October 22, N Mittmann, SJ Seung, M Sharma, BURST Investigators

Transcription

1 October 22, 2009 N Mittmann, SJ Seung, M Sharma, BURST Investigators

2 Objectives To understand the burden of stroke To describe a prospective study evaluating stroke resources To understand the relationship between costing and disability

3 Disclosure Initial funding through an unrestricted grant from AstraZeneca Canada. Secondary funding from a CSN grant. Study design, conduct and analysis was investigator-driven.

4 Background 50,000 Canadians are admitted to hospital annually due to stroke. Stroke admissions associated with a long length of stay in hospital. Acute care costs are fairly well documented. 300,000 Canadians are living with effects of stroke. Canadian Stroke Network

5 MODIFIED RANKIN SCALE SCOREDESCRIPTION 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention TOTAL (0-5): Instructions: The Modified Rankin Scale (MRS) describes grades of disability after a stroke (grade 5 denotes severe disability, bedridden; and grade 0 denotes no symptoms at all). Please check ONLY ONE box.

6 Economic Burden of Stroke The economic impact of stroke is substantial and the costs of stroke to society are high. The life time cost of stroke to society has been estimated to be $1.7 billion in Australia (2004); $857 million (1994/95) in Canada, $194 to 239 million (2005) in Argentina and 8.9 billion (2004) in the UK. A literature review of cost effectiveness evaluations showed costs ranging from $468 to $146,149 $US with the majority of studies provided costs at hospital discharge and few studies reporting on productivity losses.

7 BURST Investigators Ottawa M Sharma, A Fisher, D Cousineau Toronto DJ Gladstone, L Valentine, S Ramagano, N Fedasko, G Valencia Calgary M Hill, M McClelland Montreal R Côte, A M Fontaine Quebec City A Mackey, A Haché Edmonton A Shuaib, AM Nasser Vancouver P Teal, T Steele, K Murray Halifax S Phillips, G Gubitz, S Nearing, W Simpkin Saint John P Bailey, P Cook Thunder Bay D Howse, S Stoger, MJ Cameron Grey Nuns B Buck, T Griffin Stead London V Hachinski, C Frank, K Hesser, K Baptista

8 Study Objective The objective was to determine the resource utilization and associated costs of treating ischemic stroke in the first six months including post acute components: Outpatient stroke centre care Outpatient stroke rehabilitation care Community (home) care Indirect costs related to changes in patient s employment and out of pocket costs (i.e. purchase of medical equipment aids)

9 Background The BURST Study is the first pan Canadian study to determine resource utilization and direct and indirect costs of managing ischemic strokes in the first six months post stroke.

10 Methods Study cohort (N=232) of eligible adult ischemic stroke subjects recruited in a consecutive manner at sites (N=12) across Canada.

11 Methods 12 Sites Edmonton (2) Vancouver Calgary Thunder Bay Quebec Montreal Ottawa Saint John London Toronto Halifax

12 Inclusion/Exclusion Criteria AGE LANGUAGE COMMUNICATION STROKE TYPE OF STROKE CLINICAL TRIALS 19 years or older. Patient/caregiver fluent in English or French. Patient/caregiver able to participate (aphasia not an exclusion factor). Incident stroke. Imaging-verified ischemic stroke. Patients participating in clinical trials influencing resource utilization excluded.

13 Methods Study Documents Informed Consent & Stroke Discharge; Baseline Questionnaire 3-Month Questionnaire 6-Month Questionnaire Diary #1 Diary #2

14 Baseline Questionnaire Demographics Clinical History Co morbidities Discharge Destinations Drug History NIH Stroke Scale (NIHSS) Modified Rankin Scale (mrs) Barthel Index (BI) Hamilton Depression Rating Scale (HAM D) Health Utilities Index (HUI) Mark III Resource Utilization

15 Cost Variables Time Horizon Direct Hyper-acute Costs Indirect Hyper-acute Costs Direct Acute Costs Indirect Acute Costs Direct Post-Acute Costs Indirect Post-Acute Costs Costs Included Transportation, Emergency, Physician, Diagnostics, Laboratory, Medications Not applicable Hospitalization, Medications, Diagnostics, Physician, Rehabilitation, Home Care (private/public), Devices, Home Changes (residential/personal), Out-of-Pocket Expenses Patient Lost productivity, Unpaid Caregiver Hospitalization, Medications, Diagnostics, Physician, Rehabilitation, Home Care (private/public), Devices, Home Changes (residential/personal), Out-of-Pocket Expenses Patient Lost productivity, Unpaid Caregiver

16 N = % male Average age ± stdev (range) = 69.4 ± 15.4 years (27 94) Median age = 70.5 years

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19 VARIABLE VALUE (N=232) VALUE (N=3323) % male subjects 51% 54% Median age (years) Co-morbidities (%): Hypertension Dyslipidemia Diabetes Atrial fibrillation TIA 58% 52% 23% 19% 6% 58% 30% 22% 14% 4% [3] Kapral MK et al. Sex Difference in Stroke Care and Outcomes. Stroke (4):

20 Definitions Hyperacute (pre admission) Acute (0 3 months) Post acute (4 6 months)

21 Costs 2009 Canadian $; Ontario based Sources Ministry of Health, Institutions, Ontario Case Costing Initiative, Statistics Canada, Private Companies Non 2009 costs were converted to 2009 costs

22 Analysis Cost Overall Disabled (mrs 3 5) vs. Non disabled (mrs 0 2) mrs level Disaggregated

23 Costs by Time Cost

24 Cost by Disability

25 Disaggregated Costs

26 Post Acute Costs (4 6 months)

27 Disaggregated Post Acute Costs

28 Discussion Population is representative of Canadian stroke population. As disability increases, so does cost. Most of the costs occur in the first 3 months after a stroke. Reduction in the severity of stroke would improve clinical and economic value.

29 What to do with data? Decision makers Identify cost drivers Examine impact of new drugs

30 Future Costs at 12 months Change in disability over time Utility cross section and prospective Regional variation

31 Thank you Co investigators Clinic Coordinators Canadian Stroke Network Astra Zeneca

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