Endovascular Treatment Costs High for Acute Stroke

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Hospitalization costs for patients treated with endovascular clot removal for acute stroke are high even in those with good outcomes. Moreover, according to findings reported online October 6, 2011, ahead of print in Stroke, the expense often outstrips Medicare reimbursements.

Harry J. Cloft, MD, PhD, of the Mayo Clinic (Rochester, MN), and colleagues evaluated hospitalization costs for 3,864 acute stroke patients in the National Inpatient Sample who received endovascular embolectomy in the United States from 2006 to 2008.

Of the entire cohort, about half (51.3%) were discharged to long-term facilities due to severe disability and 24.3% died in-hospital, with 24.4% discharged to home with a good outcome. Over half (57.3%) were aged 65 years or older.

High Costs, Poor Outcomes

Median hospital costs in 2008 dollars were $36,999 for patients with a good outcome and $50,628 for those with severe disability (P < 0.0001). For patients who died, median costs were $35,109.

In 2008, the average Medicare payment for mechanical embolectomy without major complication was $22,075, $26,639 with complication. For Medicare patients in 2008, hospitals typically lost roughly $15,000 on each acute stroke patient treated with embolectomy who had a good outcome, $24,000 on each patient with disability, and $9,000 on each patient who died.

On subgroup analysis, median costs did not differ by age at the 65-year threshold (P = 0.61). However, complications proved costly, with intracranial hemorrhage, mechanical ventilation, gastrostomy, and tracheostomy resulting in higher hospitalization costs (table 1).

Table 1. Costs in Acute Stroke Patients Treated with Endovascular Embolectomy

Complication  Median Hospital Cost  P Value 
Intracranial hemorrhage
No Intracranial hemorrhage 
$44,523
$40,899
0.08
GI Bleeding
No GI Bleeding 
$53,769
$41,551
0.10
Mechanical Ventilation
No Mechanical Ventilation 
$50,489
$38,437
<0.0001
Gastrostomy
No Gastrostomy 
$53,196
$40,640
0.02
Tracheostomy
No Tracheostomy 
$55,490
$40,712
0.0002

 

Length of stay followed the same pattern, with longer median stays in patients with severe disability compared with those discharged home with a good outcome (11 days vs. 6 days; P < 0.0001). Length of stay was likewise increased in subgroups defined by various complications, but not age.

“Our study of the [National Inpatient Sample] shows that hospitalization costs in the United Sates for patients with ischemic stroke treated with endovascular embolectomy are rather high, probably due to the serious nature of their illness,” the researchers conclude. “Medicare payments have not been adequate in reimbursing these hospitalizations.”

The surprising part, they add, “is that costs are relatively high even for patients who have a good outcome and presumably incur considerably less intensive care costs than patients who have major morbidity.”

It’s Just Business

“We had a suspicion that we were going to find what we found,” Dr. Cloft told TCTMD in a telephone interview. “These patients tend to be sick and use up a lot of expensive resources, and therefore the [diagnosis-related group], the Medicare payment, was likely to not cover the cost of taking care of them.”

He stressed that the study was not a cost-effectiveness analysis, which takes into account other aspects of patient care as well as societal costs. “This is just a simple business calculation,” Dr. Cloft said. “If you’re a hospital and in the business of taking care of these patients, what are you spending and what are you recouping?”

He explained that due to the nature of the NIS database, the researchers were unable to obtain actual procedural costs, only overall hospital costs. Dr. Cloft estimated that under 5% of acute ischemic stroke patients are candidates for endovascular clot retrieval. “It’s a small fraction, but probably growing,” he said.

Dr. Cloft expressed hope that in the future, hospitals and the Centers for Medicare and Medicaid Services will work together “to figure out how to get the charges and costs more in line with one another.”

Cost vs. Stroke Center Status

In the meantime, while he did not think the cost/reimbursement ratio would discourage any physicians from performing such procedures, “it might be a disincentive for a hospital that wants to be a stroke center,” Dr. Cloft said.

In a telephone interview with TCTMD, Philip M. Meyers, MD, of Columbia University Medical Center (New York, NY), agreed, noting that many hospitals are looking into becoming stroke centers due in part to an expectation of high reimbursement rates. “Now there’s some cost data showing it might not be that cost effective, so why would a hospital want to do that?” he asked.

To Dr. Meyers, one of the main messages from the study is how few acute stroke patients actually benefit from endovascular therapy. “If you look at the number of good outcomes, it’s not that high when you treat even selected patients with large strokes,” he said. “And the data are showing that it’s very expensive to get them through to the point where they’re actually going to recover.”

‘The Problems Are Just Beginning’

Dr. Myers added that the study demonstrates a key difference between stroke treatment and PCI. “When you revascularize the heart, the patient starts to get better almost immediately. You’re bringing more blood to the heart, so the heart’s recovering,” he said. “It’s completely different for stroke. What this study points out is that when you reopen that artery, the problems are just beginning. While we think opening the artery is going to be better, there’s no hard evidence for that yet, there’ve been no trials proving that.”

He added that as opposed to cardiology—interventional cardiology in particular—which has performed rigorous clinical trials to answer important questions about new therapies, the stroke field is not as organized in enrolling patients to gather data about new treatments such as endovascular embolectomy.

“I still see this as a research procedure where there’s a big movement in the community to just roll it out, like ‘we need to be treating these patients, so let’s just do it and we’ll figure it out later,’ ” Dr. Meyers said. “So we’re kind of circling: We’re not coming up with the data we need to get things reimbursed, but reimbursement is too low, the physician side has no payment for these procedures, and we’re not collecting the data because patients are being treated willy nilly.”

He added that without such data, it is an open question as to whether offering endovascular therapy to a widening pool of acute stroke patients is appropriate. “We could be doing more harm than good and at a very high cost,” Dr. Meyers said.

 

 


Source:

Brinjikji W, Kallmes DF, Rabinstein AA, et al. Hospitalization costs for patients with acute ischemic stroke treated with endovascular embolectomy in the United States. Stroke. 2011;Epub ahead of print.

Disclosures:

  • Dr. Cloft reports receiving research support from Cordis Endovascular and Mindframe.
  • Dr. Meyers reports no relevant conflicts of interest.

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Jason R. Kahn, the former News Editor of TCTMD, worked at CRF for 11 years until his death in 2014…

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