1 Costs and Rehabilitation of Stroke Patients: A Retrospective Study of Medicare Beneficiaries Richard D. Zorowitz, MD 1 ; Er Chen, MPP 2 ; Kuo B. Tong, MS 2 1 Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD; 2 Quorum Consulting, Inc., San Francisco, CA International Stroke Conference 2008 February New Orleans, LA

2 Disclosures The study was funded by Northstar Neuroscience Inc. Dr. Zorowitz is a member of the Northstar Stroke Advisory Board

3 Background and Rationale Stroke is the leading cause of adult disability in the US affecting some 750,000 people annually 50% of survivors with hemiparesis,15-30% left permanently disabled 1,2 Stroke results in substantial costs to the US health care system Direct and indirect costs: estimated at $65.5 billion in Average lifetime cost of ischemic stroke: $140,000 4 Few studies on long-term stroke outcomes Patients with hemiparesis were not profiled among overall stroke population Population-based estimates of prevalence and costs of rehabilitation are lacking 1 Kelley-Hayes M, Beiser A, Kase CS, Scaramucci A, D’Agostino RB, Wolf PA. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003;12:119 – Asplund K, Stegmayr B, Peltonen M. From the twentieth to the twenty-first century: a public health perspective on stroke. In: Ginsberg MD, Bogousslavsky J, eds. Cerebrovascular Disease Pathophysiology, Diagnosis, and Management. Vol 2. Malden, Mass: Blackwell Science; 1998:chap Rosamond W, Flegal K, Furie K, et al. Heart Disease and Stroke Statistics_2008 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2007; DOI: /CIRCULATIONAHA , e37-e51. 4 Taylor TN, Davis PH, Torner JC, Holmes J, Meyer JW, Jacobson MF. Lifetime cost of stroke in the United States. Stroke. 1996;27:1459 –1466.

4 Objectives Among incident stroke patients, we aim to assess long-term overall medical costs utilization of therapy and rehabilitation (TR) and associated costs the impact of hemiparesis on long-term overall medical costs and TR use and costs

5 Data Source 5% randomly selected Medicare beneficiary-level records (Medicare Standard Analytic File) provided by CMS Demographic information (e.g., age, gender, race) Clinical characteristics (e.g., diagnosis, vital status) Medical care services provided across different care settings (e.g., visits, procedures, dates of service) Costs (i.e., Medicare payments) for each service  Beneficiaries’ data were linked across different claims settings and followed longitudinally from 2003 to 2005

Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 Index Follow-up window Wash-out window Study Design Stratified pts by the presence of hemiparesis (ICD-9-CM: 438.2); analyzed the patient outcomes Removed pts if they had any cerebral vascular disease (ICD-9-CM: ); analyzed comorbidity status for selected pts Q1, 2003 Selected pts based on stroke diagnosis (ICD-9-CM code 433.8, , 434.1, , and ) and DRG code 14; analyzed demographics for selected pts ComorbiditiesDemographics Mortality, overall Medial costs, utilization of TR and costs

7 Source: Centers for Medicare and Medicaid Services (CMS) Standard Analytical File (SAF) 5% Sample De novo stroke pts N=1,849 Hemiparesis Cohort Non-Hemiparesis Cohort ,8491,2911,141 1, % Medicare sample in CY2003 Number of pts in each year 2.1 million total beneficiaries 1.7 million with medical claims Study Cohort Stroke pts survived hospitalization N=2,517

8 Baseline Characteristics Overall (N=1,849) Non-Hemiparesis Cohort (N=1,070) Hemiparesis Cohort (N=779) P Value* Age (year) Mean (SD) 77 (9.6)78 (9.6)77 (8.9)0.148 Gender, N (%) Male Female 771 (41.7) 1,076 (58.2) 462 (43.2) 607 (56.8) 309 (39.8) 469 (60.3) Race, N (%) White African American Other 1,520 (82.2) 254 (13.7) 75 (4.1) 892 (83.4) 135 (12.6) 43 (4.0) 628 (80.6) 119 (15.3) 32 (4.1) Charlson Comorbidity Index (CCI), N (%) ≥4 686 (40.5) 473 (27.9) 535 (31.6) 381 (39.2) 269 (27.7) 321 (33.1) 305 (42.2) 204 (28.2) 214 (29.6) * T-test for Age and chi-square tests for Gender, Race and CCI

9 Mortality

10 Medicare Costs Per Patient Costs include hospital inpatient, hospital outpatient, physician care, skilled nursing facility, home health service, durable medical equipment, and hospice services

11 Medicare Costs by Claim Type OVERALL STROKE PATIENTS

12 Utilization of Therapy & Rehabilitation

13 Costs Per Patient of Therapy & Rehabilitation

14 Costs of Therapy & Rehabilitation by Claim Type OVERALL STROKE PATIENTS

15 Discussions  Limitations Serial dependency was expected Our study did not distinguish stroke-related costs and non-stroke related costs Diagnosis, resource use and costs were based on patients’ medical claims Our study did not stratify resource use and costs by stroke sub-type and/or severity  Conclusion Long-term care and rehabilitation services constituted a significant proportion of the total medical costs The management of post-stroke patients should consider clinical and economic impacts, esp. costs incurred outside of a hospital inpatient setting