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Dates: 2005-2012
Funding: National Institute for Health Research, Medical Research Council, Economic and Social Research Council
Collaborators: Stroke Prevention Research Unit, Oxford
Information: Ramon Luengo-Fernandez

Aims

The aims of the project were to:
1)    Estimate the size and predictors of immediate and long-term (i.e. 5 years after the event) National Health Service (NHS) resource use and health care costs of stroke and transient ischaemic attacks (TIA);
2)    Estimate the size and predictors of immediate and long-term health outcomes, including 5-year life expectancy, patient disability, quality of life, and quality-adjusted life expectancy; and to
3)    Assess if urgent clinical assessment and treatment of non-hospitalised patients with minor stroke or TIA was cost-effective.

Methods

The project was based on data from the Oxford Vascular Study (OXVASC), led by Prof. Peter Rothwell, Stroke Prevention Research Unit, University of Oxford. OXVASC is the first ever study of the incidence, risk factors and outcome of all acute vascular events (TIA, stroke, acute coronary syndrome (ACS), and acute peripheral vascular events (PVE)) in the same population comprising over 91,000 individuals registered in 9 general practices across Oxfordshire. Nested within OXVASC, the Early use of eXisting PREventive Strategies for Stroke (EXPRESS) study aimed at determining the effect of more rapid treatment after TIA and minor stroke in patients who are not admitted directly to hospital.

All suspected TIA/stroke patients were assessed by an OXVASC clinician as soon as possible after event. Informed formal written patient consent was sought, and if this was not possible assent from a relative was obtained.  At assessment, detailed data were collected, which included information on history and timing of presentation, past medical history, vascular risk factors, medication usage, independence prior to the index event, neurological assessment, and social history. Face to face follow-up of TIA and stroke patients, which was carried out by a study research nurse, took place at 1, 6, 12 and 24 months. Detailed data collected as part of follow-up included: disability, quality of life, and institutionalisation into long-term residential or nursing home care. 

Main results


5-year costs after stroke and TIA
Mean censor-adjusted 5-year hospital costs after index stroke were £16,474 (95% CI: 15,142-17,865), with costs varying considerably by severity: £13,526 after minor stroke, £21,196 after moderate stroke, and £18,273 after severe stroke. For the 239 surviving stroke patients who had reached final follow-up, mean costs were £15,601 (12,900-18,301), with over half of costs (£8,302) being incurred in the first year after the event. After index TIA, the mean censor-adjusted 5-year costs were £11,578 (10,206-12,965). A multivariate analysis showed that event severity, recurrent stroke and coronary events after the index event were independent predictors of 5-year costs. Differences by stroke subtype were mostly explained by stroke severity and subsequent events.

5-year disability and institutionalisation after stroke and TIA
For TIA patients, disability levels increased from 14% pre-morbidly to 23% at 5 years (p=0.002), with occurrence of subsequent stroke being a major predictor of disability. For stroke survivors, the proportion disabled (modified Rankin Scale >2) increased from 21% pre-morbidly to 43% at 1-month (p<0.001), with 39% of survivors disabled 5 years post-stroke. 5 years post-event, 70% of stroke patients and 48% (179/375) of TIA patients were either dead or disabled. The 5-year risk of care home institutionalisation was 11% after TIA and 19% after stroke. The average 5-year cost per institutionalised TIA patient was £67,765 (S.D. 45,493) and £85,093 (S.D. 61,853) for stroke patients.

5-year quality of life and quality-adjusted life expectancy after stroke and TIA
Quality of life remained constant at around 0.78 over the 5 years following TIA. Quality of life improved from 0.64 1-month after stroke to 0.70 at 6 months (p=0.006), remaining at around 0.70 thereafter. Matched-controls had considerably higher quality of life levels than stroke/TIA patients (0.85, p<0.001). Event severity and recurrent stroke were significant predictors of decreased long-term quality of life. 5-year quality-adjusted life-expectancy was 3.32 (95% CI: 3.22-3.48) Quality-Adjusted Life Years (QALYS) after TIA and 2.21 (2.15-2.37) after stroke, varying considerably by severity (minor: 2.94, moderate: 1.65 and severe: 0.70).

Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study)
EXPRESS was a prospective population-based before (phase 1: April 1, 2002, to Sept 30, 2004) versus after (phase 2: Oct 1, 2004, to March 31, 2007) study of the effect of early assessment and treatment of TIA or minor stroke on the risk of early recurrent stroke. The study assessed the effect of the introduction of the phase 2 clinic on admissions to hospital within 90 days, hospital bed-days, hospital costs, and 6-month new disability (progression from no disability before event [modified Rankin scale score ≤2 points] to disability at 6 months [modified Rankin scale score >2 points]) or death, compared with the phase 1 clinic. To assess the main predictors of these outcomes, multivariate regression analyses were done.

The 90-day risk of fatal or disabling stroke was reduced in phase 2 (1 of 281 vs 16 of 310; p=0.0005). Hospital admissions for recurrent stroke were also lower in phase 2 than in phase 1 (5 vs 25; p=0.001), which reduced the overall number of hospital bed-days compared with phase 1 (672 vs 1957 days; p=0.017). Hospital bed-days for admissions to hospital due to vascular causes were also lower in phase 2 (427 vs 1365 days; p=0・016), which generated savings of £624 per patient referred to the phase 2 clinic (p=0・028). Results from the multivariate analyses showed that assessment in
phase 2 was an independent predictor of reduced disability, days in hospital, and costs

Publications

•    Luengo-Fernandez R, Gray AM, Bull L, Welch S, Cuthbertson F, Rothwell PM, Oxford Vascular Study. Quality of life after TIA and stroke: ten-year results of the Oxford Vascular Study. (2013), Neurology, 81, 1588 - 1595.

•    Luengo-Fernandez R, Paul N, Gray AM, Pendlebury ST, Bull LM, Welch SJV, Cuthbertson F, Rothwell PM, and on behalf of the Oxford Vascular Study. A population-based study of disability and institutionalisation after TIA and stroke: 10-year results of the Oxford Vascular Study. Stroke 2013; doi: 10.1161/STROKEAHA.113.001584.
•    Luengo-Fernandez R, Silver L, Gutnikov S, Gray A, Rothwell P. Hospitalisation resource use and costs before and after TIA and stroke: Results from a population-based cohort study (OXVASC). Value in Health 2013;16:280-287.
•    Paul NLM, Koton S, Simoni S, Geraghty OC, Luengo-Fernandez R, Rothwell PM. Feasibility, safety and cost of outpatient management of acute minor ischaemic stroke: a population-based study. J Neurol Neurosurg Psychiatry 2013;84:356-361.
•    Luengo-Fernandez R, Yiin G, Gray AM, Rothwell PM. Population-based study of acute- and long-term care costs after stroke in patients with AF. Int J Stroke 2013;8:308-314.
•    Luengo-Fernandez R, Gray AM, Rothwell PM, and on behalf of the Oxford Vascular Study. A Population-Based Study of Hospital Care Costs During 5 Years After Transient Ischemic Attack and Stroke. Stroke 2012;43:3343-3351.
•    Luengo-Fernandez R, Hernandez-Quesada C, Rivero-Arias O. Economic evaluation of healthcare technologies: an introduction for physicians. Rev Neurol 2011;53:107-115.
•    Chandratheva A, Geraghty OC, Luengo-Fernandez R, Rothwell PM.  ABCD2 Score Predicts Severity Rather Than Risk of Early Recurrent Events After Transient Ischemic Attack. Stroke 2010;41:851-856.
•    Koton S, Luengo-Fernandez R, Mehta Z, Rothwell PM. Independent Validation of the Prolonged Length of Stay Score. Neuroepidemiology 2010;35:263-266.
•    Rivero-Arias O, Ouellet M, Gray A, Wolstenholme J, Rothwell PM, Luengo-Fernandez R. Mapping the Modified Rankin Scale (mRS) measurement into the generic EuroQol (EQ-5D) health outcome. Med Decis Making 2010;30:341-354.
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison. Lancet Neurol 2009;8:235-243
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Costs of stroke using patient-level data: a critical review of the literature. Stroke 2009;40:e18-e23.
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Population-based study of determinants of initial secondary care costs of acute stroke in the United Kingdom. Stroke 2006;37:2579-2587.

Presentations

•    Luengo-Fernandez R, Gray AM, Rothwell PM. Long-term outcome and costs after stroke and TIA: Evidence from the Oxford Vascular Study
. Health Informatics Centre, School of Medicine, University of Dundee, 21 March 2012, Dundee.
•    Luengo-Fernandez R. Investigaciones sobre economía del cáncer y las enfermedades crónicas. Elementos Para Una Política Pública Sobre Cáncer En Chile, 13 October 2011, Santiago de Chile.
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Impact of baseline resource use on disease costs: the example of cerebrovascular events. HESG, January 2011, York
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Are results from costing studies overestimated? iHEA 7th World Congress, 12-15 July 2009, Beijing.
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Impact of disease and socio-economic status on quality of life: panel evidence from the Oxford Vascular Study. iHEA 7th World Congress, 12-15 July 2009, Beijing.
•    Rivero-Arias O, Ouellett M, Gray A, Wolstenholme J, Rothwell PM, Luengo-Fernandez R. Mapping the modified Rankin Scale (mRS) measurement into the generic EuroQol (EQ-5D) health outcome. iHEA 7th World Congress, 12-15 July 2009, Beijing.
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Impact of urgent management of TIA and minor stroke on hospital costs and 6-month disability: Results of the EXPRESS study. 6th World Stroke Congress, 24-27 September 2008, Vienna.
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Impact of urgent management of TIA and minor stroke on hospital costs and 6-month disability: Results of the EXPRESS study. 2nd Annual NIHR Trainee Conference, NHS National Institute for Health Research, 10-11 September 2008, Manchester (prize for best poster).
•    Luengo-Fernandez R, Gray AM, Rothwell PM. Impact of disease on health-related quality of life: the case of cerebrovascular diseases. iHEA 6th World Congress, 8-11 July, Copenhagen.
•    Luengo-Fernandez R, Gray AM, Rothwell PM. A population-based study of determinants of initial secondary care costs of acute stroke in the UK. HESG, July 2006, York.
•    Luengo-Fernandez R, Gray A, Rothwell P. Estimating care costs from observational data: Acute costs of stroke in the UK National Health Service. HESG, January 2005, Oxford.
•    Wolstenholme J, Luengo-Fernandez R, Leal J, Gray A. Making difficult choices: Are health care resources being deployed according to the principles of health economics. HESG, January 2005, Oxford.