Intracerebral Hemorrhage Associated With Cumbersome Healthcare Costs

A significant proportion of survivors from ICH required substantial continuing care sector resources, namely complex continuing care, long-term care, rehabilitation services, and home care.

Data from a retrospective cohort study published in Neurology of adult patients with intracerebral hemorrhage (ICH) in Ontario, Canada, suggest that the disease is associated with significant healthcare costs, with the median cost of case at roughly 10-times the median inpatient cost.

Lead author Shannon M. Fernando, MD, MSc, professor of emergency medicine, University of Ottawa, and colleagues evaluated the short- and long-term resource utilization and costs associated with ICH, as well as the association of oral anticoagulation (OAC) and healthcare costs. Total 1-year direct healthcare costs in 2020 US dollars was the primary outcome of the study.

The investigators identified 16,248 individuals (mean age, 71.2 years; male, 52.3%) with spontaneous ICH during the study period of 2009 to 2017. A total of 5437 patients (33.5%) died in-hospital, and 7,472 (46%) had died by the 1-year mark. Only 2290 patients (14.1%) were discharged home independently, with 7076 (34.1%) discharged to long-term hospital rehabilitation centers and 876 (4.2%) discharged to long-term care.

Overall, the median total cost per patient in the 1 year following ICH was $26,886 (interquartile range [IQR], 9641-62,907). Among hospital decedents, median total cost per patient was $7268 (IQR, 4031-14,966), while among patients who survived to discharge, median total cost per patient was $44,969 (IQR, 20,264-82,414), of which $26,250 (IQR, 6579-52,655) was attributed to post-discharge costs.

"Our work provides novel data from a complete population regarding the financial burden of ICH, with particular implications for health service administration, and highlights the system-level cost of this devastating condition,” Fernando et al wrote.

Analysis of OAC use was limited to patients over 66 years of age. The most common OAC prescribed was warfarin (76.7%), followed by rivaroxaban (12.5%), and apixaban (7.6%). Median costs among patients without OAC use was $25,240 compared to $18,919 for those with OAC use (P <.001). Investigators noted that when only evaluating patients surviving to discharge, patients with OAC use had higher median 1-year costs than patients without OAC use ($44,282 vs $47,411; P <.001).

The total direct cost among all patients in the 1-year following OAC-associated ICH in Ontario was $121,663,958. Following discharge, those with OAC use had costs of $29,505 compared to $27,356 for those without (P = .02). "In order to maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, and not only improve mortality,” Fernando and colleagues noted.

Generalized linear model for 1-year cost among a subpopulation of patients at least 66 years of age surviving to discharge and those who died in hospital showed that OAC use was associated with increased cost (cost ratio [CR], 1.06 [95% CI, 1.01-1.11]). Additionally, oral antiplatelet use was not associated with cost (CR, 0.99 [95% CI, 0.92-1.06]).

Median inpatient cost per patient was $10,120 (IQR, 5356-23,940). Median cost per patient for outpatient complex continuing care, long-term care, rehabilitation, and home care were $23,702 (IQR, 6476-55,297), $13,835 (IQR, 2099-26,811), $23,969 (IQR, 17,096-31,951), and $1294 (IQR, 344-4868), respectively.

Post-discharge costs accounted for 54.4% of all costs from the entire cohort. “Home time,” a factor associated with 1-year costs in the cohort, had median costs of $68,092 (IQR, 27,744-123,726) for patients in the lowest quartile and $13,124 (IQR, 9904-22,134) for those in the highest quartile (P <.001).

Readmission to hospital for ICH within 1 year of index admission occurred for 3812 patients (23.5%). Among these, the median 1-year costs were $69,470 (IQR, 41,552-114,210). Notably, these readmitted patients accounted for 43.7% of all ICH patient costs. In the entire provincial cohort, the total direct healthcare costs in the 1-year following ICH over the 8-year stretch was $1,008,773,328, with an annual cost of $126,096,666 per year.

Fernando SM, Quereshi D, Talarico R, et al. Short- and long-term health care resource utilization and costs following intracerebral hemorrhage. Neurology. Published online June 9, 2021. doi: 10.1212/WNL.0000000000012355