Cost-effectiveness of organised inpatient care for stroke

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Every year, 120 000 French are suffering from a stroke. One year mortality rates are around 30% for cerebral infarction and 50% for cerebral haemorrhage. The sequelae from this serious pathology are often extremely persistant with the consequence that individuals who survived a stroke require treatment in all types of care facility in the French healthcare system.

METHODS :

The stroke path within the healthcare system has been simulated, using a Markov modelisation. The choosen length of the simulation is 5 years, which means 20 cycles of 3 months. Markov states were defined from clinical elements of the pathology, disability rate of the patients (Barthel index) and pathways of cares (rehabilitation centers, home, geriatric institutions). Three disability levels were picked up in each path, using the Barthel index. There are 4*(2+3*3) clinical status, making 45 Markov states, including death, no matter of its cause, as absorbing state. 3, 6, 9 and 12 months mortality rates were calculated for each mechanism from cohort of 213 patients. The course taken by patients through the French healthcare system after acute hospitalisation for stroke was identified from an observational survey carried out by the stroke registry, Dijon. Costs were estimated using the national costs database, PMSI. All calculations of cost were made using the point of view of the healthcare system, limiting expenditure to healthcare consumption and use of medical or medicosocial resources (ODAS 97). Expenditures were discounted at 5%.

RESULTS :

The model enabled us to calculate how long patients spent with each of the different levels of disability or in the different places of residence, according to whether they received care in a stroke unit or conventional care. Through these 5 years, 36.9% of patients died. The survivors spent an average of 11.6% of the time in hospital, 14.6% of the time in geriatric institutions and 73.8% of the time at home. Through 5 years with disability consecutive to a hospilatization, 69.2% of those are with mild disability (Barthel 95-100), 16.2% are with moderate disability (Barthel 60-90) and 14.6% are with severe disability (Barthel 0-55). Taking care of the 120 000 annual stroke cases in France would cost € 4.5 billion after 5 years, ischaemic strokes and subarachnoid haemorrhages apart. Of those 43.1% are from short term hospitalization, 4.5% from rehabilitation centers, 26 % are institutional facility, 26.4 % are home care. The amount of expenditures is proportional to disability rate. A sensibility analisys was preceded.

CONCLUSION :

The incidence approach is the only one that allows a reflection on the conditions of a future change of the costs. An implementation requires a global approach of the disease.