Clinical Guidelines for Acute Stroke Management - Living on the EDge

9.1 Organisation of care
Section 9 Cost and Socioeconomic Implications
9.1.1 <strong>Stroke</strong> Unit Care
To date there has been one systematic review identified
that included three studies comparing the costs and
outcomes of stroke units to that of general wards. 476
All three studies were based in Europe (UK, Sweden
and Germany) and included costs of community and
outpatient care. All three studies found modest cost
savings (3-11%) using stroke unit care, however, the
figures failed to reach significance. The authors concluded
that there was “some” evidence <strong>for</strong> the costs to be at
least equivalent to conventional care.
More recently, an Australian prospective cohort study
comprising 468 patients from Melbourne has been
published. 477 The investigators determined that care
delivered in geographically localised units was costeffective
compared with general medical wards or mobile
stroke (inpatient) teams and that the additional cost in
providing stroke units compared with general medical
wards was found to be justified given the greater health
benefits in terms of delivering best practice processes of
care and avoiding severe complications. When compared
to general medical care costs ($12,251), costs <strong>for</strong> mobile
teams were significantly higher ($15,903 p=0.024), but
borderline <strong>for</strong> stroke units ($15,383 p=0.08). This was
primarily explained by the greater use of specialist medical
services. The incremental cost-effectiveness of stroke unit
over general wards was $AUD9,867 per patient achieving
thorough adherence to clinical processes and
$AUD16,372 per patient with severe complications
avoided, based on costs to 28 weeks.
These findings generally accord with international studies,
such as that conducted by Patel et al (2004). 478 This
is the first Australian study to detail the costs and
cost-effectiveness of different acute care models, and it
provides important in<strong>for</strong>mation to underpin increased
investment in stroke units.
Further, other work by Moodie et al (2004) has
demonstrated that when modelled over the lifetime
of a cohort of first-ever stroke patients, stroke units
when compared to general medical care, produced
considerable gains in terms of health benefits with these
additional benefits associated with additional costs.
There was an additional lifetime cost of $1,288 per
DALY recovered, or alternatively $20,172 per stroke
averted or $13,487 per premature death averted.
It was determined that the stroke unit intervention
was cost-effective given the small additional costs
per extra unit of benefit gained. 479
Currently, only 19% of public hospitals report providing
stroke unit care 480 and there is clustering of stroke units
in large urban centres. <strong>Stroke</strong> units improve outcomes <strong>for</strong>
people with stroke (see section 1.1). Further economic
modelling work has predicted that if access to stroke
units was improved to 80% from a baseline of 25%, then
more than 8,374 DALYs could be recovered. 481 Although
this literature does not specifically indicate the real costs
of setting up a stroke unit, there is evidence that health
services should be organised to provide stroke unit care
and that considerable gains in terms of health benefits
could be achieved.
9.1.2 Care Pathways and <strong>Clinical</strong> Practice
<strong>Guidelines</strong>
The effectiveness of care pathways in stroke management
is variable and the effects on length of stay and costs
are inconclusive. 44, 482 To date there has not been a costeffectiveness
study <strong>for</strong> care pathways in stroke, but there
is evidence that the setting of use may be important.
The study (pre-post audit design) conducted by Read
and Levy (2006) has shown that implementation of
pathways in regional Queensland can assist in improving
adherence to important processes of care, such as early
access to allied health, improved use of antithrombotic
agents in eligible cases at discharge and estimation of
blood glucose levels. 483 Similar studies conducted in
Victoria have also indicated improved adherence to some
important processes of care with use of care pathways or
clinical management plans. 20, 24, 484 More recent evidence
may suggest better effectiveness in acute settings than
rehabilitation settings. 45 It also appears that factors, such
as the experience of the specialist team in managing
stroke, may be important, with the use of such plans
more effective in settings that have newly organised
stroke services.
There has been one study conducted in Italy that has
examined whether adherence to clinical practice
guidelines influences the cost of acute stroke care.
Non-compliance with guidelines was shown to be
associated with increased costs (<strong>for</strong> every unit of
non-compliance there was a 1.38% increase in hospital
costs). 485 Locally, evidence published from the SCOPES
study indicates that greater adherence to important
clinical processes of care occur more often in stroke units
and there is also a reduction in severe complications,
which when these measures are used as proxies of health
outcome indicate that these units are more cost-effective
than other care modalities. 477 In SCOPES, hospitals with
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