Acute Ischemic Stroke (AIS) Patient Management in French Stroke Units and Impact Estimation of Thrombolysis on Care Pathways and Associated Costs

Abstract

Background: Stroke is the second leading cause of death and a first leading cause of acquired disability in adults worldwide. This study aims to evaluate the current management and associated costs of acute ischemic stroke (AIS) for patients admitted in stroke units in France and over a one-year follow-up period as well as to assess the impact of improved thrombolytic management in terms of increasing the proportion of patients receiving thrombolysis and/or treated within 3 h from the onset of symptoms. Methods: A decision model was developed, which comprises two components: the first corresponding to the acute hospital management phase of patients with AIS up until hospital discharge, extracted from the national hospital discharge database (PMSI 2011), and the second corresponding to the post-acute (post-discharge) phase, based on national treatment guidelines and stroke experts' advice. Five post-acute clinical care pathways were defined. In-hospital mortality and mortality at 3 months post-discharge was taken into account into the model. Patient journeys and costs were determined for both phases. Improved thrombolytic management was modeled by increasing the proportion of patients receiving thrombolysis from the current estimated level of 16.7 to 25% as well as subsequently increasing the proportion of patients treated within 3 h of the onset of symptoms post-stroke from 50 to 100%. The impact on care pathways was derived from clinical data. Results: Among 202,078 hospitalizations for a stroke or a transient ischemic attack (TIA), 90,528 were for confirmed AIS, and 33% (29,999) of them managed within a stroke unit. After hospitalization, 60% of discharges were to home, 25% to rehabilitative care and then home, 2% to rehabilitative care and then a nursing home, 7% to long-term care, and 6% of stays ended with patient death. Of a total cost over 1 year of €610 million (mean cost per patient of €20,326), 70% concern the post-acute phase. By increasing the proportion of patients being thrombolyzed, costs are reduced primarily by a decrease in rehabilitative care, with savings per additional treated patient of €1,462. By adding improved timing, savings are more than doubled (€3,183 per additional treated patient). Conclusions: This study confirms that the burden of AIS in France is heavy. By improving thrombolytic management in stroke units, patient journeys through care pathways can be modified, with increased discharges home, a change in post-acute resource consumption and net savings.

Ischemic stroke: clinical pathway impact

“…Stroke pathway effectiveness has also been explored previously, although some reported results have not been always statistically significant (Threlkeld et al, 2017;Schmidt et al, 2015;Willeit et al, 2015;Cloud et al, 2013;Taylor et al, 2006). Willeit et al (2015) demonstrated increased Stroke Unit access after implementing a comprehensive stroke management program, without changes in the mortality rate, though without statistical significance.…”

“…Limited evidence is available about clinical pathway implementation that targets acute ischemic stroke patients (Kim et al, 2014); however, implementation is associated with reduced stays (Fujino et al, 2014) and costs (Schmidt et al, 2015). Clinical pathway implementation for stroke patients has also been associated with reduced mortality (Willeit et al, 2015).…”

Cost Assessment of Inpatient Care Episodes of Stroke in Romania

“…In Senegal the cost of treatment is USD 416 (in 1997), while in Pakistan the cost is USD 5,230 (in 1998USD 5,230 (in -2001, the latter including only direct medical costs incurred during inpatient care (6). In high income countries the costs are even higher; in France, for example, the cost per patient episode (acute phase hospitalization) is estimated to be EUR 6 199.81 (in 2011) (7), while in Canada the cost sums up to USD 10544.45 (in 2008), including diagnostics, acute care services, rehabilitation, and surgical services during the inpatient stay (8). In the United States of America, the costs add up to USD 35,175 (in 2012), considering the hospital charges for the initial treatment of patients (9).…”

Improving Outcomes Achieved by a New Stroke Program in Hungary

“…The proportion of all stroke cases receiving i.v. thrombolytic therapy was 18% in 2011 (4.9% in 2003) in Austria [ 13 , 14 ], and 16.7% in 2014-2015 in France [ 15 ], while this figure was only 3.2% in 2013 in Hungary, even though the number of thrombolysis procedures doubled between 2008 and 2013 [ 16 , 17 ]. The 3.2% thrombolysis rate was derived from 1,439 thrombolysis procedures performed at 37 active thrombolysis centers in 2013 across Hungary [ 16 , 17 , 18 ].…”

“…The organization of stroke centers required careful coordination in patient care with well-defined work flow and standard operating procedures [ 19 , 20 ]. As a result, our stroke center at the MUTH has been providing gradually improving acute stroke care, although still lagging behind that of Western European countries [ 15 , 21 , 22 , 23 ].…”