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1.
Anticancer Res ; 41(2): 927-936, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33517299

RESUMO

BACKGROUND/AIM: Limited published real-world data describe adverse events (AEs) among patients treated for mantle-cell lymphoma (MCL). The aim of this retrospective study was to describe treatment patterns, AEs, and associated healthcare costs. PATIENTS AND METHODS: Patients had two or more claims coded for MCL diagnosis, the first claim date (07/01/2012-05/31/2017) was the index date. Patients with pre-index MCL diagnosis or systemic treatment, or hematopoietic stem cell transplantation were excluded. Cohorts by regimen were followed for up to three lines of therapy. RESULTS: Patients (n=395; median age 72 years; 31% female) were observed over a total of 576 lines of therapy, the most common being bendamustine plus rituximab; rituximab monotherapy; R-CHOP; and ibrutinib. The most frequent AEs were hypertension (40.5%), anemia (37.7%), and infection (36.1%). However, hepatotoxicity ($19,645), stroke ($18,893), and renal failure ($9,037) were associated with the highest medical costs per patient per month. CONCLUSION: Among patients receiving common systemic treatments for MCL, AEs occurred frequently; some imposed substantial inpatient care costs.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Doença Hepática Induzida por Substâncias e Drogas/economia , Linfoma de Célula do Manto/tratamento farmacológico , Insuficiência Renal/economia , Acidente Vascular Cerebral/economia , Adenina/efeitos adversos , Adenina/análogos & derivados , Adenina/economia , Adenina/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Cloridrato de Bendamustina/efeitos adversos , Cloridrato de Bendamustina/economia , Cloridrato de Bendamustina/uso terapêutico , Ciclofosfamida/efeitos adversos , Ciclofosfamida/economia , Ciclofosfamida/uso terapêutico , Doxorrubicina/efeitos adversos , Doxorrubicina/economia , Doxorrubicina/uso terapêutico , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Piperidinas/efeitos adversos , Piperidinas/economia , Piperidinas/uso terapêutico , Prednisona/efeitos adversos , Prednisona/economia , Prednisona/uso terapêutico , Insuficiência Renal/induzido quimicamente , Estudos Retrospectivos , Rituximab/efeitos adversos , Rituximab/economia , Rituximab/uso terapêutico , Acidente Vascular Cerebral/induzido quimicamente , Vincristina/efeitos adversos , Vincristina/economia , Vincristina/uso terapêutico
2.
J Stroke Cerebrovasc Dis ; 29(11): 105213, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066879

RESUMO

BACKGROUND: In stroke survivors, post-stroke fatigue predicts dependency in daily living and failure to return to work. Modafinil shows promise as a pharmacotherapy to reduce post-stroke fatigue and related sequelae, e.g., poorer functional and clinical outcomes. AIMS: This study explored the cost-effectiveness of modafinil in treating post-stroke fatigue in the Australian context, by determining its incremental cost-effectiveness ratio (ICER) and by simulating the potential cost-savings on a national scale, through a re-analysis of MIDAS trial data. METHODS: A post hoc cost-effectiveness analysis was undertaken. Part A: patient-level cost and health effect data (Multidimensional Fatigue Inventory (MFI) scores) were derived from the MIDAS trial and analysis undertaken from a health-system perspective. Part B: a secondary analysis simulated the societal impact of modafinil therapy in terms of national productivity costs. RESULTS: Part A: Mean cost of modafinil treatment was AUD$3.60/day/patient for a minimally clinically important change (10 points) in total MFI fatigue score, i.e., AUD$0.36/day/unit change in fatigue score per patient. For the base case scenario, the ICER of using modafinil (versus placebo) was AUD$131.73 ($90.17 - 248.15, for minimum and maximum costs, respectively). Part B: The potential productivity cost-savings to society were calculated as nearly AUD$467 million over 1 year, and up to $383,471,991,248 over 10 years, from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors, representing a significant societal benefit. CONCLUSIONS: Modafinil is a highly cost-effective treatment for post-stroke fatigue, offering significant productivity gains and potential cost-savings to society from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors.


Assuntos
Estimulantes do Sistema Nervoso Central/economia , Estimulantes do Sistema Nervoso Central/uso terapêutico , Custos de Medicamentos , Fadiga/tratamento farmacológico , Fadiga/economia , Modafinila/economia , Modafinila/uso terapêutico , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/terapia , Idoso , Austrália , Estimulantes do Sistema Nervoso Central/efeitos adversos , Ensaios Clínicos Fase II como Assunto , Redução de Custos , Análise Custo-Benefício , Fadiga/diagnóstico , Fadiga/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modafinila/efeitos adversos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
3.
Stroke ; 51(8): 2445-2453, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32673521

RESUMO

BACKGROUND AND PURPOSE: Social determinants of health (SDOH) have been previously associated with incident stroke. Although SDOH often cluster within individuals, few studies have examined associations between incident stroke and multiple SDOH within the same individual. The objective was to determine the individual and cumulative effects of SDOH on incident stroke. METHODS: This study included 27 813 participants from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study, a national, representative, prospective cohort of black and white adults aged ≥45 years. SDOH was the primary exposure. The main outcome was expert adjudicated incident stroke. Cox proportional hazards models examined associations between incident stroke and SDOH, individually and as a count of SDOH, adjusting for potential confounders. RESULTS: The mean age was 64.7 years (SD 9.4) at baseline; 55.4% were women and 40.4% were blacks. Over a median follow-up of 9.5 years (IQR, 6.0-11.5), we observed 1470 incident stroke events. Of 10 candidate SDOH, 7 were associated with stroke (P<0.10): race, education, income, zip code poverty, health insurance, social isolation, and residence in one of the 10 lowest ranked states for public health infrastructure. A significant age interaction resulted in stratification at 75 years. In fully adjusted models, among individuals <75 years, risk of stroke rose as the number of SDOH increased (hazard ratio for one SDOH, 1.26 [95% CI, 1.02-1.55]; 2 SDOH hazard ratio, 1.38 [95% CI, 1.12-1.71]; and ≥3 SDOH hazard ratio, 1.51 [95% CI, 1.21-1.89]) compared with those without any SDOH. Among those ≥75 years, none of the observed effects reached statistical significance. CONCLUSIONS: Incremental increases in the number of SDOH were independently associated with higher incident stroke risk in adults aged <75 years, with no statistically significant effects observed in individuals ≥75 years. Targeting individuals with multiple SDOH may help reduce risk of stroke among vulnerable populations.


Assuntos
Grupo com Ancestrais do Continente Africano/etnologia , Grupo com Ancestrais do Continente Europeu/etnologia , Disparidades nos Níveis de Saúde , Determinantes Sociais da Saúde/etnologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etnologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pobreza/economia , Pobreza/etnologia , Estudos Prospectivos , Fatores de Risco , Autorrelato/normas , Determinantes Sociais da Saúde/economia , Determinantes Sociais da Saúde/tendências , Fatores Socioeconômicos , Acidente Vascular Cerebral/economia
4.
J Stroke Cerebrovasc Dis ; 29(8): 104996, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689626

RESUMO

GOAL: This study aimed to compare the length of stay, saved days and service costs associated with an early supported discharge model of care for mild, moderate and severe stroke survivors, to standard treatment. MATERIALS AND METHODS: A two centre cohort study, employing a quasi-experimental design with a control group of convenience. Forty-four participants were recruited when they were deemed suitable for discharge home with intensive rehabilitation and services, with three dropouts from the treatment group (treatment n = 28, control n = 13). There were no significant differences between the groups for gender, age, Functional Independence Measure, Berg Balance Test and Modified Ranking Scale total scores at baseline. There were also no significant differences between the groups for subsequent readmissions or complications. Length of stay was measured by the days between admission and discharge from both inpatient and community services. Costs were measured by daily amounts calculated for this service. FINDINGS: The treatment group spent significantly fewer days on the acute and inpatient rehabilitation wards, with over half avoiding subacute admission altogether. However, the control group spent significantly fewer days receiving intensive rehabilitation. The treatment group cost less on average per patient, but was not significantly different in terms of overall costs per admission. CONCLUSION: Stroke survivors receiving an early supported discharge model of care spent fewer days in hospital, frequently avoided subacute admission and incurred less cost per patient than those receiving standard treatment. These findings indicate that early supported discharge reduces length of inpatient stay, for a similar cost to standard treatment.


Assuntos
Custos Hospitalares , Tempo de Internação/economia , Alta do Paciente/economia , Reabilitação do Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Análise Custo-Benefício , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Vitória
5.
Neurology ; 95(8): e1071-e1079, 2020 08 25.
Artigo em Inglês | MEDLINE | ID: mdl-32554774

RESUMO

OBJECTIVE: Hospitals participating in the Medicare Shared Savings Program (MSSP) share with the Centers for Medicare and Medicaid Services (CMS) the savings generated by reduced cost of care. Our aim was to determine whether MSSP is associated with changes in readmissions and mortality for Medicare patients hospitalized with ischemic stroke, and whether MSSP has a different impact on safety net hospitals (SNHs) compared to non-SNHs. METHODS: This study was based on the CMS Hospital Compare data for risk-standardized 30-day readmission and mortality rates for Medicare patients hospitalized with ischemic strokes between 2010 and 2017. With a propensity score-matched sample, hospital-level difference-in-difference analysis was used to determine whether MSSP was associated with changes in hospital readmission and mortality as well as to examine the impact of MSSP on SNHs compared to non-SNHs. RESULTS: MSSP-participating hospitals had slightly greater reductions in readmission rates compared to matched nonparticipating hospitals (difference, 0.25 percentage points; 95% confidence interval [CI], -0.42 to -0.08). Mortality rates decreased among all hospitals, but mortality reduction was not significantly different between MSSP-participating hospitals and matched hospitals (difference, 0.06 percentage points; 95% CI, -0.28 to 0.17). Prior to MSSP, readmission rates in SNHs were higher compared to non-SNHs, but MSSP did not have significantly different impact on hospital readmission and mortality rates for SNHs and non-SNHs. CONCLUSION: MSSP led to slightly fewer readmissions without increases in mortality for Medicare patients hospitalized with ischemic stroke. Similar reductions in readmission rates were observed in SNHs and non-SNHs participating in MSSP, indicating persistent gaps between SNHs and non-SNHs.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , Acidente Vascular Cerebral/mortalidade , Centers for Medicare and Medicaid Services, U.S. , Humanos , Medicare , Readmissão do Paciente/economia , Provedores de Redes de Segurança/economia , Acidente Vascular Cerebral/economia , Estados Unidos
6.
PLoS One ; 15(4): e0230661, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32240217

RESUMO

BACKGROUND: Multiple approaches have been proposed to measure low socio-economic status. In France the concept of precariousness, akin to social deprivation, was developed and is widely used. EPICES is a short questionnaire that was developed to measure this concept. This study aimed to evaluate Differential Item Functioning (DIF) in the EPICES questionnaire between contrasted areas: mainland France, French West Indies (FWI) and French Guiana (FG). METHODS: The population was taken from the INDIA study, which aimed to evaluate the impact of social inequalities on stroke characteristics and prognosis. Eligible people were patients referred to neurology or emergency departments for a suspicion of stroke. We assessed the DIF using hybrid ordinal logistic regression method, derived from item response theory. RESULTS: We analysed 1 553 stroke patients, including 768 from FWI (49.5%), 289 from FG (18.6%) and 496 from mainland (31.9%). We identified five items with a moderate to large DIF in area comparisons: "meeting with a social worker", "complementary health insurance", "home-owning", "financial difficulties" and "sport activities". Correlation between EPICES score and the latent variable was strong (r = 0.84). CONCLUSION: This is the first attempt to assess the DIF of the EPICES score between different French populations. We found several items with DIF, which can be explained by individual interpretation or local context. However, the DIFs did not lead to a large difference between the latent variable and the EPICES score, which indicates that it can be used to assess precariousness and social deprivation between contrasted areas.


Assuntos
Comportamentos Relacionados com a Saúde , Acesso aos Serviços de Saúde/estatística & dados numéricos , Isolamento Social , Fatores Socioeconômicos , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/psicologia , Idoso , Feminino , França , Humanos , Masculino , Pobreza , Estudos Prospectivos , Acidente Vascular Cerebral/economia , Inquéritos e Questionários
7.
World Neurosurg ; 138: e642-e651, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32173551

RESUMO

OBJECTIVE: Endovascular thrombectomy (ET) for acute large vessel occlusion reduces infarct size, and it should hypothetically decrease the incidence of major ischemic strokes requiring decompressive craniectomy (DC). The aim of this retrospective cohort study is to determine trends in the utilization of ET versus DC for stroke in the United States over a 10-year span. METHODS: We extracted data from the Nationwide Inpatient Sample using International Classification of Diseases-9/10 codes from 2006-2016. Patients with a primary diagnosis of stroke were included. Baseline demographics, outcomes, and hospital charges were analyzed. RESULTS: The study cohort comprised 14,578,654 patients diagnosed with stroke. During the study period, DC and ET were performed in 124,718 and 62,637 patients, respectively. The number of stroke patients who underwent either ET or DC increased by 266% from 2006 to 2016. During that time period, the ET utilization rate increased (0.19% in 2006 to 14.07% in 2016, P < 0.0004), whereas the DC utilization rate decreased (7.07% in 2006 to 6.43% in 2016, P < 0.0001). In 2015, the utilization rate of ET (9.73%) exceeded that of DC (9.67%). ET-treated patients had shorter hospitalization durations (mean 8.8 vs. 16.8 days, P < 0.0001), lower mortality (16.2% vs. 19.3%), higher likelihood of discharge home (27.1% vs. 24.1%, P < 0.0001), and reduced hospital charges (mean $189,724 vs. $261,314, P < 0.0001). CONCLUSIONS: We identified an inverse relationship between national trends in rising ET and diminishing DC utilization for stroke treatment over a recent decade. Although direct causation cannot be inferred, our findings suggest that ET curtails the necessity for DC.


Assuntos
Isquemia Encefálica/cirurgia , Craniectomia Descompressiva/tendências , Procedimentos Endovasculares/tendências , Acidente Vascular Cerebral/cirurgia , Trombectomia/tendências , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/economia , Estudos de Coortes , Craniectomia Descompressiva/economia , Demografia , Procedimentos Endovasculares/economia , Feminino , Custos de Cuidados de Saúde , Preços Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Acidente Vascular Cerebral/economia , Trombectomia/economia , Resultado do Tratamento
8.
JAMA Netw Open ; 3(3): e201204, 2020 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-32186746

RESUMO

Importance: Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types. Objective: To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US. Design, Setting, and Participants: This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019. Exposures: Medicare insurance plan type, TM or MA. Main Outcomes and Measures: Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge. Results: The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, -0.15 to -0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, -0.21 to -0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs within an acute care hospital) and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types. Conclusions and Relevance: This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics.


Assuntos
Tempo de Internação/economia , Medicare Part C/estatística & dados numéricos , Medicare/estatística & dados numéricos , Centros de Reabilitação/estatística & dados numéricos , Reabilitação do Acidente Vascular Cerebral/economia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Fraturas do Quadril/economia , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Acidente Vascular Cerebral/economia , Estados Unidos
9.
BMC Health Serv Res ; 20(1): 75, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-32007089

RESUMO

Value-Based Medicine (VBM) is imposing itself as 'a new paradigm in healthcare management and medical practice.In this perspective paper, we discuss the role of VBM in dealing with the large productivity issue of the healthcare industry and examine some of the worldwide industrial and technological trends linked with VBM introduction. To clarify the points, we discuss examples of VBM management of stroke patients.In our conclusions, we support the idea of VBM as a strategic aid to manage rising costs in healthcare, and we explore the idea that VBM, by establishing value-generating networks among different healthcare stakeholders, can serve as the long sought-after redistributive mechanism that compensate patients for the industrial exploitation of their personal medical records.


Assuntos
Assistência à Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Controle de Custos/métodos , Humanos , Acidente Vascular Cerebral/economia
10.
Stroke ; 51(4): 1265-1271, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32019480

RESUMO

Background and Purpose- Multifaceted quality improvement interventions of stroke care have been shown to improve hospital personnel adherence to evidence-based performance measures and subsequent stroke outcomes. This study aimed to evaluate the cost-effectiveness of a multifaceted quality improvement intervention for stroke care in China, the world's largest low- and middle-income country. Methods- A short-term decision tree model and a long-term Markov model were used to analyze the cost-effectiveness of a multifaceted quality improvement intervention for patients with acute ischemic stroke. Outcomes, transition probability, and cost data were obtained from a recent clinical trial and the published literature. The benefit of the intervention was assessed by the costs per quality-adjusted life-years gained in the short- and long-term. One-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the findings. Results- Compared with usual care, a multifaceted quality improvement intervention for stroke care was found to be cost-effective in the first year and highly cost-effective from the second year onward. In the long-term, the intervention yielded a lifetime gain of 0.246 quality-adjusted life-years at an additional cost of Chinese Yuan Renminbi 1510 (US $230), resulting in a cost of Chinese Yuan Renminbi 6138 (US $940) per quality-adjusted life-year gained. Probabilistic sensitivity analysis indicated that the intervention was highly cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of Chinese Yuan Renminbi 59 700 (1× gross domestic product per capita of China in 2017, US $9200) per quality-adjusted life-year. Conclusions- A multifaceted quality improvement intervention for stroke care was highly cost-effective in China. The results of this study may be used as a reference for delivering such interventions in low- and middle-income countries and in underserved areas of high-income countries.


Assuntos
Isquemia Encefálica/economia , Análise Custo-Benefício/métodos , Cadeias de Markov , Melhoria de Qualidade/economia , Acidente Vascular Cerebral/economia , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/terapia , China/epidemiologia , Análise Custo-Benefício/normas , Feminino , Humanos , Masculino , Melhoria de Qualidade/normas , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia
11.
Medicina (Kaunas) ; 56(2)2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-32013001

RESUMO

Stroke represents a serious illness and is extremely relevant from the public health point of view, implying important social and economic burdens. Introducing new procedures or therapies that reduce the costs both in the acute phase of the disease and in the long term becomes a priority for health systems worldwide. The present study quantifies and compares the direct costs for ischemic stroke in patients with thrombolysis treatment versus conservative treatment over a 24-month period from the initial diagnosis, in one of the 7 national pilot centres for the implementation of thrombolytic treatment. The significant reduction (p < 0.001) of the hospitalization period, especially of the days in the intensive care unit (ICU) for stroke, resulted in a significant reduction (p < 0.001) of the total average costs in the patients with thrombolysis, both at the first hospitalization and for the subsequent hospitalizations, during the period followed in the study. It was also found that the percentage of patients who were re-hospitalized within the first 24-months after stroke was significantly lower (p < 0.001) among thrombolyzed patients. The present study demonstrates that the quick intervention in cases of stroke is an efficient policy regarding costs, of Romanian Public Health System, Romania being the country with the highest rates of new strokes and deaths due to stroke in Europe.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Terapia Trombolítica/economia , Adulto , Idoso , Feminino , Fibrinolíticos/economia , Fibrinolíticos/uso terapêutico , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Romênia , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/economia , Terapia Trombolítica/métodos , Terapia Trombolítica/estatística & dados numéricos , Fatores de Tempo
12.
Neurology ; 94(9): e978-e991, 2020 03 03.
Artigo em Inglês | MEDLINE | ID: mdl-32029544

RESUMO

OBJECTIVE: Stroke is a devastating and costly disease; however, there is a paucity of information on long-term costs and on how they differ according to 3-month modified Rankin scale (mRS) score, which is a primary outcome variable in acute stroke intervention trials. METHODS: We analyzed a prospective multicenter stroke registry (Clinical Research Collaboration for Stroke in Korea) database through linkage with claims data from the National Health Insurance Service with follow-up to December 2016. Healthcare expenditures were converted into daily cost individually, and annual and cumulative costs up to 5 years were estimated and compared according to the 3-month mRS score. RESULTS: Between January 2011 and November 2013, 11,136 patients were enrolled in the study. The mean age was 68 years, and 58% were men. The median follow-up period was 3.9 years (range 0-5 years). Mean cumulative cost over 5 years was $117,576 (US dollars [USD]); the cost in the first year after stroke was the highest ($38,152 USD), which increased markedly from the cost a year before stroke ($8,718 USD). The mean 5-year cumulative costs differed significantly according to the 3-month mRS score (p < 0.001); the costs for a 3-month mRS score of 0 or 5 were $53,578 and $257,486 USD, respectively. Three-month mRS score was an independent determinant of long-term costs after stroke. CONCLUSIONS: We show that 3-month mRS score plays an important role in the prediction of long-term costs after stroke. Such estimates relating to 3-month mRS categories may be valuable when undertaking health economic evaluations related to stroke care.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Sistema de Registros , Índice de Gravidade de Doença , Acidente Vascular Cerebral/economia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , República da Coreia , Fatores de Tempo , Adulto Jovem
13.
Stroke ; 51(4): 1064-1069, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32078475

RESUMO

Background and Purpose- An excess incidence of strokes among blacks versus whites has been shown, but data on disparities related to Hispanic ethnicity remain limited. This study examines race/ethnic differences in stroke incidence in the multiethnic, largely Caribbean Hispanic, NOMAS (Northern Manhattan Study), and whether disparities vary by age. Methods- The study population included participants in the prospective population-based NOMAS, followed for a mean of 14±7 years. Multivariable-adjusted Cox proportional hazards models were constructed to estimate the association between race/ethnicity and incident stroke of any subtype and ischemic stroke, stratified by age. Results- Among 3298 participants (mean baseline age 69±10 years, 37% men, 24% black, 21% white, 52% Hispanic), 460 incident strokes accrued (400 ischemic, 43 intracerebral hemorrhage, 9 subarachnoid hemorrhage). The most common ischemic subtype was cardioembolic, followed by lacunar infarcts, then cryptogenic. The greatest incidence rate was observed in blacks (13/1000 person-years), followed by Hispanics (10/1000 person-years), and lowest in whites (9/1000 person-years), and this order was observed for crude incidence rates until age 75. By age 85, the greatest incidence rate was in Hispanics. Blacks had an increased risk of stroke versus whites overall in multivariable models that included sociodemographics (hazard ratio, 1.51 [95% CI, 1.13-2.02]), and stratified analyses showed that this disparity was driven by women of age ≥70. The increased rate of stroke among Hispanics (age/sex-adjusted hazard ratio, 1.48 [95% CI, 1.13-1.93]) was largely explained by education and insurance status (a proxy for socieoeconomic status; hazard ratio after further adjusting for these variables, 1.17 [95% CI, 0.85-1.62]) but remained significant for women age ≥70. Conclusions- This study provides novel data regarding the increased stroke risk among Caribbean Hispanics in this elderly population. Results highlight the need to create culturally tailored campaigns to reach black and Hispanic populations to reduce race/ethnic stroke disparities and support the important role of low socioeconomic status in driving an elevated risk among Caribbean Hispanics.


Assuntos
Grupo com Ancestrais do Continente Africano/etnologia , Isquemia Encefálica/etnologia , Grupo com Ancestrais do Continente Europeu/etnologia , Disparidades em Assistência à Saúde/etnologia , Hispano-Americanos , Acidente Vascular Cerebral/etnologia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/economia , Estudos de Coortes , Grupos de Populações Continentais/etnologia , Grupos Étnicos , Feminino , Seguimentos , Disparidades em Assistência à Saúde/economia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/etnologia , Estudos Prospectivos , Fatores de Risco , Classe Social , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/economia
14.
PLoS One ; 15(1): e0227541, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31945102

RESUMO

BACKGROUND: Due to substantial improvements in prevention and therapy, stroke incidence and mortality rates have decreased during the last decades, but evidence is still lacking on whether all socioeconomic groups benefited equally and how the length of life affected by stroke developed over time. Our study investigates time trends in stroke-free life years and life years affected by stroke. Special emphasis is given to the question whether trends differ between income groups, leading to decreasing or increasing social inequalities. METHODS: The analyses are based on claims data of a German statutory health insurance company of the two time periods 2006-2008 and 2014-2016. Income inequalities and time trends in incidence and mortality risks were estimated using multistate survival models. Trends in stroke-free life years and life years affected by stroke are analysed separately for income groups by applying multistate life table analyses. RESULTS: Stroke incidence and mortality risks decreased in men and women in all income groups. While stroke-free lifetime could be gained in men having higher incomes, improvements in mortality counterbalanced decreasing incidences, leading to increases in life years affected by stroke among men of the lower and higher income group. Among women, no significant changes in life years could be observed. CONCLUSIONS: Changes in stroke-affected life years occur among men in all income groups, but are more pronounced in the higher income group. However, irrespective of the income group the proportion of stroke-affected life years remains quite stable over time, pointing towards constant inequalities. Further research is needed on whether impairments due to stroke reduced over time and whether all socioeconomic groups are affected equally.


Assuntos
Renda/tendências , Seguro Saúde/estatística & dados numéricos , Fatores Socioeconômicos , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/epidemiologia , Adulto , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Risco
15.
Radiology ; 294(3): 580-588, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31934828

RESUMO

Background Minor stroke is common and may represent up to two-thirds of cases of acute ischemic stroke. The cost-effectiveness of CT angiography in patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤6) is not well established. Purpose To evaluate cost-effectiveness of CT angiography in the detection of large-vessel occlusion (LVO) in patients with acute minor stroke (NIHSS score ≤6). Materials and Methods A Markov decision-analytic model with a societal perspective was constructed. Three different management strategies were evaluated: (a) no vascular imaging and best medical management, (b) CT angiography for all patients and immediate thrombectomy for LVO after intravenous thrombolysis, and (c) CT angiography for all and best medical management (including intravenous thrombolysis, with rescue thrombectomy for patients with LVO and neurologic deterioration). One-way, two-way, and probabilistic sensitivity analyses were performed. Results Base-case calculation showed that CT angiography followed by immediate thrombectomy had the lowest cost ($346 007) and highest health benefits (9.26 quality-adjusted life-years [QALYs]). CT angiography followed by best medical management with possible rescue thrombectomy for patients with LVO had a slightly higher cost ($346 500) and lower health benefits (9.09 QALYs). No vascular imaging had the highest cost and lowest health benefits. The difference in health benefits compared with the CT angiography and immediate thrombectomy strategy was 0.39 QALY, which corresponds to 142 days in perfect health per patient. The conclusion was robust in a probabilistic sensitivity analysis. CT angiography was cost-effective when the probability of LVO was greater than 0.16% in patients with acute minor stroke. The net monetary benefit of performing CT angiography was higher in younger patients ($68 950 difference between CT angiography followed by immediate thrombectomy and no vascular imaging in 55-year-old patients compared with $20 931 in 85-year-old patients). Conclusion Screening for large-vessel occlusion with CT angiography in patients with acute minor stroke is cost-effective and associated with improved health outcomes. Undetected large-vessel occlusion in the absence of vascular imaging results in worse health outcomes and higher costs. © RSNA, 2020 Online supplemental material is available for this article.


Assuntos
Angiografia por Tomografia Computadorizada , Acidente Vascular Cerebral , Triagem , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada/economia , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Análise Custo-Benefício , Humanos , Pessoa de Meia-Idade , Acidente Vascular Cerebral/classificação , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/epidemiologia , Triagem/economia , Triagem/estatística & dados numéricos
16.
Stroke ; 51(3): 899-907, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31964289

RESUMO

Background and Purpose- The benefit that endovascular thrombectomy offers to patients with stroke with large vessel occlusions depends strongly on reperfusion grade as defined by the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Our aim was to determine the lifetime health and cost consequences of the quality of reperfusion for patients, healthcare systems, and society. Methods- A Markov model estimated lifetime quality-adjusted life years (QALY) and lifetime costs of endovascular thrombectomy-treated patients with stroke based on eTICI grades. The analysis was performed over a lifetime horizon in a United States setting, adopting healthcare and societal perspectives. The reference case analysis was conducted for stroke at 65 years of age. National health and cost consequences of improved eTICI 2c/3 reperfusion rates were estimated. Input parameters were based on best available evidence. Results- Lifetime QALYs increased for every grade of improved reperfusion (median QALYs for eTICI 0/1: 2.62; eTICI 2a: 3.46; eTICI 2b: 5.42; eTICI 2c: 5.99; eTICI 3: 6.73). Achieving eTICI 3 over eTICI 2b reperfusion resulted on average in 1.31 incremental QALYs as well as healthcare and societal cost savings of $10 327 and $20 224 per patient. A 10% increase in the eTICI 2c/3 reperfusion rate of all annually endovascular thrombectomy-treated patients with stroke in the United States is estimated to yield additional 3656 QALYs and save $21.0 million and $36.8 million for the healthcare system and society, respectively. Conclusions- Improved reperfusion grants patients with stroke additional QALYs and leads to long-term cost savings. Procedural strategies to achieve complete reperfusion should be assessed for safety and feasibility, even when initial reperfusion seems to be adequate.


Assuntos
Modelos Econômicos , Saúde Pública/economia , Qualidade de Vida , Acidente Vascular Cerebral/economia , Trombectomia/economia , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão , Acidente Vascular Cerebral/cirurgia , Estados Unidos
17.
PLoS One ; 15(1): e0225301, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31978044

RESUMO

OBJECTIVE: The objective was to assess the real-world cost-effectiveness of rivaroxaban, versus vitamin K antagonists (VKAs), for stroke prevention in patients with atrial fibrillation (AF) from a French national health insurance perspective. METHODS: A Markov model was developed with a lifetime horizon and cycle length of 3 months. All inputs were drawn from real-world evidence (RWE) studies: data on baseline patient characteristics at model entry were obtained from a French RWE study, clinical event rates as well as persistence rates for the VKA treatment arm were estimated from a variety of RWE studies, and a meta-analysis provided comparative effectiveness for rivaroxaban compared to VKA. Model outcomes included costs (drug costs, clinical event costs, and VKA monitoring costs), quality-adjusted life-years (QALY) and life-years (LY) gained, incremental cost per QALY, and incremental cost per LY. Sensitivity analyses were performed to test the robustness of the model and to better understand the results drivers. RESULTS: In the base-case analysis, the incremental total cost was €714 and the total incremental QALYs and LYs were 0.12 and 0.16, respectively. The resulting incremental cost/QALY and incremental cost/LY were €6,006 and €4,586, respectively. The results were more sensitive to the inclusion of treatment-specific utility decrements and clinical event rates. CONCLUSIONS: Although there is no official willingness-to-pay threshold in France, these results suggest that rivaroxaban is likely to be cost-effective compared to VKA in French patients with AF from a national insurance perspective.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Vitamina K/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/economia , Fibrilação Atrial/patologia , Análise Custo-Benefício , Feminino , França/epidemiologia , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Infarto do Miocárdio/economia , Infarto do Miocárdio/patologia , Infarto do Miocárdio/prevenção & controle , Anos de Vida Ajustados por Qualidade de Vida , Rivaroxabana/economia , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/prevenção & controle , Varfarina/uso terapêutico
18.
J Cardiovasc Pharmacol Ther ; 25(1): 57-64, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31405298

RESUMO

BACKGROUND: Anticoagulation therapy is recommended for stroke prevention in high-risk patients with atrial fibrillation (AF). This study aimed to estimate the time to switch from warfarin to a direct oral anticoagulant (DOAC) and identify the factors associated with it. METHODS: By using claims data, we studied 7111 warfarin-using patients with nonvalvular AF who were aged ≥65 years. The Kaplan-Meier analysis was performed to estimate the time to switch from warfarin to a DOAC, and Cox proportional hazard regression analysis was used to estimate the influencing factors. RESULTS: Approximately one-third of the patients (2403, 33.8%) switched from warfarin to a DOAC during the study period. Female sex, aged between 75 and 79 years, having a Medical Aid or Patriots and Veterans Insurance, hypertension, and history of prior stroke, and transient ischemic attack or thromboembolism (prior stroke/TIA/TE) were associated with a significantly shorter time to switch. The odds of switching to a DOAC were increased by approximately 1.2-fold in the women and 1.4-fold in the patients with prior stroke/TIA/TE. CONCLUSIONS: Approximately one-third of the warfarin-using patients switched from warfarin to a DOAC within 6 months after the change in the DOAC reimbursement criteria. In the Cox proportional hazard regression analysis, the factors that affected anticoagulant switching from warfarin to a DOAC were female sex and history of prior stroke/TIA/TE.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Custos de Medicamentos/tendências , Substituição de Medicamentos/tendências , Inibidores do Fator Xa/administração & dosagem , Reembolso de Seguro de Saúde/tendências , Acidente Vascular Cerebral/prevenção & controle , Varfarina/administração & dosagem , Administração Oral , Demandas Administrativas em Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/economia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/economia , Fibrilação Atrial/epidemiologia , Bases de Dados Factuais , Esquema de Medicação , Substituição de Medicamentos/economia , Inibidores do Fator Xa/economia , Feminino , Humanos , Reembolso de Seguro de Saúde/economia , Masculino , República da Coreia/epidemiologia , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Varfarina/economia
19.
J Intensive Care Med ; 35(1): 14-23, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30309279

RESUMO

Static indices, such as the central venous pressure, have proven to be inaccurate predictors of fluid responsiveness. An emerging approach uses dynamic assessment of fluid responsiveness (FT-DYN), such as stroke volume variation (SVV) or surrogate dynamic variables, as more accurate measures of volume status. Recent work has demonstrated that goal-directed therapy guided by FT-DYN was associated with reduced intensive care unit (ICU) mortality; however, no study has specifically assessed this in surgical ICU patients. This study aimed to conduct a systematic review and meta-analysis on the impact of employing FT-DYN in the perioperative care of surgical ICU patients on length of stay in the ICU. As secondary objectives, we performed a cost analysis of FT-DYN and assessed the impact of FT-DYN versus standard care on hospital length of stay and mortality. We identified all randomized controlled trials (RCTs) through MEDLINE, EMBASE, and CENTRAL that examined adult patients in the ICU who were randomized to standard care or to FT-DYN from inception to September 2017. Two investigators independently reviewed search results, identified appropriate studies, and extracted data using standardized spreadsheets. A random effect meta-analysis was carried out. Eleven RCTs were included with a total of 1015 patients. The incorporation of FT-DYN through SVV in surgical patients led to shorter ICU length of stay (weighted mean difference [WMD], -1.43d; 95% confidence interval [CI], -2.09 to -0.78), shorter hospital length of stay (WMD, -1.96d; 95% CI, -2.34 to -1.59), and trended toward improved mortality (odds ratio, 0.55; 95% CI, 0.30-1.03). There was a decrease in daily ICU-related costs per patient for those who received FT-DYN in the perioperative period (WMD, US$ -1619; 95% CI, -2173.68 to -1063.26). Incorporation of FT-DYN through SVV in the perioperative care of surgical ICU patients is associated with decreased ICU length of stay, hospital length of stay, and ICU costs.


Assuntos
Cuidados Críticos/métodos , Hidratação/métodos , Tempo de Internação/estatística & dados numéricos , Ressuscitação/métodos , Acidente Vascular Cerebral/terapia , Cuidados Críticos/economia , Hidratação/economia , Custos Hospitalares , Humanos , Ressuscitação/economia , Acidente Vascular Cerebral/economia , Volume Sistólico
20.
J Neurointerv Surg ; 12(4): 422-426, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31649206

RESUMO

BACKGROUND: Few studies have examined the trends in clinical and economic outcomes of patients with acute ischemic stroke (AIS) who receive endovascular therapy (ET) in the real-world setting. OBJECTIVE: To evaluate characteristics and trends in clinical and economic outcomes among commercially insured patients with AIS undergoing ET between 2011 and 2017. METHODS: Patients with AIS undergoing ET from January 1, 2011 to June 30, 2017 were identified from administrative claims contained in the IBM MarketScan Commercial and Medicare Supplemental databases. The Mann-Kendall trend test was performed to examine clinical and economic trends.Between 2011 and 2017, 3411 patients (mean age 62.85±15 years) with a primary diagnosis of AIS underwent ET (coverage: Commercial 59%, n=2008; Medicare Supplemental 41%, n=1403). In the Commercial cohort, discharge to home increased significantly (from 29.54% to 39.18%, p<0.05). Length of stay declined significantly among the overall cohort (from 10.96 to 9.05 days, p<0.01) and the Medicare Supplemental cohort (from 10.03 to 8.43 days, p<0.05). All-cause 365-day readmission decreased significantly among the overall cohort (from 47.5% to 36.7%, p<0.05) and the Commercial cohort (from 51.54% to 36.43%, p<0.05) but remained unchanged in the Medicare Supplemental cohort. While index procedure cost did not change significantly ($93 955 to $87 906, p=0.8806), total cost significantly declined in the overall cohort (from $166 922 to $130 678, p<0.05). CONCLUSIONS: Although with some variation across the samples studied, outcomes including discharge to home, length of stay, readmission, and total cost associated with endovascular stroke therapy seemed to have improved between 2011 and 2017. Index admission cost remained unchanged.


Assuntos
Isquemia Encefálica/epidemiologia , Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/tendências , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/economia , Estudos de Coortes , Bases de Dados Factuais/tendências , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/métodos , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Medicare/economia , Medicare/tendências , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/economia , Resultado do Tratamento , Estados Unidos/epidemiologia
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