Schmidt Aurélie, Heroum Chérif, Caumette Didier, Le Lay Katell, Bénard Stève
st[è]ve Consultants, Oullins, France.
Cerebrovasc Dis. 2015;39(2):94-101. doi: 10.1159/000369525. Epub 2015 Jan 23.
Stroke is the second leading cause of death and a first leading cause of acquired disability in adults worldwide. This study aims to evaluate the current management and associated costs of acute ischemic stroke (AIS) for patients admitted in stroke units in France and over a one-year follow-up period as well as to assess the impact of improved thrombolytic management in terms of increasing the proportion of patients receiving thrombolysis and/or treated within 3 h from the onset of symptoms.
A decision model was developed, which comprises two components: the first corresponding to the acute hospital management phase of patients with AIS up until hospital discharge, extracted from the national hospital discharge database (PMSI 2011), and the second corresponding to the post-acute (post-discharge) phase, based on national treatment guidelines and stroke experts' advice. Five post-acute clinical care pathways were defined. In-hospital mortality and mortality at 3 months post-discharge was taken into account into the model. Patient journeys and costs were determined for both phases. Improved thrombolytic management was modeled by increasing the proportion of patients receiving thrombolysis from the current estimated level of 16.7 to 25% as well as subsequently increasing the proportion of patients treated within 3 h of the onset of symptoms post-stroke from 50 to 100%. The impact on care pathways was derived from clinical data.
Among 202,078 hospitalizations for a stroke or a transient ischemic attack (TIA), 90,528 were for confirmed AIS, and 33% (29,999) of them managed within a stroke unit. After hospitalization, 60% of discharges were to home, 25% to rehabilitative care and then home, 2% to rehabilitative care and then a nursing home, 7% to long-term care, and 6% of stays ended with patient death. Of a total cost over 1 year of €610 million (mean cost per patient of €20,326), 70% concern the post-acute phase. By increasing the proportion of patients being thrombolyzed, costs are reduced primarily by a decrease in rehabilitative care, with savings per additional treated patient of €1,462. By adding improved timing, savings are more than doubled (€3,183 per additional treated patient).
This study confirms that the burden of AIS in France is heavy. By improving thrombolytic management in stroke units, patient journeys through care pathways can be modified, with increased discharges home, a change in post-acute resource consumption and net savings.
中风是全球成年人中第二大死因和后天残疾的首要原因。本研究旨在评估法国卒中单元收治的急性缺血性卒中（AIS）患者的当前管理情况及相关费用，并进行为期一年的随访，同时评估改善溶栓管理对增加接受溶栓治疗患者比例和/或在症状发作后3小时内接受治疗患者比例的影响。
开发了一个决策模型，该模型包括两个部分：第一部分对应AIS患者从入院到出院的急性医院管理阶段，数据取自国家医院出院数据库（PMSI 2011）；第二部分对应急性后期（出院后）阶段，基于国家治疗指南和卒中专家的建议。定义了五条急性后期临床护理路径。模型考虑了住院死亡率和出院后3个月的死亡率。确定了两个阶段的患者就医过程和费用。通过将接受溶栓治疗的患者比例从目前估计的16.7%提高到25%，以及随后将卒中症状发作后3小时内接受治疗的患者比例从50%提高到100%，对改善溶栓管理进行建模。对护理路径的影响来自临床数据。
在202,078例因中风或短暂性脑缺血发作（TIA）住院的患者中，90,528例为确诊的AIS患者，其中33%（29,999例）在卒中单元接受治疗。住院后，60%的患者出院回家，25%的患者先接受康复护理然后回家，2%的患者先接受康复护理然后入住养老院，7%的患者接受长期护理，6%的住院以患者死亡告终。在一年总计6.1亿欧元的费用中（每位患者平均费用为20,326欧元），70%涉及急性后期阶段。通过增加接受溶栓治疗的患者比例，成本主要通过减少康复护理而降低，每多治疗一名患者节省1,462欧元。通过改善治疗时机，节省的费用增加一倍多（每多治疗一名患者节省3,183欧元）。
本研究证实法国AIS的负担很重。通过改善卒中单元的溶栓管理，可以改变患者在护理路径中的就医过程，增加回家出院的人数，改变急性后期的资源消耗并实现净节省。
