Cost-Effectiveness Analysis of a Standardized Management Program for Ischemic Stroke Patients in Hainan Province,China

Despite stroke still being a leading cause of disability worldwide and resulting in significant economic and societal cost, advances are being made. A 42% decrease in stroke incidence was reported in high-income countries over the past 4 decades, which may be attributed in part to the established evidence-based guidelines for the management of ischemic stroke. Moreover, for the purpose of enhancing guideline adherence, the American Heart Association/American Stroke Association (AHA/ASA) has launched the Get With The Guidelines–Stroke program (GWTGStroke), which produced statistically and clinically significant changes in the quality of care and in the patients' lifestyles and medicine adherence. ¹ The present study aims to evaluate the cost-effectiveness of a standardized management program compared with usual care in patients with ischemic stroke in Hainan province, China.

Our study was conducted between July 2010 and October 2016 in 20 general hospitals that were distributed throughout the whole province. The study was divided into 3 periods: (1) From July 2010 to February 2012 (20 months), 3218 consecutive patients with ischemic stroke were admitted and received usual stroke management from physicians; (2) From March 2012 to November 2013 (20 months), 636 physicians and nurses from 20 hospitals involved in the management of stroke patients were trained as “health coaches” by highly experienced physicians in a 2-day workshop so that they could offer the health promotion program in their own work settings. Health coaches also provided long-term instruction via telephone, video, or onsite conferences. The training materials were designed based on China Clinical Guidelines for Stroke Management 2010 ² and China Diagnosis and Treatment Quality Control of Ischemic Stroke, ³ as well as US Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack. ⁴ The standardized management program aimed to improve the quality of stroke management in health care settings through early antithrombotics, IV tissue plasminogen activator (rt-PA), and lifestyle recommendation, among others. (3) From December 2013 to October 2016 (20 months), 3367 consecutive ischemic stroke patients were recruited as post-training patients, who were treated with standardized ischemic stroke management by the trained physicians.

The baseline demographic and clinical profiles were similar between pre- and post-training patients. The average length of stay of post-training patients was significantly shorter than that of pre-training patients (8.7 ± 0.9 vs. 11.7 ± 1.5 days, P < 0.01). Moreover, cost-effectiveness analysis implied that standardized stroke management was dominant compared with usual care. The average hospital cost of post-training inpatients was significantly less than that of pre-training patients (¥7,681.7 ± 1397.7 vs. ¥11,846.2 ± 2514.6, P < 0.01), while activities of daily living (ADL) levels were significantly higher for post-training patients (68.2 ± 3.2 vs. 43.5 ± 5.3). Multivariate linear regression analysis illustrated that standardized stroke management (P < 0.01) was negatively associated with hospital cost and positively associated with the ADL level.

A standardized stroke management program is a cost-effective choice as it significantly reduces the costs needed to manage ischemic stroke and improves patients' ADL levels. This evidence-based stroke management program has the potential to be scaled up to other resource-limited areas in China and around the world.