Κοινωνικο-οικονομικό κόστος Εγκεφαλικών Επεισοδίων Βέμμος Κ., Παθολόγος Μονάδα Οξέων Αγγειακών Εγκεφαλικών Επεισοδίων Θεραπευτική Κλινική Πανεπιστημίου Αθηνών

Stroke: a major health problem and a leading killer PREVAIL STUDY RESULTS V2 November 13, 2006 Stroke: a major health problem and a leading killer Epidemiology Worldwide stroke prevalence was 7.1 million in 2000 and is rising1 Incidence: 700,000 strokes/year (USA)2 A major health burden in western countries Third most common cause of death3 The leading cause of disability in adults3 Health care expenditures In the USA, $ 57.9 billion for stroke-related medical costs and disability in 20062 1Guillot F, Moulard O. Circulation. 1998: 98(Suppl 1):1421. 2American Heart Association. 2002 Heart; Stroke Statistical Update. AHA, 2002; www.strokeassociation.org - ASA . 3Leys D, et al. Cerebrovasc Dis. 2001:11(Suppl 2):1-4. Dr D. Sherman's presentation at ASH December 8, 2006

Leading causes of death in 2005 No of deaths All cardiovascular 17.5 million Ischemic heart disease 7.6 million Cerebrovascular disease 5.7 million All cancer Lung cancer 1.3 million Stomach cancer 1 million Liver cancer 662 000 Colon cancer 655 000 Breast cancer 502 000 Source: WHO

Projections of stroke events in men and women in EU and EFTA countries, 2000 to 2025 (solely due to the demographic changes) European Fair Trade Association Iceland, Norway, and Switzerland, Truelsen T, et al, WHO, 2004

Crude Stroke annual Incidence rates Επίπτωση Crude Stroke annual Incidence rates Region Year Rate (95% CI) Perth, Australia 1995–96 1·6 (1·4–1·8) Frederiksberg, Denmark 1989–90 3·1 (2·7–3·4) South London, UK 1995–96 1·3 (1·2–1·4) Martinique, French West Indies 1998–99 1·6 (1· 5–1 Oyabe, Japan 1987–91 4·1 (3·8–4·4) Erlangen, Germany 1994–98 1·3 (1·2–1·4) Arcadia, Greece 1993–95 3·4 (3·1–3·7) Belluno, Italy 1992–93 2·2 (2·0–2·4) L’Aquila, Italy 1994 2·8 (2·6–2·9) Auckland, New Zeeland 1991–92 1·4 (1·3–1·5) Inherred, Norway 1994–96 3·1 (2·8–3·4) Novosibirsk, Russia 1992 2·3 (2·1–2·5)

Επίπτωση Kύρια ευρήματα μελέτης Αρκαδίας (1993-95, >20 ετών, πληθυσμός 80 774 ) Ετήσια επίπτωση 275 νέα πρωτοεμφανιζόμενα ΑΕΕ στην Αρκαδία / έτος 256 νέα ΑΕΕ / 100 000 πληθυσμού στην Ελλάδα 25-30 000 νέα ΑΕΕ το χρόνο σε όλη τη χώρα Θνητότητα Θνητότητα 1ου μήνα (CFR) 26.6 % Θνητότητα 1ου έτους 36.8 % Aνεξάρτητοι προγνωστικοί δείκτες: Ηλικία, επίπεδο συνείδησης, Κολπική μαρμαρυγή Vemmos K, et al Stroke 1999

Επίπτωση Average Annual Stroke Incidence (racial differences) Northern Manhattan Stroke Study - NOMAS 300 259 250 232 222 200 172 Average Annual Age-Adjusted Incidence Rate per 100,000 150 118 100 80 White Talking Points The data from the Northern Manhattan Stroke Study clearly indicate that stroke risk is different in different races. Black Americans have the highest risk followed by Hispanics. The lowest incident rate is found in white men and women.(10) Background Stroke mortality is reported to be greater in blacks than in whites, but stroke incidence data for blacks and Hispanics are sparse. The aim of this study was to determine and compare stroke incidence rates among whites, blacks, and Hispanics living in the same urban community. A population-based incidence study was conducted to identify all cases of first stroke occurring in Northern Manhattan, New York City, between July 1, 1993, and June 30, 1996. The population of this area was approximately 210,000 at that time, based on 1990 US Census data. Surveillance for hospitalized and non-hospitalized stroke consisted of daily screening of all admissions, discharges, and computed tomography logs at Columbia-Presbyterian Medical Center, the only hospital in the region, and review of discharge lists from outside hospitals, telephone surveys of random households, and contacts with community physicians, Visiting Nurses' Services, and community agencies. Stroke incidence increased with age and was greater in men than in women. The average annual age-adjusted stroke incidence rate at age ³ 20 years per 100,000 inhabitants was 223 for blacks, 196 for Hispanics, and 93 for whites. Blacks had a 2.4-fold and Hispanics a 2-fold increase in stroke incidence as compared to whites. Cerebral infarct accounted for 77% of all strokes, intracerebral hemorrhage for 17%, and subarachnoid hemorrhage for 6%. These data from the Northern Manhattan Stroke Study suggest that part of the reported excess stroke mortality among blacks in the United States may be a reflection of racial/ethnic differences in stroke incidence.(10) 50 Black Hispanic Men Women Sacco R, et al. Am J Epidemiol 1998;147:259-268.

Feigin V, Lancet Neurology 2003 Επίπτωση Annual incidence by age per 1000 population of all types of stroke combined in selected studies Feigin V, Lancet Neurology 2003

Σύγκριση επίπτωσης μεταξύ διαφόρων μελετών για τις ηλικίες 45-84 ανά 100 000 πληθυσμού Ισχαιμικό Εγκεφαλική Υπαραχνοειδής έμφρακτο αιμορραγία αιμορραγία Dijon, France 183 (166-200) 26 (20-32) 4 (1-7) Arcadia, Greece 249 (217-281) 51 (36-66) 11 (4-17 Perth, Australia 262 (216-308) 38 (22-55) 19 (6-32) Umbria, Italy 294 (256-332) 40 (25-55) 17 (7-27) Rochester, Minnesota 318 (280-355) 35 (22-47) 17 (8-26) Oxfordshire, England 312 (283-342) 39 (29-50) 17 (10-25) Frederiksberg, Denmark 339 (281-397) 33 (14-52) 6 (0-17) Söderhamn, Sweden 349 (285-413) 49 (23-75) 12 (0-26) * Standardized incidence rates for groups aged 45-84 years to the European population Vemmos K et all, Stroke 1999 Επίπτωση

Feigin V, Lancet Neurology 2003 Επίπτωση Age-standardised annual incidence per 1000 population of all strokes combined in people aged 55 years (Segi 1996 world population) Feigin V, Lancet Neurology 2003

Επίπτωση Rates of acute vascular events in men and women in the OXVASC study -population (91 106) between 2002 and 2005- Event Total, n Men, rate Women, rate Total, rate All cerebrovascular events combined 918 2.99 3.75 3.36 All coronary vascular events 856 3.89 2.33 3.13 All peripheral vascular events 188 0.79 0.57 0.69 rates are per 1000 population per year Rothwell PM et al. Lancet 2005

Επίπτωση Age-specific rates of acute cerebrovascular and coronary vascular events in the Oxford, UK (OXVASC study) Stroke Coronary Age group N=889 rate N=827 45-54 46 1.31 71 2.03 55-64 108 3.69 133 4.54 65-74 232 11.1 221 10.57 75-84 319 23.36 279 20.44 85 or older 184 44.83 123 29.97 rates are per 1000 population per year study included some participants under age of 45 Rothwell PM et al. Lancet 2005

Feigin V, Lancet Neurology 2003 Επιπολασμός Age-standardised prevalence of stroke per 1000 population in selected studies of people aged 65 years Feigin V, Lancet Neurology 2003

Stroke death rates in 20 countries [WHO 2004]

Case-fatality within 1 month of stroke onset by major stroke type Θνητότητα Case-fatality within 1 month of stroke onset by major stroke type IS=ischaemic stroke; PICH=primary intracerebral haemorrhage; SAH=subarachnoid haemorrhage; UND=undefined. Feigin V, Lancet Neurology 2003

Θνητότητα One year survival in patients with first-ever stroke “The Arcadia Stroke Registry” Κενοτοπιώδη Αθηροσκληρωτικά Καρδιοεμβολικά Αιμορραγίες Vemmos et al, J Neurol Neurosurg Psychiatry 2000;69:595-600

Long-term Mortality Following Ischemic Stroke Θνητότητα Long-term Mortality Following Ischemic Stroke Deaths from stroke or MI among patients with a first cerebral infarction (n = 764) 30 27.0% 25 20 Percentage 15 10.1% 10 5 Talking Points This was a population-based study conducted in Rochester, Minnesota in which people suffering a stroke were then followed up to a maximum of 18 years to determine cause of death.(56) Stroke Deaths MI Deaths In data acquired over an 18-year observation period, for those with an initial stroke, the risk of death from stroke is more than 2.5 times the risk of death from MI Petty GW, et al. Neurology 1998;50:208-216.

Prognosis of Ischemic Stroke German Stroke Data Bank Πρόγνωση Prognosis of Ischemic Stroke German Stroke Data Bank Slight disabilities (mRS 0-2) Follow-up after 90 days Moderate disabilities (mRS 3) Severe disabilities (mRS 4-5) 14.70% 18.60% Deceased n = 5,017 9.40% Talking Points Stroke mortality and morbidity after acute cerebral infarction according to data from the German Stroke Data Bank (n=5,017) are as follows: 57.2% of the patients recovered completely or suffered only minor sequelae; however, these patients should be on some type of stroke prevention therapy. 9.4% suffered from moderate disability. In 18.6% of the patients, stroke caused severe impairment, and 14.7% of the patients died.(7) Score Description of modified Rankin Scale (mRS) 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance Severe disability; bedridden, incontinent and requiring constant nursing care and attention Dead 57.20% Grau AJ, et al. Stroke 2001;32:2559-2566.

The Athens Stroke Outcome Project Νοσοκομειακή έκβαση 3105 ασθενών με οξύ πρώτο εγκεφαλικό επεισόδιο (Rankin score) The Athens Stroke Outcome Project

Hospital discharges, cerebrovascular diseases per 100000 Stroke trends Hospital discharges, cerebrovascular diseases per 100000 Source: WHO/Europe, European HFA Database, November 2007      France Germany Greece Italy Spain

Stroke trends Average annual incidence rates (trends) of stroke per 100 000 population from 1955-1989 (Rochester, Minnesota) Brown RD, Stroke 1996

Stroke trends Framingham Study: Age-adjusted annual incidence of first stroke over time in men and women (per 1000 person-years) Group 1950–1977 1978–1989 1990–2004 p for trend Men 7.6 6.2 5.3 0.02 Women 5.8 5.1 0.01 Carandang R et al. JAMA 2006; 296:2939-2946

Stroke trends Age and sex-specific incidence rates (trends) for all types of stroke combined in Arcadia for the years 1994 and 2004 MEN WOMEN 367.4 (327-409) 334.7 (280-390) 316.1 (277-356) 316.5 (261-372) Vemmos et al, Stroke 1999, and ESC May 2005 Vemmos et al, Stroke 1999, and ESC May 2005

Stroke trends Framingham Study: 30-day mortality from stroke in men and women over time (%) Group 1950–1977 1990–2004 p Men 23 14 0.01 Women 21 20 0.32 Carandang R et al. JAMA 2006; 296:2939-2946

Stroke trends Trends in Case Fatality Rate (28 days) in Arcadia for the years 1994 and 2004 1994: 26.6% (95% CI, 22.9-30.2) 2004: 25.5% (95% CI, 20.3-30.7) % Vemmos et al, Stroke 1999, and ESC May 2005

The Burden of Stroke Continues After the Acute Event Stroke progression during hospitalization 24% Mortality 30 days 8–20% 1 year 15–25% 5 years 40–60% Complete or partial dependence 27–53% Dementia persisting at 1 year 34% Post-stroke rehabilitation has improved, but the consequences of stroke are still severe. In many patients, the stroke progresses during hospitalization.1 A high percentage of stroke survivors die within 30 days after sustaining a stroke, and approximately half of stroke survivors die within five years of a first stroke; almost half of these deaths can be attributed to a vascular cause.1 For people who survive a stroke, persistent disability, dementia, and decreased quality of life are common. 1 Reference Sacco RL. Neurology 1997; 49 (Suppl 4): S39–S44 Source: Sacco. Neurology. 1997; 49 (Suppl 4): S39–S44

Effects on quality of life Stroke has a major impact on quality of life Best possible health state 1 Asthma [0.79]2* Mild stroke [0.75]1† Lower back pain [0.66]2* - 0.5 Moderate/severe stroke [0.39]1† Recurrent stroke [0.12]1† Effects on quality of life Estimates of quality of life scores after stroke have been made for various categories of disability: a mild event was scored at 0.75; a moderate to severe event was scored at 0.39; and a recurrent event was scored at 0.12 (0 = dead and 1 = perfect health).1 Stroke has a considerable impact on patients’ quality of life: even a mild stroke has a similar impact on quality of life as asthma.1,2 References Gage BF. JAMA 1995; 274: 1839–1845. Burstrom K et al. Swedish population health-related quality of life results using the EQ-5D. Qual Life Res 2001; 10: 621–635. Death PLEASE NOTE THAT THESE RESULTS WERE OBTAINED FROM TWO DIFFERENT STUDIES *Based on the health-related quality of life results using the mean EQ-5D self-classifier index values and mean rating scale scores †Patients were questioned using a computer-based utility-assessment tool and the quality of life impact calculated using the time trade-off method to elicit utilities 1. Gage BF et al. JAMA 1995; 274: 1839–1845. 2. Burstrom K et al. Qual Life Res 2001; 10: 621–635.

How bad is a major stroke? Worse than death Equivalent to being well Patients (%) Equivalent to death How bad is a major stroke? A study by Samsa et al. (1998) examined attitudes towards hypothetical major stroke. Preferences were assessed by using the time trade off (TTO). Although responses were varied, 45% of respondents in the study considered major stroke to be a worse outcome than death. Reference Samsa GP et al. Am Heart J 1998; 136: 703–713. Patient attitudes to hypothetical major stroke 1. Samsa GP et al. Am Heart J 1998; 136: 703–713.

Σημαντικά προβλήματα που αντιμετωπίζουν ασθενείς με εγκεφαλικό μετά το νοσοκομείο (n=6000) Br J Gen Pract 2003;53:803–807

Ischaemic stroke survivors aged >65 years in the USA 1/4 were resident in a nursing home 1/3 required help with walking 1/4 were dependent in activities of daily living Kelley-Hayes et al. 2003

Global economic costs of stroke Short term Long term Others Emergency transportation Diagnosis In-patient stay Surgery Drugs Outpatient visits Transportation GP visits Physiotherapy Occupational therapy Speech/language therapy Drugs Tests and investigations Orthoses/incontinence pads Institutional care Income lost by informal carers Income lost due to death Income lost due to disability Benefit payments

Άμεσες δαπάνες ασθενών με ΑΕΕ

Δεδομένα από τη διεθνή βιβλιογραφία για το κόστος του ΑΕΕ Αγγλία, Σκωτία, Ολλανδία: 3-4% των δαπανών υγείας Isard 1992, Bergman 1995, Evers 1997 0,27% του ΑΕΠ στις αναπτυγμένες χώρες ΗΠΑ: 1990: $40,6 δις 1998: $43,3 δις 2001: $45,4 δις 2009: $68,9 δις Τaylor 1996 ΑSA, Heart Disease and Stroke Statistics,2001 ΑSA, Heart Disease and Stroke Statistics , 2009 update

Μέσο ετήσιο κόστος ΑΕΕ Σουηδία: $25.373-$28507 Claesson 2000 Γερμανία: $18.517 Kolominsky 2006 Ην.Βασίλειο: $13.650 (τρεις πρώτοι μήνες) Caro 2000 ΗΠΑ: $25.500 Porsdal 1999 Ελλάδα: 13.000-34.000 ευρώ (ανάλογα με βαρύτητα περιστατικού) Γειτονα και συν 2000

The High Cost of Stroke Annual Total (2001) Per Event* $28.0 billion $46,667 $29,000 $75,667 Direct costs (care and treatment) Indirect costs (lost productivity) Talking Points Based on direct costs alone, stroke is very expensive and ranks among the most expensive illnesses in the United States.(18) Direct costs may be expected to rise with: - Increasing annual stroke rates(17) - Increased use of available treatment options - Inflation Indirect cost is a controversial concept that reflects the drain on society's productivity and resources outside of direct medical care.(18) Even without indirect costs, stroke is very expensive. Background According to the most recent estimates of the American Heart Association, the United States will have spent more than $45.4 billion on stroke-related costs in 2001.(19) These costs have risen considerably over the last years.(18,19) Most of these expenditures are directly related to medical care, including those for physicians and nurses, hospital stays, nursing home or transitional care units, pharmaceuticals, rehabilitation, etc.(18) Indirect costs related to the lost productivity of the stroke victims or their caregivers are more difficult to define and quantify but nonetheless contribute to the overall economic burden of stroke.(18,19) Total *Based on 600,000 strokes per year American Heart Association, 2001 Heart and Stroke Statistical Update.

Μεταβολές άμεσου οικονομικού κόστους εγκεφαλικών για περίοδο 18 μηνών Μεταβολές άμεσου οικονομικού κόστους εγκεφαλικών για περίοδο 18 μηνών Cerebrovasc Dis 2004;17:134–142

Pharmaceuticals Only Account for 2% of Cost of Stroke Care Annual cost of stroke in USA = US$49.4 billion1 Hospital/nursing home Physicians/other professionals Pharmaceuticals/other medical durables Home healthcare Lost productivity 1. American Heart Association. 2002 Heart and Stroke Statistical Update. AHA, 2002

Ανάλυση νοσοκομειακού κόστους (n=2008) (σε τιμές ευρώ 2009)

Stroke: Mean Cost as a Function of Long-Term Care Destination*1 Chronic long-term in-hospital care 56,114 Nursing home 33,208 33,062 Rehabilitation Destination Convalescent home 22,297 New housing 11,722 In France, a recent study has shown the cost differential between the various destinations of stroke patients after discharge, with chronic long-term in-hospital and nursing home care representing the most significant burden. The mean cost per patient was 19,513 Euros, which extrapolates to a cost for France of 2.9 billion Euros per year, assuming that the incidence of stroke is 150,000 each year. The study concluded that not only the level of handicap, but socioeconomic variables were important in determining the destination of stroke patients after discharge. Return home 11,375 10,000 20,000 30,000 40,000 50,000 60,000 Euros *Excluding new acute hospitalization 1. Spieler J-F et al. Cerebrovasc Dis 2002; 13: 132–41. Reference: 1. Spieler J-F et al. Cerebrovasc Dis 2002; 13: 132–41.

Άμεσο οικονομικό κόστος εγκεφαλικών ανάλογα με την αναπηρία για περίοδο 18 μηνών (Rankin score, Euro ανά ασθενή) Cerebrovasc Dis 2004;17:134–142

Συνδυασμός θανάτων και χρόνου που χάνεται από την μη εργασία λόγω της αναπηρίας ανά 100 000 πληθυσμού (4η στη σειρά νόσος) Atlas of Heart Disease and Stroke, Mackay J, Mensah G (eds). Geneva: WHO; 2004

Συμπεράσματα-1 Τα εγκεφαλικά επεισόδια είναι μια καταστροφική νόσος που ευθύνεται για μεγάλο ποσοστό θνητότητας και αναπηρίας Η επίπτωση και ο επιπολασμός κυμαίνονται ευρέως μεταξύ των χωρών και ενδεχομένως θα αυξηθεί τα επόμενα χρόνια Η θνητότητα από εγκεφαλικά παραμένει υψηλή και δεν μειώνεται τα τελευταία χρόνια Είναι το 1ο αίτιο αναπηρίας σε ηλικιωμένα άτομα Τουλάχιστον το 50% του συνόλου των ατόμων που παθαίνουν εγκεφαλικό χρειάζονται αποκατάσταση Talking Points The causes of stroke are more heterogeneous than those associated with MI - Up to 20 % of all strokes are primary hemorrhages - Only 20% of ischemic strokes are due to large artery atherosclerosis; 30-40% are of unknown cause(10,53) Hemorrhage is a common and devastating complication of ischemic stroke, but not of MI (54,55) Strokes occur in older patients than MI - The mean age of stroke patients is 65-70 (10,53) Stroke patients are at greater risk of major hemorrhagic complications in the future than MI patients - Stroke patients are twice as likely to have major bleeding in the future as MI patients (41) Stroke patients are at higher risk of recurrent stroke than MI (16,41)

Συμπεράσματα-2 Τα εγκεφαλικά είναι μια εξαιρετικά επιβαρυντική οικονομικά νόσος, (καταναλώνεται το 2-4% του προϋπολογισμού για την υγεία) Το κόστος επιβαρύνει τον ασθενή, την οικογένεια, την κοινωνία, το προϋπολογισμό του κράτους Το υψηλό κόστος είναι αποτέλεσμα της μεγάλης αναλογίας χρόνιας αναπηρίας που αφήνει η νόσος Η μεγαλύτερη κατανάλωση πόρων γίνεται αφού ο ασθενής εξέλθει από το νοσοκομείο

Underfunding of Stroke Research A Europe-Wide Problem “for every £20 spent on cardiology research, only £1 is spent on stroke research”!! Stroke. 2004;35:2368-2371

www.stroke.gr Γιατρούς Επαγγελματίες Υγείας Ασθενείς και οικογένεια