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# Economic Burden of Stroke Disease

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Submitted by: Thinni Nurul Rochmah
(This entry belongs to Entry Collection "Hypertension and Cardiovascular Diseases ")

## Definition

Globally, one of the main causes of non-communicable disease as a cause of death every year is stroke. The objective of this study was to analyze the burden in consequence of stroke.

## 1. Introduction

Cardiovascular disease (CVD) is a non-communicable disease and the world’s main cause of death (17.9 million deaths annually) [1]. Cardiovascular disease has been responsible for 37% of total mortality in Indonesia. Stroke is the leading cause of cardiovascular disease, followed by coronary heart disease and diabetes [2]. This shows that there is currently an epidemiological transition that has shifted the burden of disease from infectious diseases to non-communicable diseases [3].
Stroke is the leading cause of death and disability worldwide, and the economic costs of post-stroke care are enormous [4]. As of now, approximately 34% of the global total healthcare expenditure is spent on stroke. The average healthcare cost of stroke per person, including inpatient care, rehabilitation, and follow-up care, is estimated at USD 140,048 in the United States [5].
Stroke burden in people under the age of 65 has increased in recent decades. Currently, there is an alarming shift from the overall stroke burden to younger age groups, particularly in low-moderate-income countries. The worldwide incidence of stroke in the 20 to 64 years age group has increased by 25%, while the incidence of stroke is higher in men aged 55–75 years [6]. The epidemic increase in cardiovascular risk factors in young adults in regions such as Russia, China, and India has contributed to the increased stroke burden among the younger population [5]. The highest incidence rate of stroke occurred in Asia, a continent containing more than 60% of the world’s population; the second highest incidence rate of stroke was experienced by people in Eastern Europe, while the lowest was in central Latin America [6]. Mortality caused by stroke is higher in Asia than in Western Europe, America, or Australasia (similar to Eastern Europe).
In Indonesia, the national prevalence of stroke has increased from 0.7% in 2013 to 1.09% in 2018 [7]. The increase in the prevalence of cardiovascular disease results in the higher number of outpatient and inpatient services, as well as the economic impact that the state must manage through the National Health Insurance (JKN) Program. The data issued by the Social Security Agency for 2016 stated that stroke costs a service fee of USD 950,715, which makes non-communicable diseases a significant disease burden. Apart from medical expenses, people with cardiovascular disease will cause economic losses for the country’s productivity. Patients with cardiovascular disease generally have disabilities, making them unable to carry out their daily activities independently. This condition causes them to depend on other people to accompany them on their activities, including patients undergoing treatment [8].
Disease burden studies could help policymakers understand the economic costs of a particular disease. Such disease burden studies identify various cost components for a particular disease or disease-related complications in different sectors that might have been saved if the disease is not present. Moreover, disease burden studies have an essential role in public health to formulate and prioritize healthcare policies and allocate healthcare resources by estimating the total costs that can be incurred by the disease(s) [9].
Various indicators could describe the disease burden in the population. Epidemiological indicators include life expectancy, mortality rates, and the total of new and existing specific disease cases (e.g., incidence and prevalence) [10]. Epidemiological indicators show the value of the disability-adjusted life year (DALY) and quality-adjusted life year (QALY) from a disease. The use of inpatient and outpatient services is also an indicator of the disease burden [11] and economic loss measurements such as absences, incapacity to work, the use of medical facilities, and other related costs. The calculated economic components include direct medical costs, direct non-medical costs, and indirect costs outlined in the cost of illness (COI) and health expenditure (HE) methods.

## 2. Characteristics of Included Studies

The characteristics of included studies (n = 13) are shown in Table 1. The characteristics of the included studies are made to determine the study design, study scope, economic perspective, and the types of diseases required in the systematic review. Furthermore, from the included studies, 13 articles (100%) were studies on types of stroke [12][13][14][15][16][17][18][19][20][21][22][23][24]. Three types of study designs included a prospective cost study of five articles (38%) [12][19][20][21][23], a retrospective cost study of six articles (46%) [12][13][15][17][21][23], and a cross-sectional study of two articles (15%) [15][17]. The calculation method used was the COI in eight articles (62%) [12][14][16][17][20][22][23][24] and the HE method in five articles (38%) [13][15][18][19][21]. The approach taken was a prevalence-based approach in 11 articles (85%) [13][14][15][16][17][18][20][21][22][23][24] and 2 articles on the basis of incidence rate (15%) [12][19]. On the other hand, there were five articles (38%) with a societal economic perspective [15][17][18][19][22], and five articles (38%) with an economic perspective of healthcare system [12][16][20][22][24]. One article (8%) had a third-party payer perspective [13], and two articles (15%) had a participant and family perspective [14][21]. Meanwhile, countries used as research locations in terms of economic status were only in upper-middle-income and high-income countries whose articles were included in the criteria. In countries with upper-middle-income economic status, there was one article (8%) that fit the criteria in Lebanon, Colombia, China, Turkey, South Africa, and Brazil [12][13][16][20][23][24]. Furthermore, study locations in countries with high-income economic status and suitable articles were South Korea, Denmark, and the Netherlands, each with one article, respectively (8%) [14][17][22], while Sweden and United States had each published two articles (15%) [15][18][19][21].
Table 1. A summary of the indicators of disease burden studied in selected articles (n = 13).
o. Researcher and Year Research Setting Country Group Approach Source of Data Indicator of Calculated Disease Burden
Research Design Calculation Method Method Cost Perspective
1 Abdo, et al. (2018) [12] Lebanon Upper-middleincome Prospective Cost of illness (COI) Incidence-based Healthcare system 203 stroke patients Direct medical cost
2 Camacho, et al. (2018) [13] Colombia Upper-middleincome Retrospective Health expenditure Prevalence-based Third-party payer Data are provided by ACEMI, an association of Colombian private health insurance companies Direct medical cost
3 Cha, Yu–Jin (2018) [14] South Korea High income Retrospective Cost of illness (COI) Prevalence-based Participant (patients) and families Insurance claims data generated during 2015 in Korea (N = 515,848) Direct medical cost, direct cost, indirect cost.
4 Ganapathy (2015) [15] United States High income Cross-sectional Health expenditure Prevalence-based Society Internet survey data were collected from 153 caregivers of stroke patients Indirect cost (productivity lost)
5 İçağasıoğlu, et al. (2017) [16] Turkey Upper-Middleincome Retrospective Cost of Illness (COI) Prevalence-based Healthcare system 84 stroke patients Direct and Indirect cost
6 Jennum, et al. (2015) [17] Denmark High income Cross-sectional Cost of illness (COI) Prevalence-based Society Records from the Danish National Patient Registry of 93,047 ischemic, 26,012 hemorrhagic, and 128,824 stroke patients were unspecified and compared with 364,433, 103,741, and 500,490 matched controls, respectively. Direct medical cost
7 Joo, et al. (2017) [18] United States High income Retrospective Health expenditure Prevalence-based Society Using the 2010 Health and Pension Study, data on un-institutionalized adults aged ≥ 65 years (n = 10,129) in 2015–2017 Indirect medical cost
8 Lekander, et al. (2017) [19] Sweden High income Prospective Health expenditure Incidence-based Society 47,807 patients were diagnosed with stroke during 2007–2010, allowing for two years of follow-up Total cost
9 Maredza and Chola (2016) [20] South Africa Upper-middleincome Prospective Cost of illness (COI) Prevalence-based Healthcare system A population of around 90,000 people living in the Agincourt sub-district of Mpumalanga province, northeast South Africa, covered by a demographic and health surveillance system (health and demographic surveillance system, HDSS) Direct cost
10 Persson, et al. (2017) [21] Sweden High income Prospective Health expenditure Prevalence-based Participant (patients) and families 53 couples provided informal support, and 168 couples did not provide informal support Indirect medical cost
11 Van Eeden, et al. (2015) [22] The Netherlands High income Retrospective Cost of illness (COI) Prevalence-based Society 395 stroke patients Total cost
12 Vieira, et al. (2019) [23] Brazil Upper-middleincome Prospective Cost of illness (COI) Prevalence-based Healthcare system 173 stroke patients Direct medical cost
13 Zhang, et al. (2019) [24] China Upper-middleincome Retrospective Cost of illness (COI) Prevalence-based Healthcare system A total of 114,872 were hospitalized for five types of stroke Direct medical cost
Table 1 shows a summary of the disease burden indicators studied in each article, which included a total of 13 studies. The indicators studied in each article depended on the method used; either direct, indirect or both direct and indirect cost. On the basis of the results of these studies, one can group them according to the determined systematic review theme, namely, the burden of stroke. Presentation of results will be determined on the basis of length of hospitalization; calculation of economic losses in terms of methods, approaches, cost components, and economic perspectives; and the condition of economic loss due to stroke as per the included articles.
There are six countries with upper-middle-income economic status that were examined in terms of economic losses due to stroke, namely, Lebanon, Turkey, South Africa, Brazil, China, and Colombia, while the remaining countries have high-income economic status. Meanwhile, calculation using the COI or HE methods depends on the objective of the study. Both COI and HE may include either direct, indirect or both direct and indirect cost, therefore, a study can use a complex disease burden analysis using both the COI and HE methods [25].

## 3. Average Length of Stay for Stroke

Of the 13 selected articles, 3 articles examined the average length of hospitalization of stroke patients. The description of the length of stay for stroke patients can be seen in Table 2.
Table 2. Descriptions of length of hospitalization for stroke patients.
No. Research Cited Results of Research on Length of Hospitalization Description on the Causes of Length of Hospitalization
1 Abdo et al. (2018) [12] In Lebanon, the average stroke hospitalization was 13–18 days. Predictors of higher LOS were high National Institution of Health Stroke Scale (NIHSS) at admission, ICU LOS, surgery, and infection complications.
2 İçağasıoğlu et al. (2017) [16] In Turkey, the length of hospitalization of stroke patients ranged from 0 and 75 days, with a mean duration of 11–15 days. NA
3 Zhang et al. (2019) [24] In China, the average length of hospitalization in the hospital was 27 days. NA
Abdo [26] showed that in Lebanon, the average length of stroke at the hospital was 13–18 days. Another study conducted by İçağasıoğlu et al. (2017) [16] showed that in Turkey, the length of stay of stroke patients ranged from 0 to 75 days, with an average length of stay of 11–15 days. Meanwhile, a study conducted by Zhang et al. (2019) [24] showed that in China, stroke patients had an average of 27 days of hospitalization.
The mean LOS was higher in patients with intracerebral hemorrhage (ICH) compared to ischemic stroke (IS). Predictors of higher LOS were the National Institution of Health Stroke Scale (NIHSS), which had a high admission scale, patients at ICU, patients undergoing surgery, and patients with infectious complications [12].
On the other hand, İçağasıoğlu et al. (2017) [16] and Zhang et al. (2019) [24] did not describe in detail the causes of the length of hospitalization, and therefore more complete information could not be obtained by the researcher. Of the three articles, Turkey occupied the lowest position in the duration of hospitalization for stroke patients, while China occupied the highest position in the length of stroke hospitalization, which reached 27 days.

## 4. Cost Incurred by Stroke

There were 13 articles included to calculate the economic loss due to stroke. The articles came from different countries with different currencies and different years of research. In this systematic review, each result of economic loss calculation from the selected articles was adjusted to USD in 2020 (INT $2020). The results of the currency conversion for each cost are presented in Table 3. Table 3. Results of cost conversion due to stroke. No. Author Country Method Calculated Indicator Result Economic Loss Direct Medical Cost Indirect Medical Cost Indirect Cost Research Result USD in 2020 Research Result USD in 2020 Research Result USD in 2020 Research Result USD 2020 1 Abdo, et al. (2018) [12] Lebanon Cost of Illness (COI) Direct medical cost N/A a N/A USD 6961 (2016 INT$) b 7536.43 N/A N/A N/A N/A
2 Camacho et al. (2018) [13] Colombia Health expenditure Direct medical cost N/A N/A USD 4277–4846 (2012 INT $) 4905.33–4905.33 N/A N/A N/A N/A N/A N/A USD 6245 (2012 INT$) 7162.45 N/A N/A N/A N/A
3 Cha, Yu-Jin (2018) [14] South Korea Cost of illness (COI) Direct medical cost, direct cost, indirect cost USD 7247 (2015 INT $) 7931.80 N/A N/A N/A N/A N/A N/A 4 Ganapathy (2015) [15] United States Health expenditure Indirect cost (productivity lost) N/A N/A N/A N/A N/A N/A Productivity loss of USD 269 for absenteeism and USD 598 for presenteeism. Total lost productivity of USD 835 per month (2012 INT$) 308.52 685.85 957.67
5 İçağasıoğlu et al. (2017) [16] Turkey Cost of illness (COI) Direct and indirect cost TL 17,253.50 (2014) c 16,662.20 TL 8668 (2014) 8370.94 N/A N/A TL 10,800 (2014) 10,429.87
6 Jennum et al. (2015) [17] Denmark Cost of illness (COI) Direct medical cost EUR 10,772–13,888 (2009) d 1701.07–2193.13 EUR 8297–10,088 (2009) 1310.23–1593.05 N/A N/A EUR 7377–10,720 (2009) 1164.94–1692.86
7 Joo et al. (2017) [18] United States Health expenditure Indirect medical cost N/A N/A N/A N/A N/A N/A USD 2883–5777 (2015 INT $) 3155.43–6322.90 8 Lekander et al. (2017) [19] Sweden Health expenditure Total cost EUR 10,000–120,000 5,367,715.39–64,412,584.69 N/A N/A N/A N/A N/A N/A 9 Maredza and Chola (2016) [20] South Africa Cost of illness (COI) Direct cost N/A N/A USD 283,465 (2012 INT$) 325,108.84 N/A N/A N/A N/A
10 Persson et al. (2017) [21] Sweden Health expenditure Indirect Cost (Informal care cost) N/A N/A N/A N/A N/A N/A EUR 991–25,127 (€ INT 2015) 123.80–3138.86
11 Van Eeden et al. (2015) [22] The Netherlands Cost of illness (COI) Total cost EUR 29,484 (2012) 25,043.49 EUR 18,068.2 (2012) 25,043.49 N/A N/A EUR 11,416 (2012) 15,823.18
12 Vieira et al. (2019) [23] Brazil Cost of illness (COI) Direct medical cost N/A N/A USD 2595–31532 (2016 INT $) 2809.51–34,138.58 N/A N/A N/A N/A 13 Zhang et al. (2019) [24] China Cost of illness (COI) Direct medical cost N/A N/A USD 3212.1 (2013 INT$) 3620.45 N/A N/A N/A N/A
Table 3 show the presentation of economic burden due to stroke was differentiated on the basis of country groups, namely, upper-middle-income and high-income countries. Each country group was also presented separately between the calculations on the basis of the COI method and the health expenditure method. The entire value of economic losses presented in this study was adjusted to USD in 2020. On the basis of 13 articles, there were 5 articles that analyzed the economic burden of stroke based on health expenditure, while the other 8 articles analyzed the economic burden of stroke on the basis of cost of illness. On the basis of the cost of illness method, we found that the largest cost component due to stroke was direct medical cost and indirect medical cost, accounting for 86.2% and 13.8% of the total cost, respectively. The economic burden of stroke disease in terms of cost of illness method was approximately equal to USD 1809.51–325,108.84. As for the articles that reported the cost on the basis of health expenditure method, only one article was found to have reported that the direct cost to treat stroke was, on average, USD 4905.33, while four articles measured the indirect cost, which was, on average, USD 2739.73.
The COI method is a method that is easy to implement but has the disadvantage of losing utility value due to disease [27]. On the other hand, the HE method can measure total health expenditure, representing the amount spent on healthcare and related activities (such as insurance administration) but lacks data that require more detailed and specific data on household spending, especially on indirect costs [21].
COI studies measure economic losses due to disease in certain populations [17]. COI studies generally involve two separate cost analyses, namely, direct costs and indirect costs. Direct costs are the value of the resources used for the treatment and rehabilitation of the person with the condition under study. Direct costs refer to all goods, services, and other resources consumed during the delivery of a health intervention for a particular disease. This includes money spent on hospital care, on the services of doctors and other medical professionals, medicines, equipment, and rehabilitation [16].
HE studies are used to calculate the costs incurred due to a disease. In this systematic review, we found that the seven articles that used the HE method focused on direct non-medical costs and indirect costs, which include informal caregiver costs and productivity lost. Informal caregivers are defined as care activities provided by relatives, with or without compensation. These activities include providing support for activities of daily living or instrumental activities of daily living [18]. Caregiver costs include personal travel time to visit sufferers and any expenses related to caregiving [15].
Loss of productivity is defined as the number of days of net sick leave and days of early retirement due to illness [28]. Meanwhile, the loss of productivity is assessed using the human capital approach with the assumption that production losses are assessed at market prices, namely, gross salary and payroll taxes. The cost of decreasing a person’s productivity is equal to the amount the employer is willing to pay for the production. This is assumed to be the average gross salary plus employer contributions [21].

## 5. Discussion

Stroke rapidly develops clinical signs of focal (or global) impairment of brain function, with symptoms lasting 24 h or more or leading to death without apparent cause other than a vascular cause [29]. To our knowledge, research is rarely conducted on the review of economic evaluation methods in various countries to see the calculation of economic losses using the COI and HE methods and to analyze the average length of stay for stroke patients.
The review identified several emerging patterns. We found that among published economic evaluations, there were no consistent outcome measures. The majority of the studies reported using the COI method, which varied on the basis of the point of view, data source, indirect cost criteria, and timeframe for cost calculation [30]. On the other hand, the use of the HE method was used to see the costs incurred by patients and families during healthcare, such as administrative costs and insurance in addition to the main variables analyzed such as the number of days at the hospital, home care services, the number of days with at least single contact with physicians, benefits of palliative home care, utilization of health services in the past weeks, and public healthcare expenditures [31]. This shows that the calculation of COI and HE could be carried out according to research needs, not with certainty. The heterogeneity of this outcome measure could prevent the comparison of the two methods to see the economic loss due to stroke in certain income groups, regions, or even countries.
On the basis of the results, the average LOS of stroke patients was 11 to 27 days. Several factors causing LOS were severity, stroke volume, infection, complications, demographic characteristics, and the presence of emergency or medical status of the patient. This is in line with research by Curtain et al. (2017) [32], who stated that stroke patients at Norwich University Hospital underwent an average hospitalization of 11 to 33 days. Furthermore, several factors affecting LOS for stroke patients included neurological lateralization, pre-stroke disability status, congestive heart failure, and age. Research conducted by Saxena and Prasad in 2016 also supported the results of this study [33], which stated that some causes of LOS for stroke patients were complications due to pressure sores and sepsis that needed them to stay for >7 days. Several studies suggested that a longer LOS leads to higher economic losses [34]. The less time the patient is hospitalized, the more effective and efficient services the hospital can provide. Meanwhile, inefficient services are one causing increased costs [35][36].
Direct costs incurred by the health system, society, families, and individual patients consisted of health and non-health costs. Health costs are defined as medical care expenditures for diagnosis, treatment, and rehabilitation. One of the challenges in calculating direct medical costs, particularly hospital costs, was that costs were often the only data available. Due to the nature of determining hospital costs, it often did not accurately reflect the underlying costs. Costs were often higher than unit costs [37], and the results of the systematic review showed that the direct medical costs due to stroke were USD 1593–34,138 [17][23]. In Indonesia, the average direct cost for stroke patients participating in the Social Security Agency at Dr. Moh. Saleh Hospital was USD 1895.36, with a minimum to the maximum value range of USD 463.43–5159.22 [38].
Meanwhile, for patients without insurance from the Social Security Agency, the total direct cost was USD 38,013.72. The systematic review results showed that the highest cost in direct medical costs was found in inpatient costs (almost 65%). This finding is in line with research by Ye et al. (2020) [39], who showed that inpatient care was the largest contributor to healthcare costs (70% of total costs), followed by outpatient services (11%) and skilled nursing care (8%).
Meanwhile, non-health costs are related to the consumption of non-healthcare resources such as transportation, household expenses, relocation, property loss, and informal care of any kinds. Estimation of the direct costs associated with chronic disease was higher than that related to an acute disease or infectious disease, for which methods of treatment and prevention were effective [40]. These non-medical direct costs were estimated to account for 50% or more of all direct costs [41]. This systematic review showed that the highest contributor to the high direct non-medical costs was the cost of caregivers (around 82%). This finding is in line with Alvarez-Sabín et al. [42], who showed that more than two-thirds of stroke care costs were spent for social costs, especially informal care.
Furthermore, indirect costs were part of the social welfare loss due to diseases. The remaining loss of welfare was represented by the loss of health time due to illness, suffering, and sadness [40]. For many diseases, the indirect costs were enormous and much greater than the direct medical costs [37]. The results of this systematic review discovered that the indirect costs of stroke were USD 957–15,823 [15][22]. In Indonesia, the average indirect cost of stroke patients participating in the Social Security Agency at Dr. Moh. Saleh Hospital was USD 223.08, with a minimum to the maximum value range of USD 102.18–486.33 [38].
Meanwhile, for patients without the insurance mechanism, the total indirect cost was USD 100,117.68. The current systematic review showed that the highest indirect costs were due to the cost of productivity lost spent for premature deaths (around 80%). This finding is in line with previous studies, which stated that 66% of the total costs of stroke in the United States was due to the indirect costs of premature deaths [43]. It is challenging to generalize the results of economic studies in various countries. Economic results were difficult to compare due to monetary issues (i.e., fluctuating exchange rates, the purchasing power of currencies), although purchasing power parity (PPP) can help compare results. It eliminates differences in price levels between countries, while regional demographic characteristics also influence resource consumption and unit costs. This resulted in the treatment costs varying widely between studies [44]. On the other hand, the epidemiological indicators found in the selected articles included prevalence and incidence.

The entry is from 10.3390/ijerph18147552

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