Reduced racial disparities among newborns with intraventricular hemorrhage.

INTRODUCTION: Intraventricular hemorrhage (IVH) can ensue permanent neurologic dysfunction, morbidity, and mortality. While previous reports have identified disparities based on patient gender or weight, no prior study has assessed how race may influence in neonatal or infantile IVH patients. The aim of this study was to investigate the impact of race on adverse event (AE) rates, length of stay (LOS), and total cost of admission among newborns with IVH. METHODS: Using the 2016-2019 National Inpatient Sample database, newborns diagnosed with IVH were identified using ICD-10-CM codes. Patients were stratified based on race. Patient characteristics and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of race on extended LOS and exorbitant cost. RESULTS: Of 1435 patients, 650 were White (45.3%), 270 African American (AA) (18.8%), 300 Hispanic (20.9%), and 215 Other (15.0%). A higher percentage of AA and Other patients than Hispanic and White patients were < 28 days old (p = 0.008). Each of the cohorts had largely similar presenting comorbidities and symptoms, although AA patients did have significantly higher rates of NEC (p < 0.001). There were no observed differences in rates of AEs, rates of mortality, mean LOS, or mean total cost of admission. Similarly, on multivariate analysis, no race was identified as a significant independent predictor of extended LOS or exorbitant cost. CONCLUSIONS: Our study found that in newborns with IVH, race is not associated with proxies of poor healthcare outcomes like prolonged LOS or excessive cost. Further studies are needed to validate these findings.

Short- and Long-term Health Care Resource Utilization and Costs Following Intracerebral Hemorrhage.

OBJECTIVE: We sought to evaluate the short- and long-term resource use and costs associated with intracerebral hemorrhage (ICH) taken from an entire population. We in addition sought to evaluate the association of oral anticoagulation (OAC) and health care costs. METHODS: This was a retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (2009-2017). We captured outcomes through linkage to health administrative databases. We used generalized linear models to identify factors associated with total cost. Analysis of OAC use was limited to patients ≥66 years of age. The primary outcome was total 1-year direct health care costs in 2020 US dollars. RESULTS: Among 16,248 individuals with ICH (mean age 71.2 years, male 52.3%), 1-year mortality was 46.0%, and 24.2% required mechanical ventilation. The median total 1-year cost was $26,886 (interquartile range [IQR] $9,641-$62,907) with costs for those who died in hospital of $7,268 (IQR $4,031-$14,966) vs $44,969 (IQR $20,264-$82,414, p < 0.001) for survivors to discharge. OAC use (analysis limited to individuals ≥66 years old) was associated with higher total 1-year costs (cost ratio 1.06 [95% confidence interval 1.01-1.11]). Total 1-year costs for the entire cohort exceeded $120 million per year over the study period. CONCLUSIONS: ICH is associated with significant health care costs, and the median cost of a patient with ICH is roughly 10 times the median inpatient cost in Ontario. Costs were higher among survivors than deceased patients. OAC use is independently associated with increased costs. To maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, not only improve mortality.

Racial Segregation and Intraventricular Hemorrhage in Preterm Infants.

BACKGROUND: Intraventricular hemorrhage (IVH) disproportionately affects black neonates. Other conditions that are more common in black neonates, including low birth weight and preterm delivery, have been linked with residential racial segregation (RRS). In this study, we investigated the association between RRS and IVH. METHODS: A retrospective cohort of neonates born between 24 and 32 weeks' gestation was constructed by using birth certificates linked to medical records from California, Missouri, and Pennsylvania between 1995 and 2009. Dissimilarity, a measure of RRS indicating the proportion of minorities in the census tract of the mother in comparison to the larger metropolitan area, was linked to patient data, yielding a cohort of 70 775 infants. Propensity score analysis matched infants born to mothers living in high segregation to those living in less segregated areas on the basis of race, sociodemographic factors, and medical comorbidities to compare the risk of developing IVH. RESULTS: Infants born to mothers in the most segregated quartile had a greater risk of developing IVH compared with those in the lowest quartile (12.9% vs 10.4%; P < .001). In 17 918 pairs matched on propensity scores, the risk of developing IVH was greater in the group exposed to a segregated environment (risk ratio = 1.08, 95% confidence interval: 1.01-1.15). This effect was stronger for black infants alone (risk ratio = 1.16; 95% confidence interval: 1.03-1.30). CONCLUSIONS: RRS is associated with an increased risk of IVH in preterm neonates, but the effect size varies by race. This association persists after balancing for community factors and birth weight, representing a novel risk factor for IVH.

Race, Socioeconomic Status, and Gastrostomy after Spontaneous Intracerebral Hemorrhage.

INTRODUCTION: Spontaneous intracerebral hemorrhage is a disabling form of stroke, and some patients will require nutritional interventions for dysphagia. We sought to determine if socioeconomic status indicators mediate whether minorities undergo gastrostomy tube placement. MATERIALS AND METHODS: Patients with spontaneous intracerebral hemorrhage were enrolled in a single center, observational cohort study from 2010 to 2017. A socioeconomic index score was imputed using neighborhood characteristics by patients' ZIP code, according to an established method utilizing 6 indicators of wealth/income, education, and occupation. Multivariable logistic regression models were generated and stratified by racial/ethnic groups to determine the association of socioeconomic status with gastrostomy tube placement. RESULTS: Among 512 patients, 93 (18.2%) underwent gastrostomy tube placement. There were 245 Whites, 220 Blacks, and 47 Hispanic. Blacks underwent the highest percentage of gastrostomy placement (22.7%), and Whites had the lowest percentage (13.5%). Among patients with gastrostomy, Blacks and Hispanics had lowest median socioeconomic index (-2.1 [IQR: -3.0, .7]; .7 [IQR: -1.6, 2.9], respectively, P < .001). Increasing intracerebral hemorrhage score was correlated with higher odds of gastrostomy across all groups (P values ≤ .01) but only Hispanics had reduced adjusted odds of gastrostomy with increasing socioeconomic index (OR .56; 95% .33-.84; P = .01). DISCUSSION: Racial/ethnic minorities had lower socioeconomic index and underwent more gastrostomy placement. Socioeconomic index was independently associated with gastrostomy only in Hispanics, in whom the odds of gastrostomy decreased with increasing socioeconomic index. Summary & Conclusion: Differences in utilization of gastrostomy were evident among minorities, and socioeconomic status may mediate this relationship among Hispanics.

Exploration of Medical Trajectories of Stroke Patients Based on Group-Based Trajectory Modeling.

A high mortality rate is an issue with acute cerebrovascular disease (ACVD), as it often leads to a high medical expenditure, and in particular to high costs of treatment for emergency medical conditions and critical care. In this study, we used group-based trajectory modeling (GBTM) to study the characteristics of various groups of patients hospitalized with ACVD. In this research, the patient data were derived from the 1 million sampled cases in the National Health Insurance Research Database (NHIRD) in Taiwan. Cases who had been admitted to hospitals fewer than four times or more than eight times were excluded. Characteristics of the ACVD patients were collected, including age, mortality rate, medical expenditure, and length of hospital stay for each admission. We then performed GBTM to examine hospitalization patterns in patients who had been hospitalized more than four times and fewer than or equal to eight times. The patients were divided into three groups according to medical expenditure: high, medium, and low groups, split at the 33rd and 66th percentiles. After exclusion of unqualified patients, a total of 27,264 cases (male/female = 15,972/11,392) were included. Analysis of the characteristics of the ACVD patients showed that there were significant differences between the two gender groups in terms of age, mortality rate, medical expenditure, and total length of hospital stay. In addition, the data were compared between two admissions, which included interval, outpatient department (OPD) visit after discharge, OPD visit after hospital discharge, and OPD cost. Finally, the differences in medical expenditure between genders and between patients with different types of stroke-ischemic stroke, spontaneous intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH)-were examined using GBTM. Overall, this study employed GBTM to examine the trends in medical expenditure for different groups of stroke patients at different admissions, and some important results were obtained. Our results demonstrated that the time interval between subsequent hospitalizations decreased in the ACVD patients, and there were significant differences between genders and between patients with different types of stroke. It is often difficult to decide when the time has been reached at which further treatment will not improve the condition of ACVD patients, and the findings of our study may be used as a reference for assessing outcomes and quality of care for stroke patients. Because of the characteristics of NHIRD, this study had some limitations; for example, the number of cases for some diseases was not sufficient for effective statistical analysis.

The cost of stroke in private hospitals in Brazil: a one-year prospective study.

OBJECTIVE: Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. METHODS: Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. RESULTS: We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). CONCLUSIONS: Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

The cost of stroke in a public hospital in Brazil: a one-year prospective study.

OBJECTIVE: Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. To measure the costs of stroke care in a public hospital in Joinville, Brazil. METHODS: We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. RESULTS: We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. CONCLUSIONS: Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

The cost of stroke in private hospitals in Brazil: a one-year prospective study / O custo do AVC em hospitais privados no Brasil: um estudo prospectivo

ABSTRACT Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. Objective To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. Methods Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. Results We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). Conclusions Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

RESUMO Poucos estudos determinam o custo do AVC em países de baixa e média renda nos setores privados. Objetivos Mensurar o custo hospitalar do tratamento do(a): AVC isquêmico com e sem reperfusão cerebral, hemorragia intracerebral primária (HIP), hemorragia subaracnóidea e ataque isquêmico transitório (AIT) em hospitais privados de Joinville, Brasil. Métodos Estudo prospectivo de custo de doença. Os custos médicos e não médicos dos pacientes admitidos com qualquer tipo de AVC ou AIT foram consecutivamente verificados em 2016-17. Os valores foram ajustados ao índice do deflator do produto interno bruto e à paridade do poder de compra. Resultados Nós incluímos 173 pacientes. A mediana de custo por paciente foi de US$ 3.827 (IQR: 2.800-8.664) para os 131 pacientes com AVC isquêmico; US$ 2.315 (1.692-2.959) para os 27 pacientes com AIT; US$ 16.442 (5.108-33.355) para os 11 pacientes com HIP e US$ 28.928 (12.424-48.037) para os quatro pacientes com HSA (p < 0,00001). Para seis pacientes submetidos à trombólise intravenosa, a mediana do custo por paciente foi de US$ 11.463 (8.931-14.291) e, para quatro pacientes submetidos à trombectomia intra-arterial, a mediana de custo por paciente foi de US$ 35.092 (31.833-37.626; p < 0,0001). Uma correlação direta foi encontrada entre custo e tempo de permanência (r = 0,67, p < 0,001). Conclusão O AVC é uma doença cara. Em ambiente privado, os custos da reperfusão cerebral foram de três a dez vezes superiores aos tratamentos habituais do AVC isquêmico. Portanto, estudos de custo-efetividade são urgentemente necessários em países de baixa e média rendas.

The cost of stroke in a public hospital in Brazil: a one-year prospective study / Custo do AVC em um hospital público no Brasil: um estudo prospectivo de um ano

ABSTRACT Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. Objective To measure the costs of stroke care in a public hospital in Joinville, Brazil. Methods We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. Results We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. Conclusions Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

RESUMO Os países de baixa e media renda enfrentam orçamentos apertados na saúde, não somente devido aos novos recursos terapêuticos, mas relacionado ao custo oneroso do tratamento do acidente vascular cerebral. No entanto, poucos dados prospectivos sobre os custos do AVC, incluindo reperfusão cerebral de países de baixa e média renda estão disponíveis. Objetivo Mensurar os custos do atendimento ao AVC em um hospital público. Métodos Avaliamos prospectivamente todos os custos médicos e não médicos de pacientes internados com diagnóstico de acidente vascular cerebral ou AIT durante 1 ano, analisamos os custos por tipo de AVC e tratamento, tempo de permanência e comparamos os custos hospitalares com o reembolso governamental. Resultados Foram avaliados 274 pacientes. O custo total em um ano foi de US$ 1.307,114; o governo reembolsou o hospital no valor de US$ 1.095.118. Encontramos uma correlação linear significativa entre LOS e custos (r = 0,71). A mediana do custo do AVCI em 134 pacientes que não sofreram reperfusão cerebral (National Institutes of Health Stroke Scale [NIHSS] mediana = 3) foi de US$ 2.803; para pacientes submetidos a alteplase intravenosa (IV) (NIHSS 10), a mediana foi de US$ 5.099 e para os pacientes submetidos a trombectomia intra-arterial (IA) (NIHSS > 10), o custo mediano foi de US$ 10.997. A mediana do custo de uma hemorragia intracerebral primária, hemorragia subaracnóidea e AIT foram de US$ 2.436, US$ 8.031 e US$ 2.677, respectivamente. Conclusões Os tratamentos de reperfusão foram duas a quatro vezes mais caros do que o tratamento conservador. Estudo de custo-efetividade para o tratamento do AVC são necessários.

Cerebral amyloid angiopathy mimicking central nervous system metastases: a case report.

BACKGROUND: This case describes an unusual presentation of an intracranial hemorrhage first thought to be metastatic disease on computed tomography and magnetic resonance imaging. The healthcare team completed an exhaustive search for a primary malignancy that was negative. Final diagnosis on brain biopsy showed intercranial hemorrhage secondary to cerebral amyloid angiopathy. With an increasing number of elderly patients and the rising cost of health care, this case can serve as a reminder to clinicians about their own responsibilities in limiting the cost of health care. CASE PRESENTATION: This is a case report about a 72-year-old white woman with an intracranial hemorrhage secondary to cerebral amyloid angiopathy. The brain lesions on computed tomography/magnetic resonance imaging mimicked a metastatic process until a brain biopsy could give a definitive diagnosis that was completely unexpected. Cerebral amyloid angiopathy is a rare cause of intracerebral hemorrhage and this diagnosis is important to consider in older patients on anticoagulation. CONCLUSIONS: Cerebral amyloid angiopathy is a rare diagnosis but should be considered in elderly patients on anticoagulation presenting with imaging findings consistent with intracerebral hemorrhage. While metastatic disease is a more common cause of intracerebral hemorrhage, cerebral amyloid angiopathy should remain in the differential diagnosis. This case report serves as a teaching point to clinicians in cases involving an older patient on anticoagulation.

Distribution and predictors of hospital charges for haemorrhagic stroke patients in Beijing, China, March 2012 to February 2015: a retrospective study.

OBJECTIVES: The purpose of this study is to analyse hospital charges for patients with haemorrhagic stroke in China and investigate potential factors associated with inpatient charges. METHODS: The study participants were in-hospital patients with a primary diagnosis of haemorrhagic stroke from all the secondary and tertiary hospitals in Beijing during the period from 1 March 2012 to 28 February 2015. Distribution characteristics of detailed hospital charges were analysed. The influence of potential factors on hospital charges was researched using a stepwise multiple regression model. RESULTS: A total of 34 890 patients with haemorrhagic stroke of mean age 61.19±14.37 years were included in the study, of which 37.2% were female. Median length of hospital stay (LOHS) was 15 days (IQR 9-23) and median hospital cost was 18 577 Chinese yuan (CNY) (IQR 10 442-39 784). The hospital costs for patients in Western medicine hospitals (median 19 651 CNY) were significantly higher (P<0.01) than those in traditional Chinese medicine hospitals (median 14 560 CNY), and were significantly higher (P<0.01) for Level 3 hospitals (median 20 029 CNY) than for Level 2 hospitals (median 16 095 CNY). The proportion of medicine fees and bed fees within total hospital charges showed a decreasing trend during the study period. With stepwise multiple regression, the major factors associated with hospital charges were LOHS, surgery, pulmonary infection, ventilator usage, hospital level, occupation, hyperlipidaemia, hospital type, in-hospital death, sex and age. CONCLUSION: We conclude that medicines form the largest part of hospital charges but are showing a decreasing trend, and LOHS is strongly associated with patient charges for haemorrhagic stroke in China. This implies that the cost structure is very unreasonable in China and medical technology costs fail to be fully manifested. A reasonable decrease in medicine charges and shortening LOHS may be effective ways to reduce hospital charges.

Rationale and Design of a Statewide Cohort to examine efficient resource utilization for patients with Intracerebral hemorrhage (EnRICH).

BACKGROUND: Intracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking. METHODS / DESIGN: "Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)" is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of "spoke" hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted. DISCUSSION: Findings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.

Short-term costs of preeclampsia to the United States health care system.

BACKGROUND: Preeclampsia is a leading cause of maternal morbidity and mortality and adverse neonatal outcomes. Little is known about the extent of the health and cost burden of preeclampsia in the United States. OBJECTIVE: This study sought to quantify the annual epidemiological and health care cost burden of preeclampsia to both mothers and infants in the United States in 2012. STUDY DESIGN: We used epidemiological and econometric methods to assess the annual cost of preeclampsia in the United States using a combination of population-based and administrative data sets: the National Center for Health Statistics Vital Statistics on Births, the California Perinatal Quality Care Collaborative Databases, the US Health Care Cost and Utilization Project database, and a commercial claims data set. RESULTS: Preeclampsia increased the probability of an adverse event from 4.6% to 10.1% for mothers and from 7.8% to 15.4% for infants while lowering gestational age by 1.7 weeks (P < .001). Overall, the total cost burden of preeclampsia during the first 12 months after birth was $1.03 billion for mothers and $1.15 billion for infants. The cost burden per infant is dependent on gestational age, ranging from $150,000 at 26 weeks gestational age to $1311 at 36 weeks gestational age. CONCLUSION: In 2012, the cost of preeclampsia within the first 12 months of delivery was $2.18 billion in the United States ($1.03 billion for mothers and $1.15 billion for infants), and was disproportionately borne by births of low gestational age.

Cost and Utility of Microbiological Cultures Early After Intensive Care Unit Admission for Intracerebral Hemorrhage.

BACKGROUND: Fever is common among intensive care unit (ICU) patients. Clinicians may use microbiological cultures to differentiate infectious and aseptic fever. However, their utility depends on the prevalence of infection; and false-positive results might adversely affect patient care. We sought to quantify the cost and utility of microbiological cultures in a cohort of ICU patients with spontaneous intracerebral hemorrhage (ICH). METHODS: We performed a secondary analysis of a cohort with spontaneous ICH requiring mechanical ventilation. We collected baseline data, measures of systemic inflammation, microbiological culture results for the first 48 h, and daily antibiotic usage. Two physicians adjudicated true-positive and false-positive culture results using standard criteria. We calculated the cost per true-positive result and used logistic regression to test the association between false-positive results with subsequent antibiotic exposure. RESULTS: Overall, 697 subjects were included. A total of 233 subjects had 432 blood cultures obtained, with one true-positive (diagnostic yield 0.1 %, $22,200 per true-positive) and 11 false-positives. True-positive urine cultures (5 %) and sputum cultures (13 %) were more common but so were false-positives (6 and 17 %, respectively). In adjusted analysis, false-positive blood and sputum results were associated with increased antibiotic exposure. CONCLUSIONS: The yield of blood cultures early after spontaneous ICH was very low. False-positive results significantly increased the odds of antibiotic exposure. Our results support limiting the use of blood cultures in the first two days after ICU admission for spontaneous ICH.

Reducing Cost and Intravenous Duration of Nicardipine in Intracerebral Hemorrhage Patients via an Interdisciplinary Approach.

BACKGROUND: The mainstay of acute management of intracerebral hemorrhage (ICH) is blood pressure reduction. Intravenous (IV) nicardipine is an effective but costly intervention for blood pressure reduction in the intensive care unit (ICU). Earlier transition to oral (PO) antihypertensive agents may reduce ICU length of stay (LOS) and associated costs. We sought to study the effectiveness of an interdisciplinary intervention to start earlier transition to PO antihypertensives. METHODS: From July 2011 to July 2012, patients with ICH who received IV nicardipine were reviewed and screened for eligibility by an interdisciplinary team including physicians and pharmacists. These patients were compared to a control group 1 year prior to this intervention. The duration of nicardipine treatment (median hours), estimated costs, and ICU LOS were measured. RESULTS: A total of 35 patients and 44 controls were studied. The median hours of IV nicardipine use were significantly decreased from a baseline mean of 118 to 30 hours (P < .001); total cost savings per year was $433,566 ($18,475 per patient). The average LOS remained similar (8.4 versus 8.9 days, P < .990). In a follow-up study 1 year later, after the intervention was no longer used, a sample of 21 consecutive patients was reviewed and the duration of IV nicardipine treatment had increased to a mean of 96 hours. CONCLUSION: A physician and pharmacist-led project to initiate oral antihyperintensive medications earlier was successful in reducing the duration of IV nicardipine treatment in patients with ICH while leading to substantial cost savings.

Trends in hospitalizations and cost associated with stroke by age, United States 2003-2012.

Background The disease burden associated with stroke by age is not well known. Aim To assess the trends in stroke hospitalizations and associated cost among adults aged ≥18 years by age groups in the United States. Methods The study population consisted of 2003-2012 adult hospitalizations from the National Inpatient Sample of the Healthcare Cost and Utilization Project. Subarachnoid hemorrhage, intracerebral hemorrhage, and acute ischemic stroke hospitalizations were identified by the principal diagnosis ICD-9-CM code. We estimated national hospitalization rates and inflation-adjusted hospital costs across five consecutive 2-year time intervals, stratified by seven age groups. Results Hospitalization rates for subarachnoid hemorrhage decreased significantly from 2003-2004 to 2011-2012 for ages 35-44 (relative percent change (RPC): -23%) and 45-54 (RPC: -22%), respectively. For intracerebral hemorrhage, the rates decreased significantly for ages ≥65 years. Acute ischemic stroke hospitalization rates increased significantly for ages 18-54 and decreased significantly for ages 65-84 years. The average per-hospitalization cost for subarachnoid hemorrhage increased 7-35% among all age groups, except those aged 65-74, and increased 10-29% for intracerabral hemorrhage except those aged 75-84, and increased 6-19% among all ages for acute ischemic stroke, respectively. Overall, the estimated total national cost increased 7% for subarachnoid hemorrhage, 10% for intracerebral hemorrhage, and 18% for acute ischemic stroke from 2003-2004 to 2011-2012. Conclusions From 2003 to 2012, subarachnoid hemorrhage and intracerabral hemorrhage stroke hospitalization rates declined across all age groups. While US acute ischemic stroke hospitalizations among ages 65-84 declined significantly, the hospitalization rates increased significantly among ages 18-54. The estimated hospital costs increased across all stroke subtypes during the study period.

Resource Utilization for Patients with Intracerebral Hemorrhage Transferred to a Comprehensive Stroke Center.

BACKGROUND: As a comprehensive stroke center (CSC), we accept transfer patients with intracerebral hemorrhage (ICH) in our region. CSC guidelines mandate receipt of patients with ICH for higher level of care. We determined resource utilization of patients accepted from outside hospitals compared with patients directly arriving to our center. METHODS: From our stroke registry, we compared patients with primary ICH transferred to those directly arriving to our CSC from March 2011-March 2012. We compared the proportion of patients who utilized at least one of these resources: neurointensive care unit (NICU), neurosurgical intervention, or clinical trial enrollment. RESULTS: Among the 362 patients, 210 (58%) were transfers. Transferred patients were older, had higher median Glasgow Coma Scale scores, and lower National Institutes of Health Stroke Scale scores than directly admitted patients. Transfers had smaller median ICH volumes (20.5 cc versus 15.2 cc; P = .04) and lower ICH scores (2.1 ± 1.4 versus 1.6 ± 1.3; P < .01). A smaller proportion of transfers utilized CSC-specific resources compared with direct admits (P = .02). Fewer transferred patients required neurosurgical intervention or were enrolled in trials. No significant difference was found in the proportion of patients who used NICU resources, although transferred patients had a significantly lower length of stay in the NICU. Average hospital stay costs were less for transferred patients than for direct admits. CONCLUSIONS: Patients with ICH transferred to our CSC underwent fewer neurosurgical procedures and had a shorter stay in the NICU. These results were reflected in the lower per-patient costs in the transferred group. Our results raise the need to analyze cost-benefits and resource utilization of transferring patients with milder ICH.

Neuroprotection of nalmefene for postoperative patients with spontaneous intracerebral hemorrhage.

BACKGROUND: Endogenous opiates play an important role in the secondary injury of brain tissue after central nervous system injury. It was confirmed that nalmefene, an opiates receptor antagonist, has neuroprotective efficacy in animal models. However, evidence of nalmefene treatment for surgical patients with spontaneous intracerebral hemorrhage is insufficient. METHODS: Outcomes of patients treated with nalmefene were retrospectively compared with that of patients without any anti-opiate treatment. The primary outcome was functional outcome at 6 months post ictus, which was assessed using modified Rankin Scales (mRSs). Secondary outcomes included mortality in 30 d post ictus, state of consciousness evaluated using Glasgow Coma Scale (GCS) at 1, 3, 7 d post operation and complications. RESULTS: Of 79 patients in the nalmefene treatment group, 22 (27.85%) had a favorable functional outcome at 6 months, while in the control group, 12 of 72 (16.67%) had the same result (p = 0.273). A significantly better outcome was observed in the treatment group during only one subgroup analyses which was GCS between 3 and 8 (32.26% vs. 6.45%, p = 0.006). CONCLUSIONS: Nalmefene treatment was safe for patients with spontaneous intracerebral hemorrhage but could not improve the outcome of either short-term consciousness or long-term functional outcome.

Comparison of costs and discharge outcomes for patients hospitalized for ischemic or hemorrhagic stroke with or without atrial fibrillation in the United States.

This retrospective analysis investigated the impact of baseline clinical characteristics, including atrial fibrillation (AF), on hospital discharge status (to home or continuing care), mortality, length of hospital stay, and treatment costs in patients hospitalized for stroke. The analysis included adult patients hospitalized with a primary diagnosis of ischemic or hemorrhagic stroke between January 2006 and June 2011 from the premier alliance database, a large nationally representative database of inpatient health records. Patients included in the analysis were categorized as with or without AF, based on the presence or absence of a secondary listed diagnosis of AF. Irrespective of stroke type (ischemic or hemorrhagic), AF was associated with an increased risk of mortality during the index hospitalization event, as well as a higher probability of discharge to a continuing care facility, longer duration of stay, and higher treatment costs. In patients hospitalized for a stroke event, AF appears to be an independent risk factor of in-hospital mortality, discharge to continuing care, length of hospital stay, and increased treatment costs.

Cost-effectiveness of transfers to centers with neurological intensive care units after intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Our aim was to estimate the cost-effectiveness of transferring patients with intracerebral hemorrhage from centers without specialized neurological intensive care units (neuro-ICUs) to centers with neuro-ICUs. METHODS: Decision analytic models were developed for the lifetime horizons. Model inputs were derived from the best available data, informed by a variety of previous cost-effectiveness models of stroke. The effect of neuro-ICU care on functional outcomes was modeled in 3 scenarios. A favorable outcomes scenario was modeled based on the best observational data and compared with moderately favorable and least-favorable outcomes scenarios. Health benefits were measured in quality-adjusted life years (QALYs), and costs were estimated from a societal perspective. Costs were combined with QALYs gained to generate incremental cost-effectiveness ratios. One-way sensitivity analysis and Monte Carlo simulations were performed to test robustness of the model assumptions. RESULTS: Transferring patients to centers with neuro-ICUs yielded an incremental cost-effectiveness ratio for the lifetime horizon of $47,431 per QALY, $91,674 per QALY, and $380,358 per QALY for favorable, moderately favorable, and least-favorable scenarios, respectively. Models were robust at a willingness-to-pay threshold of $100,000 per QALY, with 95.5%, 75.0%, and 2.1% of simulations below the threshold for favorable, moderately favorable, and least-favorable scenarios, respectively. CONCLUSIONS: Transferring patients with intracerebral hemorrhage to centers with specialized neuro-ICUs is cost-effective if observational estimates of the neuro-ICU-based functional outcome distribution are accurate. If future work confirms these functional outcome distributions, then a strong societal rationale exists to build systems of care designed to transfer intracerebral hemorrhage patients to specialized neuro-ICUs.