Costs of stroke and stroke services: Determinants of patient costs and a comparison of costs of regular care and care organised in stroke services

Stroke is a major cause of long-term disability in Western societies [1]. At present about 27,000 Dutch citizens (i.e., about 0.2% of the total population) suffer from a stroke each year and with the ageing of the population this number is expected to increase to 36,000 in 2015 [2]. One third of this group dies within 36 months and about 60% survives with moderate or severe disability [3]. In 1999 12,409 people died from a stroke, making stroke the third cause of death in the Netherlands [4]. Stroke was estimated to be responsible for 3.2% of total health care costs in the Netherlands in 1994, and 7.3% for the population aged 75 and over. Therewith stroke ranked second on the list of most costly diseases for the elderly, after dementia [5], while these costs are expected to increase with about 40% till 2015 [6].

The treatment of stroke in the Netherlands is often not optimal: many patients stay in hospital too long without medical necessity, waiting to be discharged to a nursing home (which in the Netherlands is an old people's home with a medical doctor and therapists), a rehabilitation centre or for home care. The number of such "waiting days" is quite substantial. About 10 of the average 28 days of stay in hospital after stroke are estimated to have no medical reason [7]. Moreover, as a result of this delay in discharge patients occupy beds (so-called "blocked beds") that cannot be used for other patients needing (acute) treatment, leading to waiting lists for hospital admission, additional effort of GPs trying to place acute patients, and possible risk to these patients' lives and recovery.

In recent years, stroke services are increasingly initiated to improve the management of stroke patients. A stroke service can be defined as a regional chain of caregivers – i.e., medical, nursing and therapy staff – who together, as a network, warrant integrated, expert and coherent treatment and care for stroke patients in all phases – i.e., acute, rehabilitation and chronic – of the ailment [8, 9]. A stroke service thus seeks to promote regional co-operation between the disciplines and institutions involved in the care of stroke patients so that patients would receive the right care at the right time in the right place from the right professional. Though there are different models of organised care, some common elements of a stroke service are: a hospital stroke unit, a specialist multi-disciplinary team of caregivers, protocol-based care, special staff training, and agreements about transfers from one institution to another to reduce hospital discharge delay. In the EDISSE study (Evaluation of Dutch Integrated Stroke Service Experiments) three experimental stroke services were analysed in depth with respect to costs, health effects, quality and organisation of care, and compared to three reference regions representing current standard care for stroke in the Netherlands [8]. It is not known which specific elements of a stroke service exert a beneficial effect. The need to compare different models of organized care has therefore been emphasized [10, 11]. In the present study we evaluated the extent to which three different stroke services succeeded in reducing discharge delay. In this study we demonstrated that organising stroke care in a stroke service potentially reduces the length of hospital stay for non-medical reasons considerably [8, 12], and may lead to improved health outcomes 6 months after stroke in terms of functional limitations, handicap and quality of life [8, 13]. These results are supported in recent international studies of the effectiveness of stroke services [10, 11, 14‐16]. In this paper we present patient costs, relate costs to need, predisposing and enabling factors (i.e., severity of stroke, age, gender, place of residence before stroke, waiting lists) [17], different care pathways and analyse whether costs differ between regular care for stroke patients and care organised in stroke services.

The EDISSE study is an observational, non randomised study, comparing the costs, patient outcomes and quality of care for three experimental stroke regions versus three reference regions that together represent current standard stroke care. Although the study is observational, data on case mix variables were collected, enabling us to control for differences in case-mix, see the results.

Total costs of care per patient for the 6 month follow-up after stroke are estimated at €16,000. This is comparable to what was found in other studies [26, 29‐31]. Patient costs after stroke are dominated by institutional costs, which is again similar to what other studies found [26, 30‐32]. The most important determinant of costs is death. Patients that die from a stroke bring about significantly less costs. That is, total costs. The costs per day alive are significantly higher for those who die from stroke (€275 vs. €105; p < 0.001). For patients that survive the acute phase, disability after stroke and place of residence before stroke – people living single most likely do not to have a partner and therefore no informal caregivers – are important determinants of costs as these factors have great influence on patients' stroke careers. Previous research has demonstrated that these "need" and "predisposing" factors are important determinants of costs of care after stroke and therefore potential building blocks for the development of Diagnosis Related Groups (DRGs) for stroke [26, 33, 34]. Informal care also plays a crucial role, as the support provided by informal caregivers is a key variable in determining whether and for how long the chronically ill will be institutionalised [35].

We found considerable differences in costs between the regions participating in the study, but no significant difference between the best functioning stroke service – in the Delft region – and regular care in the reference regions. One of the main reasons why the stroke service experiment in Delft was more efficient than the other two experiments appears to be the additional capacity that was made available in the nursing home, probably reinforced by the transfer co-ordination efforts of the transmural stroke nurse. This effects has been demonstrated elsewhere [36]. As a result of the successful co-ordination of patient flow, patients could be discharged from hospital soon after finishing of medical treatment. This is emphasised by the high percentage in Delft of days of stay in hospital with a hard medical reason. In Haarlem nursing home capacity was insufficient to deal with the requests from the three participating hospitals and in Nijmegen the focus of the experiment was on after care. As a result patients stayed in hospital much longer, leading to "blocked beds" and higher costs. The hospital costs for days of stay with a hard medical reason are however highly comparable between the experiments, therefore the key success factor of stroke services, at least concerning cost control, may be the co-ordination of patient flow. Delft is thus well ahead of Haarlem and Nijmegen in the development of an integrated and fully operational stroke service, and the cost estimate for Delft may be considered as a good first approximation of a DRG for stroke service care – preferably differentiated for patient life status and disability after stroke. Note, however, that we found a significant shift of costs between subsectors of care in Delft – mainly from institutional to home -and that integration of care for stroke patients may therefore have an impact on the financing of care. In addition, costs of co-ordination for setting up and maintaining a stroke service may be substantial. There are some critical comments to our study. First of all, EDISSE is a non-randomised non-controlled observational study and consequently we have to be cautious in comparing the results between regions. Though we found traces of a case-mix difference between Haarlem and the reference regions, this was not the case for the experiment in Delft which we used as benchmark of a fully operational stroke service. Second, not all nursing homes and revalidation centres made registrations of paramedical therapy available. Consequently, we used available volumes from other centres weighted for patient disability status. As a result, the presented variations in costs of paramedical therapy between regions may be an underestimation of actual differences between patients and regions.

We assert to have taken a societal perspective in calculating the costs of stroke. This is true. Still, one may argue that taking a societal perspective also implies that we should have taken in to account the effect (i.e., the opportunity costs) of dedicating additional scarce health care funds to co-ordinating and intensifying care for stroke patients. Perhaps creating additional nursing home capacity for stroke patients has lead to waiting lists for other groups of patients, especially considering the current shortage of capacity – mainly staff – in the Dutch health care system. And even if this were not the case, one could question whether stroke patients are the most deserving of patients to be allocated this additional capacity. Nonetheless, our analysis shows that a well-operating stroke service need not require additional funds – and will lead to better health outcomes [8].

It is worth mentioning that recently the Central Agency Tariffs for Health Care (CTG) in the Netherlands proposed to allocate a bonus €86 per inpatient day to nursing homes for intensive stroke care (e.g., on a nursing home stroke unit) [37]. This tariff is higher than the additional daily stroke unit costs we have estimated, but maximised to 8 weeks per patient. Because the patients in our study stay in the nursing home for an average of about 100 days, the total sum for intensive stroke unit care from CTG and from our costs study are comparable (€4,830 vs. €5,220).

Concluding, in this paper we have shown that patient costs after stroke depend on need (disability after stroke), predisposing (age, gender, place of residence/having a partner) and enabling (waiting days and waiting lists) factors. The need and predisposing (demand-side) factors may be important building-blocks for DRGs for stroke. Having a partner (or other relatives) that provides informal care may prevent, shorten or postpone (costly) institutionalisation. We also demonstrated that enabling (supply-side) factors, i.e., those related to the organisation of care, may be an important source for improving cost-efficiency of care for stroke patients. Through sound capacity planning on supra-institutional level and efficient, well co-ordinated discharge procedures the stroke service in Delft was able to reduce waiting lists for nursing homes and home care and, consequently, to discharge patients from expensive hospital beds as soon as there was no longer a hard medical reason for them to stay. Finally, and most important, our study [8] shows that a well-operating stroke service will lead to better health outcomes for patients and need not require additional health care funds. Evidence from other disease groups support the statement that this result is not exclusive for stroke care [e.g., [38, 39]].