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Economic burden of stroke in a large county in Sweden
© Persson et al.; licensee BioMed Central Ltd. 2012
Received: 8 December 2011
Accepted: 21 September 2012
Published: 26 September 2012
Stroke remains to be a major burden of disease, often causing death or physical impairment or disability. This paper estimates the economic burden of stroke in a large county of 1.5 million inhabitants in western Sweden.
The economic burden of stroke was estimated from a societal perspective with an incidence approach. Data were collected from clinical registries and 3,074 patients were included. In the cost calculations, both direct and indirect costs were estimated and were based on costs for 12 months after a first-ever stroke.
The total excess costs in the first 12 months after the first-ever stroke for a population of 1.5 million was 629 million SEK (€69 million). Men consumed more acute care in hospitals, whereas women consumed more rehabilitation and long-term care provided by the municipalities. Younger patients brought a significantly higher burden on society compared with older patients due to the loss of productivity and the increased use of resources in health care.
The results of this cost-of-illness study were based on an improved calculation process in a number of fields and are consistent with previous studies. In essence, 50% of costs for stroke care fall on acute care hospital, 40% on rehabilitation and long-time care and informal care and productivity loss explains 10% of total cost for the stroke disease. The result of this study can be used for further development of the methods for economic analyses as well as for analysis of improvements and investments in health care.
Stroke continues to be a major burden of disease [1, 2] even when the risk of premature death has been reduced . Several assessments of the direct and indirect costs have been published [4–9]. In Sweden, the comprehensive statistics from providers on the utilization of in-hospital, municipal and long-time care make it possible to evaluate the costs from a wide societal perspective in detail . Sweden, like many Organisation for Economic Co-operation and Development (OECD) countries, faces a problem of an increasing fraction of elderly persons, who will in the long run lead to a heavy burden on society and the working population . Thus, the financial burden of diseases such as stroke is important.
A health economic analysis of a disease implies that there is information available regarding the use of resources at different levels in the chain of health care and society. By using the social security number, Sweden has a unique ability to follow one patient throughout the whole chain of health care within the Swedish administrative registries. In this paper, relevant data were selected to provide a complete picture of the burden of stroke in Västra Götaland, a county in western Sweden including health care consumption, municipal care, potential productivity loss and informal care by relatives.
The aim of this exploratory study was to present the societal costs of first-ever stroke during 2008 in Västra Götaland, a large county in western Sweden, which has 1.5 million inhabitants. The study identified, quantified and valued all costs for health care, rehabilitation, long-term care and home aid and potential productivity loss. Also, all costs for patients and families during the first 12 months after the first-ever stroke as well as lifetime costs, were estimated. This study analysed the costs arising due to the increase in resource consumption due to stroke.
Demographic and clinical variables for patients with first-ever stroke in western Sweden during 2008
Age-related differences in health-related quality of life and mobility three month after first-ever stroke onset for patients in western Sweden during 2008
Direct costs in health care
Main unit cost per resource use items in hospital care, municipal rehabilitation and aid service, average income and informal care for patients with first-ever stroke in western Sweden during 2008
Municipal home care
Municipal assistant living
As this is a study of excess costs, municipal costs were calculated based on the change in the use of rehabilitation as well as long-term care and home aid before and after the stroke, respectively based on information from The Stroke Register. Municipal excess costs were small for individuals who had already used a great deal of care before the stroke. Costs for patients who died during the first three months after the stroke were limited. The average per diem cost was based on information from municipal professional workers.
Informal care volume
Estimates of the volume of hours spent on informal care were based on the information in The Stroke Register, which was verified by interviews with caregivers and employees within the municipalities. According to the register, 2,076 patients reported that they were entirely or partly dependent on their informal caregiver. It was estimated that those who were entirely dependent on their informal caregiver received four hours each day and those who were partly dependent on their informal caregiver received four hours each week. For patients above 85, this volume of informal care was halved because data from The Stroke Register on this age group indicated consumption of municipal care to a larger extent before the stroke.
Informal care costs
The opportunity cost method was used to calculate the socioeconomic value of informal care, meaning the value of the informal caregiver’s best alternative use for this time, which may be the loss of income including social security contributions and/or loss of leisure time. According to previous studies, informal care is mainly given by the patient’s partner [16–18]. Patients in the age group below 65 were estimated to have partners in working age, and were therefore estimated to have a loss of income of 200 SEK per hour based on the average income in western Sweden during 2008 calculated by from Statistics Sweden . This includes an estimation of 25% on sick leave or disability pension. Patients above 65 were estimated to have partners not in working age and therefore to have a loss of leisure time of 70 SEK per hour, which is 35%  of the production loss value (Table 3).
Cost for loss of productivity
Estimation of cost for loss of productivity was based on sick leave and early retirement due to the ICD-10 codes I61, I63 and I64 in the year 2008. This information was obtained from the social insurance authority, which registers all absence to work in Sweden. Another two weeks were added to the time the sick leave because this period is not included in the initial phase of sick leave covered by the insurance. The period was calculated in working days and then multiplied by average day-income including social security contributions based on the average monthly market income in the county  (Table 3). Total potential productivity loss was recalculated with a factor that takes into account absence from work due other causes such as unemployment and other sicknesses. By this, the employment status of the patients before and after stroke was taken in consideration and a measure of lost social potential production was calculated. The period was calculated in working days and then multiplied by average income including social security contributions, which is a measure of output from a market perspective. The potential productivity loss was estimated based on the human capital approach.
Estimation of lifetime costs was based on estimated excess total cost in the first three years after first-ever stroke. The calculation of the first year corresponds to the follow-up of patients at the individual level indicating the exact real consumption of health care services, community care and production loss. In the second year, costs were estimated based on information about the discharge of patients. This information includes mortality, survival rates, degree of handicap, change in the need of community service, health care and long sick leave. Future development of costs after three years were adjusted based on data from clinical registries and other studies [5, 21]. Future costs were discounted to present value using a discount rate of 3%. The structure of costs is substantially different in the first year after stroke compared with future costs. The weight of community costs increased after the first year.
Excess total costs
Excess total costs for all patients, excess cost per patient and lifetime costs for patients with first-ever stroke in western Sweden during 2008
Cost per 1,000 inhabitants
Costs all patients
Inpatient care costs
Outpatient care costs
Municipal care costs
Informal care costs total
Productivity loss total
Cost per patient
Average all patients
Patients under 55 years
Patients between 65–74 years
ICD-10 code I61
ICD-10 code I63
ICD-10 code I64
Patients under 55 years
Patients over 85 years
Excess cost per individual
Differences in excess costs per patient with first-ever stroke in western Sweden during 2008 for females and males
Inpatient care costs
Outpatient care costs
Total healthcare cost
Municipal care costs
Total direct costs
Productivity loss total
Excess costs the first three years
Generalizability and comparability
Costs for life time care are based on statistics for stroke and demography. Changing case-mix may have an influence on the assumptions. As indicated from our results, rising ages for patients with first stroke ever will lead to decreasing overall societal costs. Also, as a previous study  indicates, the incidence of stroke increases among the younger population, especially among younger women. These are probable scenarios and might affect the burden of stroke in a different way than this study indicates.
The estimated excess cost in this study gives a value of the societal burden that could be saved if one stroke-incidence could be avoided. One of the main strengths of this study is the detailed information covering every part throughout the whole chain of health care in addition to societal costs. This study gives indication of the costs in the year 2008; however, there may be variations due to improvements the in health of the population as an effect of new treatments as well as preventions. By this, the result in this study can be used as a basis to evaluate new improvements. Also, this study could be used to initiate a discussion of cost and priorities. However, the calculations have some limitations. There is a lack of data at the individual level in municipal care because only the county health care registers data on individual level. Municipal care is for legal reasons not registered for single individuals, which makes it impossible to perform a regression analysis exploring causality. However, the calculation of average cost is not affected by this. Other published studies in the field had the same problem . Also, there are some uncertainties in calculating the informal care due lack of systematic evidence in the area, which may have a significant influence in health economic analyses . Thus, systematic data on informal care is an essential area for further research.
Analysis of result
This study shows that the expenses for specialist health care in the first year causes most of the excess costs of stroke, but this cost varies between age groups. For individuals older than 75, most of the excess costs are within the municipal care, e.g. rehabilitation and long-time care. Within the health care, inpatient care costs dominated. The study also shows that the excess costs vary across age group, sex and diagnosis. Excess cost in the younger age group is significantly higher than in the older group due to more resources used in health and municipal care as well as productivity loss. Men consumed more resources within health care and had a higher level of productivity loss. Individuals who suffered a cerebral haemorrhage (I61) consumed more resources than other patients in all cost categories. Even though this kind of stroke affects only few individuals, the individuals who are affected are younger and require most resources, both within health care and municipal care. The estimated opportunity cost for informal care is an understatement due to lack of systematic data. However, this gives an indication of the family’s burden in monetary terms.
Comparison with other studies
When comparing the result of this study with other studies on the topic, differences in calculation methods have to be considered. However, compared with previous studies in Sweden, our study showed similar results to other studies on an aggregate level. The most recent study  in Sweden shows that the lifetime-cost per individual was 725,000 SEK (€80,000) converted to 2008 year prices and with a discount rate of 3%. This figure represents an average for Sweden. The life-time cost in this study is calculated to be 768,000 SEK (€84,500).
Comparisons with studies in other countries add even more uncertainties due to different health care systems. A European study by Porsdal and Boysen  showed differences in the use of specific recourses within the health care chain. For example in Denmark and Finland, a large amount of rehabilitation resources are used. In our study, we only estimated the rehabilitation use to 10% compared with the 23% in Porsdal’s study . In this study, the length of stay was about 12 days, whereas the corresponding figure in Porsdal’s study was 33 days . This is an example of the different choices of resource allocation within the health care chain, which have an effect on the overall costs.
The results of this cost of illness study are consistent with previous studies, although we have the cost calculation process in a number of fields. In essence, 50% of costs for stroke care fall on acute care hospital, 40% on rehabilitation and long-term care, informal care and productivity loss explain 10% of total cost for the stroke disease. The results of this study can be used as further development as well as for improvements and investments in health care as well as for development of econometric methods.
The authors’ would like to thank Strokerådet at Västra Götalandsregionen as well as Stroke Centrum Väst at Gothenburg University, for the help they provided throughout the study.
The authors acknowledge financial support from the county of Västra Götaland.
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