Suchergebnisse

Background Stroke is a high-cost condition. Detailed patient-level assessments of the costs of care received and outcomes achieved provide useful information for organisation and optimisation of the health system. Objectives To describe the costs of hospital care for stroke and transient ischaemic attack (TIA) and investigate factors associated with costs. Methods Retrospective cohort study using data from the Australian Stroke Clinical Registry (AuSCR) collected between 2009 and 2013 linked to hospital administrative data and clinical costing data in Queensland. Clinical costing data include standardised assignment of costs from hospitals that contribute to the National Hospital Costing programme. Patient-level costs for each hospital admission were described according to the demographic, clinical and treatment characteristics of patients. Multivariable median regression with clustering by hospital was used to determine factors associated with greater costs. Results Among 22 hospitals, clinical costing data were available for 3909 of 5522 patient admissions in the AuSCR (71%). Compared to those without clinical costing data, patients with clinical costing data were more often aged <65 years (30% with cost data vs 24% without cost data, p < 0.001) and male (56% with cost data vs 49% without cost data, p < 0.001). Median cost of an acute episode was $7945 (interquartile range $4176 to $14970) and the median length of stay was 5 days (interquartile range 2 to 10 days). The most expensive cost buckets were related to medical ( n = 3897, median cost $1577), nursing ( n = 3908, median cost $2478) and critical care ( n = 434, median cost $3064). Factors associated with greater total costs were a diagnosis of intracerebral haemorrhage, greater socioeconomic position, in-hospital stroke and prior history of stroke. Conclusion Medical and nursing costs were incurred by most patients admitted with stroke or TIA, and were relatively more expensive on average than other cost buckets such as imaging and allied health. Implications Scaling this data linkage to national data collections may provide valuable insights into activity-based funding at public hospitals. Regular report of these costs should be encouraged to optimise economic evaluations.

IntroductionTo prevent further vascular events, prescribing of multiple classes of medications (antihypertensive, antithrombotic and lipid-lowering) is recommended in national clinical guidelines following ischaemic stroke.
Objectives and ApproachUsing real-world data, we determined the association between optimal combination pharmacotherapy (supply of all three classes, "optimal pharmacotherapy") and survival after stroke. We linked a cohort of patients with first-ever ischaemic stroke from the Australian Stroke Clinical Registry (2010-2014) with national pharmaceutical dispensing and national mortality data. Cox regression was used to determine associations between pharmacotherapy in the first 30 days of stroke with 1-year (from day 31 to 395) all-cause mortality. All analyses were adjusted for socio-demographic (age, sex) and clinical characteristics (stroke severity, discharge destination).
ResultsAmong 6684 patients discharged following first-ever ischaemic stroke (median length-of-stay 5 days), 6466 patients who survived to 30 days were included (44% female, median age 74 years). During the first 30 days from discharge, 71.4% received ≥1 medication class, and 32.9% (n=2125) received optimal pharmacotherapy. Patients with optimal pharmacotherapy were older (≥75 years 50.3% vs <75 years 44.5%; p<0.001), discharged directly home (home 58.5% vs other 40.3%; p<0.001) and experienced a less severe stroke (able to walk on admission 46.9% vs 36.4%; p<0.001), than those without optimal pharmacotherapy. Between day 31 and 395, there were 667 deaths; 530 related to cardiovascular disease. Compared to no medication, treatment with two medications was associated with a 42% lower risk of death (hazard ratio [HR]: 0.58; 95%CI: 0.45-0.73); and optimal pharmacotherapy had a 62% lower risk of death (HR: 0.38; 95% CI: 0.31-0.47). Survival was similar between those with one or no medication.
Conclusion / ImplicationsPatients with ischaemic stroke who received optimal pharmacotherapy within 30-days of admission had greater one-year-survival. Further research is required to understand reasons for sub-optimal pharmacotherapy in these patients.

IntroductionSurvivors of stroke have complex needs from ongoing disabilities and have increased risk of cardiovascular diseases. The societal costs are therefore substantial. Person-level longitudinal data on the longer-term hospital utilizations of patients with stroke in Australia, and the factors that may influence usage in this setting, are rarely reported.
Objectives and ApproachWe used person-level linkages between the Australian Stroke Clinical Registry (AuSCR: 2009-2013) and hospital admission and Emergency Department (ED) data from four states to examine determinants of hospital utilisation following stroke. The index event was the first event recorded in AuSCR. The rate of hospital contacts/person/year was calculated from contacts 30-365 days post-discharge. Disability was determined from responses to EQ-5D-3L data collected at 90-180 days post-stroke. Comorbidities were identified using ICD-10 discharge diagnosis codes (5 year look back including the index event). Negative binomial regression was used adjusting for patient clustering by hospital and pre-stroke contacts and stratified by disability.
ResultsAmong 10,082 adults with acute stroke (55% male, median age 74 years, 81% ischaemic, 14% hemorrhagic, 5% undetermined, 44% with disability) from 39 hospitals, 57% had a hospital admission or ED contact in the first 30-365 days post-hospital discharge, with median contacts/person/year post-stroke of 1.09 (Q1, Q3: 0, 3.27) compared to a pre-contact rate of 0 (Q1, Q3: 0, 2.18). The strongest associations with subsequent hospital contacts were prior contacts (IRR:1.10, 95%CI:1.07, 1.13), not able to walk on admission (stroke severity) (IRR:1.19, 95%CI 1.07, 1.31) and having a higher comorbidity index score (IRR:1.18, 95%CI:1.14, 1.22). Within stratified cohorts younger age was associated with increased contacts in those with disability (
Conclusion/ImplicationsIn a large linked cohort of patients we have demonstrated the substantial ongoing burden that stroke imposes on hospital systems, particularly regarding survivors with other comorbidities and younger survivors with disability. Knowledge of disability and comorbidity burden may assist with targeting community and hospital interventions to reduce post-stroke hospital usage.