Decreasing Costs of Stroke Hospitalization in Toronto
To the Editor:
Our previous article on the costs of stroke care in Toronto in 19931 has been cited in numerous other publications,2 3 4 5 6 but these costs are no longer valid and may be misleading. We have recalculated them in the light of recent major changes in stroke management and hospital restructuring that has occurred throughout Canada7 since the previous publication.
Patients were retrospectively identified from the Stroke Registry at Sunnybrook Health Science Centre (SWCHSC) and via chart reviews for the 1996 fiscal year (April 1, 1996, through March 31, 1997). Only ischemic strokes (identified by clinical and CT criteria) were included. All were first strokes admitted to SWCHSC, a university teaching hospital and tertiary care center with 428 acute care beds.
Demographic, social, and clinical data were located in patient charts and recorded in the Stroke Registry. Social data was defined as family support, whether the patient was living with family before the stroke and discharged home to family after the stroke. The subtype of ischemic stroke was classified according to the TOAST criteria.8 The modified Rankin scale9 was used to determine the stroke severity: 0–1, mild stroke; 2–3, moderate stroke; and 4–5, severe stroke. Fatal stroke includes both early deaths (0 to 7 days) and late deaths (>7 days).
Treatment and hospitalization costs (direct costs only) were determined from the Transitional System Incorporated costing system at SWCHSC for the 1996 fiscal year. The costs incorporated in the total cost were nursing, medical services (psychology, speech pathology, social services, and pathology), laboratory tests (CT, vascular ultrasound, Holter, electrocardiography, conventional angiography, biochemistry, hematology, and microbiology), physiotherapy, occupational therapy, physician fees (fees for service for each patient according to the Ontario Health Insurance Plan), and pharmacy (medication costs for each patient). Canadian cost figures were converted into American dollars with use of the exchange rate from June 1998 (US $1≃ Can $1.45).
Microsoft Excel (version 7.0) was used to determine descriptive statistics (ie, mean and SD) and Pearson’s correlation coefficient the relationship between cost, length of stay (LOS), and stroke severity. The t test was used to determine significant differences between means (P<0.05), and the χ2 test was used to determine significant differences between proportions.10
A total of 73 patients were identified with a mean±SD age of 77±13 years and a mean±SD LOS of 20±21 days. There were 35 men (mean age, 72±15 years) and 38 women (81±9 years), with a significant difference in age (P<0.05). The mean LOS for the male patients was 18±20 days versus 22±23 days for the female patients (P>0.05).
The mean cost of all ischemic strokes was Can $9763±11 053 (US $6738±7628). The cost and LOS associated with large-artery disease (n=14) were Can $11 183±12 248 (US $8153±8453) and 17±18 days, respectively; for cardioembolic stroke (n=31), Can $10 756±11 485 (US $7424±7927) and 22±24 days; for lacunar strokes (n=10), Can $10 437±14 054 (US $7424±7297) and 20±23 days; and for undetermined strokes (n=18), Can $8740±$8789 (US $6032±6066) and 19±20 days, respectively. There was no significant difference in cost for the stroke subtypes (P>0.05).
Stroke costs related to LOS (r=0.94) and severity (r=0.41), with severe strokes being the most expensive and having the greatest LOS (see the Table⇓). Fatal cases were also costly because of the extended LOS before death.
Our new data, compared with the 1993 data, show that a greater proportion of patients were discharged home (41% versus 28%, P<0.05) and fewer went to rehabilitation (23% versus 35%, P<0.05) or nursing home/long-term care facilities (8% versus 22%, P<0.05). However, there were more deaths in the current group of patients than in our 1993 study (27% versus 15%, P<0.05), probably a function of the small sample size.
Patients discharged home to their family (n=41) had a shorter LOS (16±16 days) than those living alone (n=32; 24±26 days) (P<0.05). There was no difference (P>0.05) in the number of patients with family support in comparison with our 1993 study. Therefore, the cost of treating a stroke patient discharged home to family was Can $8236±9078 (US $5684±6265) compared with Can $11 721±13 053 (US $8090±9009) for a patient living alone (P>0.05).
There are some limitations to this study. First, our data were captured from one center in Canada, and the costs may represent only the province of Ontario. Second, we did not include indirect costs, which remains a difficult and complex parameter to measure,11 so the overall economic impact of stroke is underestimated. Third, our sample size was small and there may be changes in the demographic information (eg, number of stroke fatalities), as evident in a larger study that we are currently undertaking to examine hospitalization and posthospitalization stroke costs. This future study will also address the issue of whether cost shifting from the acute care hospital to rehabilitation centers, long-term care institutions, or home care has occurred. Last, thrombolytic therapy is not yet available as “open label” in Canada and thus has not been factored into these costs.
We feel that in view of the striking decrease in costs of stroke management in hospitals between 1993 and the present, a brief communication is warranted before completion of our new evaluation.
- Copyright © 1999 by American Heart Association
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