Swift treatment, less use of anesthesia lowers stroke cost

Hospitals can lower the cost of an initial acute stroke admission by shortening treatment times or reducing use of routine anesthesia in patients who receive medical or endovascular treatment, an analysis of the IMS III Trial found.

IMS (Interventional Management of Stroke) III was terminated in 2012 for futility. The international, randomized study compared the use of intravenous tissue-type plasminogen activator (tPA) with endovascular therapy followed by tPA and found no difference in clinical outcomes. Kit N. Simpson, DrPH, of the University of Cincinnati Academic Health Center, and colleagues followed up with an economic analysis of the data that was published online May 13 in Stroke.

The economic study included only clinical centers in the U.S. with usable billing information. To convert charges to costs, Simpson et al applied the hospital’s Medicare cost-charge ratio, with estimates given in 2012 dollars. They then compared costs for the two treatment groups with a sample of patients in the U.S. selected from the 2010 National Inpatient Sample.

The study population totaled 430 IMS III participants. Adjusted costs for care of patients in the endovascular group were approximately $9,500 higher than for patients in the tPA alone group ($35,130 vs. $25,630). Within the endovascular group, the mean cost for patients who received routine anesthesia was $46,444 compared with $30,350 for those who didn’t.

Baseline stroke severity and the time from onset of stroke to tPA administration also affected cost. Late intravenous tPA treatment increased cost in all patient groups except those in the tPA alone group who had moderate stroke severity, based on National Institute of Health Stroke Scale (NIHSS) scores. Early tPA treatment in patients with severe stroke in the tPA alone group offered the greatest cost benefit, with a savings of $7,706.

Patients who received tPA within two hours of stroke onset and those with baseline NIHSS scores below 20 also had a shorter length of stay.

“This finding provides strong evidence to motivate physicians and hospitals to put in place systems of care that allow for and demand rapid treatment times with special focus on assuring that these systems are effective for both patients with moderate and severe stroke,” they wrote. Hospitals looking for cost efficiencies should explore the use of routine anesthesia with intubation as well, they recommended.

The analysis also revealed a gap between cost and reimbursement for endovascular treatments. “The cost of embolectomy for IMS III subjects and patients from the National Inpatient Sample cohort exceeded the Medicare diagnosis-related group payment by more than 75 percent of patients,” they pointed out.