Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors.



It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.


Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.


Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.


Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.





Published Version (Please cite this version)


Publication Info

Tyagi, Shilpa, Gerald Choon-Huat Koh, Luo Nan, Kelvin Bryan Tan, Helen Hoenig, David B Matchar, Joanne Yoong, Eric A Finkelstein, et al. (2018). Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors. BMC health services research, 18(1). p. 881. 10.1186/s12913-018-3696-3 Retrieved from

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Helen Marie Hoenig

Professor of Medicine
  1. General Focus and Goals of Research: Dr. Hoenig's research focuses on rehabilitation, and more specifically on assistive technology and teletechnology. Patient populations of interest include geriatric patients with diverse medical problems including stroke, spinal and/or musculoskeletal disorders.

    2. Specific Approaches or Techniques: Randomized controlled trials, epidemiological studies including large data base analyses and survey research. Clinical trials include studies of the effects of motorized scooters in persons with difficulty walking, methods for providing wheelchairs, and telerehabilitation for exercise & functional mobility training in the home. Epidemiological studies and survey research have examined use of assistive technology and other coping strategies to disability.

    4. Special areas of expertise/national recognition: Rehabilitation health services research, geriatric rehabilitation, assistive technology outcomes, telerehabilitation.

    KEY WORDS/PHRASES: Rehabilitation, Process and Outcomes Research, Assistive Technology, Telehealth, Activities of Daily Living, Geriatrics, Disability.

David Bruce Matchar

Professor of Medicine

My research relates to clinical practice improvement - from the development of clinical policies to their implementation in real world clinical settings. Most recently my major content focus has been cerebrovascular disease. Other major clinical areas in which I work include the range of disabling neurological conditions, cardiovascular disease, and cancer prevention.
Notable features of my work are: (1) reliance on analytic strategies such as meta-analysis, simulation, decision analysis and cost-effectiveness analysis; (2) a balancing of methodological rigor the needs of medical professionals; and (3) dependence on interdisciplinary groups of experts.
This approach is best illustrated by the Stroke Prevention Patient Outcome Research Team (PORT), for which I served as principal investigator. Funded by the AHCPR, the PORT involved 35 investigators at 13 institutions. The Stroke PORT has been highly productive and has led to a stroke prevention project funded as a public/private partnership by the AHCPR and DuPont Pharma, the Managing Anticoagulation Services Trial (MAST). MAST is a practice improvement trial in 6 managed care organizations, focussing on optimizing anticoagulation for individuals with atrial fibrillation.
I serve as consultant in the general area of analytic strategies for clinical policy development, as well as for specific projects related to stroke (e.g., acute stroke treatment, management of atrial fibrillation, and use of carotid endarterectomy.) I have worked with AHCPR (now AHRQ), ACP, AHA, AAN, Robert Wood Johnson Foundation, NSA, WHO, and several pharmaceutical companies.
Key Words: clinical policy, disease management, stroke, decision analysis, clinical guidelines


Eric Andrew Finkelstein

Professor in Population Health Sciences

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