Background:
The economic burden of stroke is high and expected to increase with the growing stroke incidence among younger adults and the aging population. However, we are unaware of a comprehensive review of the cost drivers across the stroke care continuum. We conducted a literature review and summarized the costs incurred in the inpatient and outpatient settings during the acute and post-acute periods.
Methods:
A systematic search of MEDLINE, EMBASE, CINAHL was conducted to identify cost-of-illness studies published during January 2000-October 2019 that evaluated the direct medical costs of stroke in the US. We extracted both the index hospitalization costs and the costs incurred thereafter. We summarized the costs by stroke type (ischemic, intracerebral hemorrhage, subarachnoid hemorrhage, transient ischemic attack) and by cost component (e.g., inpatient hospital stays, skilled nursing facility for rehabilitation, physician consultation, medication use). Cost estimates were adjusted to 2019 dollars by using the US Consumer Price Index.
Results:
Thirty-six studies were included. Thirteen studies (36%) focused on inpatient costs only, twenty-one (58%) estimated both inpatient and outpatient costs, two (6%) examined outpatient costs only. Nine studies (25%) estimated the stroke-attributable costs by using propensity score matching and econometric models. The index hospitalization costed $9,050-$74,525 per admission for ischemic stroke (15 studies), $18,554-$117,991 for hemorrhagic stroke (5 studies), and $9,658-$10,544 for transient ischemic attack (2 studies). Among studies that examined costs beyond the index hospitalization (n=22, 61%), follow-up periods varied from 30 days to 4 years. Sixteen of these studies (73%) estimated total costs only; five (23%) identified costs by period. For ischemic stroke, the total cumulative post-stroke costs were estimated at $15,037 (30-day period), $17,968-$29,704 (90-day), $27,072-$37,611 (180-day), $21,642-$87,135 (1-year), $50,153-$117,683 (2-year), and $70,513-$173,904 (4-year); the proportion attributed to inpatient care reduced from 65% (30-day period) to 46% (4-year). Skilled nursing facility care accounted for 19% of the costs four years post ischemic stroke and for 13% four years post intracerebral hemorrhage stroke. For subarachnoid hemorrhage stroke, inpatient care remained the biggest cost driver four years after the index event (70% of the total cost), followed by outpatient physician services (11%) and skilled nursing facility care (8%).
Conclusions:
While caution should be taken when interpreting the cost findings due to variation in data sources, study population and analytical methods, the costs of stroke are substantial. Inpatient, skilled nursing facility and outpatient physician costs are the main cost drivers and their contribution to total costs vary greatly over time and by stroke type.
POLICY AND QUALITY: THE IMPACT ACT OF 2014 AND DEVELOPMENT OF THE SKILLED NURSING FACILITY QUALITY REPORTING PROGRAM