To provide a national view of healthcare and societal costs of stroke survivors, we enrolled a large sample of hospitals across Italian regions. The female/male ratio, the fraction of ischemic stroke and the percentage of patients over 65 in this sample are reflective of the Italian population. To our knowledge, this is the largest cost of illness study in Italy and one of the largest conducted in Europe in the last decade . In addition, this study provides original evidence about informal care over time and allows for estimates of stroke-specific costs.
Despite careful design and implementation our study presents a few limitations. Firstly, our sample was constructed to reflect major characteristics on admittance of stroke patients into hospitals and results confirm this sample representation; however centres were intentionally selected according to quotas and therefore this is not a population-based study. Secondly, although we carefully designed the collection data forms to include data attributable to stroke only, we cannot exclude that some costs associated to comobordities, rather than stroke, were computed. Thirdly, a significant number of patients lost at follow-up may present a bias as we cannot guarantee that observed and unobserved patients had the same costs (although none of the characteristics recorded was significantly different between the two groups).
In our study a stroke survivor costs €19,953 to society in the first year after the event. It is difficult to directly compare these estimates to other cost analyses available in the literature due to a variety of methods used, definition of cost components included and patient population considered. However, despite these differences, our results are similar to those of other European studies with a comparable methodology . Two studies adopting a societal perspective, with a bottom up approach and one year follow-up produced estimates of € 20,239 and € 25,493 per patient in Germany and Sweden, respectively [19, 20]. In a large population-based study using a German stroke registry overall direct healthcare costs for first-year survivors with primary ischemic stroke was estimated to be €18,517 . The analysis was comparable in the methods for data collection but included a slightly different sample population: all hospitalized and non-hospitalized patients in the study region. Similarly, our cost estimate is also relatively close to the mean value calculated from 71 stroke studies (US $ 19,027 in 2006) .
Direct comparison of overall cost estimates across studies conducted in different countries is inevitably influenced by the country specific unit costs used for the evaluation of resources. Thus, a more meaningful and informative comparison can be done with physical units of resources used and relative weight of different cost categories. In this respect, our study produced very similar estimates to a study on societal costs of stroke in Germany . In this study the mean length of stay of index hospitalisation was 14 days (compared to 13.5 days in our sample), and average costs of €4,650 accounted for 49% of direct costs (vs 47% in our study). Length of stay during index hospitalisation obtained in our study (13.5 ± 11.9 days) is also very similar with recently published estimates (12.8 ± 11.8 days) from the European Registry of Stroke Project (EROS) in one hospital in Florence .
On the basis of data of 812 stroke patients from a population based registry in Germany, rehabilitation services accounted for 37% of the total healthcare costs in the first year post event . According to our estimates, the total rehabilitation costs represented 35% of total healthcare costs overall, with major concentration of costs in the first three months following the event. More specifically, in the first quarter after the acute hospitalisation about 70% of patients got rehabilitative services and this cost component absorbed about 81% of the costs of the quarter. This suggests that rehabilitation services are widely offered in Italy and that effectiveness and efficiency concerns about the provision of these services should be of paramount importance.
It is widely recognized that informal care plays a substantial role in the total care provided to stroke patients, although empirical estimates on the informal care costs associated with stroke are currently limited in European countries . An international comparison of cost studies shows that informal care costs are omitted in the majority of cost of illness studies, especially when it concerns informal care time . In a more recent critical review on cost of stroke studies that used patient level data, authors showed that of 120 cost studies analysed only 8 (7%) included informal care costs. Our study fulfils this gap by providing detailed estimates of informal care time and costs associated with stroke. Our estimates are in line with the results of the few similar European studies that showed these cost components as a major component on the total cost of stroke. More specifically, in a recent study that quantified the annual cost of illness of stroke in the UK, informal care accounted for 27% of total societal costs . Our findings corroborate the results obtained in this study and provide important original evidence about a country which presents strong family ties and thus may have a specific attitude towards the use of informal care.
In addition to confirming mean estimates available in the literature, our study provides further information on different patterns of cost components over time. Healthcare costs change significantly over one year: while in the first quarter after the event monthly costs for healthcare amounts to €1,377 per patient, in the last two quarters the average cost per patient per month is only € 161. Conversely, non-healthcare costs tend to be more stable as they do not decrease over time. On average, a stroke patient costs €617 for informal and paid care and these two categories of costs account for about 78% of total societal costs in the second half of the observation period. Paid care and informal care costs are more persistent and may require adequate monitoring to assure that the patient benefit for appropriate social care. These results not only contribute to the existing literature on cost of stroke but also provide valuable insight on different types of data for health planning. When predicting healthcare costs, the number of events is the driver of the economic burden of disease and this implies that incident cases should be used. Contrary, for non healthcare costs the burden of the disease is driven by prevalence as these costs persist over time. While planning of hospital and rehabilitation facilities should forecast the number of incident cases, appropriate policies to assure patients receive appropriate social care should consider prevalent cases.
Our results also show that BI and mRS are good predictors of societal costs associated to stroke, specifically non healthcare costs. These findings are confirmed by previous studies and have important policy implications . Social care planning could easily use these scales/indexes for predicting the amount of support that patients should receive and to provide adequate financial and in kind support.
Our estimates for the acute phase and the following six months are substantially higher than those obtained by Gerzeli and colleagues who found € 6,111 for healthcare and € 11,607 for total societal costs . The two studies were designed similarly, demographic characteristics of patients are similar and there is no clear evidence that patients in our sample were more severe. It is thus reasonable to assume that differences in costs between the two studies reflect differences in intensity of care and their associated costs. Our patients cost more because of higher inpatient costs for the acute phase and greater use of rehabilitation services. It appears that in Italy stroke patients have had more access to rehabilitation services despite the fact that between 30% and 40% of our sample did not use any rehabilitation service. Further studies should be conducted to monitor the access to rehabilitation services and to investigate the reasons why a significant percentage of survivors still do not use these services.
As in the previous Italian study, we found that patients admitted to general medicine wards are less costly during the acute phase and patients admitted to neurology wards are less costly in the post acute phase. These results need to be taken cautiously as the study was not designed to test differences between admission settings. Despite controlling for various clinical and functional outcome variables we cannot exclude selection biases. Nevertheless, it is plausible to assume that the lower acute phase costs of patients admitted to medicine wards are due to less intense use of resources in this setting. To explain the lower post-acute phase healthcare costs of patients admitted to neurological wards it is more challenging. Both the hypotheses of better outcomes attributable to this setting and selection biases are plausible. More ad hoc investigation is warranted to test these hypotheses.
Our data illustrate how the Italian healthcare system supports stroke patients and are use to correlate costs to major clinical conditions, disability and severity of the disease. Our regression models confirm that clinical and functional outcome variables are good predictors of costs. Given the importance of data on routine care and available costs for cost-effectiveness analysis we urge the use of this evidence in modelling interventions to prevent or treat stroke patients.