Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors

Abstract

BackgroundIt is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.MethodsPatient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.ResultsFive hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.ConclusionHighlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver’s role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3696-3) contains supplementary material, which is available to authorized users.

Effect of education and muscle relaxation program on anxiety, depression and care burden in caregivers of acute stroke survivors

“…Stroke often contributes to chronic disability and difficulties of daily lives among stroke survivors, and it is common for the majority of stroke survivors to be dependent on others (such as caregivers) to continue their normal daily lives. [ 4 ] Therefore, caregivers play important roles in supporting stroke survivors during the post-stroke process, and offer care services including personal care (feeding, toileting, bathing, etc), health care (stroke monitoring, functional rehabilitation, management of stroke complication, etc), social support, which might disrupt the normal life and work of caregivers, thus leading to heavy burden and poor mental status to a certain extent. [ 18 ] According to the previous data, about 68.4% of the caregivers display moderate and severe care burden, and it is indicated that care burden burnout is correlated with several factors, including caregiving hours, the stroke severity at discharge, health-related quality of life in patients, the presence of atrial fibrillation in patients, and the degree of dependence.…”

“…[ 2 ] In the duration of post-stroke rehabilitation and recovery for acute stroke survivors, the effort of caregivers is important, while notably, caregivers often experience much stress for dealing with the patients’ social, biological and psychological needs. [ 3 , 4 ] Thus, it is common for caregivers to present psychological disorders (including anxiety and depression) with prevalence of anxiety and depression ranging from 20% to 40%, and with the increment of care burden, the severity of anxiety and depression becomes higher, which further negatively influences the quality of lives in caregivers. [ 5 – 8 ] Therefore, it is important to improve the mental health and alleviate the care burden, which could bring the welfare to the caregivers of acute stroke survivors.…”

A retrospective cohort study examining secondary prevention post stroke in primary care in an Asian setting

“…The healthcare system in Singapore comprises of public, private, and non-profit healthcare institutions delivering a range of services including inpatient and emergency services, intermediate and long-term care (ILTC) services and outpatient services comprising of both specialist and primary care services [ 19 ]. The public sector is not only the major provider in acute care setting, covering 80% of tertiary hospitals in Singapore, but it is also central to providing primary care services to individuals with chronic ailments.…”

Dyadic approach to post-stroke hospitalizations: role of caregiver and patient characteristics

“…This categorization of ward class is implemented across all clinical specialties or departments within the tertiary care setting. For current analysis, we binarized this ward class variable into subsidized and non-subsidized ward class [32]. For scales with significant (> 10) number of missing cases (NIHSS, MMSE, Revised memory and behaviour checklist), we used the person mean substitution approach to impute for missing values for cases with less than half the constituent items missing [33].…”