The impact of stroke on the cost and level of care in nursing homes: a retrospective population-based study.

OBJECTIVE: To estimate the impact of incident stroke on nursing home (NH) costs and level of care. SUBJECTS AND METHODS: This retrospective population-based cohort study is part of a larger study that identified all Rochester, Minn, residents with a confirmed first stroke occurring between January 1, 1988, and December 31, 1989. One Rochester resident who had not had a stroke was matched to each person with stroke. Persons with and without stroke were followed up in provider-linked medical records and NH files from baseline (i.e., date of stroke) through December 31, 1994, for evidence of NH use. This study characterized the NH activity of those individuals with any NH activity after baseline (58 persons with major stroke, 36 persons with minor stroke, and 63 persons without stroke) as to NH case mix at first assessment, number of NH days, and per diem Medicaid reimbursement. RESULTS: Characteristics at first NH assessment after baseline revealed that NH residents with major stroke were younger and more disabled and required more services than residents without stroke. Over the full period of follow-up, the mean number of NH days was similar for NH residents with major stroke and those without stroke, yet per diem Medicaid reimbursement was 11% higher for residents with major stroke compared with residents without stroke. Nursing home residents with minor stroke appeared similar to those without stroke with respect to time to admission, characteristics at first assessment, number of NH days, and per diem Medicaid reimbursement. CONCLUSION: Lower incidence and severity of stroke may contribute to lower care needs and per diem cost, but no fewer NH days.

Stroke-attributable nursing home use: a population-based study.

OBJECTIVE: To estimate 1) among patients with stroke, nursing home use attributable to stroke, and 2) the savings in nursing home use, assuming strokes were prevented. METHODS: All confirmed cases of first stroke among Rochester, Minnesota, residents from 1987 through 1989 (n = 290) and one nonstroke control of same gender and similar age for each patient were followed up in provider-linked medical records and State of Minnesota nursing home files until emigration, death, or December 31, 1994. Data included disability and place of residence at baseline (i.e., date of stroke for each patient and their corresponding control), length of follow-up, cumulative incidence of nursing home admission, proportion of follow-up spent in a nursing home, and number of nursing home days. RESULTS: Before baseline, patients and controls were similar in the level of disability (mean Rankin = 1.7 for patients and 1.6 for controls) and the proportion in a nursing home (11% for both groups). Among those not in the nursing home at baseline, 5-year cumulative incidence of first admission was 48% for cases versus 20% for controls. Survival was significantly shorter for cases than for controls; the proportion of follow-up spent in the nursing home was 20% for cases versus 11% for controls. When controlling for survival, cases experienced an average of 110 (95% CI, 63 to 156) more nursing home days per person than controls in the first five years. When nursing home use during differential survival was included, the difference in nursing home days between cases and controls was no longer significant (p = 0.16). CONCLUSIONS: Stroke prevention would result in fewer cases admitted to the nursing home, older age at first admission, and a smaller proportion of remaining life spent in the nursing home, but stroke prevention would not result in fewer nursing home days.

Urge incontinence. Quality of life and patients' valuation of symptom reduction.

OBJECTIVE: Previous studies have demonstrated the effect of incontinence, and urge incontinence in particular, on patients' quality of life. This study assessed the effects of urge incontinence on quality of life and measured the value of a reduction in symptoms. DESIGN: A self-administered questionnaire was mailed to 591 patients with urge or mixed incontinence. 495 (83.8%) surveys were returned with complete quality of life and symptom data. Of the total sample, 411 patients received the willingness-to-pay (WTP) survey, from which 257 (62.53%) returns were judged complete and reliable. Information was collected about the number of micturitions and urinary leakages. Health-related quality of life (HR-QOL) was measured using the Short Form 36 (SF-36) Health Survey. Socioeconomic characteristics were also recorded. Value was assessed with a binary WTP question. MAIN OUTCOME MEASURES AND RESULTS: Quality of life among the sample population was significantly lower in 5 of 8 dimensions compared with the general US population, and was significantly related to the severity of the symptoms in 6 of 8 dimensions. The median (mean) willingness to pay was $US27.24 ($US87.74) per month for a 25% reduction in micturitions and leakages, and $US75.92 ($US244.54) per month for a 50% reduction in micturitions and leakages. As expected, the willingness to pay was significantly related to the size of the reduction in micturitions and leakages, and household income. CONCLUSIONS: Patients with incontinence perceive substantial benefits from a reduction in the number of micturitions and leakages.

A cost analysis of alprostadil in liver transplantation.

Alprostadil (prostaglandin E1) administration to liver transplant recipients has been shown to result in a significant reduction in the duration of hospital admission for transplantation, and in the need for re-operations (other than re-transplants) and renal support. To study the economic impact of this finding, we examined data from a controlled trial for all single-transplant surviving patients (42 alprostadil, 49 controls) for whom complete billing records were available for transplant days -2 to +150. All costs were measured in 1992 US dollars. Patients given alprostadil had lower total charges [mean +/- standard deviation (SD) $US175 297 +/- $US70 652] than patients given placebo (mean +/- SD $US225 672 +/- $US187 208) [p = 0.043]. The data suggest that the use of alprostadil may have a significant favourable impact on the cost of liver transplantation.

Utilization of acute care services in the year before and after first stroke: A population-based study.

There is a need for accurate population-based data on the utilization of medical resources after stroke. The present study used the Rochester Stroke Registry to identify all Rochester, Minnesota residents with confirmed first stroke (hospitalized and nonhospitalized) during the period of 1987 to 1989 (n=292). Events were categorized by type of stroke and assigned Rankin severity. Inpatient and outpatient acute care activity for the 12 months before and after stroke for each individual were obtained from billing tapes provided by Mayo Clinic, Olmstead Medical Group, and affiliated hospitals. These providers account for >95% of acute care received by Rochester residents. The results showed that despite high poststroke mortality, total charges in the year after stroke were 3.4 times those for the previous year. Although greater than 50% of utilization in the year poststroke occurred within the first 30 days, mean monthly charges for acute care remained significantly above prestroke levels for up to 5 months after the event. Poststroke charges per person-day of follow-up were significantly higher for individuals who were hospitalized for the event, who had subarachnoid hemorrhage, whose stroke occurred after admission to the hospital for another reason, and who died within 7 days. Significantly lower poststroke charges were evident for persons with mild cerebral infarctions and persons whose stroke occurred in a nursing home. Neither prestroke utilization, age category, nor sex were predictive of poststroke charges. The unique population-based data presented here have important implications for efforts toward stroke prevention, intervention, and cost containment.

Hospitalizations with adverse events caused by digitalis therapy among elderly Medicare beneficiaries.

BACKGROUND: Digitalis products are among the agents most frequently prescribed to the elderly, yet previous studies have not provided age-, race-, and sex-specific rates of utilization of digitalis by this population. Estimates of the rate of hospitalization with an adverse reaction from digitalis therapy have varied considerably between systems relying on passive reports and those using active surveillance. METHODS: Medicare data from 1985 through 1991 and data from the 1987 National Medical Expenditure Survey were used to determine population-based estimates of the use of digitalis in elderly beneficiaries by age group, sex, and race. Hospitalization rates with an adverse event caused by digitalis therapy were calculated for those persons estimated to be using digitalis. Medicare data were used to identify the frequency of selected comorbidities among persons with an adverse event caused by digitalis therapy as well as the frequency of clinical manifestations associated with digitalis intoxication. RESULTS: Over 3 million Medicare beneficiaries were estimated to be using digitalis in 1987. A total of 202,011 hospitalizations with a coded adverse event caused by digitalis therapy were reported during the 7-year study period. Of persons estimated to be using digitalis, 8.53 per 1000 were hospitalized annually with an adverse event caused by digitalis therapy. Women, individuals with increasing age, and persons of black race, especially those with impaired renal function, were significantly (P < .05) more likely to experience hospitalization with an adverse event caused by digitalis therapy. CONCLUSION: This information may help identify categories of elderly patients who require more frequent monitoring to prevent adverse effects of digitalis therapy. Changes in the format of the hospital bill to include more diagnoses along with increased mandatory reporting of adverse drug events will improve the sensitivity of Medicare data for surveillance of adverse drug events.

Net economic benefit of a manufactured dinoprostone gel for pre-induction cervical ripening.

The purpose of this study was to estimate the net economic cost or benefit of pretreating women who have a medical indication for induction of labour, and an unprepared (unripe) cervix, with a manufactured dinoprostone (prostaglandin E 2) gel. Findings of a meta-analysis of the results of 3 large, randomised clinical trials were employed in the construction of a decision tree used in the economic analysis. For the intended target population, the primary clinical and economic outcomes of gel pretreatment were shortening of the treatment-to-delivery interval, an increase in the percentage of patients achieving labour and a decrease in the percentage of patients requiring delivery by caesarean section. Application of cost factors associated with these and other variables led to a finding of net savings associated with use of the dinoprostone gel pretreatment, compared with no gel pretreatment, of $US159 to $US214 (1993 prices) per treated patient, corresponding to the maximum and minimum duration of the pre-induction treatment period, respectively.