Costs of Ischemic Stroke Projected to Rise

The direct and indirect costs of ischemic stroke may exceed $2.2 trillion from 2005 to 2050 in the United States, according to research by Devin L. Brown, MD, assistant professor in the Department of Neurology at the University of Michigan, Ann Arbor, and colleagues.¹ The researchers also reported that the highest per capita contributors would be Hispanic and black persons and concluded that the costs of treating stroke could be reduced if barriers to quality care for ethnic minorities are overcome.Brown and colleagues found that the highest average costs per service for stroke were inpatient rehabilitation at $25,968 and hospitalization or emergency department visits at $12,423. Highest costs per year were related to nursing home care at $33,636, earnings lost at $22,880, and informal care at $4038. According to previous estimates, the cost of ischemic stroke was greater than $90,000 during the lifetime of a patient. In 2004, it was reported that the direct and indirect costs of stroke in the United States exceeded $53 billion, with a mean lifetime cost estimated at $140,048.²

To reach these conclusions, the researchers developed a new model to show the yearly economic burden of ischemic stroke for non-Hispanic white, Hispanic, and black persons aged 45 years and older. These data were extracted from 2 multiethnic, population-based stroke surveillance studies: the Northern Manhattan Study³ and the Brain Attack Surveillance in Corpus Christi Project.⁴ Population projections were determined using the middle series of the 2000 US census, which included multiple series of growth based on varying fertility, life expectancy, and net immigration estimates.⁵

According to this research, patients aged 45 to 64 years will account for approximately half of the total cost of stroke and patients aged 85 years and older will account for only 10%, suggesting that interventions to reduce the cost of stroke must therefore not solely be targeted toward the elderly, said Brown. This is because the younger age group was 10 times larger than the oldest age group, which is actually at higher risk for stroke.

Overall costs for non-Hispanic white persons and black and Hispanic persons were about the same. The majority of costs were lost earnings, ranging from 30% for Hispanic patients to 43% for non-Hispanic white patients. Informal care was the second highest cost, ranging from 16% for black persons to 19% for both Hispanic and non-Hispanic white persons. Brown said that he was surprised to find that the cost of informal caregiving was the second largest contributor to overall costs of stroke; however, informal caregiving costs are estimated to be substantial-approximately 4 times that of nursing home costs among Hispanic patients, who prefer informal caregiving to nursing home care,⁶ and approximately 2.5 times that of nursing home costs among black and non-Hispanic white groups.

MINORITIES CARRY HEAVIEST BURDEN
Brown pointed out that several epidemiologic studies suggest that Hispanic persons-who account for 12.5% of the US population and are the largest minority group-and black persons-who account for 12.3% of the population⁵-are at higher risk for stroke than non-Hispanic white persons, but the reasons are unclear. Black persons have a shorter life expectancy, and cardiovascular risk factors are more prevalent in this population than in the white population. The incidence of stroke and stroke-related mortality are therefore higher. Data on the risk of stroke in Hispanic persons is limited and inconsistent, with some studies showing similar or lower risk and others showing higher risk among Hispanic persons compared with non-Hispanic white persons.³According to Brown's study, black and Hispanic persons are less likely to have health insurance, have limited access to quality health care, and receive less adequate stroke prophylaxis. In these persons, the incidence of ischemic stroke is higher than in non-Hispanic white persons. These minority populations experience stroke a median 10 to 13 years earlier than non-Hispanic white persons. As persons in these minority groups age, the inequalities in the risk of stroke and corresponding health care could have costly consequences, Brown said.

This study highlights the need for more research in health care disparities in general and in stroke specifically, Brown said. Overall, improvements in medical care of minority groups in the United States are of great importance.

LOWERING RISK, LOWERING COSTS
Stroke is currently the leading cause of adult disability and the third leading cause of mortality in the United States. More than 700,000 strokes occur in the United States annually, resulting in 160,000 deaths. Stroke survivors number 4.8 million. Although there has been a 60% decline in stroke mortality from 1968 to 1996, the rate of decline began to slow in the 1990s and has plateaued.2 In light of this, Brown said that physicians should follow rigorous prevention strategies. "The cost of $2.2 trillion really highlights the economic need to improve stroke prevention and treatment strategies, especially in high-stroke-risk groups such as Hispanic Americans and African Americans."

A guide for the primary prevention of ischemic stroke was recently released by the American Heart Association and the American Heart Association Stroke Council, which lists risk factors for stroke as well as recommended treatments.⁷ Well-known risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and excess fat distribution to the abdomen. Less well-known risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated levels of lipoprotein (a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection.

Brown emphasized that greater pharmacologic intervention for hypertension and use of warfarin (Coumadin) for atrial fibrillation could significantly reduce the costs of stroke, as could stepped-up use of intravenous tissue plasminogen activator (Alteplase) for the treatment of acute ischemic stroke.

"Given that lost earnings will likely be the highest cost contributor to stroke costs from 2005 to 2050, strategies to rehabilitate stroke patients so that they can return to work also may prove to be cost-saving," Brown said. "Early rehabilitation also may reduce the need for informal caregiving or even nursing home use."

Aspirin also may provide effective treatment for persons at risk for stroke. The US Preventive Services Task Force recommends aspirin at a dosage of 75 mg/d for cardiac prophylaxis in persons whose 5-year coronary heart disease risk is 3% or greater. The regimen is thought to reduce the risk of cardiovascular events, thus reducing the risk of stroke. However, the American Heart Association and the Stroke Council suggested that more research should be done to examine the potential benefits of this treatment.With the costs of stroke skyrocketing, there is a need for the NIH to fund stroke research, according to Catherine M. Rydell, CEO and executive director of the American Academy of Neurology (AAN). The AAN is looking to secure a 5% increase ($1.4 billion) in funding from Congress, which would bring stroke research funding to $30 billion in fiscal year 2007.

"Our study is really about differential economic consequences of stroke based on ethnicity," Brown said. "We are hoping that our study will assist public health planners in prioritizing resources and setting research agendas."

REFERENCES1. Brown DL, Boden-Albala B, Langa KM, et al. Projected costs of ischemic stroke in the United States. Neurology. In press.
2. American Heart Association. Heart Disease and Stroke Statistics-2004 Update. Dallas: American Heart Association; 2003.
3. Sacco RL, Boden-Albala B, Gan R, et al. Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol. 1998;147:259-268.
4. Morgenstern LB, Smith MA, Lisabeth LD, et al. Excess stroke in Mexican Americans compared with non-Hispanic Whites: the Brain Attack Surveillance in Corpus Christi Project. Am J Epidemiol. 2004;160:376-383.
5. United States Census 2000. Available at: http://www.census.gov/. Accessed September 12, 2004.
6. Weiss CO, Gonzalez HM, Kabeto MU, Langa KM. Differences in amount of informal care received by non-Hispanic whites and Latinos in a nationally representative sample of older Americans. J Am Geriatr Soc. 2005;53:146-151. 7. Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease.
Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006;37:1583-1633.