Original Article
Cost of stroke from a tertiary center in northwest India Gagandeep Kwatra, Paramdeep Kaur1, Gagan Toor1, Dinesh K. Badyal, Raminder Kaur1, Yashpal Singh1, Jeyaraj D. Pandian1 Department of Pharmacology, 1Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
Abstract
Address for correspondence: Dr. Jeyaraj D. Pandian, Department of Neurology, Head of Research, Betty Cowan Research and Innovation Centre, Christian Medical College, Ludhiana, Punjab - 141 008, India. E‑mail: [email protected] Received: 22‑06‑2013 Review completed: 27‑07‑2013 Accepted: 18‑12‑2013
Aim: We aimed to study the cost of stroke, its predictors, and the impact on social determinants of the family. Settings and Design: This prospective study was done in the Stroke unit and Neurology clinic between April 2009 and October 2011. Materials and Methods: All first ever stroke patients during the study period were enrolled. Direct and indirect costs at admission, at 1 and 6 months follow‑up were obtained. The follow‑up included information about the patient’s poststroke outcome using modified Rankin Scale (mRS), work status, modifications made at home, loan requirement, etc., Results: Two hundred patients were enrolled in this study and final analysis was performed on 189 patients. The mean age was 58 ± 13 years and 128 (67.7%) were men. Majority (54%) were living in a joint family. The mean overall cost of stroke per patient was rupees (INR) 80612 at 6 months. Higher income (P = 0.008), poor outcome (mRS >2) (P = 0.001), and length of hospital stay (P = 0.001) were the cost driving factors of total cost of stroke at 6 months. There was a decline in the requirement of help (P < 0.0001) and need for loan (P = 0.003) at 6 months follow‑up. Conclusions: Direct medical cost or acute care of stroke accounted for a major component of cost of stroke. Poor outcome, length of hospital stay, and higher income were the cost driving factors. The socioeconomic impact on the family decreased at follow up probably due to joint family system. Key words: Cost, developing country, indirect costs, socioeconomic, stroke,
treatment
Introduction Stroke is one of the leading causes of death and disabilities worldwide. There is a high economic impact of stroke in developed countries like Australia, United Kingdom, Canada, New Zealand, Korea, and Taiwan.[1‑6] In India, a good number of stroke epidemiological data have been published recently.[7‑9] However, little is known about the cost and economic impact of stroke. The health system in India is also different from other Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125270
Neurology India | Jan-Feb 2013 | Vol 61 | Issue 1
countries. While Government hospitals are available, the major health provider is the private sector. Health insurance covers only 10% of people and old people are not covered by health insurance policies.[10] The cost of treating a stroke patient can thus differ from other regions of the world. We carried out this study with the following objectives: a) to study the cost of illness of stroke, that is, direct medical, nonmedical and indirect costs; b) To study the predictors of cost of stroke; and c) to explore the changes in the social determinants following stroke in the family.
Materials and Methods This prospective study was carried out in the Stroke unit and Neurology clinic of a tertiary referral center in northwest India from April 2009 to October 2011. The study protocol was approved by the Institutional Research Committee. 627
Kwatra, et al.: Cost of stroke
Stroke was defined as per World Health Organization (WHO) criteria and was confirmed by computed tomography (CT) or magnetic resonance imaging (MRI). Both ischemic as well as hemorrhagic stroke cases were included in the study. An informed consent was taken from all patients before the questionnaire was administered. If the patient had cognitive impairment, altered sensorium or dysphasia, then the consent was obtained from the next of kin.
the information provided by the patient and/or the caregivers. If the patient was brought to the hospital in an ambulance or hired vehicle, the actual charges were used. If the patient was transported using own or friends’/ relatives’ vehicle, then the cost was calculated using the approximate distance and average fuel cost. If the patient had to be shifted to another house or additional appliances were purchased, then those costs were added to direct nonmedical costs.
The inclusion criteria were: a) all consecutive first ever stroke patients; b) age ≥18 years; ischemic and hemorrhagic stroke patients; and c) patients with premorbid modified Rankin Scale (mRS) of 0-1. Exclusion criteria were: a) patients with subarachnoid hemorrhage; and b) patients with one or more chronic diseases like renal failure, liver disease, bilateral severe osteoarthritis of knee, hip, etc.
Indirect costs Indirect costs of disease are defined as the production value lost to society due to absence from work, disability and death.[12] In this study, the human capital approach was used to estimate the indirect cost or productivity losses.[11] The indirect costs were estimated for patients who had a paid job prior to the stroke and also for patients involved in unpaid domestic work. In case of sick leave, the number of sick leave days was multiplied by the average daily income of the patient. Productivity losses were also calculated for the informal caregivers based on the number of working days missed. For the patients or caregivers who performed unpaid domestic activities, the loss of productivity was based on the average labor wages applicable in our country.[13] For patients who had a premature death, productivity losses were estimated from the time of their death up to 6 months of follow‑up.
Baseline information included demographics, medical history, Oxfordshire community stroke project classification (OCSP), prestroke mRS, and risk factor assessment. The questionnaire also included information about the number of earning members, family income, and the patient’s housing conditions prior to the stroke. The cost‑related data collected was analyzed from a societal perspective and included the direct as well as indirect costs. Intangible costs, which refer to patients’ psychological pain and discomfort, were not included. The information related to hospital cost was obtained from the hospital bills. Patients and their caregivers provided the information regarding family income and expenditures related to hospitalization both during admission and follow‑up. The same research staff had collected the information throughout the study. Cost calculations Direct cost Direct cost was calculated as a sum of direct medical and nonmedical cost. Direct medical costs The information related to cost of hospitalization, laboratory, radiology and cardiology‑related investigations, drugs, nursing charges, consultant fees, rehabilitation services, and interdepartmental consultations was obtained from the hospital bills. Direct nonmedical costs Nonmedical direct costs include transportation costs to healthcare providers; relocation expenses; and costs of making changes to one’s diet, house, car, or related items.[11] This study included the cost of transportation of the patient to the hospital and costs incurred by the caregivers during the period of patient’s hospitalization: meals, transportation, lodging, etc., This was based on 628
Patient follow‑up The patients were followed up at 1 and 6 months’ time following the stroke. At the time of follow up, direct medical costs related to hospital record charges, laboratory investigations, drugs, and rehabilitation were calculated. The direct nonmedical costs were based on the transportation charges for the patient’s hospital visit and relocation expenses, if any. For the indirect costs, it was assumed that there was loss of one day of paid production for the patient as well as for the caregivers and calculations were made accordingly. A telephonic follow‑up was conducted if any patient did not come to the hospital on the designated day. In addition, information regarding patient’s functional and socioeconomic status following the stroke was obtained. Patient’s functional capacity was assessed by getting information about the patient’s poststroke mRS, work status, need for a caregiver either as a family member or a paid helper, modifications made at home or appliances purchased for the patient following the stroke. If the patient needed help for daily activities, information about the number of caregivers and the impact of the patient’s stroke on their earning capacity was also obtained. To assess the economic impact of stroke on the patient and his/her family, there were questions about any change in Neurology India | Jan-Feb 2013 | Vol 61 | Issue 1
Kwatra, et al.: Cost of stroke
the patient’s housing condition, and also if the patient’s family had to borrow money for the treatment in the form of a bank loan or a soft loan from friends/relatives. Joint family (extended family/complex family) was defined as multiple generations in a family living in a single house. Education was classified into lower (illiterate and up to primary level) and upper (secondary school and beyond). Income was classified into lower (10 days tPA|| received Yes No Health insurance Yes No Medical and neurological complications** Yes No
Number Mean
P
95%CI*
0.007 114 74
70987 63107-81130 96079 82634-111085 0.01
142 47
86105 64015
77274-96886 50926-79534 0.001
104 85
64276 56723-73483 100600 88709-113190
34 39 31 21 6 4 54
52400 60506 82042 74998 84505 130458 110133
92 93
54480 104480
6 180
109206 79182
47 141
89470 76999
9 180
151425 83889-231237 77071 69820-85479
43774-62535
Cost of stroke from a tertiary center in northwest India Gagandeep Kwatra, Paramdeep Kaur1, Gagan Toor1, Dinesh K. Badyal, Raminder Kaur1, Yashpal Singh1, Jeyaraj D. Pandian1 Department of Pharmacology, 1Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
Abstract
Address for correspondence: Dr. Jeyaraj D. Pandian, Department of Neurology, Head of Research, Betty Cowan Research and Innovation Centre, Christian Medical College, Ludhiana, Punjab - 141 008, India. E‑mail: [email protected] Received: 22‑06‑2013 Review completed: 27‑07‑2013 Accepted: 18‑12‑2013
Aim: We aimed to study the cost of stroke, its predictors, and the impact on social determinants of the family. Settings and Design: This prospective study was done in the Stroke unit and Neurology clinic between April 2009 and October 2011. Materials and Methods: All first ever stroke patients during the study period were enrolled. Direct and indirect costs at admission, at 1 and 6 months follow‑up were obtained. The follow‑up included information about the patient’s poststroke outcome using modified Rankin Scale (mRS), work status, modifications made at home, loan requirement, etc., Results: Two hundred patients were enrolled in this study and final analysis was performed on 189 patients. The mean age was 58 ± 13 years and 128 (67.7%) were men. Majority (54%) were living in a joint family. The mean overall cost of stroke per patient was rupees (INR) 80612 at 6 months. Higher income (P = 0.008), poor outcome (mRS >2) (P = 0.001), and length of hospital stay (P = 0.001) were the cost driving factors of total cost of stroke at 6 months. There was a decline in the requirement of help (P < 0.0001) and need for loan (P = 0.003) at 6 months follow‑up. Conclusions: Direct medical cost or acute care of stroke accounted for a major component of cost of stroke. Poor outcome, length of hospital stay, and higher income were the cost driving factors. The socioeconomic impact on the family decreased at follow up probably due to joint family system. Key words: Cost, developing country, indirect costs, socioeconomic, stroke,
treatment
Introduction Stroke is one of the leading causes of death and disabilities worldwide. There is a high economic impact of stroke in developed countries like Australia, United Kingdom, Canada, New Zealand, Korea, and Taiwan.[1‑6] In India, a good number of stroke epidemiological data have been published recently.[7‑9] However, little is known about the cost and economic impact of stroke. The health system in India is also different from other Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125270
Neurology India | Jan-Feb 2013 | Vol 61 | Issue 1
countries. While Government hospitals are available, the major health provider is the private sector. Health insurance covers only 10% of people and old people are not covered by health insurance policies.[10] The cost of treating a stroke patient can thus differ from other regions of the world. We carried out this study with the following objectives: a) to study the cost of illness of stroke, that is, direct medical, nonmedical and indirect costs; b) To study the predictors of cost of stroke; and c) to explore the changes in the social determinants following stroke in the family.
Materials and Methods This prospective study was carried out in the Stroke unit and Neurology clinic of a tertiary referral center in northwest India from April 2009 to October 2011. The study protocol was approved by the Institutional Research Committee. 627
Kwatra, et al.: Cost of stroke
Stroke was defined as per World Health Organization (WHO) criteria and was confirmed by computed tomography (CT) or magnetic resonance imaging (MRI). Both ischemic as well as hemorrhagic stroke cases were included in the study. An informed consent was taken from all patients before the questionnaire was administered. If the patient had cognitive impairment, altered sensorium or dysphasia, then the consent was obtained from the next of kin.
the information provided by the patient and/or the caregivers. If the patient was brought to the hospital in an ambulance or hired vehicle, the actual charges were used. If the patient was transported using own or friends’/ relatives’ vehicle, then the cost was calculated using the approximate distance and average fuel cost. If the patient had to be shifted to another house or additional appliances were purchased, then those costs were added to direct nonmedical costs.
The inclusion criteria were: a) all consecutive first ever stroke patients; b) age ≥18 years; ischemic and hemorrhagic stroke patients; and c) patients with premorbid modified Rankin Scale (mRS) of 0-1. Exclusion criteria were: a) patients with subarachnoid hemorrhage; and b) patients with one or more chronic diseases like renal failure, liver disease, bilateral severe osteoarthritis of knee, hip, etc.
Indirect costs Indirect costs of disease are defined as the production value lost to society due to absence from work, disability and death.[12] In this study, the human capital approach was used to estimate the indirect cost or productivity losses.[11] The indirect costs were estimated for patients who had a paid job prior to the stroke and also for patients involved in unpaid domestic work. In case of sick leave, the number of sick leave days was multiplied by the average daily income of the patient. Productivity losses were also calculated for the informal caregivers based on the number of working days missed. For the patients or caregivers who performed unpaid domestic activities, the loss of productivity was based on the average labor wages applicable in our country.[13] For patients who had a premature death, productivity losses were estimated from the time of their death up to 6 months of follow‑up.
Baseline information included demographics, medical history, Oxfordshire community stroke project classification (OCSP), prestroke mRS, and risk factor assessment. The questionnaire also included information about the number of earning members, family income, and the patient’s housing conditions prior to the stroke. The cost‑related data collected was analyzed from a societal perspective and included the direct as well as indirect costs. Intangible costs, which refer to patients’ psychological pain and discomfort, were not included. The information related to hospital cost was obtained from the hospital bills. Patients and their caregivers provided the information regarding family income and expenditures related to hospitalization both during admission and follow‑up. The same research staff had collected the information throughout the study. Cost calculations Direct cost Direct cost was calculated as a sum of direct medical and nonmedical cost. Direct medical costs The information related to cost of hospitalization, laboratory, radiology and cardiology‑related investigations, drugs, nursing charges, consultant fees, rehabilitation services, and interdepartmental consultations was obtained from the hospital bills. Direct nonmedical costs Nonmedical direct costs include transportation costs to healthcare providers; relocation expenses; and costs of making changes to one’s diet, house, car, or related items.[11] This study included the cost of transportation of the patient to the hospital and costs incurred by the caregivers during the period of patient’s hospitalization: meals, transportation, lodging, etc., This was based on 628
Patient follow‑up The patients were followed up at 1 and 6 months’ time following the stroke. At the time of follow up, direct medical costs related to hospital record charges, laboratory investigations, drugs, and rehabilitation were calculated. The direct nonmedical costs were based on the transportation charges for the patient’s hospital visit and relocation expenses, if any. For the indirect costs, it was assumed that there was loss of one day of paid production for the patient as well as for the caregivers and calculations were made accordingly. A telephonic follow‑up was conducted if any patient did not come to the hospital on the designated day. In addition, information regarding patient’s functional and socioeconomic status following the stroke was obtained. Patient’s functional capacity was assessed by getting information about the patient’s poststroke mRS, work status, need for a caregiver either as a family member or a paid helper, modifications made at home or appliances purchased for the patient following the stroke. If the patient needed help for daily activities, information about the number of caregivers and the impact of the patient’s stroke on their earning capacity was also obtained. To assess the economic impact of stroke on the patient and his/her family, there were questions about any change in Neurology India | Jan-Feb 2013 | Vol 61 | Issue 1
Kwatra, et al.: Cost of stroke
the patient’s housing condition, and also if the patient’s family had to borrow money for the treatment in the form of a bank loan or a soft loan from friends/relatives. Joint family (extended family/complex family) was defined as multiple generations in a family living in a single house. Education was classified into lower (illiterate and up to primary level) and upper (secondary school and beyond). Income was classified into lower (10 days tPA|| received Yes No Health insurance Yes No Medical and neurological complications** Yes No
Number Mean
P
95%CI*
0.007 114 74
70987 63107-81130 96079 82634-111085 0.01
142 47
86105 64015
77274-96886 50926-79534 0.001
104 85
64276 56723-73483 100600 88709-113190
34 39 31 21 6 4 54
52400 60506 82042 74998 84505 130458 110133
92 93
54480 104480
6 180
109206 79182
47 141
89470 76999
9 180
151425 83889-231237 77071 69820-85479
43774-62535
