ESO East Supplement 2023 - 24

24
European Stroke Journal 8(1S)
Figure 3. Discharge destinations according to RES-Q registry
data.
Average first year cost for all patients was 18,221 EUR
having 0372 QALYs.
Post-discharge rehabilitation and related care costs may
often be underestimated and can depend on acute stroke
treatment. Having in mind that a shift post-stroke from inhospital
to home-based rehabilitation might bring better
treatment and costing efficiency, we have shown data from
Res-Q on discharge location in Croatia
Discussion
Our study provides a snapshot of the economic consequences
posed by stroke to Croatia where decreasing stroke
burden is one of the state priorities. Moreover, it is one of
the priorities of the EU where the burden of stroke is projected
to increase due to demographic changes, mostly due
ageing and better treatment options.15 Despite improved
diagnostic and treatment options the Central and Eastern
European countries have not so far achieved the substantial
decrease stroke incidence and mortality and DALYs lost
which have been achieved in Western European countries.16
The difference was primarily caused by low efficacy of
stroke prevention programmes in Central and more
expressed in Eastern European countries.16 The improvement
in stroke prevention might be achieved by improved
targetting of common and well-known risk factors such as
arterial hypertension, hyperlipidaemia, diabetes mellitus,
atrial fibrillation, stress and depression, smoking, alcohol
consumption, physical inactivity and inadequate diet which
already have shown in improvement of stroke incidence
and DALYs in high-income countries.3,17,18 By addressing
these risk factors the vast majority of stroke could be prevented
- up to 90% of strokes.17 The burden of stroke shows
significant regional variation.3,18 Due to these disparities
regarding epidemiology and treatment through Europe,
European Stroke Organisation has prepared and started to
implement Stroke Action Plan for Europe where these challenges
are pointed out.15
A 30-year projection was based on current trends and
there is an estimated 3% increase in the incidence of stroke
along with an 27% increase in prevalence, however there is
also a projected 17% decrease in mortality and 33%
decrease in DALY.19 As seen in Figure 1, there are different
paths that patients can go through, even though stroke
severity and response time are the determining factors in
patient management,20 pre-morbid modified Rankin scale
(mRS) is a strong predictor of discharge destination, as had
previously been shown in a paper that used machine learning
to predict discharge destination based on multiple variables
at admission.21 Mees et al.22 found that the main
predictor of other than home discharge after stroke were:
functional dependence/comorbidities, neurocognitive disfunction
and previous living circumstances/marital status,
furthermore medium and large infarcts were associated
with institutionalisation.
Up to 4% of total health care expenditures in Western
countries are spent on stroke management.18,23 Generally,
overall (inpatient and outpatient) poststroke care per month
cost from 752 USD in Australia to 4850 USD in the US -
where rehabilitation services represent the main cost
driver.24 The systematic review by Rajsic et al.24 have found
that the outpatient poststroke care varies between 192 USD
(in Malaysia) to 883 USD per month (in the United
Kingdom). Hospital and nursing home costs contribute to
most of total cost of stroke in Australia, whereas inpatient
rehabilitation accounts for cca 27% of total first-year
costs.24
In our study, the key aspects determining costs and quality
of life were rehabilitation, discharge to residential care
(currently 13% of patients in Croatia) and recurrent stroke.
Recent analysis by Patel et al.25 found that the mean cost of
new-onset stroke is £ 45,409 (53958.83 euros) in the first
year and £ 24,778 in subsequent years, what exceeded previous
cost estimates. The largest compound of total costs is
related to unpaid care (61%) and interventions at rehabilitation
and reducing new and recurrent stroke may yield substantial
benefit to carers and cost saving to society.25
Post-discharge rehabilitation and care costs are often underestimated
and can depend on acute stroke treatment.
Another possible way to reduce the cost of stroke is to shift
post-stroke rehabilitation from in-hospital to home-based
rehabilitation, previous cost estimates by Anderson et al.26
had shown that for every six patients that had received inhospital
rehabilitation another patient could have received
rehabilitation if it had been done at home, furthermore the
same practice would allow more patients to be treated using
the same number of hospital beds. Rasmussen et al.27 have
shown that early home-based rehabilitation improved lifequality
and reduced disability while being cost effective.
Two trials tracked patients that had undergone early homebased
rehabilitation and compared them to a control group
that had undergone standard rehabilitation and both trials
found no convincing difference in disability while being the
ESO East Supplement 2023

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