The Impact of Atrial Fibrillation on the Cost of Stroke: The Berlin Acute Stroke Study

Background: Risk factors for stroke may alter hemodynamics or invoke ischemic preconditioning, yet the impact of such factors on response to acute stroke treatment and the potential relationship with collateral circulation remains unknown. Methods: Consecutive cases enrolled in the International Multicenter Registry for Mechanical Recanalization Procedures in Acute Stroke (ENDOSTROKE) were analyzed with respect to collateral status on baseline angiography before endovascular therapy. ASITN/SIR collateral grade (0-1/2/3-4) was scored by the core lab, blind to all other data. Collateral grade was analyzed with respect to numerous baseline risk factors, demographics and outcomes after endovascular intervention. Results: 109 patients (median age 69 years (25 th , 75 th percentiles: 56, 77); 51% women; median baseline NIHSS 15 (13, 18)) with complete (TICI 0) anterior circulation occlusions (M1, n=71; ICA, n=28; M2, n=10) at baseline were evaluated based on collateral grade (0-1, n=12; 2, n=41; 3-4, n=56). Worse collaterals were noted in patients with atrial fibrillation (ASITN grades 0-1/2/3-4: 21%/30%/49%) as compared to patients without atrial fibrillation (5%/42%/53%, p=0.024), yet cardioembolic stroke etiology was unrelated. Other baseline features such as age, gender, time to presentation, other co-morbidities and labs were unrelated to collateral grade. Post-procedure reperfusion (TICI 2b-3) was significantly associated with better collaterals (OR 2.58 (1.343-4.957, p=0.004). Similarly, final infarct size was significantly smaller in those with better collaterals. Good clinical outcomes (mRS 0-2 at day 90) were less frequent in those with poorer collaterals (OR 0.403 (0.199-0.813, p=0.011). Conclusions: Atrial fibrillation, but not cardioembolic stroke etiology, is associated with worse collaterals. Hemodynamic implications, such as diminished cardiac output due to atrial fibrillation, may result in less favorable outcomes after endovascular therapy for acute stroke.

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Abstract T P158: Albuminuria Is Associated With Neurological Deterioration and Poor Outcome in Acute Stroke Patients With Non-valvular Atrial Fibrillation: The SAMURAI-NVAF Study

Stroke ◽

10.1161/str.46.suppl_1.tp158 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Takayuki Matsuki ◽

Masatoshi Koga ◽

Shoji Arihiro ◽

Kenichi Todo ◽

Hiroshi Yamagami ◽

...

Keyword(s):

Atrial Fibrillation ◽

Acute Stroke ◽

Clinical Outcomes ◽

Reperfusion Therapy ◽

Neurological Deterioration ◽

Stroke Patients ◽

Multicenter Observational Study ◽

Spot Urine ◽

Poor Outcome ◽

The Impact

Background and purpose: The impact of albuminuria on clinical outcomes in acute cardioembolic stroke is not fully investigated. We assessed whether high spot urine albumin/creatinine ratio (ACR) was associated with clinical outcomes in acute stroke with non-valvular atrial fibrillation (NVAF). Methods: From 2011 to 2014, we enrolled acute ischemic stroke/TIA patients with NVAF in the SAMURAI-NVAF study, which is a multicenter, observational study. Patients with complete ACR values were included in the analysis. They were divided into the N (normal, ACR < 30mg/g) and the H (high, ACR ≥ 30mg/g) groups. Clinical outcomes were neurological deterioration (an increase of NIHSS ≥1 point during the initial 7 days) and poor outcome (mRS of 4-6 at 3 months). Results: Of 558 patients (328 men, 77±10 y) who were included, 271 and 287 were assigned to the H group and the N group, respectively. As compared with patients in the N group, those in the H group were more frequently female (52 vs 31%, p < 0.001) and older (80±10 vs 75±10 y, p < 0.001). On admission, patients in the H group more frequently had diabetes (28 vs 17%, p = 0.003), less frequently had paroxysmal AF (68 vs 57%, p = 0.009), had higher levels of SBP (157±28 vs 151±24 mmHg, p = 0.003), NIHSS score (11 vs 5, p < 0.001), CHA2DS2-VASc score (6 vs 5, p < 0.001), plasma glucose (141±62 vs 132±41 mg/dL, p = 0.04), and brain natriuretic peptide (348±331 vs 259±309 pg/mL, p = 0.002), and had lower levels of hemoglobin (13±2 vs 14±2 g/dL, p = 0.02), and estimated glomerular filtration ratio (eGFR) (60±24 vs 66±20 mL/min/1.73m2 p = 0.002). On imaging studies, patients in the H group more frequently had large infarct (29 vs 20 %, p = 0.02) and culprit artery occlusion (64 vs 48%, p < 0.001). Neurological deterioration (14 vs 4%, p < 0.001) and poor outcome (49 vs 24%, p < 0.001) were more frequently observed in the H group. On multivariate regression analysis adjusted for significant confounders and reperfusion therapy, the H group was associated with neurological deterioration (OR 2.43; 95% CI 1.14-5.5; p = 0.02) and poor outcome (OR 2.75; 95% CI 1.45-5.2; p = 0.002), although eGFR was not significantly related to either. Conclusion: High ACR, a marker of albuminuria, was independently associated with unfavorable outcomes in acute stroke patients with NVAF.

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036 The impact of a clinical support tool on stroke key performance indicators

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-anzan.33 ◽

2019 ◽

Vol 90 (e7) ◽

pp. A12.3-A13

Author(s):

Khaled Alanati ◽

James Evans

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Acute Stroke ◽

Performance Indicators ◽

Meta Analysis ◽

Stroke Care ◽

Key Performance Indicators ◽

Google Scholar ◽

Cochrane Database ◽

The Impact

IntroductionAdherence to key performance indicators (KPIs) in stroke care is associated with better outcomes.1–6 The complexity in management of acute strokes, however, has created barriers towards delivering best care with plateauing of KPIs as measured by The National Stroke Foundation Clinical Audit.We examined the impact on stroke KPIs in our local health district of a web-based decision support stroke platform which provides clinicians with up-to-date information about the patient’s management flagging potential areas for improvement, allowing treatment to be optimised in real time.MethodsSix months following the introduction of the platform we performed a retrospective analysis of Electronic medical records of patients admitted to Gosford hospital with acute stroke between June 2018 and September 2018 assessing access to the stroke unit as well as being discharged on appropriate secondary prophylactics, including antihypertensives and correct antithrombotic therapy. Patients whose direction of care was palliative and patients with documented contraindication to secondary prophylactics were excluded.ResultsOver four months, 136 patients presented with acute ischaemic stroke and 11 patients had a haemorrhagic stroke. 49 ischaemic stroke patients had atrial fibrillation. Stroke unit access was higher following its introduction in 2018 compared to 2017 (97% vs 76%, respectively). Similar findings were noted for patients with atrial fibrillation who received oral anticoagulants on discharge (90% vs 50%) and patients discharged on antihypertensives (95% vs 80%).ConclusionUse of a clinical support platform in managing acute stroke is an intervention that improves stroke care.ReferencesUrimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. European Stroke Journal 2017;2(4):287–307. https://doi.org/10.1177/2396987317735426Sandercock P, Gubitz G, Foley P. Antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2003;2: CD000029. Google ScholarKwan J, Sandercock P. In-hospital care pathways for stroke. Cochrane Database Syst Rev2004;4: CD002924. Google ScholarSaxena R, Koudstaal PJ. Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack. Cochrane Database Syst Rev 2004;4: CD000187. Google ScholarGoyal M, Menon BK, van Zwam WH. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trial. Lancet 2016;387:1723–1731. Google Scholar | Crossref | Medline | ISIMiddleton S, McElduff P, Ward J. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011;378:1699–1706. Google Scholar | Crossref | Medline | ISI

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Mortality in acute stroke with atrial fibrillation. The Italian Acute Stroke Study Group.

Stroke ◽

10.1161/01.str.22.2.169 ◽

1991 ◽

Vol 22 (2) ◽

pp. 169-174 ◽

Cited By ~ 52

Author(s):

L Candelise ◽

G Pinardi ◽

A Morabito

Keyword(s):

Atrial Fibrillation ◽

Acute Stroke ◽

Study Group ◽

Stroke Study ◽

Stroke Study Group

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How Big Is the Impact of the Warfarin Cost on the Cost–Effectiveness of Rivaroxoban for Stroke Prevention in Atrial Fibrillation?

The American Journal of Cardiology ◽

10.1016/j.amjcard.2012.07.016 ◽

2012 ◽

Vol 110 (9) ◽

pp. 1384-1385

Author(s):

Omid Sanaei

Keyword(s):

Atrial Fibrillation ◽

Cost Effectiveness ◽

Stroke Prevention ◽

The Cost ◽

The Impact

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Implementing the NHS England Long Term Plan for stroke: how should reperfusion services be configured? A modelling study

10.31219/osf.io/yg3x8 ◽

2021 ◽

Author(s):

Michael Allen ◽

Kerry Pearn ◽

Gary A. Ford ◽

Phil White ◽

Anthony Rudd ◽

...

Keyword(s):

Acute Stroke ◽

Computer Modelling ◽

Systems Of Care ◽

Stroke Care ◽

Net Benefit ◽

Acute Stroke Care ◽

Modest Improvement ◽

Secondary Transfer ◽

The Cost ◽

The Impact

Objectives: To guide policy when planning reperfusion thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship' (secondary transfer for MT after local IVT) provision and the impact of bypassing local acute stroke centres.Methods: Computer modelling was used to estimate the likely outcomes from reperfusion therapies, along with admission numbers to units, based on expected times to IVT and MT.Results: Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit accrues from direct conveyance to an IVT/MT centre. If this model was followed then net benefit from reperfusion is predicted to be increased from 31 to 34 additional disability-free outcomes / 1,000 admissions. However, this policy produces unsustainable admission numbers at these centres, and depletes all but 19 IVT-only units of all stroke admissions. Implementing a maximum permitted additional travel time to bypass an IVT-only unit, or using a pre-hospital test for LAO, both increase net benefit over the current drip-and-ship model, but produce a similar destabilising effect on acute systems of care. Use of IVT-only units manage admission numbers to IVT/MT centres.Conclusions: The mothership model reduces time to MT at the cost of increased time to IVT, but the benefit of faster MT is predicted to lead to a modest improvement in overall outcomes. Providing a sustainable national system of acute stroke care requires a hybrid of mothership and drip-and-ship provision.

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Economics and Outcomes of Sotalol In-Patient Dosing Approaches in Patients with Atrial Fibrillation

10.22541/au.163253963.32016624/v1 ◽

2021 ◽

Author(s):

Daniel Varela ◽

Tyson Burnham ◽

Heidi May ◽

Tami Bair ◽

Benjamin Steinberg ◽

...

Keyword(s):

Atrial Fibrillation ◽

Length Of Stay ◽

Average Length ◽

Drug Loading ◽

Hospital Costs ◽

Cost Savings ◽

Post Discharge ◽

Hospitalization Costs ◽

The Cost ◽

The Impact

Background: There exists variability in the administration of inpatient sotalol therapy for symptomatic atrial fibrillation(AF). The impact of this variability on patient in-hospital and 30-day post-hospitalization costs and outcomes is not known. Also, the cost impact of intravenous sotalol, which can accelerate drug loading to therapeutic levels, is unknown. Methods: 133 AF patients admitted for sotalol initiation at an Intermountain Healthcare Hospital from January 2017-December 2018 were included. Patient and dosing characteristics were described descriptively, and the impact of dosing schedule was correlated with daily hospital costs/clinical outcomes during the index hospitalization and for 30 days. The CMS reimbursement for 3-day sotalol initiation is $9,263.51. Projections of cost savings were made considering a 1-day load using intravenous sotalol that costs $2,500.00 to administer. Results: The average age was 70.3±12.3 years, 60.2% were male with comorbidities of: hypertension(83%), diabetes(36%), and coronary artery disease(53%). Mean ejection fraction was 59.9±7.8% and median QTc was 453.7±37.6 ms before sotalol. No ventricular arrhythmias developed, but bradycardia(<60 bpm) was observed in 37.6% of patients. The average length of stay was 3.9±4.6(median: 2.2) days. Post-discharge outcomes and rehospitalization rates stratified by length of stay were similar. The cost per day was estimated at $2,931.55 (1:$2,931.55, 2:$5,863.10, 3:$8,794.65, 4:$11,726.20). Conclusions: Inpatient sotalol dosing is markedly variable and results in the potential of both cost gain and loss to a hospital. In consideration of estimated costs, there is the potential for $871.55 cost savings compared to a 2-day oral load and $3,803.10 compared to a 3-day oral load.

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Demonstrating Nutrient Cost Gradients: A Brooklyn Case Study

International Journal for Vitamin and Nutrition Research ◽

10.1024/0300-9831/a000210 ◽

2014 ◽

Vol 84 (5-6) ◽

pp. 244-251 ◽

Cited By ~ 2

Author(s):

Robert J. Karp ◽

Gary Wong ◽

Marguerite Orsi

Keyword(s):

Low Income ◽

Energy Content ◽

Food Selection ◽

The United States ◽

United States Department ◽

Micronutrient Deficiencies ◽

Caloric Density ◽

Low Income Families ◽

The Cost ◽

The Impact

Abstract. Introduction: Foods dense in micronutrients are generally more expensive than those with higher energy content. These cost-differentials may put low-income families at risk of diminished micronutrient intake. Objectives: We sought to determine differences in the cost for iron, folate, and choline in foods available for purchase in a low-income community when assessed for energy content and serving size. Methods: Sixty-nine foods listed in the menu plans provided by the United States Department of Agriculture (USDA) for low-income families were considered, in 10 domains. The cost and micronutrient content for-energy and per-serving of these foods were determined for the three micronutrients. Exact Kruskal-Wallis tests were used for comparisons of energy costs; Spearman rho tests for comparisons of micronutrient content. Ninety families were interviewed in a pediatric clinic to assess the impact of food cost on food selection. Results: Significant differences between domains were shown for energy density with both cost-for-energy (p < 0.001) and cost-per-serving (p < 0.05) comparisons. All three micronutrient contents were significantly correlated with cost-for-energy (p < 0.01). Both iron and choline contents were significantly correlated with cost-per-serving (p < 0.05). Of the 90 families, 38 (42 %) worried about food costs; 40 (44 %) had chosen foods of high caloric density in response to that fear, and 29 of 40 families experiencing both worry and making such food selection. Conclusion: Adjustments to USDA meal plans using cost-for-energy analysis showed differentials for both energy and micronutrients. These differentials were reduced using cost-per-serving analysis, but were not eliminated. A substantial proportion of low-income families are vulnerable to micronutrient deficiencies.

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Stroke Prevention in Non-Valvular Atrial Fibrillation

Hämostaseologie ◽

10.1055/s-0038-1659985 ◽

1997 ◽

Vol 17 (03) ◽

pp. 166-169

Author(s):

Judith O’Brien ◽

Wendy Klittich ◽

J. Jaime Caro

Keyword(s):

Atrial Fibrillation ◽

Clinical Trials ◽

Care Home ◽

Relevant Literature ◽

Clinical Trial Data ◽

Outcome Data ◽

Sensitivity Analyses ◽

Bleeding Events ◽

Discharge Data ◽

The Cost

SummaryDespite evidence from 6 major clinical trials that warfarin effectively prevents strokes in atrial fibrillation, clinicians and health care managers may remain reluctant to support anticoagulant prophylaxis because of its perceived costs. Yet, doing nothing also has a price. To assess this, we carried out a pharmacoe-conomic analysis of warfarin use in atrial fibrillation. The course of the disease, including the occurrence of cerebral and systemic emboli, intracranial and other major bleeding events, was modeled and a meta-analysis of the clinical trials and other relevant literature was carried out to estimate the required probabilities with and without warfarin use. The cost of managing each event, including acute and subsequent care, home care equipment and MD costs, was derived by estimating the cost per resource unit, the proportion consuming each resource and the volume of use. Unit costs and volumes of use were determined from established US government databases, all charges were adjusted using cost-to-charge ratios, and a 3% discount rate was applied to costs incurred beyond the first year. The proportions of patients consuming each resource were estimated by fitting a joint distribution to the clinical trial data, stroke outcome data from a recent Swedish study and aggregate ICD-9 specific, Massachusetts discharge data. If nothing is done, 3.2% more patients will suffer serious emboli annually and the expected annual cost of managing a patient will increase by DM 2,544 (1996 German Marks), from DM 4,366 to DM 6,910. Extensive multiway sensitivity analyses revealed that the higher price of doing nothing persists except for very extreme combinations of inputs unsupported by literature or clinical standards. The price of doing nothing is thus so high, both in health and economic terms, that cost-consciousness as well as clinical considerations mandate warfarin prophylaxis in atrial fibrillation.

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TRANSFER FİYATLAMA UYGULAMASININ İŞLETME PERFORMANSINA ETKİSİ VE VERGİSEL AÇIDAN DEĞERLENDİRİLMESİ

Business And Management Studies An International Journal ◽

10.15295/bmij.v1i2.63 ◽

2014 ◽

Vol 1 (2) ◽

pp. 187

Author(s):

Serdar KUZU

Keyword(s):

Business Performance ◽

Transfer Pricing ◽

Tax Law ◽

Economic Activities ◽

Tax System ◽

Goods And Services ◽

Tax Legislation ◽

International Transactions ◽

The Cost ◽

The Impact

The size of international trade continues to extend rapidly from day to day as a result of the globalization process. This situation causes an increase in the economic activities of businesses in the trading area. One of the main objectives of the cost system applied in businesses is to be able to monitor the competitors and the changes that can be occured as a result of the developments in the sector. Thus, making cost accounting that is proper according to IAS / IFRS and tax legislation has become one of the strategic targets of the companies in most countries. In this respect, businesses should form their cost and pricing systems according to new regulations. Transfer pricing practice is usefull in setting the most proper price for goods that are subject to the transaction, in evaluating the performance of the responsibility centers of business, and in determining if the inter-departmental pricing system is consistent with targets of the business. The taxing powers of different countries and also the taxing powers of different institutions in a country did not overlap. Because of this reason, bringing new regulations to the tax system has become essential. The transfer pricing practice that has been incorporated into the Turkish Tax System is one of the these regulations. The transfer pricing practice which includes national and international transactions has been included in the Corporate Tax Law and Income Tax Law. The aim of this study is to analyse the impact of goods and services transfer that will occur between departments of businesses on the responsibility center and business performance, and also the impact of transfer pricing practice on the business performance on the basis of tax-related matters. As a result of the study, it can be said that transfer pricing practice has an impact on business performance in terms of both price and tax-related matters.

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