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Costs and Rehabilitation of Stroke Patients: A Retrospective Study of Medicare Beneficiaries

Richard D. Zorowitz, MD 1; Er Chen, MPP 2; Kuo B. Tong, MS 2

1 Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD; 2 Quorum Consulting, Inc., San Francisco, CA

International Stroke Conference 2008

February 20-22

New Orleans, LA

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DisclosuresThe study was funded by Northstar Neuroscience Inc.

Dr. Zorowitz is a member of the Northstar Stroke Advisory Board

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Background and Rationale Stroke is the leading cause of adult disability in the US affecting some

750,000 people annually• 50% of survivors with hemiparesis,15-30% left permanently disabled 1,2

Stroke results in substantial costs to the US health care system• Direct and indirect costs: estimated at $65.5 billion in 2008 3

• Average lifetime cost of ischemic stroke: $140,000 4

Few studies on long-term stroke outcomes• Patients with hemiparesis were not profiled among overall stroke

population• Population-based estimates of prevalence and costs of rehabilitation are

lacking

1 Kelley-Hayes M, Beiser A, Kase CS, Scaramucci A, D’Agostino RB, Wolf PA. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003;12:119 –126.2 Asplund K, Stegmayr B, Peltonen M. From the twentieth to the twenty-first century: a public health perspective on stroke. In: Ginsberg MD, Bogousslavsky J, eds. Cerebrovascular Disease Pathophysiology, Diagnosis, and Management. Vol 2. Malden, Mass: Blackwell Science; 1998:chap 64.3 Rosamond W, Flegal K, Furie K, et al. Heart Disease and Stroke Statistics_2008 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.107.187998, e37-e51.4 Taylor TN, Davis PH, Torner JC, Holmes J, Meyer JW, Jacobson MF. Lifetime cost of stroke in the United States. Stroke. 1996;27:1459 –1466.

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ObjectivesAmong incident stroke patients, we aim to assess long-term overall medical costs utilization of therapy and rehabilitation (TR) and

associated costs the impact of hemiparesis on long-term overall medical

costs and TR use and costs

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Data Source 5% randomly selected Medicare beneficiary-level

records (Medicare Standard Analytic File) provided by CMS• Demographic information (e.g., age, gender, race)• Clinical characteristics (e.g., diagnosis, vital status)• Medical care services provided across different care

settings (e.g., visits, procedures, dates of service)• Costs (i.e., Medicare payments) for each service

Beneficiaries’ data were linked across different claims settings and followed longitudinally from 2003 to 2005

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2002 2003 2004 2005Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Index

Follow-up window

Wash-out window

Study Design

Stratified pts by the presence of hemiparesis (ICD-9-CM: 438.2); analyzed the patient outcomes 2003-2005

2002 Removed pts if they had any cerebral vascular disease (ICD-9-CM: 430-438); analyzed comorbidity status for selected pts

Q1, 2003 Selected pts based on stroke diagnosis (ICD-9-CM code 433.8, 434.01, 434.1, 434.11, and 434.91) and DRG code 14; analyzed demographics for selected pts

Comorbidities Demographics Mortality, overall Medial costs, utilization of TR and costs

7Source: Centers for Medicare and Medicaid Services (CMS) Standard Analytical File (SAF) 5% Sample

De novo stroke pts

N=1,849

Hemiparesis Cohort

Non-Hemiparesis Cohort

779 605 528

1,849 1,291 1,141

1,070 686 613

2003 2004 2005

5% Medicare sample in CY2003

Number of pts in each year 2.1 million total beneficiaries 1.7 million with medical

claims

Study Cohort

Stroke pts survived

hospitalization

N=2,517

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Baseline CharacteristicsOverall

(N=1,849)

Non-Hemiparesis Cohort

(N=1,070)

Hemiparesis Cohort

(N=779)

P Value*

Age (year)

Mean (SD)77 (9.6) 78 (9.6) 77 (8.9) 0.148

Gender, N (%)

Male

Female

771 (41.7)

1,076 (58.2)

462 (43.2)

607 (56.8)

309 (39.8)

469 (60.3)

0.132

Race, N (%)

White

African American

Other

1,520 (82.2)

254 (13.7)

75 (4.1)

892 (83.4)

135 (12.6)

43 (4.0)

628 (80.6)

119 (15.3)

32 (4.1)

0.254

Charlson Comorbidity Index (CCI), N (%)

0-1

3-4

≥4

686 (40.5)

473 (27.9)

535 (31.6)

381 (39.2)

269 (27.7)

321 (33.1)

305 (42.2)

204 (28.2)

214 (29.6)

0.287

* T-test for Age and chi-square tests for Gender, Race and CCI

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Mortality

4.5%

30.2%

35.9%

22.3%

4.3%

11.6% 10.6%12.7%

4.3%

12.4% 11.8% 13.1%

86.9%

45.8%41.7%

51.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overall MedicarePopulation

Overall Stroke Patients Non-hemiparesis Cohort Hemiparesis Cohort

2003 2004 2005 Alive

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$6,739

$31,979

$22,874

$44,487

$7,779

$13,063$10,681

$15,766

$8,417

$15,540$10,989

$13,095

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

$50,000

Overall MedicarePopulation

Overall Stroke Patients Non-hemiparesisCohort

Hemiparesis Cohort

2003 2004 2005

Medicare Costs Per Patient

Costs include hospital inpatient, hospital outpatient, physician care, skilled nursing facility, home health service, durable medical equipment, and hospice services

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Medicare Costs by Claim Type OVERALL STROKE PATIENTS

58%

43%

42%

16%

13%

12%

12%

18%

19%

6%

8%

9%

5%

10%

10%

4%

7%

9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2003

2004

2005

Hospital Inpatient Skilled Nursing Facilities Physcian Care Home Health Service Hospital Outpatient Other

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Utilization of Therapy & Rehabilitation

48.6%

86.8%

17.1%

35.4%

16.3%

32.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Non-hemiparesis Cohort Hemiparesis Cohort

2003 2004 2005

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Costs Per Patient of Therapy & Rehabilitation

7,488

18,678

5,237

9,280

5,661

9,248

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

Non-hemiparesis Cohort Hemiparesis Cohort

2003 2004 2005

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Costs of Therapy & Rehabilitation by Claim Type

OVERALL STROKE PATIENTS

39%

23%

21%

44%

38%

44%

16%

35%

32%

2%

4%

3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2003

2004

2005

Hospital Inpatient Skilled Nursing Faclity Home Health Service Other

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Discussions Limitations

• Serial dependency was expected• Our study did not distinguish stroke-related costs and

non-stroke related costs• Diagnosis, resource use and costs were based on

patients’ medical claims• Our study did not stratify resource use and costs by

stroke sub-type and/or severity Conclusion

• Long-term care and rehabilitation services constituted a significant proportion of the total medical costs

• The management of post-stroke patients should consider clinical and economic impacts, esp. costs incurred outside of a hospital inpatient setting