BackgroundIt 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.MethodsPatient 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.ResultsFive 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.ConclusionHighlighting 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.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3696-3) contains supplementary material, which is available to authorized users.

AimTo study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3–12 months post-stroke in Singapore.MethodsPatients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome.ResultsTwo hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3–12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization.ConclusionRecommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

ObjectivesEndovascular therapy (EVT) significantly improves clinical outcomes in patients with acute ischaemic stroke (AIS), while the time of EVT initiation after stroke onset influences both patient clinical outcomes and healthcare costs. This study determined the impact of EVT treatment delay on cost effectiveness of EVT in the Singapore healthcare setting.DesignA short-term decision tree and long-term Markov health state transition model was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes (modified Rankin Scale scores), short-term costs and long-term modelled (lifetime) costs; all of which were used in calculating an incremental cost-effectiveness ratio of EVT vs non-EVT treatment. Clinical outcomes and cost data were derived from clinical trials, literature, expert opinion, electronic medical records and community-based surveys from Singapore. Deterministic one-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the model. The willingness to pay for per quality-adjusted life-year (QALY) was set to Singapore $50 000 (US$36 500).SettingSingapore healthcare perspective.ParticipantsThe model included patients with AIS in Singapore.InterventionsEVT performed within 6 hours of stroke onset.Outcome measuresThe model estimated incremental cost-effectiveness ratios (ICERs) and net monetary benefits (NMB) for EVT versus non-EVT treatment, varied by time from symptom onset to time of treatment.ResultsEVT performed between 61 min and 120 min after the stroke onset was most cost-effective time window to perform EVT in the Singapore population, with an ICER of Singapore $7197 per QALY (US$5254) for performing EVT at 61–120 min versus 121–180 min. The resulting incremental NMB associated with receipt of EVT at the earlier time point is Singapore $39 827 (US$29 074) per patient at the willingness-to-pay threshold of Singapore $50 000. Each hour delay in EVT resulted in an average loss of 0.54 QALYs and 195.35 healthy days, with an average net monetary loss of Singapore $26 255 (US$19 166).ConclusionsFrom the Singapore healthcare perspective, although EVT is more expensive than alternative treatments in the short term, the lifetime ICER is below the willingness-to-pay threshold. Thus, healthcare policies and procedures should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration.

BackgroundHealth services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors’ HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients.MethodsA prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types.ResultsWe observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%.ConclusionsThe accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3634-4) contains supplementary material, which is available to authorized users.

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