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(Circulation. 1999;99:370-376.)
© 1999 American Heart Association, Inc.

Clinical Investigation and Reports

Effects of Stroke on Medical Resource Use and Costs in Acute Myocardial Infarction

Chen Y. Tung, MD; Christopher B. Granger, MD; Michael A. Sloan, MD; Eric J. Topol, MD; J. David Knight, MS; W. Douglas Weaver, MD; Kenneth W. Mahaffey, MD; Harvey White, MB; Nancy Clapp-Channing, MPH; Maarten L. Simoons, MD; Joel M. Gore, MD; Robert M. Califf, MD; Daniel B. Mark, MD, MPH; for the GUSTO I Investigators

From the Duke Clinical Research Institute, Durham, NC (C.Y.T., C.B.G., J.D.K., K.W.M., N.C.-C., R.M.C., D.B.M.); Harbin Clinic, Rome, Ga (M.A.S.); the Cleveland Clinic Foundation, Cleveland, Ohio (E.J.T.); Henry Ford Hospital, Detroit, Mich (W.D.W.); Erasmus University, Rotterdam, Netherlands (M.L.S.); University of Massachusetts Medical Center, Worcester (J.M.G.); and Green Lane Hospital, Auckland, New Zealand (H.W.).

Correspondence to Chen Y. Tung, MD, Box 2966, Duke University Medical Center, Durham, NC 27710. E-mail tung0001{at}mc.duke.edu

Background—Stroke occurs concurrently with myocardial infarction (MI) in 30 000 US patients each year. This number is expected to rise with the increasing use of thrombolytic therapy for MI. However, no data exist for the economic effect of stroke in the setting of acute MI (AMI). The purpose of this prospective study was to assess the effect of stroke on medical resource use and costs in AMI patients in the United States.

Methods and Results—Medical resource use and cost data were prospectively collected for 2566 randomly selected US GUSTO I patients (from 23 105 patients) and for the 321 US GUSTO I patients who developed non–bypass surgery–related stroke during the baseline hospitalization. Follow-up was for 1 year. All costs are expressed in 1993 US dollars. During the baseline hospitalization, stroke was associated with a reduction in cardiac procedure rates and an increase in length of stay, despite a hospital mortality rate of 37%. Together with stroke-related procedural costs of $2220 per patient, the baseline medical costs increased by 44% ($29 242 versus $20 301, P<0.0001). Follow-up medical costs were substantially higher for stroke survivors ($22 400 versus $5282, P<0.0001), dominated by the cost of institutional care. The main determinant for institutional care was discharge disability status. The cumulative 1-year medical costs for stroke patients were $15 092 higher than for no-stroke patients. Hemorrhagic stroke patients had a much higher hospital mortality rate than non–hemorrhagic stroke patients (53% versus 15%, P<0.001), which was associated with $7200 lower mean baseline hospitalization cost. At discharge, hemorrhagic stroke patients were more likely to be disabled (68% versus 46%, P=0.002).

Conclusions—In this first large prospective economic study of stroke in AMI patients, we found that strokes were associated with a 60% ($15 092) increase in cumulative 1-year medical costs. Baseline hospitalization costs were 44% higher because of longer mean lengths of stay. Stroke type was a key determinant of baseline cost. Follow-up costs were more than quadrupled for stroke survivors because of the need for institutional care. Disability level was the main determinant of institutional care and thus of follow-up costs.

Key Words: stroke • myocardial infarction • cost-benefit analysis

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