Stroke in elderly people. A randomised study of stroke unit care. Evaluation of health care utilisation and costs

Abstract: The overall aim of this thesis was to evaluate stroke unit care for elderly patients, aged > 70 years, in daily life activities, health-related quality of life and costs, to describe patients´ conditions from the perspectives of re-admissions to hospital care and to identify the consequences of cognitive impairments on daily life activities and costs.I-II. Two hundred and forty-nine patients aged > 70 years with acute stroke within seven days before admission and living at home were entered consecutively into the study and randomised to two groups: 166 patients (intervention) were assigned to a non-intensive stroke unit care with a care continuum including stroke unit in geriatric wards for patients needing long rehabilitation time and 83 patients (control) were assigned to general medical wards. Outcome measures were patients at home after one year, ability in daily life activities (ADL), health-related quality of life, use of resources and costs of health care. Two registered occupational therapists not involved in the design of the study and the treatment of the patients made all evaluations of the study outcome.Sixty-one percent of the patients in the stroke unit group and 59% in the general medical ward group were at home after one year. There were no significant differences in survival rates, ability in daily life activities and health-related quality of life. The mean annual cost per patient was 170 000 Swedish crowns (SEK) and 191 000 SEK in the stroke unit and the general medical wards, respectively (not statistical significant). Seventy percent of the total cost was for in-patient care, and 30% was for outpatient care, social service and informal care. The costs varied greatly depending on the severity of the stroke. III. Two hundred and sixteen patients were discharged to their homes or to nursing homes after acute stroke. Nearly half of these patients were re-admitted to hospital care. One re-admission was most common. Stroke-related diagnoses, followed by heart disease, were most frequently reasons for re-admission. The re-admitted patients were significantly more dependent in daily life activities and reported a lower health-related quality of life as compared to patients who were not re-admitted. IV. Cognitive impairment was assessed one and a half year after acute stroke. Patients with cognitive impairment were more dependent on personal assistance in ADL. Costs per patients during the study were three times higher for patient's with cognitive impairment. Hospital care, institutional living and different kinds of support from society were associated with the highest costs.V. Evaluations were made of concordance on the item level between the assessments of ADL by the Functional Independence Measure (FIM) and Sunnaas Index of ADL. The concordance was high for many items, but operational differences were identified between some FIM and SI items. In some of the items the seven-point item scale in the FIM could be reduced to four levels without loss of information.