In China, the stroke burden is expected to increase further as a result of population aging and an ongoing high prevalence of risk factors for stroke; however, the costs for different stroke subtypes have not been comprehensively analyzed. Describing the distribution and characteristics of the hospitalization costs in stroke and examining the associated factors are essential steps to providing high-quality health care services while avoiding increasing the socioeconomic burden. To the best of our knowledge, our study is the latest study that analyzes the distribution and potential factors associated with hospitalization costs for different subtypes of stroke in the Chinese population, based on a prospective multicenter study.
In the present study, the mean (median) hospitalization costs per person were RMB 442,319.67 ± 53,986.27 (RMB 22,656.79; IQR 9016.51, 56,486.00), which are lower than those in developed countries of North America and Europe, as well as in Japan. A study in the United States indicated that the average cost of stroke was USD 20,396 ± 23,256 (RMB 141,652.26 ± 161,515.25, the spending estimates were converted to RMB (CNY) based on exchange rates in 2008 (1 USD = 6.9451 CNY)) . Research from Germany suggested that the mean hospitalization cost for hemorrhagic stroke was 26,602 USD (RMB 220,222.00, the spending estimates were converted to RMB (CNY) based on exchange rates in 2000 (1 USD = 8.2784 CNY)) . Tu et al. studied hospitalized patients with ischemic stroke in Japan (from 1995 to 1999) and found that the mean (median) hospital charges per patient were USD 9020 (USD 7974) (RMB 74,681.99 (RMB 66,021.53), the spending estimates were converted to RMB (CNY) based on exchange rates in 1999 (1 USD = 8.2796 CNY)) .
Additionally, hospitalization costs were notably higher in IHS than IIS (RMB 47,000.68, IQR 19,827.37, 91,877.09 vs. RMB 16,587.44, IQR 7020.13, 36,357.65). It is plausible that IHS tend to require more complex medical treatment or nursing interventions than IIS; thus, the median materials fees, medical service fees, and total costs for patients with severe illness may be higher in IHS. This is in line with the results of other resource-use studies indicating higher costs in patients with hemorrhagic stroke than in those who have ischemic stroke [10, 11]. Therefore, it is necessary to increase the reimbursement ratio of medical insurance for patients with hemorrhagic stroke, to reduce the personal medical expenses of these patients.
As for cost composition analysis, we found that medicine fees represented the largest proportion of overall hospitalization costs (as high as 37.42%); materials fees (24.70%) and medical service fees (21.94%) ranked second and third in the total hospitalization costs. Also, the composition of hospitalization costs is parallel in IHS or IIS. Compared with other studies carried out in China, the cost composition is mostly consistent with those in previous studies whereas the proportion of medicine fees is lower [7, 10, 11]. This may be attributable to the large reform to China’s health system implemented in public hospitals during the past decade, which imposed zero markup on drug costs and encouraged the use of inexpensive medications [20, 21].
In contrast, the cost composition in our study was quite different from those reported in Western countries. In Greece, Gioldasis et al. indicated that only about 7% of the total charges for stroke was attributable to medicines . In Germany, Dodel et al. suggested that the costs for medicines were low, with a mean total cost of EUR 120 ± 240 . Asil et al. analyzed the direct costs of acute ischemic and hemorrhagic stroke in Turkey, indicating that 29.9% of the total charge was for medicine . For one thing, perhaps because most patients enrolled in this study ended up with complications thereby requiring more medications. For another thing, the Chinese government has made great efforts to reduce prescribing and medicine costs; however, the government must further standardize medical treatment and introduce additional and more effective policies. Dodel et al. suggested that nursing fees are related to the hospital LoS . The average LoS in this study was 15.45 ± 11.89 days for all patients with stroke, which is longer than in developed countries, yet the nursing fees only accounted for a minimum proportion (1.83%) of the total costs, which is lower than the 8% in Greece . However, countries may differ in their developmental level and medical insurance service systems. Therefore, longitudinal comparisons within countries in this regard are more important than comparisons between countries.
In linear regression analysis, LoS, hospital level, previous surgery, previous ICU admission, invasive ventilation therapy, urethral invasive operation, respiratory invasive operation, pneumonia, and stroke subtype (hemorrhagic stroke) were found to be significantly associated with hospitalization costs for all immobile patients with stroke in this study. Identifying such factors can help to understand the nature of hospitalization expenses, so as to improve the efficiency of health care delivery. LoS was highly correlated with the hospitalization costs for immobile patients with stroke, which is in accordance with the results of several previous studies [11, 12, 17, 22, 23]. LoS is closely related to medical complications after stroke , the complication rates in this study were higher than those for previous studies; thus, as a controllable factor, LoS can be shortened by preventing nosocomial infections and medical complications. Other contributors such as hospital level, previous surgery, previous ICU admission, invasive ventilation therapy, urethral and respiratory invasive operations, and stroke subtype may represent the severity of illness.
The average LoS for all immobile patients with stroke was 15.45 ± 11.89 days in this study, which is longer than in previous reports from China [10, 11] and Europe [18, 22]. In most countries, patients with stroke are hospitalized for a short period of 10 to 15 days . The potential reasons for the difference in our results may be that patients in this study were immobile and were therefore more susceptible to medical complications such as pneumonia, PI, and so on, which could prolong LoS [24, 25]. Moreover, patients with hemorrhagic stroke had longer LoS than those with ischemic stroke, which was consistent with earlier reports on ischemic and hemorrhagic stroke in China from 2015 to 2018 [10,11,12]. Previous studies have identified that payment type influences stroke costs [6, 10]. In our study, 2023 patients (42.9%) who were covered by the NCMS had lower costs, possibly because this type of payment forces hospitals to control costs with shorter LoS.
Subgroup analysis indicated that hospital level was highly correlated with the hospitalization costs for IHS. The potential reasons for this difference may be that hemorrhagic stroke is less prevalent but more likely to be fatal , and patients with more severe physical impairment definitely require more medical care resources [12, 15, 27]. Tertiary hospitals are top-level hospitals in China, in which the health services and medical resources are more advanced. Therefore, patients with severe neurological impairment tend to be treated in tertiary hospitals. Furthermore, the professional level of physicians in tertiary hospitals is generally higher, and more advanced professional skills are related to higher medical service fees [11, 12, 22].
Our study findings also suggested that pneumonia and DVT were significantly associated with hospitalization costs in IIS. However, the complication rates in our study were somewhat higher than those of previous studies (DVT: 0.8% vs. 0.2% ; pneumonia: 7.8% vs. 4.6% ). Balami et al.  and Bustamante et al.  indicated that complications after ischemic stroke could prolong the LoS, which may explain the impact of DVT and pneumonia on hospitalization costs for ischemic stroke [24, 32].
The duration of immobility was another significant predictor in the patient subgroup with hemorrhagic but not ischemic stroke. The duration of immobility after hemorrhagic stroke was longer than that after ischemic stroke (12.11 ± 9.98 days vs. 7.36 ± 9.77 days) in our sample. In addition, complications such as pneumonia or DVT can arise as a direct consequence of stroke itself, owing to ensuing immobility or disability . These complications present barriers to optimal recovery and positive clinical outcomes or they can increase the costs of hospital care when complications are non-fatal.
This study has some limitations. The cost data reported in the present study reflect only direct health care spending and do not account for indirect societal costs associated with rehabilitation and intangible costs to patients with stroke; further research is required to estimate these costs and to obtain an estimate of the total costs for immobile patients with stroke. Given the cross-sectional nature of this study, we could not determine causation or the direction of the observed relationships. In addition, we were unable to assess all potentially associated factors that may determine hospitalization costs, such as alcohol use. For the univariate and multivariate analysis, when there is a large sample size, there is a tendency for small differences to become statistically significant. In Supplementary Tables 1 and 2, we can find actual cost difference is also very obvious in different categorical variables layers (such as subtype of stroke, age group, experience of surgery, experience of ICU, hospital level). This made us think that the test power of the analysis was in a relatively reasonable range. However, a more rigorous analytical method with more sophisticated evaluations are required to confirm our findings. The etiology, complications, and comorbidities for an ischemic stroke may potentially influence the initial cost of hospitalization. We will continue to explore in depth in the next step of the study.
The strength of our study is that we analyzed the distribution and predictors associated with hospitalization costs for different subtypes of stroke; patients enrolled in this study were from six regions of China, and this work was based on a prospective multicenter study. Therefore, our results will be valuable in economic evaluations to support policymaking regarding reimbursement, investment, and pricing for medical or nursing interventions. This study is of practical utility in developing countries and some developed countries aiming to provide comprehensive health services in immobile patients with stroke, to better balance patients’ health gains, personal costs, and social welfare costs.