Alternative strategies for stroke care: cost-effectiveness and cost-utility analyses from a prospective randomized controlled trial.

BACKGROUND AND PURPOSE Although stroke units reduce mortality and institutionalization, their comparative cost-effectiveness is unknown. METHODS Healthcare, social services, and informal care costs were compared for 447 acute stroke patients randomly assigned to stroke unit, stroke team, or domiciliary stroke care. Prospective and retrospective methods were used to identify resource use over 12 months after stroke onset. Cost-effectiveness and cost-utility analyses were undertaken. RESULTS Mean healthcare and social care costs over 12 months were 11 450 pounds sterling for stroke unit, 9527 pounds sterling for stroke team, and 6840 pounds sterling for domiciliary care. More than half the costs were for the initial episode of care. Institutionalization was a large proportion of follow-up costs. Inclusion of informal care increased costs considerably. When informal care was excluded, the incremental cost-effectiveness ratio per percentage point in deaths or institutionalizations avoided in the first year was 496 pounds sterling for the stroke unit over domiciliary care; incremental cost per quality-adjusted life year quality-adjusted life year gained was 64 097 pounds sterling between these 2 groups. The stroke team was dominated by domiciliary care. CONCLUSIONS Cost perspectives, especially those related to long-term and informal care, are important when stroke services are evaluated. Improved health outcomes in the stroke unit come at a higher cost.