In view of the lack of reliable economic information from most European countries, Sweden (population 8.5 million) is used here as an example of the cost-effectiveness of stroke care in Europe. In 1988, stroke patients in Sweden accounted for 3.25 million bed days in hospitals and nursing homes (382,000/million inhabitants). The total direct and indirect costs associated with stroke have been calculated for these patients, using 1991 prices. The total direct costs (made up mainly of medical care and social services costs) are calculated to be US$ 1,579 million (US$ 185.8 million/million inhabitants) and the total indirect costs (made up of sickness benefits, stroke-related early retirement and death before the age of 65 years) are calculated to be US$ 396 million (US$ 46.6 million/million inhabitants). The total calculated costs are therefore US$ 1,975 million (US$ 232.4 million/million inhabitants). Stroke patients are major consumers of medical care and social services even before the occurrence of stroke. Adjusting for this, the national incremental cost attributed to stroke is calculated to be US$ 1,017 million (US$ 120 million/million inhabitants). The average cost from first stroke to death is US$ 79,000 per patient (US$ 41,000 if adjusted for the high consumption of medical care and social services before stroke). The economic benefits of three types of preventive strategy have been calculated using the results of recent randomized trials applied to the Swedish medical setting. Anticoagulants given to eligible patients with atrial fibrillation might prevent 420 strokes/year, and give a net economic saving of US$ 1.5 million/year (US$ 0.2 million/million inhabitants), provided that the risk of intracranial bleeding is low (1.3%/year), as in well-controlled routine care in Sweden. Carotid surgery in patients with transient ischemic attack or minor stroke might prevent 255 strokes/year and save US$ 8 million/year (US$ 0.9 million/million inhabitants). Antiplatelet agents in patients with transient ischemic attack or minor stroke have the potential to prevent 180 strokes/year and save US$ 7.2 million/year (US$ 0.8 million/million inhabitants); these drugs now being used routinely, the US$ 7.2 million saving has already been made. Intensified efforts to identify and treat hypertension have a high potential for reducing the number of strokes (at least 1,000 prevented per year in Sweden), but the costs are considerable. Recent randomized trials have shown that antihypertensive therapy effectively reduces the risk of stroke and also of myocardial infarction in people above 70 years of age. In the 70- to 80-year age range, the net cost is approximately US$ 250/year gained. At 50 years, the corresponding economic saving approaches US$ 250/year gained. At 50 years, the corresponding economic saving approaches US$ 60,000/year. Nonpharmacological strategies to reduce blood pressure levels in the population and campaigns against smoking are probably cost-effective, but no data are yet available to support this proposition. Admitting stroke patients to specialized stroke units during the acute phase has no major influence on mortality. However, early intensive rehabilitation in such units reduces the need for long-term institutional care, as shown by two Scandinavian randomized trials. Ongoing analyses indicate that stroke units are also extremely beneficial from an economic perspective.
Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care.All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care.The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health).Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.
Thrombolysis is a highly promising treatment in acute ischaemic stroke. There is evidence of positive effects at least up to three hours and most probably up to six. The risk of intracranial haemorrhage is increased fourfold with thrombolysis; risk factors other than the treatment as such have not been identified for certain; the risk is not related to giving thrombolysis during the 0-3 as opposed to the 3-6 hour time window. There is a non-significant excess of deaths, ranging from a small reduction to a substantial excess. There is not enough evidence to answer several questions regarding the influence of patient- and stroke characteristics on effectsize; death; and risk of intracranial haemorrhage. Giving priority to new large randomized controlled trials is essential to achieve this knowledge.
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