Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors

Abstract

Background: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.

Methods: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.

Results: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.

Conclusion: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Keywords: Caregivers; Health services; Healthcare costs; Hospitalization; Stroke.

Fig. 1

Acute and outpatient healthcare service utilization and associated costs across 4 quarters post-stroke. Estimates are taken from Model 2 with following variables in final model. Service utilization model. Acute inpatient service: patient age, gender, ethnicity, caregiver identity, comorbid status; Acute ED service: patient age, gender, ethnicity, caregiver identity, comorbid status, religion; Outpatient SOC service: patient age, gender, ethnicity, stroke disability (measured on modified rankin scale), comorbid status; Outpatient PC service: patient age, gender, ethnicity, stroke type, stroke severity, ward class, comorbid status. Cost model. Acute inpatient cost: age, gender, ethnicity, caregiver identity, comorbid status, marital status, recurrent stroke; Acute ED cost: age, gender, ethnicity, caregiver identity, comorbid status; Outpatient PC cost: age, gender, ethnicity, stroke type, stroke severity, comorbid status. a Inpatient and emergency department service utilization and costs (ACUTE), b Specialist outpatient clinic and primary care utilization and costs (OUTPATIENT). Abbreviations: IRR = incidence rate ratio; ED = emergency department; SOC = specialist outpatient clinic; PC = primary care. *: For Hospitalization/ED (or PC) cost, the y-axis is the ratio of expected cost from Q2 to Q4 to the reference quarter (Q1) respectively

Fig. 2

Hospitalization and associated costs by caregiver identity. Estimates are taken from Model 2 with following variables in final model. Service utilization model. Acute inpatient service: patient age, gender, ethnicity, caregiver identity, comorbid status. Cost model. Acute inpatient cost: age, gender, ethnicity, caregiver identity, comorbid status, marital status, recurrent stroke. Reference group for caregiver identity variable is stroke patients with no caregiver. a Incidence risk ratio of hospitalization by caregiver identity (HOSPITALIZATION), b Multiplier of hospitalization associated costs by caregiver identity (COST). Abbreviation: IRR = incidence rate ratio. *: For hospitalization cost, the y-axis is the ratio of expected cost from Q2 to Q4 to the reference quarter (Q1) respectively

Fig. 3

Specialist outpatient visits across 4 quarters post-stroke by disability sub-groups. Estimates taken from Model 3 with following variables in the final model. Service utilization model. Outpatient SOC service: patient age, gender, ethnicity, stroke disability (measured on modified rankin scale), comorbid status. Disability measured using Modified Rankin Scale (mRS): mRS score of 0 to 2 = no or slight disability group, mRS score of 3 to 5 = moderate or severe disability. Abbreviation: IRR = incidence rate ratio; SOC = specialist outpatient clinic

Fig. 4

Primary care costs across 4 quarters post-stroke by stroke type and severity. Estimates taken from Model 3 with following variables in the final model. Cost model. Outpatient PC cost: age, gender, ethnicity, stroke type, stroke severity, comorbid status. a Ratio of expected primary care costs by stroke severity in ischemic stroke sub-group (ISCHEMIC), b Ratio of expected primary care costs by stroke severity in non-ischemic stroke sub-group (NON-ISCHEMIC). Stroke severity measured using National Institute of Health Stroke Scale (NIHSS): mild = 0 to 4, moderately severe = 5 to 14, severe = 15 to 24. Abbreviations: Mild = mild stroke; Moderate = moderately severe stroke; Severe = severe stroke *: For primary care cost, the y-axis is the ratio of expected cost from Q2 to Q4 to the reference quarter (Q1) respectively