ORLANDO, Fla. -- In the first economic analysis of its kind, Duke University Medical Center researchers have found that heart attack patients who suffer from a stroke shortly after the heart attack have a 56 percent increase in their medical bills.
The higher cost is due to a combination of longer hospital stays and stroke-related procedures (such as head CT scans). Stroke patients also are less likely than non-stroke heart patients to receive further cardiac procedures, the researchers concluded.
These economic findings are important, said lead researcher and cardiologist Dr. Chen Tung, because most new therapies for heart attacks, whether drug- or procedure-based, carry some risk of stroke.
"As primary angioplasty and newer clot-dissolving medications are used to treat heart attacks, it is important that we carefully monitor stroke rates," Tung said. "Any significant changes in these rates will not only adversely affect patient outcome, but will have a large impact on the cost of care."
Tung, a cardiology fellow at the Duke Clinical Research Institute (DCRI), prepared the results of his study for presentation Wednesday (Nov. 12 ) at the scientific sessions of the American Heart Association.
"Patients who have a stroke on top of a heart attack are in double jeopardy," Tung said. "They have a high death rate - about 35 percent of them will die during their initial hospitalization. Of those who survive, 50 percent have significant disability, many of whom require rehabilitative or institutional care, driving up costs."
The Duke team gathered information from the 2,600-patient Economics and Quality of Life substudy of the GUSTO (Global Utilization of Strategies to Open Occluded Arteries in Acute Coronary Syndromes) trial, which compared the benefits of the clot-busting drugs (streptokinase and t-PA) in more than 41,000 patients around the world.
There are two main types of strokes: those caused by bleeding in the brain, and ischemic strokes, which are caused by blockages in blood vessels to the brain. Both cut off the supply of oxygen to brain cells, causing them to die. In the GUSTO trial, the incidence of the two types of strokes was about the same, Tung said.
While thrombolytic agents are effective in treating strokes caused by blocked blood vessels, they worsen bleeding strokes. In the current study, half the patients with bleeding strokes died, while only 15 percent of ischemic stroke patients died.
The team analyzed detailed economic and resource usage data on the 352 U.S. heart attack patients who suffered a stroke during their initial hospitalization.
Among the findings were:
- The main cost driver for the initial hospitalization was the stroke type (bleeding $27,824 vs. ischemic $38,529).
- For follow-up costs, the main cost driver was level of disability at discharge (disabled $2,623 vs. non-disabled $5,353).
- Stroke patients were less likely to receive cardiac catheterization, 46 percent to 72 percent.
- Stroke patients were less likely to receive angioplasty, 15 percent to 30 percent.
- Stroke-related procedures added $2,180 per stroke patient.
- Stroke patients remained an additional 2.2 days in intensive care units and an additional 3.1 days in regular hospitals rooms.
"The net effect was an increase of $12,030 in costs for the initial hospitalization, when compared to the non-stroke patients," Tung said.
After following patients for six months, the researchers found that medical care costs for stroke patients were almost five times more than non-stroke patients ($17,272 vs. $3,543), which was nearly entirely accounted for by the need for institutional care.
"This reflects the impact of the residual neurological deficit many stroke patients have," Tung said. "Many of these patients require extensive rehabilitation services or institutional care."
For stroke patients who have residual disability, their physicians tend to view the stroke as the more serious of the two conditions, explaining the lower rates of invasive heart procedures, Tung said.
"Their physicians tend to be more conservative in the management of these patients' coronary disease for two reasons," Tung explained. "First, because of their disability, the patients are less likely to benefit from a procedure, and secondly, the lifespan and/or quality of life of these patients are limited more by the stroke rather than the heart disease."
The study was conducted at the DCRI, which manages large multi-center clinical trials and analyzes the resulting data.
Joining Tung in his study were, from Duke, Dr. Christopher Granger, Dr. Robert Califf, Nancy Clapp-Channing, J.David Knight, Dr. Kenneth Mahaffey, Linda Davidson-Ray and Dr. Daniel Mark; Dr. Eric Topol, Cleveland Clinic; Dr. Michael Sloan, University of Maryland; Dr. Harvey White, Greenlane Hospital, Aukland, New Zealand; and Dr. Joel Gore, University of Massachusetts.