Strategies to improve cost-efficiency of stroke care: Stroke units and telestroke

Minal Jain*, Anunaya Jain, Babak S. Jahromi

*Corresponding author for this work

Research output: Chapter in Book/Report/Conference proceedingChapter

1 Scopus citations


Background: New treatments, protocols and technologies have been emerging for effective management of stroke. Establishment of a Stroke Unit (SU) has been one of the oldest concepts that has undergone constant change over time while consistently improving outcomes in stroke patients. On the other hand, Telestroke, a relatively new concept has also proven its mettle in expediting diagnosis and decision making for inaccessible stroke patients. This chapter presents a brief literature review comparing outcome and costs of care in SU versus conventional care (CC). As a secondary aim we also analyze which SU subtype is the most cost effective. We also present a business case for cost effectiveness of Telestroke. Methods: A Pubmed search was performed with the search term "stroke unit" to access all English language studies published from 01/01/1996 to 01/01/2011. Of these, articles reporting length of stay and/or cost and outcomes were included for the review. Articles wherein research was conducted before 01/01/1996; articles reporting only on rehabilitation units and all review articles were excluded. Costs of care were documented from the studies themselves or by using length of stay as a surrogate. Logistic regressions from literature were used to convert all non-QALY (quality-adjusted life year) outcome measures to QALYs. All cost were reported in 2010 US dollar;. Incremental Cost Effectiveness ratios (ICER) were calculated for care at SU versus CC. Cost/QALY and weighted average of the cost effectiveness ratios were calculated for different types of stroke units [acute only SU, acute + rehabilitation SU (acute + rehab SU), acute + rehabilitation + early supported discharge (acute + Rehab + ESD SU) and SU with continuous monitoring]. Ratios less than dollar;50,000/QALY were considered cost effective and ratios greater than dollar;100,000 /QALY were considered non-cost effective. We also searched Pubmed for all studies on "Telestroke" networks conducted across the developed world in English language. For simplicity we have presented an overall perspective of this technology from the perspective of the healthcare system. Further, we did a meta-analysis comparing the cost savings offered by a Telestroke networks to traditional care models for treating acute ischemic stroke patients. We also simulated revenue generation and compared them to reported costs of initiation of Telestroke networks to conduct a break-even probability analysis. A sensitivity analysis was also done to comment on the robustness of this model to changing variable costs of Telestroke mediated care. Results: Review of Stroke Units - A total of 5537 articles in Pubmed were studied, of which 19 studies met the inclusion criteria. 7 studies had comparison reported between SU and CC. Length of stay for patients managed at SU ranged from 9.2-32.3 days versus 8-35.3 days for CC units and average incremental QALY between them were 0.09. The average incremental cost/QALY was $41,204.37. The average cost/QALY for different types of SU were dollar;19,428.64 for acute only SU, $44,228.81 for acute +rehab SU, $29,145.93 for acute +rehab+ESD SU and $20,460.56 for SU with continuous monitoring. In comparison to an acute only SU, SU with continuous monitoring and acute+rehab+ESD SU were cost effective alternatives. (ICER SU with continuous monitoring - $25,120.89, ICER acute+rehab+ESD - $24,574.59). Review of Telestroke - A total of 15 Telestroke networks were analyzed. Of almost 24,000 consultations nearly 10.8% had received IV thrombolytic therapy, which translated into cost savings of $90,000 per 100 consultations. The average duration of consultation reported by these networks was 28.25 minutes (SD 18.86 minutes) generating an average revenue of $48.7 per consultation for the healthcare system. The total approximate fixed costs of setup was $33,400/year/spoke site. While conducting the simulation analysis we found that at least 283 patients are needed to break even for the investment costs of telestroke, with just reimbursement of consultation costs. After introducing uncertainties, the model generated a probability of 80.1% that the network would break-even its costs within the first year of operations. After accounting for increasing variable costs of operations and maintenance of the network, we concluded that the if the hub-unit sees atleast 283 patients annually, and if variable costs are kept below $35/patients, the Telestroke model would prove to be sustainable and cost effective. Conclusion: Stroke Units and Telestroke seems to be cost effective strategies when compared to the conventional systems of care. Active collaborations between different in-hospital services to create a cohesive environment conducive to specialized care of stroke patients, and inter-hospital networks to leverage infrastructure and clinical expertise are both initiatives that should be pursued widely.

Original languageEnglish (US)
Title of host publicationToward Healthcare Resource Stewardship
PublisherNova Science Publishers, Inc.
Number of pages26
ISBN (Print)9781621001829
StatePublished - Dec 1 2012

ASJC Scopus subject areas

  • Medicine(all)

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