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Original article

Factors Influencing Costs of Inpatient Ischaemic Stroke Care in Singapore


Wai Leng Chow, MBBS (Singapore), GDFM (Singapore), Aung Soe Tin, MBBS (Myanmar), MMed Public Health (Singapore), Amutha
Meyyappan, MSocSci (Singapore)
SingHealth Centre for Health Services Research, Singapore

Abstract

Introduction: Stroke is a major public issue in Singapore, accounting for almost 10,000 admissions annually and
the burden of disease is set to increase with an ageing population.

We therefore seek to examine the factors influencing the cost of acute stroke care in Singapore.

Methods: This is a retrospective analysis of 2,087 discharges with a primary discharge diagnosis of stroke from
a tertiary hospital in Singapore from 1 January 2007 to 31 December 2008. Data including age, gender, length
of hospital stay, components of direct cost and discharge disposition were obtained. A generalised linear model
with a log link function and gamma distribution was used to determine the predictors of total hospital cost.

Results: Mean age was 67.8 12.4 years and 54.5% were males. Mean length of stay was 12.3 16 days and mean
total overall cost was S$6,783. Ward costs accounted for 48% of total cost.

Length of stay strongly correlated to total cost. Being discharged to step-down facilities, death, receiving inpatient
rehabilitation and length of stay significantly incurred higher total cost in multivariate analysis. However, there was
an inverse relationship between age and total cost, possibly as a result of higher costs incurred for radiological,
laboratory investigations and expert care.

Conclusion: Further research is needed to examine factors influencing the cost of treatment particularly for
those being discharged to step-down facilities and receiving inpatient rehabilitation as they have been found
to incur higher total cost. This would impact on the planning of the continuum of healthcare facilities for
stroke management.

Keywords: cerebrovascular accident, determinants, health economics

Introduction to cost Australia and the United Kingdom A$2.14


Every year stroke accounts for an estimated 10,000 billion and 4 billion per year respectively4,5.
admissions and it is the fourth leading cause of
death after cancer, ischaemic heart disease and In Singapore, Venketasubramanian and Yin
severe chest infection in Singapore. Although the reported in 2000, the direct cost of each
death rates from stroke have been stable, there has hospitalisation to an acute hospital for stroke came
been an increase in the number of admissions from up to an average of S$7,547 per discharge. This cost
stroke over the last 3 years (20052007)1. Stroke is was computed based on patients treated for both
also the third leading specific cause for disability ischaemic and haemorrhagic stroke. Length of stay
adjusted life years in Singapore2. was found to be strongly correlated to total cost,
with ward charges contributing 38% of total cost6.
In the United States, it has been estimated that
direct healthcare cost as a result of stroke would hit Some studies were performed to examine
US$48 billion in 20103. Stroke has been estimated specifically, factors influencing the length of

Proceedings of Singapore Healthcare Volume 19 Number 4 2010 283


Original Article

hospital stay, a determinant of acute cost7,8, while (whether the patient was discharged home
others reported on factors influencing the cost with or without outpatient follow-up with
of stroke care. However, factors influencing total primary care physician or the specialist, a step-
direct cost can vary from country to country and down rehabilitation facility, that is, community
even from centre to centre internationally916. This hospital or nursing home, transferred to another
observation can be attributed in part to variations hospital for continuation of acute management
in healthcare financing systems, differences or discharged against medical advice) as well
in clinical practices as well as differences as death status.
in study design.
Collection of Cost Data
With 1 in 5 residents projected to be 65 years and Actual cost incurred from each hospitalisation
above in 203017, there is an expected consequent upon discharge was extracted from the financial
increase in the prevalence of stroke. It is therefore database for the list of patients extracted using ICD
timely to examine the factors influencing the cost 9 codes. Hospital bills that were sent to patients
of acute stroke care in Singapore to provide local were not used for computation of cost as the
baseline information to healthcare providers and cost reflected on these bills typically reflect the
policy makers on the factors influencing the cost amount payable by the patient after subsidy by
of acute stroke management. This would be a the government. Patients who seek treatment at
preliminary study into identifying areas for further a public hospital could receive highly affordable
research on the organisation of care for stroke care to varying degrees as a result of government
patients in order to optimise the cost of ischaemic subsidies depending on the type of ward facilities
stroke care in an acute hospital. that they have chosen on admission. Only private
patients pay the full cost incurred.
We seek to examine if demographic factors such
as age, gender and ethnicity as well as if being The perspective of the healthcare provider
discharged to a step-down facility and receiving was taken in this study and only direct costs
inpatient rehabilitation in the acute hospital incurred during each hospitalisation at the
would influence the cost of acute ischaemic stroke full cost without government subsidy was
management in Singapore. included. Direct costs included cost of resources
utilised and services received. These would
Methods include ward charges, investigations, surgery,
Study Design rehabilitative therapy, drugs and doctors fee.
This is a retrospective analysis of patients with a The individual components were grouped as
diagnosis of ischaemic stroke who were discharged follows: (1) ward cost includes total operational
from Singapore General Hospital (SGH), a 1,400- charge, daily fee, facilities charges and ward
bed tertiary public hospital located centrally in charges; (2) radiology investigations includes
Singapore18, between 1 January 2007 and 31 X-rays and magnetic resonance imaging
December 2008. (MRI); (3) laboratory investigations includes
laboratory tests and special investigations;
Patients were identified using the International (4) cost of expert medical care are charges incurred
Classification for Diseases 9th Revision (ICD 9) codes when referrals are made to doctors outside of the
433.X, 434.X, and 436. Patients diagnosed with primary medical team caring for the patient and
transient ischaemic attack (TIA) and intracerebral include doctor fees, surgeon fees and anaesthetist
haemorrhage (ICH) were not included in this fees; (5) cost of services rendered includes ward
analysis. A total of 2,087 ischaemic stroke patients procedures, emergency services, implant fees and
were included in this study. rehabilitation; (6) medication cost includes medical
supply, medicines to take home and consumables;
Collection of Data and (7) miscellaneous cost includes items classified
Administrative databases were used to extract as miscellaneous and others.
demographic data including age, gender, and
ethnicity, length of stay (LOS), data on whether Cost data is presented in the original currency,
inpatient rehabilitation was provided during Singapore dollars (S$). (US $1 equals approximately
the period of hospitalisation, discharge location S$1.44 in 20072008).

284 Proceedings of Singapore Healthcare Volume 19 Number 4 2010


Factors Influencing Costs of Inpatient Ischaemic Stroke Care in Singapore

Data Analysis hospitals, discharged against medical advice, social


Patients were categorised into 65 years and above overstayers, had absconded, were classified as
( 65 years) and below 65 years old (<65 years) for coroner case and others. There were 1,102 and 985
analysis. Length of stay was analysed as a continuous discharges with the primary diagnosis of ischaemic
variable. Provision of inpatient rehabilitation in the stroke in 2007 and 2008 respectively.
acute hospital was categorised into Yes or No.
Patient Characteristics
Discharge location was re-categorised into 5 Overall mean age was 67.8 years [standard
categories: (1) Discharged home include patients deviation (SD) 12.4 years] and 61.3% were 65
discharged with or without follow-up either by years. Fifty-four point five per cent of the patients
primary care physicians or specialists; (2) Discharged were male and 79% were Chinese. Mean length
to step-down facilities include patients discharged of stay (LOS) in the acute hospital was 12.3 days
to either nursing homes or community hospitals; (SD 16.0 days) and median LOS was 6 days (range:
(3) Transferred out include patients who were 1190 days).
transferred to another hospital for continuation of
acute care; (4) Discharged against medical advice Ten point one per cent of patients received
were patients who chose to be discharged from intensive inpatient rehabilitation in the acute
the hospital against the advice of their attending hospital under the care of Rehabilitation Medicine
physician; and (5) Death includes patients who physicians. Patients discharged home with out-
died in hospital. patient follow-up accounted for 82.0% of all
discharges; 13.7% were discharged to step-down
Those who were transferred out and discharged facilities and death accounted for 4.3% of discharges
against medical advice were excluded from (Table 1, overleaf ).
further analysis.
Furthermore, among the 187 patients who
Categorical data were presented in frequency and received intensive inpatient rehabilitation in the
percentage. Continuous data were presented in acute hospital, 88.6% were discharged home with
mean, median, minimum, maximum and standard only 10% being discharged to a step-down facility.
deviation. As the cost data were highly skewed Death accounted for 1.4% of discharges within this
positively in nature, we used non-parametric tests group. There were significantly more patients who
for bivariate analysis such as Mann Whitney U tests were discharged home as compared to those who
and Kruskal-Wallis tests to explore the presence did not receive inpatient rehabilitation in the acute
of any significant differences in total cost among hospital (88.6% versus 81.3%; p=0.017).
different groups. Bivariate correlation tests with
Spearman correlation coefficients were used for Cost of Acute Stroke Management
continuous data. Ward costs, which consist of total operational
charge, daily fee, facilities charges and ward charges,
Generalised linear model with log link function accounted for 48.1% of total overall charges. This
and gamma distribution was used as it could give was followed by laboratory investigations (18%),
better estimates than a multiple linear regression radiological investigations (12.8%), medications
model for skewed cost data19 in adjusting for (9.2%), services rendered (8.6%), miscellaneous
potential confounding variables. The estimates (1.9%) and expert care (1.5%).
of each independent variable were presented
as odds ratios and percentages. Data cleaning, Mean total charges for the overall population were
coding and analysing were performed using the S$6,783 (median S$4,238; range S$246S$119,042).
Statistical Package for Social Sciences (SPSS) 15 for Mean daily average charges were S$769 (median
Windows statistics program. The level of statistical S$668; range S$203S$13,967)
significance was set at p<0.05.
Being 65 years and above (p=0.002), discharge
Results destination (p=0.001) and whether patient
A total of 2,087 discharges were included in the underwent inpatient rehabilitation (p=0.001) were
analysis after excluding 49 cases which included found to be significantly associated with the total
patients who were transferred out to other cost of acute stroke management (Table 2, overleaf).

Proceedings of Singapore Healthcare Volume 19 Number 4 2010 285


Original Article

Table 1. Baseline characteristics of study population.


Variables
Age Mean 67.84
years Median 68.50
Standard deviation 12.37
MinMax 195101
Length of stay Mean 12.28
days Median 6.00
Standard deviation 15.96
MinMax 1190
Age group <65 years 807 (38.7%)
freq (%) 65 years 1,280 (61.3%)
Gender Male 1,138 (54.5%)
freq (%) Female 949 (45.5%)
Ethnicity Chinese 1,648 (79.0%)
freq (%) Malay 209 (10.0%)
Indian 156 (7.5%)
Others 74 (3.5%)
Discharge destination Discharged home 1,712 (82.0%)
freq (%) Discharged to step-
down facilities 285 (13.7%)
Death 90 (4.3%)
Patients received inpatient Yes 211 (10.1%)
acute hospital rehabilitation No 1,876 (89.9%)
freq (%)
Number of discharges 2007 1,102 (52.8%)
freq (%) 2008 985 (47.2%)

Table 2. Relationship between baseline characteristics and total charges of hospitalization for ischaemic stroke patients.
(All values are expressed in Singapore Dollars.)
Mean Median
Std
N Total Total Min Max p-value Test
Deviation
Charges Charges
Age Group
<65 years 807 6,234.3 3,777.1 7,714.5 494.8 116,340 0.002 MWU
65 years 1,270 7,129.1 4,659.1 8,607.8 246.0 119,041
Gender
Male 1,138 7,137.2 4,318.1 9,359.6 246.0 119,041 0.454 MWU
Female 949 6,358.4 4,105.1 6,751.4 598.2 56,762.1
Ethnicity
Chinese 1,648 6,890.1 4,313.6 8,623.4 246.0 119,041
Malay 209 6,334.5 4,313.6 5,693.6 989.6 44,475.0 0.274 KW
Indian 156 6,108.4 3,710.1 7,622.1 454.9 54,495.6
Others 74 7,089.7 4,502.1 8,082.4 829.2 56,048.7
Discharge Destination
Discharged home 1,712 5,615.4 3,490.4 7,051.3 246.0 119,041
Discharged to step-down 0.001 KW
facilities 285 11,990 9,122.6 10,063.1 989.7 81,416.6
Death 90 12,508 6,544.5 13,528.4 1029.9 61,496.3
Patients Received Inpatient
Acute Hospital Rehabilitation
0.001 MWU
Yes 211 11,776 9,878.2 6,365.3 2360.2 34,900.8
No 1,876 6,221.5 3,735.4 8,288.2 246.0 11,9041
Total 2,087 6,783.1 4237.5 8283.4 246.0 119041
MWU Mann-Whitney U test; KW Kruskal-Wallis test

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Factors Influencing Costs of Inpatient Ischaemic Stroke Care in Singapore

Table 3. Relationship between baseline characteristics and hospital Length of Stay (LOS) in days.
Median Std
N Mean LOS Min Max p-value Test
LOS Deviation
Age Group
<65 years 807 10.6 4 14.6 1 117 0.001 MWU
65 years 1,270 13.4 8 16.7 1 190
Gender
Male 1,138 12.6 6 17.4 1 190 0.727 MWU
Female 949 11.6 7 14.0 1 141
Ethnicity
Chinese 1,648 12.8 6 16.7 1 190
Malay 209 11.2 6 11.6 1 62 0.019 KW
Indian 156 10.0 4 14.5 1 105
Others 74 8.4 5 9.4 1 52
Discharge Destination
Discharged home 1,712 9.8 5 13.2 1 190
Discharged to step-down 0.001 KW
facilities 285 26.4 20 21.7 1 141
Death 90 14.9 8 18.4 1 113
Patients Received Inpatient
Acute Hospital Rehabilitation
0.001 MWU
Yes 211 26.6 23 12.7 2 72
No 1,876 10.7 5 15.5 1 190
Total 2,087 12.3 6 16.0 1 190
MWU Mann-Whitney U test; KW Kruskal-Wallis test

Length of stay was found to be strongly correlated Those who were <65 years were likely to incur 6%
to total hospital charges (R2=0.764). more total charges than those who were 65 years
[Cost Ratio (CR) = 1.060; p = 0.007]. Those who
Additionally, LOS was also significantly influenced underwent inpatient rehabilitation incurred 11.9%
by age group (p=0.01), ethnicity (p=0.019), (CR = 1.119; p = 0.003) more in total charges than
discharge destination (p=0.01) and whether those who did not. Patients who died and those
patient underwent inpatient rehabilitation were discharged to step-down facility incurred
(p=0.01). In particular, those who were discharged 75.8% (CR = 1.758; p < 0.001) and 17.3% (CR =
to a step-down facility stayed an average of 26.4 1.173; p < 0.001) more in terms of total hospital
days compared to 9.8 days for those who were charges respectively as compared to those who
discharged home. Those who underwent inpatient were discharged home.
rehabilitation in the acute hospital also stayed an
average of 26.6 days as compared to 10.7 days for An additional 4.8% (CR = 1.048; p < 0.001) of total
those who did not (Table 3). charges was also incurred with each additional day
of stay in the acute hospital (Table 4, overleaf ).
Generalised Linear Model (GLM)
The Generalised Linear Model (GLM) with log link Subgroup analysis on the effect of age group and
function and gamma distribution was used to sub-components of total cost.
estimate the total charges of acute hospitalisation.
Possible confounding variables such as age Further subgroup analysis was performed using
group, LOS, discharge destination, whether the above model to examine if there were any
patient underwent inpatient rehabilitation differences in cost incurred for those <65 years
were entered into the model. These variables compared with those aged 65years for the
were selected based on the results from the respective components of total hospitalisation
bivariate analysis. cost that might account for the inverse relationship

Proceedings of Singapore Healthcare Volume 19 Number 4 2010 287


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Table 4. Factors influencing total charges of hospitalisation using Generalised Linear Model (GLM)
with gamma distribution and log link function.

Cost Ratio 95% Confidence


Parameter B Std Error (Exponentiated Interval for CR p-value
Coefficient) Lower Upper
Age Group
<65 years 0.059 0.0218 1.060 1.016 1.107 0.007
65 years 0 1
Discharge Destination
Death 0.564 0.0521 1.758 1.588 1.947 0.000
Discharged to step-down
facilities 0.159 0.0330 1.173 1.099 1.251 0.000
Discharged home 0 1
Patients Received Inpatient
Acute Hospital Rehabilitation
Yes 0.112 0.0381 1.119 1.038 1.206 0.003
No (Ref ) 0 1
Length of Stay 0.047 0.0010 1.048 1.046 1.051 0.000

between total cost and age group. There are a rehabilitation and the discharge destination after
total of 7 cost components that contribute to adjusting for potential confounding factors. With
total cost, namely: (1) ward costs; (2) radiological increasing spending on healthcare both locally20
investigations; (3) laboratory investigations; and internationally21,22, our findings suggest that
(4) cost of expert care; (5) cost of services rendered; it is timely to examine in greater detail, factors
(6) medications; and (7) miscellaneous. Seven GLMs, influencing care transition and cost of care
one for each cost component, were constructed particularly for patients requiring discharge to
and analysed. The same possible confounding step-down facilities as well as those receiving
variables such as age group, LOS, discharge inpatient rehabilitation in the acute hospital. Length
destination, whether patient underwent inpatient of stay and delivery of care at the appropriate
rehabilitation were entered into the model. The facilities could be optimised through improved
reference age group in each model was the group planning and organization of the healthcare
that was 65years. delivery system.

It was found that those <65years were likely to incur Venketasubramanian et al reported in 2000 that
28.5% (CR = 1.285; p < 0.001) more for radiological the mean cost per discharge was S$7,547 with
investigations, 13.8% (CR = 1.138; p<0.001) an average length of stay of 17 days, whereas
(CR = 1.151; p = 0.027) more for expert medical care. the mean cost per discharge for our study was
S$6,783 and average length of stay was 12.3 days6.
Discussion The higher cost reported by Venketasubramanian
The number of hospitalisations as a result of et al could be a result of including the cost of
ischaemic stroke has been on the increase. In management of haemorrhagic strokes; strokes
20072008, the mean total cost of hospitalisation as a result of subarachnoid haemorrhage and
in our study was S$6,783 and the average length of intraparenchyma haemorrhage cost 4 times
stay was 12.3 days. Ward costs accounted for 48.1% and 2 times more respectively than those from
of the total cost. Length of stay accounted for non-lacunar infarcts in the former study (mean
76% of the variability in total cost. Length of stay cost per discharge were S$28,539 and S$14,398
was significantly different between patients with respectively versus S$7,476). The average length
different discharge destinations and dependent on of stay could have also been longer in the earlier
whether inpatient rehabilitation was provided. We study for the same reason; the mean length of
found that total cost was significantly influenced stay were 2 times and 1.5 times more respectively
by age, LOS, whether the patient received inpatient for strokes from subarachnoid haemorrhage and

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Factors Influencing Costs of Inpatient Ischaemic Stroke Care in Singapore

intraparenchyma haemorrhage respectively as found to be significant predictors of extended


compared to non-lacunar infarct strokes (mean LOS hospital stay7,8. Gubitz et al described that 76%
were 41 days and 32 days respectively versus 19 of those with delayed discharge post stroke were
days)6. Higher total hospitalisation cost in patients discharged to a rehabilitation facility or nursing
with haemorrhagic strokes were also observed in home25. In addition, other factors such as discharge
other studies14. to the care of foreign domestic helper, lower
admission Functional Independence Measure
The strong correlation between LOS and total (FIM) motor score and lack of structured discharge
cost observed in our study was similarly reported planning process were also found to be associated
in other earlier studies6,10,14. We did not find with delayed discharge among stroke patients post
any correlation between gender and the total inpatient rehabilitation locally8. Further research
cost of hospitalisation as was reported by other into the relationship between factors that could
investigators6,10. delay discharges and total costs of acute stroke
care is warranted as we have found that total cost
Interestingly, being younger than 65 years predicted increased by 4.8% with each additional day spent
an increase of 6% in the cost of acute stroke in the acute hospital.
care after adjusting for inpatient rehabilitation,
discharge destination and length of stay. While We found that receiving inpatient rehabilitation in
previous studies have reported the lack of an acute hospital incurred about 12% more in total
influence of age on the total cost of stroke care6,9,10, cost than those who did not, and had an average
Mamoli et al reported that a younger age length of stay of 26.6 days instead of 10.7 days. On
significantly increased ancillary cost during acute the other hand, patients who are discharged to
management23. Reed et al also reported that step-down facilities could incur 17% more in total
increasing age was associated with decreasing cost with similar average LOS in the acute hospital.
average cost of treatment regardless of type of However, studies have found the provision of
stroke24. This observation could be a result of rehabilitation outside of the acute hospital to be
more investigative procedures being performed less costly in the long run. Anderson et al reported
for younger stroke patients. This hypothesis was in a systematic review that the cost of stroke
consistent with our subanalysis that younger care in the first year could be reduced with early
patients incurred higher cost for radiological and discharge from acute hospital even after taking into
laboratory investigations. consideration an increase in the cost of community
and home rehabilitation26. This finding was similarly
Those who died in hospital during acute reported by van Exel et al in their study on the cost
management were found to incur almost 76% of stroke care services over 6 months follow-up in
more in terms of total cost as compared to one the Netherlands27. These findings could be a result
who was discharged home with outpatient follow- of differences in healthcare financing systems but
up. This was similar to findings reported on stroke also highlights the need for further research locally
care cost previously6. This could be a result of the to examine the cost of stroke services across the
higher utilisation of resources in the initial period continuum of acute tertiary care to community
of treatment in this group of patients who might rehabilitation after discharge for stroke survivors
have presented with a more severe stroke. in order for better planning and organisation of
more cost-effective stroke care and post-stroke
For those who were eventually discharged to rehabilitation locally.
step-down care facilities, which could include
either nursing homes or community hospitals, This is especially pertinent as the Singapore
17% more in total cost was incurred than one who Government reorganises healthcare into regional
was discharged home. There was also a longer clusters to provide patient-centric care through
average LOS, more than twice that of those who integration of acute hospitals with other healthcare
were discharged home. Previous studies published facilities such as community hospitals within the
so far examined the relationship between LOS same geographical region28. This model of care
and discharge destination rather than the direct might enable a more seamless transition from
relationship with total cost. Awaiting for placement the acute hospital to step-down facilities for the
to residential care like nursing homes, have been appropriate patient population.

Proceedings of Singapore Healthcare Volume 19 Number 4 2010 289


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