Original Article
International Comparison of Poststroke Resource Use: A Longitudinal Analysis in Europe

https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.06.020Get rights and content

Background

Long-term costs often represent a large proportion of the total costs induced by stroke, but data on long-term poststroke resource use are sparse, especially regarding the trajectory of costs by severity. We used a multinational longitudinal survey to estimate patterns of poststroke resource use by degree of functional disability and to compare resource use between regions.

Methods

The Survey of Health, Ageing and Retirement in Europe (SHARE) is a multinational database of adults 50 years and older, which includes demographic information about respondents, age when stroke first occurred, current activity of daily living (ADL) limitations, and health care resource use in the year before interview. We modeled resource use with a 2-part regression for number of hospital days, home nursing hours, and paid and unpaid home caregiving hours.

Results

After accounting for time since stroke, number of strokes and comorbidities, age, gender, and European regions, we found that poststroke resource use was strongly associated with ADL limitations. The duration since the stroke event was significantly associated only with inpatient care, and informal help showed significant regional heterogeneity across all ADL limitation levels.

Conclusions

Poststroke physical deficits appear to be a strong driver of long-term resource utilization; treatments that decrease such deficits offer substantial potential for downline cost savings. Analyzing internationally comparable panel data, such as SHARE, provide valuable insight into long-term cost of stroke. More comprehensive international comparisons will require registries with follow-up, particularly for informal and formal home-based care.

Introduction

The value of stroke prevention and treatment strategies depends not only on the nature of the acute event and the effectiveness of the intervention but also on the type and volume of resources used. Such economic evaluations typically take the form of cost-effectiveness analyses, a foundation for clinical and policy decision making. Costs relevant to economic evaluations include short-term costs (eg, acute hospitalization) and long-term costs (eg, rehabilitation, nursing home, and home-based services).1 The economic case for interventions that reduce stroke severity is based on the extent to which the therapies reduce institutional and home-based long-term care costs. If not cost saving, even treatments that are modestly effective in reducing stroke severity can be cost effective.2

Although long-term costs often represent a large proportion of the total costs induced by stroke,3 data on long-term poststroke resource use are sparse, especially regarding the trajectory of costs by severity. Longitudinal studies, which are ideal for assessing long-term stroke costs, can be difficult and expensive.4 Moreover, resource use is highly variable, often reflecting idiosyncratic regional patterns based on clinical training, resource availability, and reimbursement.1, 5, 6 Because policy decisions are often local, resource-use studies should capture this diversity by addressing issues of regional variations.7

This article aims to quantify the estimated poststroke utilization of inpatient and home-based services as a function of disability and European regions, using the first 2 waves' data of Survey of Health, Ageing and Retirement in Europe (SHARE)8 and to contribute to the current understanding of long-term resource utilization for stroke by projecting and comparing the resource-use patterns in Europe.

Section snippets

Data Source and Study Population

Our study population was chosen from the respondents of the first 2 waves (wave 1 in 2004/2005 and wave 2 in 2006/2007) of the SHARE, which is a cross-national longitudinal survey of individuals dwelling in the community aged at least 50 years on their health, socioeconomic status, and social and family networks (n = 62,127). SHARE is notably consistent with the US Health and Retirement Study and the English Longitudinal Study of Ageing.8

We selected respondents who answered affirmatively to the

Results

Sixty percent of our study sample resided in Central Europe, and the rest of the population was balanced between Northern (21%) and Southern Europe (19%; Table 1). The average duration since stroke was 25.9 months; it was similar across all the regions (P value = .983); 30.2% of our study population had moderate ADL limitations; 6.6% had severe ADL limitations. About 6% of the study population had more than 1 stroke at the interview date, which was relatively homogenous across all regions (P

Discussion

In this study, we primarily found that poststroke resource use across all European regions was positively and strongly associated with the level of ADL limitations with patients' demographic information and the type of acute and/or subacute treatment received; several studies in the countries participating in SHARE have highlighted the effect of functional disability on poststroke resource utilization. A cohort study of stroke patients in the Netherlands found that one of the most important

Acknowledgments

This article uses data from SHARE waves 1 and 2, release 2.6.0, as of November 29 2013 (DOI: 10.6103/SHARE.w1.260 and 10.6103/SHARE.w2.260). The SHARE data collection has been primarily funded by the European Commission through the fifth Framework Programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life), through the sixth Framework Programme (projects SHARE-I3, RII-CT-2006-062193, COMPARE, CIT5-CT-2005-028857, and SHARELIFE, CIT4-CT-2006-028812), and through the seventh

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  • Cited by (0)

    This work was funded by the Singapore Ministry of Health's National Medical Research Council under its Singapore Translational Research (STaR) Award grant (grant number NMRC|STaR|0005|2009) as part of the project “Establishing a Practical and Theoretical Foundation for Comprehensive and Integrated Community, Policy and Academic Efforts to Improve Dementia Care in Singapore.” This study is also funded by the US National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, R21 AG025169, Y1-AG-4553-01, IAG BSR06-11, and OGHA 04-064), the German Ministry of Education and Research, and various national sources.

    Disclosures: D.B.M. has worked as a consultant (<$10,000) to Boehringer Ingelheim. The other authors have no conflicts to report.

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