ESO East Supplement 2023 - 25

Benković et al.
25
lower-cost
option.27,28
Early home-based rehabilitation
shows promise as a low-cost alternative to classical in-hospital
rehabilitation while allowing for less burden on hospital
stays and the quality-of-life improvement of familiar
surroundings.27,28
However, not all countries can afford interdisciplinary
medical teams who visit people in their own homes, thus an
alternative is needed that could be found in telerehabilitation.29
A meta-analysis done by Tchero et al. 30 found that
telerehabilitation has results comparable to standard rehabilitation
practices. Lloréns et al.31 in their trial managed to
achieve comparable results while cutting the cost of rehabilitation
by $645.30 Another point in favour of telerehabilitation
is that it can be done with very little infrastructure,
some models can be accomplished via smartphone,
although such models raise complex equity issues for
patients from low-income backgrounds.32
Post discharge stroke costs can vary vastly and are the
greatest during the first 6 months. It has been shown there
are significant direct, costs that occur when the patient is
confronted with everyday tasks and mobility, and thus need
wheelchairs, home modifications, drugs, diapers, transportation
and new drugs. Most stroke survivors also need
physiotherapy, speech therapy, nursing services and occupational
therapy that also directly increase the cost of
stroke. In the Italian study the average direct cost of a stroke
was estimated to $3710.33 One of the main driving factors
of the cost of stroke and post-stroke rehabilitation is the
residual neurological deficit after stroke. Angerova et al.34
in their study measured the cost of rehabilitation, based on
the severity of the deficit and found that the cost for the
most severely disabled group was 2.4-fold greater than the
self-sufficient group, furthermore the least disabled group
had benefitted the most from the rehabilitation. However,
in Chien et al.35 study on Taiwanese population calculated
that patient that had been transferred to a rehabilitation
ward had higher 10-year medical costs and longer life
expectancy than those that had no rehabilitation or had
rehabilitation outside the rehabilitation ward. Nevertheless,
their per day cost effectiveness was greater, possibly related
to better quality of life, good function recovery and longer
life expectancy.
In our study, 12% of patients were admitted to the intensive
care unit/ward, mostly for the revascularisation therapy
- intravenous thrombolysis (IVT) and/or mechanical
thrombectomy (MT). Despite the high costs of mechanical
thrombectomy and intravenous thrombolysis, they are
cost-effective, shortening hospital stay and improving
functional outcome for patients.36,37 IVT and MT are the
only currently approved recanalisation treatment of stroke,
their rates are increasing, and they are the base of future
stroke treatments that could further reduce the burden of
stroke.38 Inpatient hospital costs for acute stroke accounts
for 70% of first year post-stroke care-.18,23 However, the
severe strokes cost is twice that of mild strokes.18,23 The
cost of haemorrhagic stroke is generally higher.18,23 The
per year per patient cost of stroke varies depending on the
country a patient lives in and is higher in higher income
countries, per patient per year cost varies from $2100 in
low-income countries to $27,702 in high-income
countries.39
When comparing our results to the prices in other countries
according to the systematic review done by Strilciuc
et al.39 on Romanian population, our value of 18,221 EUR,
which is roughly equivalent to $20,125 USD according to
the current exchange rate, places Croatia above the value of
upper-middle income countries ($14,478) and well above
the value of low-middle income countries (6850 USD).
This value is comparable to Italy's 19,200 USD and higher
than Denmark's 11,625 USD, where the beforementioned
direct cost of 3710 USD is the direct cost that the patient
has to spend, without the cost covered by the healthcare
system. The highest per year cost was in the USA (59,900
USD) which could partially be due to their specific organisation
of the healthcare system, Sweden (52,725 USD) is a
country with a much more comparable system to Croatia, at
least considering the model of the healthcare system, however
the living standard in Sweden is significantly higher
thus the difference in per year per patient price.33,39 The
average cost per case during first 12 months and over the
lifetime in Australia was 14,361 USD and 33,658 USD
respectively.40 The economic burden of stroke report for
Europe estimated in 2017 total stroke costs of 27 billion
euros (18.5 for direct medical costs and 8.5 for indirect
costs), with total stroke cost of 60 billion.41 Similarly,
American Heart Association projected increase of total
stroke costs from 105.2 billion dollars in 2012 to 240.7 billion
dollars in 2030.42
Strengths and limitations
One of the key strengths of this study is that for the first
time in the region, registry data was accompanied with
estimations of costs and quality of life. The real-world data
that was available to us from the RES-Q registry provided
a solid base for a detailed model design. However, the
study has several limitations. The major limitations are
that the study was based on approximation of registry data
which did not cover the whole country and whole calendar
year. This model did not consider the societal perspective
such as costs to patients or family members which are
reflected as loss of income/informal care, too. As much as
we would like to include patient costs, they are not available
publicly without undertaking primary exploratory
research. The QALY mapping to DRGs may not reflect the
real-world picture for several reasons such as miscoding
and the fact that utilities were not measured locally. In
Croatian Health Care System DRG codes are not adjusted
as often as they should, the last revision was not related to
real life costing change, which also influenced the
ESO East Supplement 2023

Table of Contents for the Digital Edition of ESO East Supplement 2023
