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(Stroke. 2000;31:2569.)
© 2000 American Heart Association, Inc.
Original Contribution |
Resource Utilization and Costs of Stroke Unit Care Integrated in a Care Continuum: A 1-Year Controlled, Prospective, Randomized Study in Elderly Patients
The Göteborg 70+ Stroke Study
From the Institute of Clinical Neuroscience, Neurological Disease Section (L.C., G.G.-H., C.B.), and the Department of Medicine (B.F.), Sahlgrenska University Hospital, and the Department of Occupational Therapy and Physiotherapy, College of Health and Caring Science (L.C., G.G.-H.), Göteborg University, Göteborg, Sweden, and the Centre for Health Economics, Stockholm School of Economics (M.J.), Stockholm, Sweden.
Correspondence to Prof Christian Blomstrand, Institute of Clinical Neuroscience, Neurological Disease Section, Sahlgrenska University Hospital, SE 413 45 Göteborg, Sweden. E-mail cbl{at}neuro.gu.se
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Abstract |
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Background and Purpose—The aim of the present study was to examine resource utilization during a 12-month period after acute stroke in elderly patients randomized to care in an acute stroke unit integrated with a care continuum compared with conventional care in general medical wards. A secondary aim was to describe costs related to the severity of stroke.
Methods—Two hundred forty-nine consecutive patients aged 
70
years with acute stroke within 7 days before admission, living in their
own homes in Göteborg, Sweden, without recognized need of care
were randomized to 2 groups: 166 patients were assigned to nonintensive
stroke unit care with a care continuum, and 83 patients were assigned
to conventional care. There was no difference in mortality or the
proportion of patients living at home after 1 year. Main outcomes were
costs from inpatient care, outpatient care, and informal care.
Results—Mean annual cost per patient was 170 000 Swedish crowns (SEK) (equivalent to $25 373) and 191 000 SEK ($28 507) in the stroke unit and the general medical ward groups, respectively (P=NS). Seventy percent of the total cost was for inpatient care, and 30% was for outpatient and informal care. For patients with mild, moderate, and severe stroke, the mean annual costs per patient were 107 000 SEK ($15 970), 263 000 SEK ($39 254), and 220 000 SEK ($32 836), respectively (P<0.001). There was no statistical difference in age or nonstroke diagnosis.
Conclusions—The total costs the first year did not differ significantly between the treatment groups in this prospective study. The total annual cost per patient showed a very large variation, which was related to stroke severity at onset and not to age or nonstroke diagnoses. Costs other than those for hospital care constituted a substantial fraction of total costs and must be taken into account when organizing the management of stroke patients. The high variability in costs necessitates a larger study to assess long-term cost effectiveness.
Key Words: costs and cost analysis • elderly • stroke units • Sweden
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Stroke is a major public health problem associated with high mortality, disability, and cost. Therefore, it is important to develop effective treatment strategies for this health problem. The Stroke Unit Trialists’ Collaboration1 concludes from the meta-analyses data that stroke unit care improves survival and health status after a stroke.1 2 3 However, there is a lack of evidence concerning economic evaluations of stroke unit care versus conventional care.1 It has been emphasized that economic evaluations of stroke care are not easy to perform because of the complexity of costs.4 This increases the need for prospective studies with reliable data concerning the impact of stroke unit care.
Thus, when cost implications of acute stroke unit care are examined, many factors in the study design may improve the quality of the outcome measures, eg, screening procedure of background population when recruiting patients, randomization, prospective approach to data collection, and inclusion of all costs related to the studied patients.
So far, no study has considered all these aspects, and only one research group5 6 has studied the costs of stroke unit care; however, that study did not use a randomization procedure. The other studies have not been focused on stroke unit care.7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Some studies have been based on data collected retrospectively and not prospectively.14 19 21 Many reports do not provide information on costs for outpatient care,5 6 8 10 13 14 19 25 social services,5 6 8 10 13 14 19 25 and informal care.5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 23 24 25 26 In some studies, data on costs have not been registered for individual patients but for categories of patients.8 16 18 23
We have performed a 1-year randomized study comparing treatment outcome at an acute stroke unit with a care continuum with the outcome of conventional treatment and have prospectively collected all types of costs for these patients. A care continuum implies an acute stroke unit linked to continued care in geriatric stroke units when a long rehabilitation period is needed. The clinical results have been reported elsewhere and showed no overall significant difference in proportions of patients living at home or in patient mortality or functional ability between the 2 treatment groups after 1 year.27 However, our data indicate that stroke unit care reduced mortality or the need for institutional care in the short-term perspective, especially among those with severe stroke (95% CI -32% to 9%) or in patients with cardiac disease (95% CI -40% to -3%), supporting the results of the Stroke Unit Trailists’ meta-analysis1 and a previous Swedish study.28
If the health effects are identical for the 2 treatments, an economic evaluation can be carried out as a comparison of the total costs of the treatments. Such an analysis is often referred to as a cost-minimization analysis in the health economics literature.29
The primary aim of the present study was to identify and analyze costs associated with the treatment of elderly patients with acute stroke by using the experimental setup of a randomized study of care in a stroke unit and conventional care referred to above. Detailed data on resource consumption were collected prospectively during the study. A secondary aim was to estimate the total costs of stroke during the first year after its occurrence in relation to the severity of the stroke.
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Subjects and Methods |
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The design was a randomized prospective study with 2 parallel groups followed for 1 year in Sahlgrenska University Hospital in Göteborg, Sweden, the Göteborg 70+ Stroke study. Patients aged
70 years (n=249) were randomized after informed consent in
connection with acute admission to a stroke unit (SU group) integrated
with a care continuum to geriatric wards or to a general medical ward
(GW group) between February 1, 1993, and May 17,1994. The randomization
was a 2:1 ratio of stroke unit to conventional treatment at general
medical wards.30 A 2:1 randomization to the SU groups was
applied to obtain a continuous input of patients to these units. At the
acute hospital, the stroke unit consisted of 2 wards, 1 in a general
medical ward and 1 in a neurological ward. The SU group was composed of
166 patients; the GW group was composed of 83 patients. There were no
significant differences between the groups at entry with regard to sex:
66% (n=110) of the SU group and 54% (n=45) of the GW group were
women. The mean age of the SU and GW groups was 80.1 and 79.7 years,
respectively. There was no difference in living conditions: 59% (n=96)
of the SU group and 48% (n=39) of the GW group were living alone.
Concerning the medical history, there were no differences; however,
angina pectoris was significantly (P>0.05) more common in
the SU group. Furthermore, the groups were comparable with regard to
neurological score at entry, with a median score of 45 in the SU group
and 46 in the GW group. The side of predominant neurological deficit
was the right side for 45% (n=74) in the SU group and 42% (n=35) in
the GW group and the left side for 51% (n=85) and 45% (n=37),
respectively. Speech disorder occurred in 48% (n=79) of the SU group
and 49% (n=41) of the GW group. Two patients in each group did not fulfill the criteria for acute cerebrovascular disease.27
Intervention
A nonintensive stroke unit28 31 was organized in a
care continuum with 2 acute stroke units and 2 stroke units at
geriatric wards working according to identical principles. The
treatment program was built on the principle of stroke unit care with a
teamwork concept for nursing and rehabilitation. The program was
standardized with regard to diagnostic evaluation,
observation, acute treatment, mobilization, and rehabilitation. All
staff at the acute wards and at the geriatric wards had a continuous
educational program. The acute and geriatric stroke units collaborated
in terms of treatment principles, training, and work procedures.
Support and information to relatives was an important part of the
program, as was the focus on the patients’ needs and participation in
the treatment. Patients in need of prolonged rehabilitation were
transferred to geriatric stroke units. The patients in the general ward
received conventional acute medical care, physiotherapy, and
occupational therapy, although not within the framework of a structured
stroke unit care approach. At the stroke unit, the patients received
significantly more occupational and physical
therapy.27
Measurements
Two registered occupational therapists not involved in the
design of the study and the treatment of the patients made all
evaluations of the study outcome. The assessments were performed 0 to 3
days after randomization and after 3 weeks, 3 months, and 12 months.
The assessments were made at the hospital, in nursing homes, and/or in
the patients’ homes by means of interviews. If there were any doubts
about ability, the patients were asked to perform the activity.
Patients were randomly assigned to the occupational therapists, who
evaluated them during follow-up. The occupational therapists were
experienced and well-trained in assessing activities of daily living
(ADL).27 Established methods were used to assess
neurological status (Scandinavian Stroke Study Group32 ),
the ability to perform daily life activities (Barthel
index33 and Sunnaas index of ADL34 35 ), and
health-related quality of life (Nottingham Health
Profile36 37 38 ). There were no differences between the
groups regarding survival. The proportion of patients at home or in
institutions did not differ between the groups after 3 or 12 months. At
the 12-month assessment, 73% of the SU group and 77% of the GW group
were alive, and 63% and 60%, respectively, were living at home. There
were no significant differences between the groups regarding
neurological score, ADL scores, or the 6 dimensions of the Nottingham
Health Profile questionnaire at the 12-month assessment.27
The study was approved by the ethics committee of the Sahlgrenska
University Hospital.
Costs
All costs were estimated from the time of randomization to the
end of the 12-month follow-up. The costs were divided into costs for
hospitalization, institutionalized living, outpatient care, different
kinds of support, and informal care provided by relatives. The costs of
each of these units are shown in Table 1
. The total cost was obtained by taking
the sum of all separate units and multiplying them by their costs. All
costs were estimated according to 1996 prices in Swedish crowns (SEK;
exchange rate in 1996, $1=6.70 SEK and £1=10.50 SEK).
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Data on all hospitalizations during the study were collected from hospital records. The costs were estimated separately for the initial hospitalization, and a distinction was made between acute hospitalization and nonacute hospitalization. For nonacute hospitalization (geriatric wards and postcare unit), unit costs per hospital day were taken from estimations made by the civic administration of the city of Göteborg. For acute hospitalization, the cost was divided into a "hotel cost" per hospital day and patient-related costs. The hotel cost per hospital day at different wards was based on the hotel costs at the Sahlgrenska University Hospital and included staff costs, rent costs, and overhead costs for food, drugs, cleaning, washing, and transportation. Patient-related costs included medical examinations and treatments related to each individual patient. The internal transfer payments used at the Sahlgrenska University Hospital were considered (as judged by the hospital administration to reflect the actual costs) as unit costs for these medical examinations and treatments. The stroke unit in the internal medicine ward had a stroke nurse (full time), an occupational therapist (part time), and a physiotherapist (part time) as extra medical staff in the team. The cost of this extra medical staff was added to the hotel cost at this stroke unit.
The number of days of institutionalized living (nursing home, home for the elderly, and assisted living) was obtained from hospital records. Unit costs per day were taken from estimations made by the civic administration of the city of Göteborg.
Structured interview questionnaires at 3- and 12-month assessments were used to collect data concerning use of outpatient care. If the client was unable to answer, the questions were posted to relatives and/or medical staff. Outpatient care included the following: use of prescription drugs; visits to physicians, nurses, occupational therapists, physiotherapists, and/or speech therapists; outpatient rehabilitation; and visits for anticoagulation treatment. Unit costs for these types of visits were taken from estimations made by the civic administration of the city of Göteborg. To estimate the cost of prescription drugs, official Swedish retail prices were used.39
In the structured interview questionnaires at 3 and 12 months, data about different kinds of support were also collected. Data were collected concerning hours of home assistance, the number of 1-way taxi trips for disabled people, and the use of safety alarms, assistive devices, and housing adaptations required after stroke. From estimations made by the civic administration of the city of Göteborg, the unit costs for these resources were derived. Costs for housing adaptations and assistive devices varied according to the type of housing adaptation and assistive devices.
The final cost component estimated was the informal care provided by relatives. The number of hours of informal care was collected in the structured interview questionnaires at 3 and 12 months. Thirty-eight SEK per hour was used as the unit cost of informal care. This corresponds to 35% of the gross wage rate, and this cost has been used as the cost of leisure time in previous economic evaluations of health care in Sweden.40 41
No costs for outpatient care, different forms of support, and informal care were estimated for patients who died before 3 months. For patients who died 3 to 12 months after randomization, the units from the 3-month assessment were used to estimate the consumption of these utility resources until the date of death.
Statistical Analyses
The analyses were performed according to the
intention-to-treat principle.42 Differences in use of
resources and costs were compared by use of a Mann-Whitney
nonparametric test for continuous variables, and a
x2 test was used for categorical
variables. In addition to testing for whether the costs differed
between the 2 treatment groups, a Kruskal-Wallis test was also made to
determine whether the costs differed between mild, moderate, and severe
stroke.43 The classification of stroke into mild,
moderate, and severe was based on the Barthel index score within the
first 3 days after randomization according to a definition used by the
Stroke Unit Trialists’ Collaboration. Mild, moderate, and severe
stroke were defined as Barthel scores 50 to 100, 15 to 45, and 0 to 10,
respectively.44 45 There were no differences in the number
of patients with mild, moderate, and severe stroke allocated to the
stroke unit and general ward. A value of P<0.05 (2-sided)
was considered significant.
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Results |
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The use of resources per patient during the study are shown in Table 2
, and the costs per patient during
the study are shown in Table 3. The costs
did not differ significantly between the groups for any of the cost
components. The mean total costs per patient were numerically somewhat
lower for the SU patients than for the GW patients (170 000 SEK
[$25 373] versus 191 000 SEK [$28 657], respectively), but the
difference was not significant. The total costs per patient ranged from
5032 SEK ($751) to 717 905 SEK ($107 150) for the SU patients and
from 5661 SEK ($845) to 815 673 SEK ($121 742) for the GW
patients.
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Table 4 shows the costs for mild,
moderate, and severe stroke. The mean total costs per patient were
107 000 SEK ($15 970) for mild stroke, 263 000 SEK ($39 254) for
moderate stroke, and 220 000 SEK ($32 836) for severe stroke. There
was a significant difference (P<0.001) in total costs for
mild, moderate, and severe stroke. The total costs for mild stroke were
lower than the costs for moderate and severe stroke, and the highest
total costs were shown in moderate stroke. The bulk of the lower costs
of mild stroke were the result of lower costs at the initial
hospitalization and lower costs of institutionalized living. There were
no statistical differences between patients with mild, moderate, or
severe stroke in age, sex, living arrangements, or nonstroke diagnosis
(Table 5).
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A problem in the comparison of the costs of mild, moderate, and severe
stroke during the first year after the stroke was that the mortality
differed for these groups. After 1 year, 13%, 34%, and 45% of the
patients had died in the mild, moderate, and severe groups,
respectively. Because mortality differed depending on the severity of
the stroke, we also estimated the costs for the patients that were
alive at the end of the study; these results are shown in Table 6. For patients who survived, the mean
total costs per patient were 101 000 SEK ($15 075) for mild stroke,
283 000 SEK ($42 239) for moderate stroke, and 331 000 SEK
($49 403) for severe stroke. There was a significant difference
(P<0.001) in total costs for mild, moderate, and severe
stroke. The total costs for mild stroke were lower than the costs for
moderate and severe stroke, and the highest total costs were shown in
severe stroke.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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To our knowledge, this is the first randomized controlled trial of acute stroke unit care with a care continuum that prospectively collected comprehensive data about resource consumption in elderly patients with acute stroke. There was no effect on the number of patients living at home after 1 year, but a beneficial effect was found after 3 months of stroke unit care on mortality and need of institutional care among those with concomitant heart disease. There were no significant differences between the groups regarding neurological score, ADL scores, or the 6 dimensions of the Nottingham Health Profile questionnaire at the 12-month assessment.27 During the 12 months of follow-up, detailed data about inpatient care, institutional living, outpatient care, social services, and informal care were collected. According to the results of the present study, the total costs per patient did not differ significantly between patients randomized to a stroke unit and patients randomized to a general medicine ward. A secondary aim of the present study was to estimate the costs of stroke in relation to the severity of the stroke (mild, moderate, and severe stroke). This analysis showed that the costs increase with the severity of the stroke; this was not explained by differences in age or in comorbidity. This is in accordance with Jörgensen et al,6 who found that comorbidity did not increase the length of hospital stay in stroke patients. The costs were substantially lower among patients with mild stroke. The lower costs at the initial hospitalization and the lower costs of institutionalized living explain the total lower costs of mild stroke. A previous study has demonstrated a similar finding, although the comorbidity was not reported.7
The costs per patient varied greatly depending on the severity of
stroke; they also varied within each severity class. This great
variability in costs affected the statistical power to find a
significant difference in costs between the treatment groups. The power
calculations of the present study, and thus the sample size, were
based on detecting a difference in the proportion of patients
discharged to their own homes. The result of the present study can
be used for sample-size calculations of future studies of the costs of
stroke. Our data indicate that 
400 patients must be recruited to
obtain sufficient statistical power to show a 25% reduction in costs
the first year after stroke. The present study included 249
patients, and it had a limited statistical power in demonstrating a
significant difference in costs between the treatment groups.
An advantage of this randomized study was that patient-specific data on both costs and outcomes were collected prospectively, indicating a high internal validity. Increased reliability was considered by the fact that the 2 occupational therapists responsible for evaluations were experienced and independent with respect to the treatment of the patients. All data on resource consumption were also scrupulously collected prospectively within the trial. It has been pointed out that a weakness in this type of study could be a lower degree of external validity.29 However, this randomized study has been based on generally accepted clinical practice, which decreases the problem of external validity. The patients recruited to the study are also likely to be representative of elderly patients treated for stroke in Sweden. An alternate method might be to predict long-term costs from functional status.46 Lifetime costs for persons suffering from stroke is another method of expressing costs.16 18 There are also studies that have estimated costs for stroke care during 1 calendar year.8 23
The present data are not directly comparable to the results
of previous studies, because the present study is the only one to
have used a design of prospectively collected data on all types of
costs in a randomized clinical trial based on a
representative elderly stroke population. Accordingly,
these results cannot be directly compared with any previous studies.
However, many previous studies have estimated the costs of
stroke.5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Most of them have concentrated on the costs
of inpatient care and institutional
living,5 6 8 10 13 14 19 20 21 25 and costs for outpatient
care, social services, and informal care were not included. The total
costs found in the present study are of the same order as those
estimated in a thorough analysis of costs of stroke in
Sweden,11 but the relative costs for nonhospital care are
higher in the present study. The present study showed that
inpatient care and institutional living constituted 70% of the total
costs for patients randomized to the SU group and 71% of the total
costs for patients randomized to the GW group. Twenty percent of the
total costs in the SU group were costs of outpatient care, and 10%
were costs of informal care. In the GW group, these shares were 16%
and 13%, respectively. Thus, one third of the total costs during the
year of follow-up were costs that were not associated with inpatient
care and institutionalized living, which indicates the importance of
comprehensive prospective studies on stroke care. It is also likely
that the fraction of these costs would increase further with longer
follow-up, because the initial hospitalization determined a large
fraction of the costs during the first year after the stroke. It should
also be pointed out that the costs of informal care were conservatively
estimated, inasmuch as it was assumed that the informal care reduced
the leisure time rather than the working time of the caregivers.
Leisure time was also valued rather conservatively at 38 SEK per hour
(35% of the gross wage rate). Doubling the value of leisure time to 76
SEK per hour would increase the share of total costs for informal care
to 20%.
The present study showed that the total costs after stroke increased with the severity of the stroke. A possibly better stroke unit effect for patients with severe stroke corresponds with the findings of other studies, which have shown that the severity of stroke influences the length of hospital stay6 21 and the pattern of total utilization of both hospital and nonhospital care.7 17 Furthermore, Stroke Unit Trialists’ Collaborations’ meta-analytic data indicate a more marked effect of stroke unit care for patients with severe stroke versus mild stroke.44
In conclusion, the present study showed that the total costs the first year did not differ significantly between the treatment groups. The total annual cost per patient showed a very large variation, which was related to stroke severity at onset and not to age or nonstroke diagnoses. Costs other than those for hospital care constituted a substantial fraction of total costs and must be taken into account when organizing the management of stroke patients. The high variability in costs necessitates a larger study to assess long-term cost effectiveness.
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Acknowledgments |
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This study was supported by the Vårdal Foundation, Trygghetsfonden, the Swedish Stroke Association, John and Brit Wennerström’s Foundation for Neurological Research, Felix Neuberg Foundation, Rune and Ulla Amlöv’s Foundation for Neurological Research, Hjalmar Svensson Research Foundation, and King Gustav V and Queen Viktoria Foundation. Prof Birgitta Lundgren-Lindquist (present address La Trobe University, Melbourne, Australia) generously provided us with resources and support. We are grateful for the cooperation of Dr Ulla Hallhagen (Högsbo Hospital) and Dr Michaela Holmdahl (previously Vasa Hospital, now Department of Geriatrics, Sahlgrenska University Hospital). We would like to thank Dr Lena Bokemark (Department of Medicine), who helped us to collect necessary data from the medical records. We would also like to thank Agneta Hallén and Henrik Siverbo, who helped us with the data administration, and Stefan Granbom for valuable help with statistics. A special thanks to the staff at the stroke units and the physicians and staff at the Emergency Department who assisted in randomizing the patients.
Received June 24, 2000; revision received June 24, 2000; accepted June 29, 2000.
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