Stroke: Hospitals lose money on endovascular embolectomies

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Medicare payments for acute ischemic stroke patients who underwent endovascular embolectomy did not adequately reimburse hospital costs, according to a report published online in the Oct. 6 issue of Stroke. Even when patients had a good outcome, reimbursement fell $15,000 short of costs, the analysis found.

Waleed Brinjikji, MD, of the Mayo Clinic in Rochester, Minn., and colleagues designed the analysis to determine the costs of hospitalizing acute ischemic stroke patients who undergo endovascular embolectomy. They noted that while the treatment is now widely accepted, it also involves a severely ill patient population whose care requires potentially costly resources. Their goal was to determine whether payments were in line with hospital costs.

The researchers used the National Inpatient Sample hospital discharge database to identify patients who experienced acute ischemic strokes between 2006 and 2008. Based on procedural codes, they then found 3,864 patients who underwent endovascular clot retrieval. Brinjikji et al calculated hospital costs, which was their primary endpoint, by multiplying the patient’s total hospital charges by the hospital’s mean cost-to-charge ratio, adjusting for inflation. Charges and costs were converted to their 2008 dollar value.

Of the 3,864 patients, 42.7 were 65 years old or older. The majority of the patients, 51.3 percent of the 3,864 total, were discharged to a long-term facility, which suggested they had severe disabilities. Another 24.4 percent of patients were discharged to a home or short-term facility, suggesting a good outcome. The remaining 24.3 percent of patients died in-hospital.

In their cost analysis, the researchers found that the median cost of hospitalization for patients who received endovascular embolectomies and had good outcomes was $36,999 while the average 2008 Medicare reimbursement for the procedure without major complications was $22,075. Median hospital costs for patients with morbidity was $50,628 and was $35,109 for patients who died in-hospital, well short of the $26,639 average 2008 Medicare reimbursements for embolectomy with major complications.

“For Medicare patients in 2008, hospitals typically lost approximately $15,000 on each patient with a good outcome, $24,000 on each patient with disability and $9,000 on each patient with mortality,” Brinjikji and colleagues wrote.

They noted that high costs associated with the sickest patients were expected, given the severity of their illness and need for resources. “What is perhaps surprising is that costs are relatively high even for patients who have a good outcome and presumably incur considerable less intensive care costs than patients who have major morbidity,” they said.

They added that the high hospitalization charges were not due to the endovascular embolectomy itself, and speculated that without the procedure patients would have more disabilities that in turn would increase costs. Given the data limitations, they could not identify patients with similar ischemic stroke profiles who did not receive endovascular embolectomy, which then would have allowed a comparison.

“Outcomes tend to be better with endovascular recanalization with reduced death and higher percentage with no or little disability, so it is quite possible that costs associated with hospitalization will be compensated later by decreases in long-term costs,” they proposed.