Stroke Care Costs and Cost-Effectiveness to Inform Health Policy
Advances in stroke care policy during 2021 remained influenced by the COVID-19 pandemic, but several notable papers called attention to the costs of stroke care or the cost-effectiveness of options for care. Despite the variation in how costs were measured, estimated, and reported, policy recommendations for resourcing stroke services to support guideline-based care were found. The availability of cost data associated with all facets of stroke care and different perspectives (patients, hospitals, and payors) is increasing, but there are advances still to be made (Figure). This synthesis of a selection of papers published in 2021 on costs and stroke care effectiveness highlights the most recent efforts in examining the intersection of stroke care delivery and financial implications that could inform policy. The attention to appropriately financing stroke care delivery and its infrastructure for optimal quality and outcomes needs to remain at the forefront for decision makers who are responsible for allocating resources.
Cost Burden of Stroke
The Global Burden of Disease Collaborators reported in 2021 that stroke remains the second leading cause of death and third leading cause of death and disability globally.1,2 Yet, the true cost burden for families and health care providers is challenging to estimate. In one review of the economic burden associated with stroke, the authors aimed to examine the direct medical and nonmedical costs, indirect costs of illness, and health expenditures but found few studies with these costs clearly delineated.3 Another review was published of the economic burden of stroke with data from 46 studies inclusive of countries in each continent and all stroke types. The authors concluded that the 3 countries with the greatest annual average per-patient costs adjusted for a common reference year 2020 were the United States, Sweden, and Spain (US dollars 59 900, 52 725, and 41 950, respectively), and the highest per-patient lifetime cost was in Australia.4 While informative, their recommendation for establishing an international standard to examine costs at the patient, provider, and societal levels is of particular importance.4 Calls for reducing methodological heterogeneity have been outlined previously5 and can lead to more targeted analyses and clearer messages for advocating to policy makers and institutional leaders on the allocation of health system resources for the prevention and treatment of stroke.
Costs and Stroke Outcomes
In an effort to design policy recommendations based on the cost-effectiveness of implementing guideline-based comprehensive ischemic stroke care, the European Brain Council Value of Treatment initiative examined published literature and reports from national agencies and organizations. Full implementation of comprehensive stroke services was associated with a 9.8% absolute reduction in risk of death or dependency with an incremental cost-effectiveness ratio of £5227.89 (≈$6900 US dollars) for comprehensive stroke care versus usual standard of care assessed across countries.6 Their analysis identified significant gaps in the treatment for atrial fibrillation and inadequate access to neurorehabilitation. Policy recommendations to government officials called attention to both areas, improved primary and secondary stroke prevention and greater access to timely and effective rehabilitation. These authors also noted the need for investment in specific components of comprehensive stroke centers including stroke units and resources to support the provision of reperfusion therapies.6 Similar gaps in care across the continuum persist in other regions, but economic data are sparse. A review on the cost-effectiveness of neuropsychological rehabilitation interventions by Stolwyk et al7 identified few studies with cost-effectiveness analysis, and thus evidence was mixed. It is difficult to build a business case for specific stroke services without more robust evidence.
Despite advances in health policy to improve care coordination, primary health care, and integrated health and social care,8,9 evaluations of cost or cost-effectiveness inclusive of posthospital care are especially limited. In the United States, several payment reforms over the last decade have aimed to improve the organization, delivery, and payment of care after an acute stroke. The largest US clinical trial in this area was the COMPASS study (Comprehensive Post-Acute Stroke Services), which was designed to implement an evidence-based and policy-supported comprehensive transitional care intervention focused on discharge from the acute care setting to home.10,11 Implementation varied widely across the 22 intervention sites, but using an activity-based costing approach and findings from the trial, it was determined that this transitional care intervention could reduce hospital-level resource costs and may be most feasible in hospitals treating a larger number of patients.12 In the absence of universal health coverage in the United States, the authors recommend hospitals consider care redesign strategies that address care transitions as part of bundled payment models. This approach to payment for a targeted episode of care is time limited but presents opportunities to improve efficiencies and the quality of care with better care coordination. Several other alternative payment models for stroke including pay-per-performance, prospective payments, shared savings, and capitated payment models have been evaluated for their impact on stroke outcomes and utilization.13 The greatest limitation of these evaluations to date is the lack of available patient-reported outcome measures. Although more stroke services are measuring patient-reported outcomes,14,15 more countries and regions could be using these in conjunction with health service use data to guide payment and policy reform.
Cost-Effectiveness of Alternate Care Models
Economic evaluations—a comparison of costs and health outcomes achieved from two or more care options—provide essential evidence to inform the return on investment and potential benefits of innovative or alternate models of stroke care. Mobile stroke units are one example where there is ongoing debate about whether or not investment in expensive capital equipment and the staffing models for mobile stroke units are worthwhile.16 This innovation of bringing specialized stroke-trained staff and portable computed tomography scanning equipment directly to the patient to enable prehospital imaging and treatment decisions has emerging cost-effectiveness data that indicate the additional costs can be offset from greater health benefits from earlier access to reperfusion treatments.17 Kim et al17 caution the translation of cost-effectiveness information from different regions as there is a need to account for variations in health systems, geography, and underlying stroke incidence.
Telehealth is another financially debated innovation despite its potential to provide greater access to stroke specialists18 and guideline-based care. Tabriz et al19 provided an analysis of the telemedicine adoption rate for cardiac and stroke care in the United States between 2012 and 2017. Use increased during the study period, and the financial status of the hospital (for profit or not for profit) was a major driver of adoption for urban hospitals compared with rural hospitals. An important nonfinancial factor for rural hospitals’ adoption of telehealth was having a large number of emergency department visits. For acute telestroke specifically, a review by Tan et al18 found telestroke was either cost-saving or a cost-effective intervention in 5 of the 8 studies and using a simulation model illustrated the cost savings and incremental health benefits that might be possible. The COVID-19 pandemic has underscored the need for greater telehealth use across the continuum of stroke care. Economic evaluations to guide policy are emerging for the telepractice treatment for aphasia20 and other forms of telerehabilitation,21 but more research is needed and particularly for low- and middle-income countries.
Advances and Opportunities Ahead
Recent assessments of stroke care, costs, and outcomes presented clear opportunities for policy reform. The attention to service delivery and quality of care persists; however, an important opportunity for policy leaders to address is adequate financing to optimize care quality and outcomes and requirements for measuring and reporting patient-reported outcomes for inclusion in policy decision-making. Similar to the International Consortium for Health Outcomes Measurement 2016 recommendations for a standard set of stroke outcome measures, an international forum is needed to establish methodological consensus for measuring stroke care costs and cost-effectiveness. Important consideration is needed for research on stroke care financing and cost assessments that are currently lacking in low- and middle-income countries. Without guidance and investment in low- and middle-income countries’ capacity to assess stroke care costs, these nations will not have the data necessary to influence policy makers for health insurance coverage and investment in resources to expand stroke services, the workforce, information technology, or medicines, medical products, and technology. As each nation continues to assess costs of resources used, the potential for investments, and opportunities for value-based care—the best outcomes per unit of cost—international dialogue on this topic could lead to methodological consensus that could advance policy and payment reform aimed to improve stroke care and outcomes.
Dr Cadilhac acknowledges research fellowship support from the National Health and Medical Research Council (No. 1154273).
Sources of Funding
- 1. Collaborators GBDS. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Neurol. 2021; 20:795–820. doi: 10.1016/S1474-4422(21)00252-0CrossrefGoogle Scholar
Lanas F, Seron P. Facing the stroke burden worldwide.Lancet Glob Health. 2021; 9:e235–e236. doi: 10.1016/S2214-109X(20)30520-9CrossrefGoogle Scholar
Rochmah TN, Rahmawati IT, Dahlui M, Budiarto W, Bilqis N. Economic burden of stroke disease: a systematic review.Int J Environ Res Public Health. 2021; 18:7552. doi: 10.3390/ijerph18147552CrossrefGoogle Scholar
Strilciuc S, Grad DA, Radu C, Chira D, Stan A, Ungureanu M, Gheorghe A, Muresanu FD. The economic burden of stroke: a systematic review of cost of illness studies.J Med Life. 2021; 14:606–619. doi: 10.25122/jml-2021-0361CrossrefGoogle Scholar
Cadilhac DA, Kim J, Wilson A, Berge E, Patel A, Ali M, Saver J, Christensen H, Cuche M, Crews S,; ESO Health Economics Working Group. Improving economic evaluations in stroke: a report from the ESO Health Economics Working Group.Eur Stroke J. 2020; 5:184–192. doi: 10.1177/2396987319897466CrossrefGoogle Scholar
Webb AJS, Fonseca AC, Berge E, Randall G, Fazekas F, Norrving B, Nivelle E, Thijs V, Vanhooren G; Stroke Working Group of the European Brain Council Value of Treatment Initiative. Value of treatment by comprehensive stroke services for the reduction of critical gaps in acute stroke care in Europe.Eur J Neurol. 2021; 28:717–725. doi: 10.1111/ene.14583CrossrefGoogle Scholar
Stolwyk RJ, Gooden JR, Kim J, Cadilhac DA. What is known about the cost-effectiveness of neuropsychological interventions for individuals with acquired brain injury? A scoping review.Neuropsychol Rehabil. 2021; 31:316–344. doi: 10.1080/09602011.2019.1692672CrossrefGoogle Scholar
Sandhu S, Sharma A, Cholera R, Bettger JP. Integrated health and social care in the United States: a decade of policy progress.Int J Integr Care. 2021; 21:9. doi: 10.5334/ijic.5687CrossrefGoogle Scholar
Lukey A, Johnston S, Montesanti S, Donnelly C, Wankah P, Breton M, Gaboury I, Parniak S, Pritchard C, Berg S,. Facilitating integration through team-based primary healthcare: a cross-case policy analysis of four Canadian provinces.Int J Integr Care. 2021; 21:12. doi: 10.5334/ijic.5680CrossrefGoogle Scholar
Gesell SB, Bushnell CD, Jones SB, Coleman SW, Levy SM, Xenakis JG, Lutz BJ, Bettger JP, Freburger J, Halladay JR,. Implementation of a billable transitional care model for stroke patients: the COMPASS study.BMC Health Serv Res. 2019; 19:978. doi: 10.1186/s12913-019-4771-0CrossrefMedlineGoogle Scholar
Hou Y, Bushnell CD, Duncan PW, Kucharska-Newton AM, Halladay JR, Freburger JK, Trogdon JG. Hospital to home transition for patients with stroke under bundled payments.Arch Phys Med Rehabil. 2021; 102:1658–1664. doi: 10.1016/j.apmr.2021.03.010CrossrefGoogle Scholar
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. doi: 10.1097/MLR.0000000000001462CrossrefGoogle Scholar
Brown K, El Husseini N, Grimley R, Ranta A, Kass-Hout T, Kaplan S, Kaufman BG. Alternative payment models and associations with stroke outcomes, spending, and service utilization: a systematic review.Stroke. 2022; 53:268–278. doi: 10.1161/STROKEAHA.121.033983LinkGoogle Scholar
Reeves M, Lisabeth L, Williams L, Katzan I, Kapral M, Deutsch A, Prvu-Bettger J. Patient-reported outcome measures (PROMs) for acute stroke: rationale, methods and future directions.Stroke. 2018; 49:1549–1556. doi: 10.1161/STROKEAHA.117.018912LinkGoogle Scholar
Reeves MJ, Fritz MC, Osunkwo I, Grudzen CR, Hsu LL, Li J, Lawrence RH, Bettger JP. Opening Pandora’s box: from readmissions to transitional care patient-centered outcome measures.Med Care. 2021; 59(suppl 4):S336–S343. doi: 10.1097/MLR.0000000000001592CrossrefGoogle Scholar
Cadilhac DA, Rajan SS, Kim J. In response to mobile stroke units - cost-effective or just an expensive hype?Curr Atheroscler Rep. 2019; 21:5. doi: 10.1007/s11883-019-0764-zCrossrefGoogle Scholar
Kim J, Easton D, Zhao H, Coote S, Sookram G, Smith K, Stephenson M, Bernard S, W Parsons M, Yan B,. Economic evaluation of the Melbourne Mobile Stroke Unit.Int J Stroke. 2021; 16:466–475. doi: 10.1177/1747493020929944CrossrefGoogle Scholar
Tan E, Gao L, Tran HN, Cadilhac D, Bladin C, Moodie M. Telestroke for acute ischaemic stroke: a systematic review of economic evaluations and a de novo cost-utility analysis for a middle income country [published online July 22, 2021].J Telemed Telecare. 2021. doi: 10.1177/1357633X211032407CrossrefGoogle Scholar
Tabriz AA, Turner K, Williams D, Babu N, North S, Shea CM. Association of financial factors and telemedicine adoption for heart attack and stroke care among rural and urban hospitals: a longitudinal study [published online September 20, 2021].Telemed e-Health. doi: 10.1089/tmj.2021.0341CrossrefGoogle Scholar
Jacobs M, Ellis C. Estimating the cost and value of functional changes in communication ability following telepractice treatment for aphasia.PLoS One. 2021; 16:e0257462. doi: 10.1371/journal.pone.0257462CrossrefGoogle Scholar
Knepley KD, Mao JZ, Wieczorek P, Okoye FO, Jain AP, Harel NY. Impact of telerehabilitation for stroke-related deficits.Telemed J E Health. 2021; 27:239–246. doi: 10.1089/tmj.2020.0019CrossrefGoogle Scholar