NEW ORLEANS—The cost of stroke care among patients who receive t-PA might be reduced if patients were monitored outside the ICU after receiving t-PA, had fewer MRI and CT scans, and did not take empirical antibiotics or use insulin sliding scales, researchers reported at the 64th Annual Meeting of the American Academy of Neurology.
“While protocol-driven stroke practice may reduce the variations in stroke care, it may have also prompted practitioners to order items that may not be necessary, or may just be convenient,” said David Wang, DO, FAHA, FAAN of the OSF/Illinois Neurological Institute (INI) Stroke Network, OSF Saint Francis Medical Center in Peoria, Illinois. “Reducing costs does not mean providing less or inadequate care,” he told Neurology Reviews.
Assessing the Cost of Stroke Care
The investigators retrospectively assessed the care processes and cost structures at the OSF/INI Stroke Network. Record reviews were conducted for all patients with acute ischemic stroke who received only IV t-PA since the advent of an electronic health record system in March 2010.
Several areas were analyzed, including patient demographics, the length of neuro-ICU (NICU) stays, and the use of pharmacy services, imaging studies, rehabilitation services, and lab tests. NIH Stroke Scale scores were also assessed, and patients were separated into six subgroups based on these scores. The study authors also collected data on charges and costs accrued.
Results showed that 51 stroke patients with an average age of 71 received IV t-PA from March 2010 to June 2011. Length of stay ranged from 3.8 days for the six patients with NIH Stroke Scale scores of less than 5, to 13 days for the two patients with an NIH Stroke Scale score greater than 25. Costs also varied, ranging from $5,965 for the six patients with NIH Stroke Scale scores of less than 5, to $15,445 for the 10 patients who stayed for 7.9 days in the hospital and had NIH Stroke Scale scores between 16 and 20.
Dr. Wang noted that staying in the NICU increased costs for patients with severe stroke and that use of interventional radiology, MRI and CT, and physical therapy increased by 50% in these patients. In every stroke subgroup, the most costly items were NICU stay and expenses associated with pharmacy, lab, and radiology, he added.
Although certain expensive treatments must be offered despite high prices, costs might be reduced if clinicians considered whether all routinely prescribed treatments are necessary and supported by evidence, said Dr. Wang. For example, a patient with a clear stroke diagnosis might receive brain MRI and CT at one hospital, followed by repeat imaging after a transfer to a tertiary hospital. “A brain scan is often repeated, because the receiving physician likes the images generated at his or her own institution. In this case, cutting down on the unnecessary tests may reduce costs, and good care can still be provided,” Dr. Wang commented.
Dr. Wang recommends that clinicians first provide evidence-based care and then individualized care in areas without sufficient evidence. By doing so, care providers might reduce frequent lab draws, blood glucose monitoring, IV fluid, and unproven and expensive treatment options for stroke patients. While preprinted orders and protocols may provide a sense of security and completeness, they can also lead to unnecessary procedures and increased health care costs, he said.
“Finding efficiency in stroke diagnosis and treatment without sacrificing the quality is a challenge to all,” Dr. Wang added. “Fortunately, the results from comparative effectiveness research can offer us some guidance in selecting our therapeutic strategies. If we do well according to the evidence we already have, our patients will already be getting better care at lower cost.”
Brown DL, Boden-Albala B, Langa KM, et al. Projected costs of ischemic stroke in the United States. Neurology. 2006;67(8):1390-1395.
Meretoja A, Kaste M, Roine RO, et al. Direct costs of patients with stroke can be continuously monitored on a national level: performance, effectiveness, and costs of treatment episodes in stroke (PERFECT Stroke) database in Finland. Stroke. 2011;42(7):2007-2012.