Costs of Medical Care After First-Ever Stroke in the Netherlands
Background and Purpose Stroke causes high morbidity and mortality. The aging of the population further increases the demands on healthcare costs.
Methods We estimated the lifetime direct costs of care of first-ever stroke patients in the Netherlands in 1991 using epidemiological data from national and international studies. In addition, we examined the effect of an aging population on future healthcare costs.
Results The lifetime costs for 24 007 first-ever stroke patients are estimated to be 1870 million Dutch guilders (Dfl) (1 Dfl=0.53 US dollar, 1991). Per-person costs are higher for women (83 000 Dfl) than for men (71 000 Dfl). The major cost component of first-year costs is hospital costs (45%), while nursing home costs dominate lifetime costs (50%). An increase of the elderly population older than 65 years of 27% between 1991 and 2010 might lead to a parallel increase of total costs of 30%, or 1.5% per year.
Conclusions Long-term care rather than acute care dominates the lifetime costs for stroke patients now and in the future.
Stroke is a major contributor to death and disability in developed countries. Although in the Netherlands stroke mortality declined between 1970 and 1985 by approximately 4% per year for both men and women, stroke is still the third leading cause of death.1 Four percent of hospital beds are occupied by stroke patients.2 Stroke is a disease of the elderly and with an aging population, the consumption of healthcare services and related costs by elderly stroke patients may rise steadily in the future.
Despite the obvious burden of disease, there have been surprisingly few recent cost-of-illness studies in the stroke field and even fewer that have been population-based. Stroke accounts for 2% to 4% of total and more than 4% of direct healthcare costs in various countries.3 4 In the last 20 years direct costs for stroke increased from approximately 45% to 75% of total stroke costs because of the increasing number of hospital patient-days.5 6
Calculations of lifetime costs for stroke patients are dependent on reliable estimates of incidence, long-term survival probabilities, and the use of healthcare facilities. Unfortunately, well-documented data concerning these issues are scarce. Furthermore, the effects of demographic changes on stroke costs have not yet been estimated quantitatively. Recently, stroke costs in the Netherlands have been estimated as a proportion of total Dutch healthcare costs on an aggregate level (“top-down” approach).4 In contrast, the present study uses a “bottom-up” approach: We calculate the lifetime direct costs of medical care for all patients with a first-ever stroke in the Netherlands in 1991 by adding the costs for individual components. Epidemiological data from several national and international studies are used regarding incidence, prognosis, and place of residence after stroke. The advantage of the latter method is that the effects of variations in care on stroke costs can be quantified. Suggestions about cost containment might be used for an efficient utilization of healthcare costs. Finally, the effect of aging on costs in the year 2010 is estimated.
Subjects and Methods
The lifetime direct costs of medical care were calculated for all first-ever-in-a-lifetime stroke patients and separately for patients with a cerebral infarction (CI) or a primary intracerebral hemorrhage (PICH) in the Netherlands in 1991. Direct medical costs include all costs of (1) diagnosis, treatment, and rehabilitation for stroke patients in hospital or a nursing home and (2) healthcare services provided by professionals for patients living independently. We calculated the number of patients per location by combining data on incidence, prognosis, and the percentage of stroke survivors living in different locations at different time intervals according to sex, type of stroke, and age category. We calculated the average length of stay by multiplying the number of patients per location in a given time interval by the number of days in that time interval and adding the total number of days in all time intervals per location and in each category. We calculated the costs of stay by multiplying the average length of stay by the daily costs of stay. The lifetime costs of care for an individual patient according to sex, type of stroke, and age category is the sum of the total cost of stay for all time intervals and locations. We calculated the lifetime costs for all stroke patients by multiplying the individual lifetime costs of care according to age, sex, and type of stroke category by the total number of patients per category and adding the results for all categories.
Costs are presented for patients with CI and PICH. Stroke was defined according to the criteria of the World Health Organization.7 The following age categories were used: younger than 65, 65 through 74, 75 through 84, and 85 years and older. Lifetime costs were calculated for a maximum of 15 years.
Under the assumption that our study population is stable with respect to age and sex composition and that age-specific incidence of stroke, prognosis, and costs of stroke do not change, lifetime costs may be interpreted as yearly costs. This means that all lifetime costs were assigned to the calendar year in which the stroke occurred, 1991. When preventive programs are evaluated, this “incidence approach” is more relevant than the “prevalence approach,” which focuses on current costs.6 Therefore, discounting was not used.
We calculated the incidence of all first-ever stroke patients in the Netherlands in 1991 by aggregating the incidence rates for the Tilburg Epidemiological Study of Stroke (TESS)8 and the Oxfordshire Community Stroke Project (OCSP), which has produced comparable age-specific and overall incidence rates.9 To our knowledge, the OCSP is the only well-designed and recent population-based study of a white population comparable to that of the Netherlands that is currently available and that provides detailed incidence rates of first-ever stroke patients according to age and sex. The total number of first-ever stroke patients of both studies according to age and sex category was divided by the total population at risk of both studies per category to estimate the “pooled” incidence per category. We calculated the total number of first-ever stroke patients in the Netherlands in 1991 by multiplying the pooled incidence rates per category by the total population of the Netherlands in 1991 in each category and adding the cases in all categories. These incidence rates also include patients with subarachnoid hemorrhage or undefined stroke. Therefore, incidence figures are further broken down for CI and PICH patients with the use of sex-, age-, and type-specific incidence rates of the OCSP.9
We estimated survival after stroke in three steps: (1) calculating average monthly death risks within the first year by aggregating the results of six population-based studies that have used data on all first-ever stroke patients published after 1975,10 11 12 13 14 15 16 (2) calculating annual death risks for all patients after the first year with data from the OCSP, and (3) disaggregating death risks by age and type of stroke (CI and PICH) with data from the OCSP. In the first step, calculations were made for all patients. Initially, death risks in the first year have been calculated at the following intervals: less than 1 month, 1 to 6 months, and 7 to 12 months. Individual studies contribute to the calculation of the average death risk in these intervals until the end of their observation period. We calculated the average death risk per interval by adding the total number of deaths per interval of contributing studies and dividing the sum by the total number of patients at risk at the beginning of the interval for all studies reporting at least until this interval. In addition, the monthly death risks were estimated based on the death risks in the intervals 1 to 6 months and 7 to 12 months.
In the second step, death risks in the second and third years were calculated for all stroke patients with data from the OCSP. We estimated annual death risks after the third year by multiplying the sex- and age-specific annual mortality risks from the Dutch general population17 with the annual relative risk after the first year (2.2) reported by the OCSP.11 Since the relative risk is approximately constant in the first years after diagnosis, we assumed it to be constant during subsequent years.
In the third step, death risks for PICH and CI patients were estimated according to age. Data of the OCSP were used to estimate death risks until the fourth year. The risk of dying after the first month was assumed to be equal for PICH patients and CI patients.18 Annual death risks after the third year were calculated as described above with the use of age-specific relative risks reported by the OCSP11 and the death risks of the Dutch population of the same age and sex.
Places of Residence
Information on the percentage of stroke survivors living at different locations during the first year after a first-ever stroke is based on a study of 1% of the Dutch population.14 We distinguished the following three groups of residences: (1) hospital, (2) nursing home/rehabilitation center, and (3) home/old people’s home/other residences. Only minor shifts between locations occurred between 2 and 12 months. Therefore, we assumed no major changes in proportion of survivors at the different locations after the first year. Because of lack of data, no relationship was assumed between the location and age or type of stroke. It is known, however, that one half of hospital stroke patients and one third of nursing home patients in the Netherlands are men.19 20 When we combine this knowledge with data on incidence and percentage of survivors at different locations in time (see above), the percentage of stroke survivors according to sex living at different locations in time can be estimated.
Calculation of Costs
The hospital costs were derived from a recent study of 760 stroke patients from 23 hospitals in the Netherlands, of which the present study is part (J.H.P. van der Meulen, unpublished, 1995) (for more details, see Appendix). Costs have been estimated with the use of hospital files and detailed financial information obtained on several neurological wards. The costs of nursing care, medical and nonmedical staff, nutrition, and nursing materials were based on real prices. Costs for administration, maintenance, and security were estimated from all overhead costs of the hospital and attributed to these neurological wards on the basis of number of nursing days and personnel. The numbers of laboratory tests, diagnostic and therapeutic procedures, medical and paramedical services, and consultations were collected from hospital records. The costs were based on tariff charges.
The average daily costs (223 Dutch guilders [Dfl] [1 Dfl=0.53 US dollar, 1991]) for nursing home care were based on a report on resource utilization for nursing home patients in the Netherlands.21 In this report nursing home patients were classified according to nursing time consumed and activities of daily living status. According to the activities of daily living status at discharge from the hospital to a nursing home, we classified our hospital stroke study group as a group receiving complex nursing care. The average daily costs for this group were estimated accordingly (231 Dfl).
Information on the type and consumption of professional healthcare services during the first year after stroke for patients living at home was obtained from two Dutch studies.14 22 Care services are divided into three categories: (1) therapy (physical, occupational, and speech therapy); (2) care (eg, home help, nursing care); and (3) aids (body- and non–body-adapted aids). The consumption of services, which is mainly determined by the patient’s functional status, is assumed to be constant after the first year. The daily costs for patients at home (58 Dfl within the first 6 months, 14 Dfl after 6 months) were based on a recent Dutch report.23 Tariffs or real prices per hour were used.
We estimated the number of first-ever strokes in the Netherlands to be 26 653 (Table 1⇓) for all patients and 24 007 for patients with CI and PICH (Table 2⇓) in 1991. As expected, the rate of incidence rose with age. Stroke incidence was slightly higher among men in all age groups except the oldest. However, since the general population older than 65 years contained more women than men, the majority of stroke patients older than 65 years were female.
Mortality of stroke patients was highest within the first months, especially within the first week (16%) (Fig 1a⇓). For patients who survived the first year, the average annual risk of death was approximately 10%, representing a continuously increased risk of dying compared with the general population with similar sex and age (Fig 1a⇓). The difference in survival between PICH patients and CI patients stems from the high mortality rates of PICH patients within the first month after diagnosis (Fig 1b⇓ and 1c⇓).
Place of Residence
Approximately 70% of all first-ever stroke patients were admitted to the hospital in the Netherlands, while 2% were living in a nursing home at the onset of stroke. After the first month, the percentage of patients in the hospital dropped dramatically to 8%, because 75% of stroke survivors had returned home. Nineteen percent of the stroke survivors were discharged to nursing homes that have hospital facilities in the Netherlands (Fig 2⇓). The average duration of stay of stroke patients in nursing homes was approximately 470 days. At 6 months, 81% of stroke survivors were living at home, while 18% were in nursing homes or rehabilitation centers. Only minor shifts from nursing homes to home occurred at this time. At 1 year after stroke approximately 2% of the original stroke cohort was readmitted to the hospital, probably because of recurrences or comorbid diseases.
Costs of Medical Care
Total expected medical costs for CI and PICH patients were approximately 1870 million Dfl during a maximum of 15 years (Table 2⇑). Advanced age reduced the average per-person costs in both men and women, reflecting the longer survival of younger patients. The average costs per person with an ischemic stroke were 81 000 Dfl versus 49 000 Dfl for a patient with a hemorrhagic stroke. This difference derives from the longer survival of CI patients, who subsequently have higher costs for rehabilitation services. The higher average per-person costs combined with the larger number of CI patients led to an approximately 14-fold difference in total costs between CI and PICH patients. For both types of stroke combined, per-person costs were higher for women (83 000 Dfl) than for men (71 000 Dfl). The total costs for women were 48% higher than for men. This result is largely due to the higher nursing home costs for women, who are at higher risk of being discharged to a nursing home, which is the major cost component (50%) of lifetime costs (Tables 3⇓ and 4⇓). The average per-person costs for hospital care were lower for women than for men in all age groups, because men have a higher likelihood of being admitted to the hospital. Per-person costs varied with age, expressing variations in incidence per age group and expected duration of care after stroke.
Approximately 75% of survivors living at home use or have used one or more types of healthcare services in the first 6 months after stroke onset; this percentage was 66% after 1 year.14 22 Home care costs accounted for approximately 20% of first-year and lifetime costs (Table 4⇑).
The projected population of those 65 years and older is approximately 27% larger in 2010 than in 1991 in the Netherlands.24 As a result, the total number of patients with first-ever strokes will rise from 26 653 in 1991 to 34 952 in 2010, an increase of 30%, assuming no change in incidence between 1991 and 2010. Consequently, the expected direct lifetime costs for a stroke cohort of 34 952 patients in 2010 with mortality similar to that in 1991 will be approximately 2424 million Dfl (30% higher than in 1991) (Table 4⇑).
Our incidence-based study reveals that the lifetime direct medical costs for all first-ever stroke patients in 1991 were 1870 million Dfl, accounting for 4% of total healthcare costs in the Netherlands. This percentage accords well with estimates in other countries (2% to 4%).3 However, stroke costs of different countries are generally difficult to compare because of the differences in methods used and in the utilization of healthcare resources. In contrast to most other international cost-of-illness studies, the present study calculates the total medical lifetime costs caused by stroke itself as well as by comorbid diseases. This means that costs in our study are best seen as costs of patient care rather than costs of illness. This policy was followed because it is hardly possible to distinguish costs caused by stroke from those caused by other diseases after the acute phase. Furthermore, stroke patients have a higher risk of developing other cardiovascular diseases during their lifetime, generating excess costs compared with the general population.11 Our approach overestimates the cost due to stroke itself, because part of the calculated costs will also be made by an elderly population free of stroke. Considering that at least 3% of total healthcare costs are due to stroke costs4 and that the average healthcare costs for a 75-year-old person are estimated to be 8000 Dfl per year,4 we calculated that approximately 47% of our total stroke costs are related to comorbid diseases, including stroke-related cardiovascular diseases.
The bottom-up approach of our study, in which we calculated total stroke costs by adding the costs for all components according to age, sex, and type of stroke, led to higher total stroke costs than estimated in a recent Dutch study (1150 million Dfl).4 Koopmanschap et al4 estimated stroke costs as a proportion of total Dutch healthcare costs by dividing total costs by type of care and diagnostic category (top-down approach). Consequently, costs were assigned per head of the population and not per patient, as in the present study. Furthermore, 25% of all costs could not be allocated to diseases. Another reason for the higher total costs in our study compared with those of Koopmanschap et al is that we included costs generated by comorbid diseases, as mentioned above. Despite the differences in methods, the costs of hospital care correspond remarkably well (497 million Dfl4 versus 509 million Dfl), probably because comorbid diseases play a minor part in initial hospital costs.
Hospital costs in the Netherlands accounted for a relatively small proportion (45%) of total costs compared with other countries in which hospital costs varied between 40%25 26 and 85%3 5 27 28 29 of total direct costs in the first year. First, the latter studies included costs for long-term care hospital departments in which patients had been placed after the acute phase. In the Netherlands, however, long-term care for stroke patients is not provided in hospitals but in nursing homes that have hospital facilities. Consequently, the average length of stay in hospital for stroke patients is relatively short in the Netherlands (27 days) (J.H.P. van der Meulen, unpublished observations, 1995) compared with Sweden (59 days)31 or Scotland (65 days).28 The majority of stroke survivors in the Netherlands return to their home after an average stay of 21 days, while severely disabled patients stay in the hospital an average of 50 days because they are “waiting” for a place in a nursing home (J.H.P. van der Meulen, unpublished observations, 1995). Consequently, while hospital costs are proportionally small, nursing home costs are relatively high both in the first year and subsequent years. This latter observation particularly applies to women, who compose the majority of the nursing home population, reflecting their higher age. A prolonged hospital stay and increased nursing home costs for women have also been observed in Sweden5 25 and Canada.29
When interpreting the high nursing home costs of the present study, we probably overestimated the number of nursing home days and related costs by assuming no major changes in the proportion of survivors at different locations after the first year. With the aging of the population, the chance of being admitted to a nursing home for stroke survivors living independently will rise in time. On the other hand, the average life expectancy of stroke survivors in a nursing home is relatively short (1.3 years).19 At present, a follow-up of the hospital cohort is being performed to gain more insight into the consumption of healthcare services and place of residence in time.
The present study is useful to quantify the effects of variations in patterns of care. Although a Swedish study concluded that total stroke inpatient costs during the first year were similar regardless of the care provider,30 we believe that the costs of care might be reduced in the Netherlands by a policy aimed at improving healthcare services for stroke patients by substituting home care for nursing home care for patients with minor strokes. Second, hospital costs might be further reduced by limiting the number of hospital days for severely disabled patients waiting before being discharged to a nursing home.
The results in this study have been obtained with certain assumptions regarding the stability of the population, epidemiology, and costs. Our projections in Table 4⇑ of an increase in cost of 30% in the year 2010 are based on expected demographic changes only, not on possible changes in incidence, mortality, or cost. When we consider the different opinions31 32 about the trend in incidence and the uniform observation of a declining trend in mortality in western countries, our cost projections for the year 2010 may be too low, because a larger proportion of patients is expected to survive. Future costs may also differ from the demographic extrapolations because of changes in diagnostic and therapeutic management and changes in healthcare costs in general: eg, in the Netherlands costs of medical procedures have been increasing by 4% per year.
Malmgren et al33 concluded that the burden of care caused by a future increase in the number of first-ever strokes as a result of aging will be concentrated on acute care rather than on the care of long-term survivors. This conclusion was made because the percentage of severely handicapped patients increased by only 4% as a result of the high first-month mortality rate of this group. The results of our study, however, demonstrate that long-term care dominates lifetime costs. This conclusion was strengthened by sensitivity analysis. The extrapolation of costs after the first year after stroke is based on the assumption that no major changes in proportion of survivors occur at the different locations after the first year. However, it is likely that nursing home patients are subjected to an increased yearly mortality risk because of their worse physical condition compared with independently living elderly patients. In sensitivity analysis the balance of costs would only swing in favor of acute-care costs, when the yearly mortality risk of nursing home patients is at least 4 times higher than that of patients living at home. This is unrealistic, because with this high mortality risk there would be no nursing home patients left after 13 years. In our view, better early and intensive care combined with optimal therapeutic measures and early rehabilitation aimed at reducing short-term mortality may result in an increased prevalence of long-term survivors. A recently developed model designed to predict future trends in stroke incidence and mortality in the Netherlands supports the view that prevalence rates will rise, particularly among the oldest age groups.34
In conclusion, the costs for long-term care of stroke survivors dominate the lifetime costs. Cost reductions may be achieved by reducing the number of waiting days in the hospital and improving long-term healthcare services for stroke patients at home. However, given the aging of the population and the accompanying increase of costs, an overoptimistic view of the realization of this goal should be tempered.
Summary of Hospital Study
A detailed study was performed on hospital care provided to 760 consecutively admitted stroke patients in 26 Dutch hospitals. For each patient the need for nursing care was recorded from nursing records for each of the first 4 weeks after admission. The need for nursing care was subdivided into four categories: (1) minimal care: the patient does not need any support with his/her activities; (2) average care: the patient needs some help; (3) above average care: the patient needs help for most of his/her activities; (4) high care: the patient needs constant observation.
In a subgroup of 50 consecutive patients, the precise number of performed diagnostic and therapeutic procedures was registered (tariffs).
A detailed questionnaire was sent to six of the hospitals requesting information about actual costs for personnel, material, and overhead. The costs of nursing care for a patient within a particular nursing care category were estimated on the basis of the amount of time the nursing staff spent on activities that are related to individual and collective patient care or ward and personal activities (eg, coffee breaks). The amount of nursing time was measured by multimoment methodology (ie, registration of the activities of individual nurses at regular intervals of 15 minutes). Results of nursing time measurements performed in 10 hospitals were pooled.
The results of this study are shown in Table 5⇓.
This study was supported in part by a grant from the National Committee on Investigative Medicine of the Health Insurance Executive Board of the Netherlands and Nederlandse Hartstichting. Dr Limburg is a clinical investigator of de Nederlandse Hartstichting. We would like to thank the colleagues of the Nederlands Instituut voor onderzoek van de eersteljinsgezondheidszorg, het Huisartsen Instituut Groningen, and OCSP for providing data, Ruud Versloot for calculating cost prices, and Mike McDowall of the OCSP for his assistance in data processing.
- Received January 17, 1995.
- Revision received June 15, 1995.
- Accepted June 20, 1995.
- Copyright © 1995 by American Heart Association
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