Sunday, August 21, 2011

Estimating the lifetime economic burden of stroke according to the age of onset in South Korea: a cost of illness study

The recently-observed trend towards younger stroke patients in Korea raises economic concerns, including erosion of the workforce. We compared per-person lifetime costs of stroke according to the age of stroke onset from the Korean societal perspective.


A state-transition Markov model consisted of three health states ('post primary stroke event', 'alive post stroke', and 'dead') was developed to simulate the natural history of stroke. The transition probabilities for fatal and non-fatal recurrent stroke by age and gender and for non-stroke causes of death were derived from the national epidemiologic data of the Korean Health Insurance Review and Assessment Services and data from the Danish Monitoring Trends in Cardiovascular Disease study. We used an incidence-based approach to estimate the long-term costs of stroke. The model captured stroke-related costs including costs within the health sector, patients' out-of-pocket costs outside the health sector, and costs resulting from loss of productivity due to morbidity and premature death using a human capital approach. Average insurance-covered costs occurring within the health sector were estimated from the National Health Insurance claims database. Other costs were estimated based on the national epidemiologic data and literature. All costs are presented in 2008 Korean currency values (Korean won = KRW).


The lifetime costs of stroke were estimated to be: 200.7, 81.9, and 16.4 million Korean won (1,200 KRW is approximately equal to one US dollar) for men who suffered a first stroke at age 45, 55 and 65 years, respectively, and 75.7, 39.2, and 19.3 million KRW for women at the same age. While stroke occurring among Koreans aged 45 to 64 years accounted for only 30% of the total disease incidence, this age group incurred 75% of the total national lifetime costs of stroke.


A higher lifetime burden and increasing incidence of stroke among younger Koreans highlight the need for more effective strategies for the prevention and management of stroke especially for people between 40 and 60 years of ages.

Angry reaction to new stroke figures

hitting back ... Dr Jon Scott of South Tyneside NHS Trust.
HOSPITAL bosses in South Tyneside have hit back at figures which appear to show that the treatment of stroke patients in the borough is not up to scratch.
Quarterly data on the quality of stroke care, released by the Royal College of Physicians, charts the first 72 hours of care a patient receives.
The figures, collected between April and June, show South Tyneside District Hospital NHS Trust performed significantly worse than the national average.
Hospital chiefs say the figures are not a true representation of their performance because they don’t take into account the way patients are admitted in the borough.
The Trust has spent £1m revamping the stroke unit at the Harton Lane hospital and say the numbers aren’t a true representation because a third of the 75 units involved didn’t supply information and the way in which patients receive treatment is also not taken into account.
The data claimed that it took 421 minutes for patients in the borough to receive a scan on arrival at hospital, compared with the national average of 143 minutes.
It also highlighted that it took 227 minutes – compared with 128 minutes nationally – for patients to come into contact with a member of the stroke team.
This increased to 230 minutes – above the national average of 188 – when out of hours.
Dr Jon Scott, consultant stroke physician, said the figures are assumed to be correct, but not all stroke units entered data into the Stroke Improvement National Audit Programme (SINAP) so the national average wasn’t a true representation.
He said: “The guidance for CT scans is that they need to be done for all patients within 24 hours and, for a small minority, as soon as possible.
“The national average includes data from hyperacute units, where patients are diverted past their local hospital. Therefore, it is rather difficult to interpret as the national average figure comprises many different types of stroke service.”
He said South Tyneside has a 24/7 consultant-led and delivered service that is able to guarantee treatment, irrespective of time of onset of symptoms and guarantees a consultant review within 24 hours for all patients, even at weekends and bank holidays.
Dr Scott says the pathway the hospital uses to treat its patients through its A&E department, before they are transferred to the stroke unit, has also affected scores.
He said: “Our pathway utilises the on-call registrar to review acute stroke patients in A&E.
“This is not classified as a ‘member of the stroke team’ according to the SINAP data definitions, hence the higher than average score.
“First contact with someone who fits the SINAP definition tends to occur when the patient arrives on the stoke unit.
“This is why our in-hours and out-of hours contact times are virtually identical.”
The next audit figures are due in November.

Neurology: Ultrasound markers may predict high stroke risk

A pair of visual ultrasound markers may help physicians better determine which patients with asymptomatic carotid stenosis face a higher stroke risk, and better determine which patients might benefit from carotid endarterectomy (CEA), according to a study published online Aug. 17 in Neurology.

The absolute benefit of CEA is small, which has spurred concerns about the cost effectiveness and utility of the procedure. However, limiting the procedure to patients with asymptomatic carotid stenosis (CS) at higher risk for ipsilateral stroke could yield cost and clinical benefits.

Thus, Raffi Topakian, MD, of the department of neurology at Academic Teaching Hospital Wagner-Jauregg in Linz, Austria, and colleagues devised a study to determine whether a predictive score based ultrasonic plaque morphology assessment and the detection of asymptomatic emboli signals on transcranial Doppler ultrasound might improve prediction of stroke or transient ischemic attack (TIA).

The researchers leveraged data from 435 patients with  asymptomatic CS enrolled in the Asymptomatic Carotid Emboli Study (ACES). Participants were enrolled between July 1999 and August 2007 and had > 70 percent asymptomatic CS. Ultrasound was performed at study entry.

The primary endpoint was stroke or stroke/TIA risk predicted by plaque echolucency at study entry. Secondary endpoints were ipsilateral stroke alone, any stroke or cardiovascular death.

The research team analyzed plaque morphology and graded plaques as echolucent or echogenic, using a five-type classification scale.

Nearly 38 percent of plaques were graded as echolucent, and of the 428 patients with analyzable transcranial Doppler recordings, 17.1 percent had at least one emboli signal detected on either of the two baseline recordings.

During the nearly two-year follow-up, researchers recorded 10 ipsilateral strokes, 20 ipsilateral TIAs and 17 strokes in any territory, with 33 patients suffering any stroke or CV death.

Also, during follow-up, 33 patients underwent CEA and there were 29 deaths.

According to Topakian et al, plaque echolucency was associated with an increased risk of ipsilateral stroke and showed a trend toward association with ipsilateral stroke and TIA and any stroke. Subjects with both echolucency and embolic signal positivity at baseline faced a significant increase in risk for ipsilateral stroke and TIA, ipsilateral stroke and any stroke.

“[Patients] with both conditions present had at least a 10-fold increase in the risk of ipsilateral stroke with an annual risk of about 8.9 percent compared with a 0.8 percent risk in individuals without both risk markers,” wrote Topakian.

The researchers noted that the visual scale is relatively easy to use and could be incorporated into outpatient clinical management of patients with asymptomatic CS, while providing a strong prediction of future risk.

However, one limitation of the study is that physicians may have excluded high risk patients with asymptomatic CS from ACES.

Still, the researchers concluded that the combined markers enable differentiation between low-risk and high-risk patients and may help inform decision-making and selection of appropriate candidates for CEA.