in additional costs of between $445,000 and $888,000 annually over the next 5 years. Patients and caregivers who we spoke with felt that patients who have experienced a stroke should be able to continue with physiotherapy.
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Cao Y, Nie J, Sisto SA, Niewczyk P, Noyes K. Assessment of Differences in Inpatient Rehabilitation Services for Length of Stay and Health Outcomes Between US Medicare Advantage and Traditional Medicare Beneficiaries. JAMA Netw Open 2020; 3:e201204. [PMID: 32186746 PMCID: PMC7081121 DOI: 10.1001/jamanetworkopen.2020.1204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types. OBJECTIVE To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US. DESIGN, SETTING, AND PARTICIPANTS This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019. EXPOSURES Medicare insurance plan type, TM or MA. MAIN OUTCOMES AND MEASURES Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge. RESULTS The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, -0.15 to -0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, -0.21 to -0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs within an acute care hospital) and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types. CONCLUSIONS AND RELEVANCE This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics.
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Affiliation(s)
- Ying Cao
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York
| | - Jing Nie
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York
| | - Sue Ann Sisto
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York
| | - Paulette Niewczyk
- Uniform Data System for Medical Rehabilitation, University at Buffalo, Buffalo, New York
| | - Katia Noyes
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York
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Bangalore S, Shah R, Gao X, Pappadopulos E, Deshpande CG, Shelbaya A, Prieto R, Stephens J, Chambers R, Schepman P, McIntyre RS. Economic burden associated with inadequate antidepressant medication management among patients with depression and known cardiovascular diseases: insights from a United States-based retrospective claims database analysis. J Med Econ 2020; 23:262-270. [PMID: 31665949 DOI: 10.1080/13696998.2019.1686311] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Aims: The current study examined the association between insufficient major depressive disorder (MDD) care and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke.Methods: This was a retrospective study conducted using the MarketScan Claims Database (2010-2015). The date of the first MI/stroke diagnosis was defined as the cardiovascular disease (CVD) index date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90 days following the index MDD date (profiling period) using 2 measures: dosage adequacy (average fluoxetine equivalent dose of ≥20 mg/day for nonelderly and ≥10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Study outcomes included all-cause and CVD-related HCRU and costs which were determined from the end of the profiling period until the end of study follow-up. Propensity-score adjusted generalized linear models (GLMs) were used to compare patients receiving adequate versus inadequate MDD care in terms of study outcomes.Results: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Results from the GLMs suggested that patients receiving inadequate MDD care had 14% more all-cause hospitalizations, 4% more all-cause outpatient visits, 17% more CVD-related outpatient visits, 13% more CVD-related emergency room (ER) visits, higher per patient per year CVD-related hospitalization costs ($21,485 vs. $17,756), higher all-cause outpatient costs ($2,820 vs. $2,055), and higher CVD-related outpatient costs ($520 vs. $434) compared to patients receiving adequate MDD care.Limitations: Clinical information such as depression severity and frailty, which are potential predictors of adverse CVD outcomes, could not be ascertained using administrative claims data.Conclusions: Among post-MI and post-stroke patients, inadequate MDD care was associated with a significantly higher economic burden.
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Affiliation(s)
- Sripal Bangalore
- Cardiovascular Outcomes Group, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | | | - Xin Gao
- Pharmerit International, LP, Bethesda, MD, USA
| | | | | | - Ahmed Shelbaya
- Pfizer Inc., New York, NY, USA
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | | | | | | | - Roger S McIntyre
- Mood Disorders PsychoPharmacology Unit University Health Network, University of Toronto, Toronto, Canada
- Brain and Cognition Discovery Foundation, Toronto, Canada
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Giner-Soriano M, Casajuana M, Roso-Llorach A, Vedia C, Morros R. [Effectiveness, safety and costs of stroke prevention in non-valvular auricular fibrillation. Study of cohorts matched by Propensity score]. Aten Primaria 2020; 52:176-184. [PMID: 31551166 PMCID: PMC7063152 DOI: 10.1016/j.aprim.2019.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/28/2019] [Accepted: 06/05/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To analyze the use, effectiveness, safety and costs of stroke prevention in non-valvular atrial fibrillation (AF) in patients initiating treatment with dabigatran or vitamin K antagonists (VKA). SETTING Primary Care (PC) at the Catalan Health Institute (ICS) in Catalonia, during 2011-2013. PARTICIPANTS Patients attended in ICS PC centres with a registered diagnosis of AF who initiate dabigatran or VKA. INTERVENTIONS Not applicable MAIN MEASUREMENTS: Number of prescriptions and reimbursements of dabigatran and VKA, incidence of stroke and haemorrhages, incidence of mortatlity, number of sickness leave, and costs associated to all the previous variables. RESULTS 14,930 patients were included; 94.6% initiated VKA and 5.4%, dabigatran. Dabigatran patients were younger and with less comorbidity. There were no statistically significant differences between VKA and dabigatran in the risk of stroke, haemorrhages or death. The costs associated to AF management were higher for PC visits in the VKA group, and higher for laboratory and pharmacy in the dabigatran group, although overall costs were not statistically different. CONCLUSIONS Most patients initiated VKA. We found no differences between VKA and dabigatran in the risk of stroke, haemorrhages or mortality.
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Affiliation(s)
- Maria Giner-Soriano
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, España; Institut Català de la Salut, Departament de Salut, Generalitat de Catalunya, Barcelona, España.
| | - Marc Casajuana
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, España
| | - Albert Roso-Llorach
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, España
| | - Cristina Vedia
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, España; Unitat de Farmàcia, Servei d'Atenció Primària Barcelonès Nord i Maresme, Institut Català de la Salut, Badalona, Barcelona, España
| | - Rosa Morros
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, España; Institut Català de la Salut, Departament de Salut, Generalitat de Catalunya, Barcelona, España
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Abstract
Value-Based Medicine (VBM) is imposing itself as 'a new paradigm in healthcare management and medical practice.In this perspective paper, we discuss the role of VBM in dealing with the large productivity issue of the healthcare industry and examine some of the worldwide industrial and technological trends linked with VBM introduction. To clarify the points, we discuss examples of VBM management of stroke patients.In our conclusions, we support the idea of VBM as a strategic aid to manage rising costs in healthcare, and we explore the idea that VBM, by establishing value-generating networks among different healthcare stakeholders, can serve as the long sought-after redistributive mechanism that compensate patients for the industrial exploitation of their personal medical records.
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Affiliation(s)
- Federico Esposti
- Università Vita-Salute San Raffaele, via Olgettina 58, Milan, Italy
- IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy
| | - Giuseppe Banfi
- Università Vita-Salute San Raffaele, via Olgettina 58, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, via Galeazzi 4, Milan, Italy
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Maggioni AP, Dondi L, Andreotti F, Pedrini A, Calabria S, Ronconi G, Piccinni C, Martini N. Four-year trends in oral anticoagulant use and declining rates of ischemic stroke among 194,030 atrial fibrillation patients drawn from a sample of 12 million people. Am Heart J 2020; 220:12-19. [PMID: 31759279 DOI: 10.1016/j.ahj.2019.10.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/30/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Administrative data were used to investigate changes in hospitalizations for atrial fibrillation (AF), AF-related stroke, and treatment patterns between 2012 and 2016. METHODS From the 'Ricerca e Salute' database, a population- and patient-based repository involving >12 million inhabitants and linking demographics, prescriptions, and hospital discharge records, all patients discharged alive with a diagnosis of AF between 2012 and 2015 were followed for 1 year. RESULTS A total of 194,030 AF patients were included. The number of AF cases increased ~10% over time, from 4.0 per 1,000 inhabitants in 2012 to 4.4 per 1,000 in 2015. At 1 year, hospitalizations for ischemic stroke decreased from 21.3 per 1,000 patients with AF in 2012-2013 to 14.7 per 1,000 in 2015-2016 (-31%, 95% CI -18 to -41). Over the same period, oral anticoagulant (OAC) use increased from 56.7% to 64.4% (+14%, 95% CI +8 to +26), vitamin K antagonist use decreased (from 55.9 to 36.7%; -34%, 95% CI -21 to -44), whereas direct OACs (DOACs) increased (from <1% in 2012 to 27.7% in 2015). Antiplatelet prescriptions fell from 42.6% in 2012 to 28.1% in 2015. Hospitalizations for major bleeds, mainly gastrointestinal, increased from 1.5‰ in 2012-2013 to 2.3‰ in 2015-2016, whereas hemorrhagic stroke admissions decreased from 6.5‰ to 4.1‰. CONCLUSIONS There was a slight increase in the prevalence of AF between 2012 and 2015, whereas the overall use of antiplatelet agents decreased and that of OAC, particularly DOACs, increased. Over the same period, 1-year hospitalizations for ischemic stroke declined substantially, with a declining rate of hemorrhagic strokes.
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Affiliation(s)
- Aldo P Maggioni
- Fondazione ReS (Ricerca e Salute)-Research and Health Foundation, Rome, Italy; ANMCO Research Center, Florence, Italy.
| | - Letizia Dondi
- Fondazione ReS (Ricerca e Salute)-Research and Health Foundation, Rome, Italy
| | - Felicita Andreotti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Antonella Pedrini
- Fondazione ReS (Ricerca e Salute)-Research and Health Foundation, Rome, Italy
| | - Silvia Calabria
- Fondazione ReS (Ricerca e Salute)-Research and Health Foundation, Rome, Italy
| | - Giulia Ronconi
- Fondazione ReS (Ricerca e Salute)-Research and Health Foundation, Rome, Italy
| | - Carlo Piccinni
- Fondazione ReS (Ricerca e Salute)-Research and Health Foundation, Rome, Italy
| | - Nello Martini
- Fondazione ReS (Ricerca e Salute)-Research and Health Foundation, Rome, Italy
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Uivarosan D, Bungau S, Tit DM, Moisa C, Fratila O, Rus M, Bratu OG, Diaconu CC, Pantis C. Financial Burden of Stroke Reflected in a Pilot Center for the Implementation of Thrombolysis. Medicina (Kaunas) 2020; 56:E54. [PMID: 32013001 PMCID: PMC7074434 DOI: 10.3390/medicina56020054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 01/01/2023]
Abstract
Stroke represents a serious illness and is extremely relevant from the public health point of view, implying important social and economic burdens. Introducing new procedures or therapies that reduce the costs both in the acute phase of the disease and in the long term becomes a priority for health systems worldwide. The present study quantifies and compares the direct costs for ischemic stroke in patients with thrombolysis treatment versus conservative treatment over a 24-month period from the initial diagnosis, in one of the 7 national pilot centres for the implementation of thrombolytic treatment. The significant reduction (p < 0.001) of the hospitalization period, especially of the days in the intensive care unit (ICU) for stroke, resulted in a significant reduction (p < 0.001) of the total average costs in the patients with thrombolysis, both at the first hospitalization and for the subsequent hospitalizations, during the period followed in the study. It was also found that the percentage of patients who were re-hospitalized within the first 24-months after stroke was significantly lower (p < 0.001) among thrombolyzed patients. The present study demonstrates that the quick intervention in cases of stroke is an efficient policy regarding costs, of Romanian Public Health System, Romania being the country with the highest rates of new strokes and deaths due to stroke in Europe.
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Affiliation(s)
- Diana Uivarosan
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania; (D.M.T.); (C.M.)
| | - Delia Mirela Tit
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania; (D.M.T.); (C.M.)
| | - Corina Moisa
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania; (D.M.T.); (C.M.)
| | - Ovidiu Fratila
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (O.F.); (M.R.)
| | - Marius Rus
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (O.F.); (M.R.)
| | - Ovidiu Gabriel Bratu
- Clinical Department 3, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania;
| | - Camelia C. Diaconu
- Department 5, University of Medicine and Pharmacy ”Carol Davila”, 050474 Bucharest, Romania;
- Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Carmen Pantis
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
- Emergency Clinical County Hospital, 410169 Oradea, Romania
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Bowrin K, Briere JB, Fauchier L, Coleman C, Millier A, Toumi M, Clay E, Levy P. Real-world cost-effectiveness of rivaroxaban compared with vitamin K antagonists in the context of stroke prevention in atrial fibrillation in France. PLoS One 2020; 15:e0225301. [PMID: 31978044 PMCID: PMC6980557 DOI: 10.1371/journal.pone.0225301] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 11/01/2019] [Indexed: 12/29/2022] Open
Abstract
Objective The objective was to assess the real-world cost-effectiveness of rivaroxaban, versus vitamin K antagonists (VKAs), for stroke prevention in patients with atrial fibrillation (AF) from a French national health insurance perspective. Methods A Markov model was developed with a lifetime horizon and cycle length of 3 months. All inputs were drawn from real-world evidence (RWE) studies: data on baseline patient characteristics at model entry were obtained from a French RWE study, clinical event rates as well as persistence rates for the VKA treatment arm were estimated from a variety of RWE studies, and a meta-analysis provided comparative effectiveness for rivaroxaban compared to VKA. Model outcomes included costs (drug costs, clinical event costs, and VKA monitoring costs), quality-adjusted life-years (QALY) and life-years (LY) gained, incremental cost per QALY, and incremental cost per LY. Sensitivity analyses were performed to test the robustness of the model and to better understand the results drivers. Results In the base-case analysis, the incremental total cost was €714 and the total incremental QALYs and LYs were 0.12 and 0.16, respectively. The resulting incremental cost/QALY and incremental cost/LY were €6,006 and €4,586, respectively. The results were more sensitive to the inclusion of treatment-specific utility decrements and clinical event rates. Conclusions Although there is no official willingness-to-pay threshold in France, these results suggest that rivaroxaban is likely to be cost-effective compared to VKA in French patients with AF from a national insurance perspective.
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Affiliation(s)
- Kevin Bowrin
- Bayer Plc, Reading, England, United Kingdom
- * E-mail:
| | | | - Laurent Fauchier
- Cardiologie, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | - Craig Coleman
- University of Connecticut, School of Pharmacy, Storrs, Connecticut, United States of America
| | | | | | | | - Pierre Levy
- Université Paris-Dauphine, PSL Research University, LEDa-LEGOS, Paris, France
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Tetzlaff J, Geyer S, Tetzlaff F, Epping J. Income inequalities in stroke incidence and mortality: Trends in stroke-free and stroke-affected life years based on German health insurance data. PLoS One 2020; 15:e0227541. [PMID: 31945102 PMCID: PMC6964859 DOI: 10.1371/journal.pone.0227541] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/20/2019] [Indexed: 12/28/2022] Open
Abstract
Background Due to substantial improvements in prevention and therapy, stroke incidence and mortality rates have decreased during the last decades, but evidence is still lacking on whether all socioeconomic groups benefited equally and how the length of life affected by stroke developed over time. Our study investigates time trends in stroke-free life years and life years affected by stroke. Special emphasis is given to the question whether trends differ between income groups, leading to decreasing or increasing social inequalities. Methods The analyses are based on claims data of a German statutory health insurance company of the two time periods 2006–2008 and 2014–2016. Income inequalities and time trends in incidence and mortality risks were estimated using multistate survival models. Trends in stroke-free life years and life years affected by stroke are analysed separately for income groups by applying multistate life table analyses. Results Stroke incidence and mortality risks decreased in men and women in all income groups. While stroke-free lifetime could be gained in men having higher incomes, improvements in mortality counterbalanced decreasing incidences, leading to increases in life years affected by stroke among men of the lower and higher income group. Among women, no significant changes in life years could be observed. Conclusions Changes in stroke-affected life years occur among men in all income groups, but are more pronounced in the higher income group. However, irrespective of the income group the proportion of stroke-affected life years remains quite stable over time, pointing towards constant inequalities. Further research is needed on whether impairments due to stroke reduced over time and whether all socioeconomic groups are affected equally.
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Affiliation(s)
- Juliane Tetzlaff
- Medical Sociology Unit, Hannover Medical School, Hanover, Germany
- * E-mail:
| | - Siegfried Geyer
- Medical Sociology Unit, Hannover Medical School, Hanover, Germany
| | - Fabian Tetzlaff
- Institute for General Practice, Hannover Medical School, Hanover, Germany
| | - Jelena Epping
- Medical Sociology Unit, Hannover Medical School, Hanover, Germany
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Du X, He X, Jia Y, Wu J, Long D, Yu R, Sang C, Yin H, Xuan J, Dong J, Ma C. A Long-Term Cost-Effectiveness Analysis Comparing Radiofrequency Catheter Ablation with Antiarrhythmic Drugs in Treatment of Chinese Patients with Atrial Fibrillation. Am J Cardiovasc Drugs 2019; 19:569-577. [PMID: 31090018 DOI: 10.1007/s40256-019-00349-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Radiofrequency catheter ablation (RFCA) is widely used to treat atrial fibrillation (AF) in China. OBJECTIVE We aimed to determine the long-term cost effectiveness of RFCA versus antiarrhythmic drugs (AADs) in treating AF from the perspective of third-party payers. METHODS The model was structured as a 12-month decision tree leading to a Markov model that simulated the follow-up treatment outcomes and costs with time horizons of 8, 15, and 20 years. Comparators were standard-of-care AADs. Clinical parameters captured normal sinus rhythm, AF, stroke, post-stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding, post-ICH, and death. The risk of operative death, procedural complications, and adverse drug toxicity were also considered. The model output was quality-adjusted life-years (QALYs) and incremental cost per QALY gained. RESULTS RFCA incurred more costs than the AADs but resulted in more QALYs gained than did AADs. The incremental cost per QALY gained with RFCA versus AADs was ¥66,764, ¥36,280, and ¥29,359 at 8, 15, and 20 years, respectively. The sensitivity analyses showed that the results were most sensitive to the changes in RFCA cost and CHADS2 score (clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic AF). CONCLUSION Compared with AADs, RFCA significantly improves clinical outcomes and QALYs among patients with paroxysmal or persistent AF. From the Chinese payer's perspective, RFCA is a cost-effective therapy over long-term horizons.
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Affiliation(s)
- Xin Du
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Xiaonan He
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Yu Jia
- Strategic Medical Affairs, Johnson & Johnson Medical (China) Ltd., Shanghai, China
| | - Jiahui Wu
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Deyong Long
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Ronghui Yu
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Caihua Sang
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Hongjun Yin
- Shanghai Centennial Scientific Ltd., Inc., Shanghai, China
| | - Jianwei Xuan
- Shanghai Centennial Scientific Ltd., Inc., Shanghai, China
- Health Economic Research Institute, Sun-Yat-sen University, Zhongshan, Guangdong, China
| | - Jianzeng Dong
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Changsheng Ma
- Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, China.
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Laxy M, Schöning VM, Kurz C, Holle R, Peters A, Meisinger C, Rathmann W, Mühlenbruch K, Kähm K. Performance of the UKPDS Outcomes Model 2 for Predicting Death and Cardiovascular Events in Patients with Type 2 Diabetes Mellitus from a German Population-Based Cohort. Pharmacoeconomics 2019; 37:1485-1494. [PMID: 31350720 DOI: 10.1007/s40273-019-00822-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Accurate prediction of relevant outcomes is important for targeting therapies and to support health economic evaluations of healthcare interventions in patients with diabetes. The United Kingdom Prospective Diabetes Study (UKPDS) risk equations are some of the most frequently used risk equations. This study aims to analyze the calibration and discrimination of the updated UKPDS risk equations as implemented in the UKPDS Outcomes Model 2 (UKPDS-OM2) for predicting cardiovascular (CV) events and death in patients with type 2 diabetes mellitus (T2DM) from population-based German samples. METHODS Analyses are based on data of 456 individuals diagnosed with T2DM who participated in two population-based studies in southern Germany (KORA (Cooperative Health Research in the Region of Augsburg)-A: 1997/1998, n = 178; KORA-S4: 1999-2001, n = 278). We compared the participants' 10-year observed incidence of mortality, CV mortality, myocardial infarction (MI), and stroke with the predicted event rate of the UKPDS-OM2. The model's calibration was evaluated by Greenwood-Nam-D'Agostino tests and discrimination was evaluated by C-statistics. RESULTS Of the 456 participants with T2DM (mean age 65 years, mean diabetes duration 8 years, 56% male), over the 10-year follow-up time 129 died (61 due to CV events), 64 experienced an MI, and 46 a stroke. The UKPDS-OM2 significantly over-predicted mortality and CV mortality by 25% and 28%, respectively (Greenwood-Nam-D'Agostino tests: p < 0.01), but there was no significant difference between predicted and observed MI and stroke risk. The model poorly discriminated for death (C-statistic [95% confidence interval] = 0.64 [0.60-0.69]), CV death (0.64 [0.58-0.71]), and MI (0.58 [0.52-0.66]), and failed to discriminate for stroke (0.57 [0.47-0.66]). CONCLUSIONS The study results demonstrate acceptable calibration and poor discrimination of the UKPDS-OM2 for predicting death and CV events in this population-based German sample. Those limitations should be considered when using the UKPDS-OM2 for economic evaluations of healthcare strategies or using the risk equations for clinical decision-making.
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Affiliation(s)
- Michael Laxy
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany.
- German Center for Diabetes Research, DZD, Neuherberg-Munich, Germany.
| | - Verena Maria Schöning
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Christoph Kurz
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
- German Center for Diabetes Research, DZD, Neuherberg-Munich, Germany
| | - Rolf Holle
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
- German Center for Diabetes Research, DZD, Neuherberg-Munich, Germany
| | - Annette Peters
- Institute of Epidemiology II, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
| | - Christa Meisinger
- Institute of Epidemiology II, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Düsseldorf, Germany
| | - Kristin Mühlenbruch
- Department of Molecular Epidemiology, German Institute of Human Nutrition, Potsdam, Germany
| | - Katharina Kähm
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
- German Center for Diabetes Research, DZD, Neuherberg-Munich, Germany
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Chowdhury R, Franchino-Elder J, Wang L, Yuce H, Wang C, Hartaigh BO. Healthcare resource utilization and expenditures among newly-diagnosed elderly non-valvular atrial fibrillation patients initiating oral anticoagulants. J Med Econ 2019; 22:1338-1350. [PMID: 31549883 DOI: 10.1080/13696998.2019.1672698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: Non-valvular atrial fibrillation (NVAF) prevalence increases with age. Hence, evaluating the economic burden among older-aged patients is vital. This study aimed to compare healthcare resource utilization (HRU) and costs among newly-diagnosed older-aged NVAF patients treated with warfarin, rivaroxaban, or apixaban vs. dabigatran.Materials and Methods: Newly-diagnosed older-aged (aged ≥65 years) NVAF patients initiating dabigatran, warfarin, rivaroxaban, or apixaban (first prescription date = index date) from 01JAN2010-31DEC2015 and with continuous enrollment for ≥12 months pre-index date were included from 100% Medicare database. Patient data were assessed until drug discontinuation/switch/dose change/death/disenrollment/study end (up to 12 months). Dabigatran initiators were 1:1 propensity score-matched (PSM) with warfarin, rivaroxaban, or apixaban initiators. Generalized linear models were used to compare all-cause HRU and costs per-patient-per-month (PPPM) between the matched cohorts.Results: After PSM with dabigatran, 70,531 warfarin, 51,673 rivaroxaban, and 25,209 apixaban patients were identified. Dabigatran patients had significantly fewer generalized-linear-model-adjusted PPPM hospitalizations (0.114 vs. 0.123; 0.111 vs. 0.121), and outpatient visits (2.864 vs. 4.201; 2.839 vs. 2.949) than warfarin and rivaroxaban patients, respectively, but had significantly more PPPM hospitalizations (0.103 vs. 0.090) and outpatient visits (2.780 vs. 2.673) than apixaban patients (all p < .0001). Dabigatran patients incurred significantly lower adjusted total PPPM costs ($3,309 vs. $3,362; $3,285 vs. $3,474) than warfarin and rivaroxaban patients, respectively (all p < .01) but higher total PPPM costs ($3,192 vs. $2,986) than apixaban patients (all p < .0001).Limitations: This study is subject to the inherent limitations of any claims dataset, including potential bias from coding errors and identification of medical conditions using diagnosis codes as opposed to clinical evidence. Medications filled over-the-counter or provided as samples by the physician are never captured in claims data.Conclusions: Newly-diagnosed older-aged NVAF patients initiating dabigatran incurred significantly lower adjusted all-cause HRU and costs than warfarin and rivaroxaban patients but higher adjusted HRU and costs than apixaban patients.
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Affiliation(s)
- Ritam Chowdhury
- Center for Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA, USA
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | | | - Li Wang
- STATinMED Research, Plano, TX, USA
- New York City College of Technology (CUNY), New York, NY, USA
| | - Huseyin Yuce
- New York City College of Technology (CUNY), New York, NY, USA
| | - Cheng Wang
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
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Ueno Y, Miyamoto N, Yamashiro K, Tanaka R, Hattori N. Omega-3 Polyunsaturated Fatty Acids and Stroke Burden. Int J Mol Sci 2019; 20:ijms20225549. [PMID: 31703271 PMCID: PMC6888676 DOI: 10.3390/ijms20225549] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/01/2019] [Accepted: 11/05/2019] [Indexed: 12/30/2022] Open
Abstract
Stroke is a major leading cause of death and disability worldwide. N-3 polyunsaturated fatty acids (PUFAs) including eicosapentaenoic acid and docosahexaenoic acid have potent anti-inflammatory effects, reduce platelet aggregation, and regress atherosclerotic plaques. Since the discovery that the Greenland Eskimo population, whose diet is high in marine n-3 PUFAs, have a lower incidence of coronary heart disease than Western populations, numerous epidemiological studies to explore the associations of dietary intakes of fish and n-3 PUFAs with cardiovascular diseases, and large-scale clinical trials to identify the benefits of treatment with n-3 PUFAs have been conducted. In most of these studies the incidence and mortality of stroke were also evaluated mainly as secondary endpoints. Thus, a systematic literature review regarding the association of dietary intake of n-3 PUFAs with stroke in the epidemiological studies and the treatment effects of n-3 PUFAs in the clinical trials was conducted. Moreover, recent experimental studies were also reviewed to explore the molecular mechanisms of the neuroprotective effects of n-3 PUFAs after stroke.
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Affiliation(s)
- Yuji Ueno
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo 113-8421, Japan; (N.M.); (K.Y.); (N.H.)
- Correspondence: ; Tel.: +81-3-3813-3111; Fax: +81-3-5800-0547
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo 113-8421, Japan; (N.M.); (K.Y.); (N.H.)
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo 113-8421, Japan; (N.M.); (K.Y.); (N.H.)
| | - Ryota Tanaka
- Stroke Center and Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi 329-0498, Japan;
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo 113-8421, Japan; (N.M.); (K.Y.); (N.H.)
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Stevens ER, Roberts E, Kuczynski HC, Boden-Albala B. Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention. Value Health 2019; 22:1240-1247. [PMID: 31708060 PMCID: PMC6857539 DOI: 10.1016/j.jval.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/09/2019] [Accepted: 06/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. OBJECTIVE We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times. METHODS Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%. RESULTS The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY. CONCLUSION II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.
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Affiliation(s)
- Elizabeth R Stevens
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Eric Roberts
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| | - Heather Carman Kuczynski
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| | - Bernadette Boden-Albala
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
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Michelson KA, Bachur RG, Mahajan P, Finkelstein JA. Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization. J Pediatr 2019; 214:103-112.e3. [PMID: 31383471 DOI: 10.1016/j.jpeds.2019.06.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.
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Affiliation(s)
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Prashant Mahajan
- Department of Emergency Medicine and Pediatrics, University of Michigan Medical School, Ann Arbor, MI
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Dhamane AD, Baker CL, Rajpura J, Mardekian J, Dina O, Russ C, Rosenblatt L, Lingohr-Smith M, Lin J. Continuation with apixaban treatment is associated with lower risk for hospitalization and medical costs among elderly patients. Curr Med Res Opin 2019; 35:1769-1776. [PMID: 31120309 DOI: 10.1080/03007995.2019.1623187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: To compare the risk of hospitalization and costs associated with major bleeding (MB) or stroke/systemic embolism (SE) among elderly patients with nonvalvular atrial fibrillation (NVAF) who initiated apixaban then switched to another oral anticoagulant (OAC) vs. those who continued with apixaban treatment. Methods: NVAF patients (≥65 years) initiating apixaban were identified from the Humana database (1 January 2013-30 September 2017) and grouped into switcher and continuer cohorts. For switchers, the earliest switch from apixaban to another OAC was defined as the index event/date. A random date during apixaban treatment was selected as the index date for continuers. Patients were followed from index date to health plan disenrollment or 31 December 2017, whichever was earlier. Multivariable regression analyses were used to examine the association of switchers vs. continuers with risk of MB-related or stroke/SE-related hospitalization and healthcare costs during follow-up. Results: Of 7858 elderly NVAF patients included in the study, 14% (N = 1110; mean age: 78 years) were switchers; 86% (N = 6748; mean age: 79 years) were continuers. Apixaban switchers vs. continuers had significantly greater risk of MB-related hospitalization (hazard ratio [HR]: 2.00; 95% CI: 1.52-2.64; p < .001) during follow-up; risk of stroke/SE hospitalization did not differ significantly (HR: 1.36, 95% CI: 0.89-2.06, p = .154). MB- and stroke/SE-related medical costs were higher for switchers vs. continuers, although total all-cause healthcare costs were similar. Conclusion: Elderly patients with NVAF in the US who continued with apixaban treatment had a lower risk of MB-related hospitalization and lower MB- and stroke/SE-related medical costs compared to patients who switched to another OAC.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jay Lin
- Novosys Health , Green Brook , NJ , USA
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Barker-Collo S, Krishnamurthi R, Theadom A, Jones K, Starkey N, Feigin V. Incidence of stroke and traumatic brain injury in New Zealand: contrasting the BIONIC and ARCOS-IV studies. N Z Med J 2019; 132:40-54. [PMID: 31563926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
AIMS Traumatic Brain Injury (TBI) and stroke are the main causes of acquired brain injury. The differences in demographic profiles of stroke and TBI suggest that high-quality epidemiological studies of the two be compared. This study examined incidence of stroke and TBI by age and ethnicity in New Zealand. METHODS Incidence rates are presented by age and ethnicity from two New Zealand population-based epidemiological studies (Brain Injury Outcomes New Zealand In the Community (BIONIC); and Auckland Regional Outcomes of Stroke Studies (ARCOS-IV)). RESULTS Males and females had similar stroke risk, while males had 2x relative risk of mild TBI and 3x the relative risk of moderate/severe TBI compared to females. More TBI cases (35.6%) were identified through non-medical sources compared to stroke (3%). Incidence of TBI was greater than 5 times that of stroke. New Zealand European/Pākehā had the highest TBI incidence when less than 5 years of age, while Māori had the highest incidence after five years of age. For stroke, Pacific people and Māori had higher incidences until 75-84 years, after which Europeans had higher incidence. CONCLUSIONS Differences in TBI and stroke incidence suggest targeting prevention very differently for the two groups. Incidence profiles suggest TBI is much more common; and a need to target males and those of Māori ethnicity for TBI prevention.
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Affiliation(s)
| | - Rita Krishnamurthi
- National Institute for Stroke and Applied Neurorehabilitation(NISAN), AUT University, Auckland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurorehabilitation(NISAN), AUT University, Auckland
| | - Kelly Jones
- National Institute for Stroke and Applied Neurorehabilitation(NISAN), AUT University, Auckland
| | | | - Valery Feigin
- National Institute for Stroke and Applied Neurorehabilitation(NISAN), AUT University, Auckland, on behalf of the BIONIC and ARCOS-IV study groups
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Volpi JJ, Ridge JR, Nakum M, Rhodes JF, Søndergaard L, Kasner SE. Cost-effectiveness of percutaneous closure of a patent foramen ovale compared with medical management in patients with a cryptogenic stroke: from the US payer perspective. J Med Econ 2019; 22:883-890. [PMID: 31025589 DOI: 10.1080/13696998.2019.1611587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: To evaluate the cost-effectiveness of percutaneous patent foramen ovale (PFO) closure, from a US payer perspective. Lower rates of recurrent ischemic stroke have been documented following percutaneous PFO closure in properly selected patients. Stroke in patients aged <60 years is particularly interesting because this population is typically at peak economic productivity and vulnerable to prolonged disability. Materials and methods: A Markov model comprising six health states (Stable after index stroke, Transient ischemic attack, Post-Transient Ischemic Attack, Clinical ischemic stroke, Post-clinical ischemic stroke, and Death) was constructed to evaluate the cost-effectiveness of PFO closure in combination with medical management versus medical management alone. The base-case model employed a 5-year time-horizon, with transition probabilities, clinical inputs, costs, and utility values ascertained from published and national costing sources. Incremental cost-effectiveness ratio (ICER) was evaluated per US guidelines, utilizing a discount rate of 3.0%. Results: At 5 years, overall costs and quality-adjusted life-years (QALYs) obtained from PFO closure compared with medical management were $16,323 vs $7,670 and 4.18 vs 3.77, respectively. At 5 years, PFO closure achieved an ICER of $21,049, beneficially lower than the conventional threshold of $50,000. PFO closure reached cost-effectiveness at 2.3 years (ICER = $47,145). Applying discount rates of 0% and 6% had a negligible impact on base-case model findings. Furthermore, PFO closure was 95.4% likely to be cost-effective, with a willingness-to-pay (WTP) threshold of $50,000 and a 5-year time horizon. Limitations: From a cost perspective, our economic model employed a US patient sub-population, so cost data may not extrapolate to other non-US stroke populations. Conclusion: Percutaneous PFO closure plus medical management represents a cost-effective approach for lowering the risk of recurrent stroke compared with medical management alone.
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Affiliation(s)
- John J Volpi
- a The Houston Methodist Institute for Academic Medicine , Houston , TX , USA
| | - John R Ridge
- b W. L. Gore & Associates, Health Economics , Carmel , IN , USA
| | | | - John F Rhodes
- d The Congenital Heart Center, Medical University of South Carolina , Charleston , SC , USA
| | - Lars Søndergaard
- e The Heart Centre, Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
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Rozjabek HM, Coleman CI, Ashton V, Laliberté F, Oyefesobi P, Lejeune D, Germain G, Schein JR, Yuan Z, Lefebvre P, Peterson ED. Healthcare costs of stroke and major bleeding in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants. J Med Econ 2019; 22:751-759. [PMID: 30939954 DOI: 10.1080/13696998.2019.1603156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objective: To assess long-term healthcare costs related to ischemic stroke and systemic embolism (stroke/SE) and major bleeding (MB) events in patients with non-valvular atrial fibrillation (NVAF) treated with non-vitamin K antagonist oral anticoagulants (NOACs). Materials and methods: Optum's Clinformatics Data Mart database from 1/2009-12/2016 was analyzed. Adult patients with ≥1 stroke/SE hospitalization (index date) were matched 1:1 to patients without stroke/SE (random index date), based on propensity scores. Patients with an MB event were matched to patients without MB. All patients had an NOAC dispensing overlapping index date, ≥12 months of eligibility pre-index date, and ≥1 NVAF diagnosis. The observation period spanned from the index date until the earliest date of death, switch to warfarin, end of insurance coverage, or end of data availability. Mean costs were evaluated: (1) per-patient-per-year (PPPY) and (2) at 1, 2, 3, and 4 years using Lin's method. Results: The cost differences were, respectively, $48,807 and $28,298 PPPY for NOAC users with stroke/SE (n = 1,340) and those with MB (n = 3,774) events compared to controls. Cost differences of patients with vs without stroke/SE were $49,876, $51,627, $57,822, and $60,691 at 1, 2, 3, and 4 years post-index, respectively (p < 0.001). These cost differences were $31,292, $35,658, $44,069, and $47,022 for patients with vs without MB after 1, 2, 3, and 4 years post-index, respectively (p < 0.001). Limitations: Limitations include unobserved confounders, coding and/or billing inaccuracies, limited sample sizes over longer follow-up, and the under-reporting of mortality for deaths occurring after 2011. Conclusions: The incremental healthcare costs incurred by patients with vs without stroke/SE was nearly twice as high as those of patients with vs without MB. Moreover, each additional year up to 4 years after the first event was associated with an incremental cost for patients with a stroke/SE or MB event compared to those without an event.
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Affiliation(s)
| | - Craig I Coleman
- b School of Pharmacy , University of Connecticut , Storrs , CT , USA
| | | | | | - Paul Oyefesobi
- a Janssen Scientific Affairs, LLC , Titusville , NJ , USA
| | | | | | - Jeff R Schein
- a Janssen Scientific Affairs, LLC , Titusville , NJ , USA
| | - Zhong Yuan
- d Janssen Research & Development, LLC , Titusville , NJ , USA
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Gaziano TA, Pandya A, Sy S, Jardim TV, Ogden JM, Rodgers A, Weinstein MC. Modeling the cost effectiveness and budgetary impact of Polypills for secondary prevention of cardiovascular disease in the United States. Am Heart J 2019; 214:77-87. [PMID: 31174054 DOI: 10.1016/j.ahj.2019.04.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 04/26/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is underutilization of appropriate medications for secondary prevention of cardiovascular disease (CVD). METHODS Usual care (UC) was compared to polypill-based care with 3 versions using a validated micro-simulation model in the NHANES population with prior CVD. UC included individual prescription of up to 4 drug classes (antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone inhibitors and statins). The polypills modeled were aspirin 81 mg, atenolol 50 mg, ramipril 5 mg, and either simvastatin 40 mg (Polypill I), atorvastatin 80 mg (Polypill II), or rosuvastatin 40 mg (Polypill III). Baseline medication use and adherence came from United Healthcare claims data. RESULTS When compared to UC, there were annual reductions of 130,000 to 178,000 myocardial infarctions and 54,000 to 74,000 strokes using Polypill I and II, respectively. From a health sector perspective, in incremental analysis the ICERs for Polypill I and II were $20,073/QALY and $21,818/QALY respectively; Polypill III was dominated but had a similar cost-effectiveness ratio to Polypill II when compared directly to usual care. From a societal perspective, Polypill II was cost-saving and dominated all strategies. Over a 5-year period, those taking Polypill I and II compared to UC saved approximately $12 and $6 per-patient-per-year alive, respectively. Polypill II was the preferred strategy in 98% of runs at a willingness to pay of $50,000 in the probability sensitivity analysis. CONCLUSIONS Use of a polypill has a favorable cost profile for secondary CVD prevention in the United States. Reductions in CVD-related healthcare costs outweighed medication cost increases on a per-patient-per-year basis, suggesting that a polypill would be economically advantageous to both patients and payers.
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Affiliation(s)
- Thomas A Gaziano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA.
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Stephen Sy
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Thiago Veiga Jardim
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Jenna M Ogden
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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Ming J, Wei Y, Sun H, Wong G, Yang G, Pong R, Chen Y. Cost-Effectiveness of Cryoballoon Ablation Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation in China: Results Based on Real-World Data. Value Health 2019; 22:863-870. [PMID: 31426926 DOI: 10.1016/j.jval.2019.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/27/2019] [Accepted: 02/03/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Paroxysmal atrial fibrillation (AF) presents a significant economic burden to the healthcare system. Catheter ablations is a commonly adopted treatment for paroxysmal AF. OBJECTIVES To evaluate the cost effectiveness of cryoballoon ablation versus radiofrequency ablation in patients with drug-refractory paroxysmal AF in a tertiary hospital in China. METHODS A Markov model was developed to study the effects and costs. Cost and probability input data were obtained mainly from a retrospective real-world study conducted in a tertiary hospital. Propensity score matching was used to overcome retrospective bias. Input data gaps were remedied by means of literature review and advice from experts. A simulation was performed for the post-procedure lifetime years. Univariate and probabilistic sensitivity analyses were conducted. RESULTS In the base-case analysis of a lifetime time horizon, a patient treated with cryoballoon ablation was associated with 7.85 quality-adjusted life-years (QALYs) and ¥132 222 ($19 913) total costs, whereas a radiofrequency ablation treated patient was associated with 7.71 QALYs and ¥147 304 ($22 184) total costs. The cryoballoon group had slightly better health outcomes (with a difference of 0.14 QALY) and lower total costs (with a difference of ¥15 082) (USD $2 271), and it may be considered as cost-effective or cost-saving strategy (incremental cost-effectiveness ratio -¥110 158 [$16 590] per QALY) for the management of paroxysmal AF. Different scenarios were tested with sensitivity analyses, but still, the outcomes remained cost-effective or cost-saving for cryoballoon ablation. CONCLUSIONS An economic evaluation based on real-world data suggests that, relative to radiofrequency ablation, cryoballoon ablation may be considered as a more cost-effective or cost-saving long-term strategy for drug-refractory paroxysmal AF in this tertiary hospital in China. However, further evidence is needed using data from large-scale studies in order to reflect a national perspective.
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Affiliation(s)
- Jian Ming
- Key Lab of Health Technology Assessment, National Health Commission, School of Public Health, Fudan University, Shanghai, China
| | - Yan Wei
- Key Lab of Health Technology Assessment, National Health Commission, School of Public Health, Fudan University, Shanghai, China
| | - Hui Sun
- Key Lab of Health Technology Assessment, National Health Commission, School of Public Health, Fudan University, Shanghai, China
| | - Gongru Wong
- Key Lab of Health Technology Assessment, National Health Commission, School of Public Health, Fudan University, Shanghai, China
| | - Gang Yang
- Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China
| | - Raymond Pong
- Centre for Rural and Northern Health Research, Northern Ontario School of Medicine, Laurentian University, Sudbury, Ontario, Canada
| | - Yingyao Chen
- Key Lab of Health Technology Assessment, National Health Commission, School of Public Health, Fudan University, Shanghai, China.
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Abstract
Background and Purpose- Multiple randomized clinical trials have demonstrated the superiority of endovascular therapy (ET) for large vessel occlusion acute ischemic stroke (AIS). Few centers can provide ET, and significant debate exists about the most efficient and effective ways to provide ET. We sought to assess real-world utilization of ET, the extent to which patients are transferred from one hospital to another for therapy and the implications of transfer status on outcomes. Methods- We used the 2015 to 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which contains nationwide data on nearly half of US admissions. We identified index AIS admissions, vascular risk factors, and treatment with intravenous thrombolysis and ET using International Classification of Disease, Ninth Revision, and International Classification of Disease, Tenth Revision Clinical Modification codes. Main predictors of outcome were treatment with ET and whether there was an interhospital transfer during the index AIS hospitalization. Among patients with AIS readmitted within 30 days, we examined 3 main outcomes: total charges, length of stay, and in-hospital mortality. Results- A total of 23 121 AIS admissions were treated with ET and 874 229 without. Over 5% of patients who received ET were transferred during the index admission compared with <2% of those not treated with ET. Length of stay and total charges were significantly higher in patients transferred (12.3 versus 9.6 days and $233 626 versus $182 881, respectively). More patients treated with ET who were not transferred to the index hospital were discharged home (25.3% versus 44.4%), and ≈25% of patients transferred for ET died during the hospitalization compared with 15.5% not transferred. Conclusions- The minority of all patients with AIS receive ET. The majority of patients who receive ET present directly to the center that performs the procedure, and those transferred for ET have higher length of stay, cost, and mortality that those not transferred.
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Affiliation(s)
- Laura K Stein
- From the Department of Neurology (L.K.S., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stanley Tuhrim
- From the Department of Neurology (L.K.S., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Johanna Fifi
- Department of Neurosurgery (J.F., J.M.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Mocco
- Department of Neurosurgery (J.F., J.M.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mandip S Dhamoon
- From the Department of Neurology (L.K.S., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, New York, NY
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