Poorer Outcomes and Greater Costs Noted with Recurrent Stroke
abstract & commentary
Source: Samsa GP, et al. Epidemiology of recurrent cerebral infarction. A Medicare claims-based comparison of first and recurrent strokes on 2-year survival and cost. Stroke 1999; 30:338-349.
One of the main goals of acute and long- term management of stroke is to prevent its recurrence. Most physicians assume that recurrent strokes will leave patients with greater disability than first strokes, and that patients with recurrent strokes will have poorer outcomes, but no comprehensive study has established this as fact. Samsa and colleagues used a large, nationally representative cohort of patients to contrast 24-month survival and direct medical costs of first and recurrent strokes. From Medicare Provider Analysis and Review files, they selected a random 20% sample of 49,333 patients aged 65 and older who were hospitalized with a primary diagnosis of cerebral infarction during 1991. Of these, 90% had no record of a previous stroke and 10% had a record of at least one previous stroke. (See Table.)
Two-year survival from first stroke (56.7%) was significantly better than that for recurrent stroke (48.3%). The probability of surviving for at least two years after stroke was higher for women and for younger patients. Costs were similar for the initial hospital stay—although patients with recurrent stroke had longer stays than patients with first stroke by 0.7 days on average—and in months one to three after stroke. Thereafter, total costs were higher among recurrent stroke patients by approximately $375 per month across all patients, but the difference was greatest for younger patients, and least for patients aged 80 years or older. Most of the difference in cost was attributable to nursing home use (averaging approximately $150 per month) and acute hospitalization (averaging approximately $120 per month). Samsa et al conclude that to be accurate, decision and cost-effectiveness models should use different estimates of survival and cost outcomes for first and recurrent strokes.
| Table | ||
| Characteristics of Patients with First or Recurrent Stroke | ||
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(n = 44,386) |
(n = 49,47) |
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| Age in Years (mean ± SD) |
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| Men |
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| White |
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| Hypertension |
|
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| Diabetes Mellitus |
|
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| Myocardial Infarction |
|
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| Congestive Heart Failure |
|
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| Chronic Obstructive Pulmonary Disease |
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| Valvular Heart Disease |
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|
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COMMENTARY
Samsa et al found that patients with recurrent stroke have, on average, poorer survival, but higher costs than those with first stroke. In addition, they noted that patients with more than one previous stroke generally had worse outcomes than patients with a history of only one previous stroke, who, in turn, had poorer outcomes on average than patients with a first-ever stroke. These outcome patterns are consistent with the hypothesis that patients with recurrent strokes tend to have greater levels of mental and physical disability than those with first strokes. The relationship between chronic disability and higher costs is borne out by Samsa et al’s observation that the cost of acute hospital treatment was similar in the two stroke groups, but that later costs were greater for recurrent stroke patients because of more nursing home stays and more hospitalizations.
The findings in this study can help public healthcare analysts to better estimate the true national economic burden of stroke. For clinicians, the study underlines the need for greater efforts on their part to prevent stroke by risk factor modification and to treat acute strokes, whether first or recurrent, vigorously to minimize the amount of brain damage and, hopefully, avert chronic disability.
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