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The burden of stroke in Sweden: studies on costs and quality of life based on Riks-Stroke, the Swedish stroke register
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The costs for stroke management and reduced health related quality of life (QoL) can extend throughout life as mental and physical disabilities are common. The aim of this thesis was to quantify this stroke-related burden with data from Riks-Stroke (RS), the Swedish stroke register.

Costs for hospital and primary care, secondary drug prevention, home and residential care services, and production losses were estimated for first-ever stroke patients registered in the RS. The present value lifetime costs were estimated from the expected survival and discounted by 3%. Quality of life was estimated with the EQ-5D instrument on a subset of patients at 3 months after the index event and mapped to patient-reported outcome measures in the RS. Standard descriptive and analytic (multivariate regressions) statistical methods were used.

The life-time societal present value cost per patient in 2009 was approximately €69,000 whereof home and residential care due to stroke was 59% and indirect costs for productivity losses accounted for 21% (year 2009 prices). Women had higher costs than men in all age groups. Treatment at stroke units had a low incremental cost per life-year gained compared to patients who were not treated at such facilities. The estimated disutility from stroke was greatest for women and the oldest, and compared to 1997 the cost per patient increased after a revised assumption. Hospitalisation costs were stable while long-term costs for ADL support increased in part due to a changed age structure. Patients with atrial fibrillation (AF; 24%) had €367 higher inpatient costs compared to non-AF stroke patients €8,914 (P<0.01; year 2001 prices). As the index case fatality was higher among AF patients, the cost difference was higher for patients surviving the first 28 days. A multivariate regression showed that AF, diabetes, stroke severity, and death during the 3-year follow-up period were independent cost drivers. Three regression techniques (OLS, Tobit, CLAD) were chosen for mapping EQ-5D utilities to patient-reported outcome measures in the RS. The mean utility was overestimated with all models and had lower variance than the original data.

In conclusion, total societal lifetime cost for 22,000 first-ever stroke patients in 2009 amounted to €1.5 billion (whereof production losses were €314 million). About 56,600 QALYs were lost due to premature death and disability. Including a preference-based QoL instrument in the RS would allow cost-utility analyses, but it is important to control for confounders in comparator arms to avoid bias.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2013. , 47 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1587
Keyword [en]
Stroke, atrial fibrillation, cost of illness, utility, mapping, Sweden
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
hälso- och sjukvårdsforskning
Identifiers
URN: urn:nbn:se:umu:diva-80917ISBN: 978-91-7459-707-3 (print)OAI: oai:DiVA.org:umu-80917DiVA: diva2:652080
Public defence
2013-10-31, Hörsal D, Unod T9, Umeå Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2013-10-07 Created: 2013-09-28 Last updated: 2014-07-21Bibliographically approved
List of papers
1. Cost of stroke in Sweden: an incidence estimate
Open this publication in new window or tab >>Cost of stroke in Sweden: an incidence estimate
2004 (English)In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 20, no 3, 375-380 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To estimate the excess cost of stroke in Sweden and the potential costs that could be avoided by preventing first-ever strokes.

METHODS: We adopted the incidence approach for estimating the present value of both direct and indirect costs. Data on mortality, stroke recurrence, and inpatient care were estimated from a national register of patient data with a four-year follow-up period. To estimate costs for social services, we used survey data on living conditions before stroke onset and at three and at twenty-four months. Costs for outpatient visits, rehabilitation, drugs, and production losses due to premature death and early retirement were estimated on the basis of both published and nonpublished sources. Lifetime costs were based on life tables adjusted for excess mortality of stroke, and costs in year 4 were extrapolated to subsequent years.

RESULTS: The present value direct cost for an average stroke patient is SEK 513,800 (USdollars 56,024 or Euro 60,825). The corresponding indirect cost is SEK 125,110 (USdollars 13,640 or Euro 14,810). Almost 45 percent of the direct costs were attributable to social services. Women had higher costs than men, and costs for survivors increased with age due to social services.

CONCLUSIONS: With an incidence of 213 first-ever strokes per 100,000 individuals, the total excess direct and indirect cost of stroke would be SEK 12.3 billion (approximately US$ 1.3 billion or Euro 1.5 billion). Hence, there are large potential cost offsets both in the health-care sector and in the social service sector if the incidence of first-ever stroke could be reduced.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-19201 (URN)10.1017/S0266462304001217 (DOI)15446769 (PubMedID)
Available from: 2009-03-05 Created: 2009-03-05 Last updated: 2017-12-13Bibliographically approved
2. The effect of atrial fibrillation on stroke-related inpatient costs in Sweden: a 3-year analysis of registry incidence data from 2001
Open this publication in new window or tab >>The effect of atrial fibrillation on stroke-related inpatient costs in Sweden: a 3-year analysis of registry incidence data from 2001
2008 (English)In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 11, no 5, 862-868 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Atrial fibrillation (AF) is an important risk factor for stroke. It is prevalent in approximately one-fourth of stroke patients, and predictive of worse outcomes. This study aimed to analyze the effect of AF on stroke-related inpatient costs among first-ever stroke patients in Sweden.

Methods: Hospitalizations and death records were monitored for 3 years in 6611 first-ever stroke patients. For stroke as primary diagnosis, inpatient costs were calculated on the basis of length of stay at different wards. For stroke as secondary diagnosis, costs were based on diagnosis-related groups.

Results: Patients with AF (24% of all patients) were older (80 years vs. 73 years), had a higher prevalence of hypertension (49% vs. 41%) and/or diabetes (22% vs. 19%), higher risk of experiencing a restroke, and higher case fatality rate (43% vs. 25%) than patients without AF. The average cost per patient over 3 years was euro9004, with no statistically significant difference between AF and non-AF patients. However, a multiple regression analysis showed that the presence of AF resulted in higher costs after considering a number of background factors. Among patients surviving the index event, AF patients had on average euro818 higher inpatient costs over 3 years than non-AF patients (euro10,192 vs. euro9374, P < 0.01). The difference in costs was highest for patients aged <65 years, with a difference of euro4412 (P < 0.01).

Conclusion: AF-related strokes are associated with higher 3-year inpatient costs than non-AF strokes when controlling for factors such as case fatality rates, other risk factors for stroke, and age.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-19406 (URN)10.1111/j.1524-4733.2008.00359.x (DOI)18489491 (PubMedID)
Available from: 2009-03-05 Created: 2009-03-05 Last updated: 2017-12-13Bibliographically approved
3. Mapping health outcome measures from a stroke registry to EQ-5D weights
Open this publication in new window or tab >>Mapping health outcome measures from a stroke registry to EQ-5D weights
2013 (English)In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 11, no 34Article in journal (Refereed) Published
Abstract [en]

Purpose: To map health outcome related variables from a national register, not part of any validated instrument, with EQ-5D weights among stroke patients.

Methods: We used two cross-sectional data sets including patient characteristics, outcome variables and EQ-5D weights from the national Swedish stroke register. Three regression techniques were used on the estimation set (n = 272): ordinary least squares (OLS), Tobit, and censored least absolute deviation (CLAD). The regression coefficients for “dressing“, “toileting“, “mobility”, “mood”, “general health” and “proxy-responders” were applied to the validation set (n = 272), and the performance was analysed with mean absolute error (MAE) and mean square error (MSE).

Results: The number of statistically significant coefficients varied by model, but all models generated consistent coefficients in terms of sign. Mean utility was underestimated in all models (least in OLS) and with lower variation (least in OLS) compared to the observed. The maximum attainable EQ-5D weight ranged from 0.90 (OLS) to 1.00 (Tobit and CLAD). Health states with utility weights <0.5 had greater errors than those with weights ≥0.5 (P < 0.01).

Conclusion: This study indicates that it is possible to map non-validated health outcome measures from a stroke register into preference-based utilities to study the development of stroke care over time, and to compare with other conditions in terms of utility.

Place, publisher, year, edition, pages
London, England: BioMed Central, 2013
Keyword
Mapping, Quality of life, Stroke, Sweden, Transfer to utility, Utility
National Category
Clinical Medicine
Identifiers
urn:nbn:se:umu:diva-67367 (URN)10.1186/1477-7525-11-34 (DOI)
Available from: 2013-03-18 Created: 2013-03-18 Last updated: 2017-12-06Bibliographically approved
4. Costs for stroke in Sweden 2009 and developments since 1997
Open this publication in new window or tab >>Costs for stroke in Sweden 2009 and developments since 1997
2014 (English)In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 30, no 2, 203-209 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The aim of this study was to estimate direct and indirect excess costs attributable to stroke in Sweden in 2009 and to compare these with similar estimates from 1997. Methods: Data on first-ever stoke admissions in the first half of 2009 from the Swedish national stroke register (RS) were used for cost calculations and compared with results from 1997 also using RS data. A societal perspective was taken including the acute and follow-up phase, rehabilitation, stroke re-admissions, drugs, home-and residential care services for activities of daily life (ADL) support, and indirect costs for premature death and productivity losses (2009 prices). Survival was extrapolated to estimate the lifetime present value cost of stroke. Results: The societal lifetime present value cost for stroke in 2009 was (sic)68,800 per patient (ADL support: 59 percent; productivity losses: 21 percent). Women had higher costs than men in all age groups as a result from greater need for ADL support. Patients treated at a stroke unit indicated low incremental cost per life-year gained compared with those who had not. The total lifetime cost increased between 1997 and 2009. Hospitalization costs per patient were stable, while long-term costs for home-and residential care services increased. Conclusions: Changes in patient characteristics, longer expected survival, and possibly in the Swedish stroke care, have led to higher annual and lifetime costs per patient in 2009 compared with 1997. A comprehensive national stroke care performance register like RS may be suitable for health economic assessments.

Keyword
Stroke, Cost of illness, Technology assessment, Stroke units, Sweden
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-91228 (URN)10.1017/S0266462314000075 (DOI)000337738300010 ()
Note

Included in thesis in manuscript form, with the title "The societal cost of stroke in Sweden 2009 and its development since 1997".

Available from: 2014-07-21 Created: 2014-07-21 Last updated: 2017-12-05Bibliographically approved

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