Chapter 4 - Cost of AF to individuals and society?
- AF-related stroke impairs stroke survivors’ quality of life more than non-AF-related stroke
- Permanent disability and other consequences of AF-related stroke place a heavy burden on carers, family members and health and social services
- Healthcare costs associated with stroke are higher for patients with AF than for patients without AF
Significant impact on quality of life
Survivors of strokes have described their subsequent life as a fate worse than death. This description is not only dramatic and intuitively apparent, it is also supported in the scientific literature. For purposes of research, the impact of a stroke can be evaluated on a scale of zero to ten where 10/10 represents perfect health and 0/10 represents death. 53
In a study that used these scores to evaluate the impact of stroke on the quality of life for patients with AF, 83% of patients rated their quality of life after a severe stroke as equal to, or worse than, death. 54
Other scores have been developed to assess specific aspects of quality of life; such as neurological function. A comparison of AF and non-AF strokes is presented in table 4 across several of these aspects. As above, the scores in the table consistently show that AF-related stroke has a more negative impact on quality of life than non-AF-related stroke. 72
AF also increases the risk of medical complications following stroke. Compared with those without AF, patients with AF suffer more frequently from pneumonia, pulmonary oedema (accumulation of fluid in the lungs) and bleeding in the brain after stroke. 55
Heavy burden on carers, families and society
This sustained impact of strokes has a devastating impact not only on the individual and their carers but also on the wider family, particularly children.
Increased disability and poor health
More than one-third of patients who experience a stroke return to their home with some level of permanent disability. 56 They then rely on informal care, typically from family members, to help with their normal daily activities and to arrange the required additional assistance from healthcare services.
The disabling consequences of stroke are worse for those patients who survive an AF-related stroke, than for those without AF. The presence of AF increases the risk of remaining disabled after a stroke by almost 50%. 5
This disability takes many forms. When compared with non-AF patients, the presence of AF at the time of stroke has been found to:
- Increase significantly the loss of ability to perform normal daily activities,
- Decrease the level of consciousness,
- Increase the partial paralysis of the arm, hand and/or leg
Increase the difficulty in swallowing
This was found to be the case both immediately after the stroke and after rehabilitation. 72
Psychological impact on patients, family and carers
In addition to providing day-today practical care, the family also has to manage the emotional, mental and behavioural changes in the patient. These changes can be among the most difficult for family members to handle. They include mood swings, personality changes, irritability, anxiety, memory loss and depression. 56 58 Faced with such transformations, and the corresponding effort required to provide vital care, members of the family can experience a loss of independence, identity and social life. They also suffer extreme tiredness and depression. These carers also report fears regarding the safety of the patient and distress at not having time to attend to all of the patient’s needs. 56 58
High long-term demand on health and social services
The rehabilitation and long-term care of stroke survivors also place a significant demand on formal health and social services, often involving community nursing, social care, physiotherapy as well as speech and occupational therapy. 56 59 Research indicates that AF increases the requirement and costs for the provision of this formal care compared to non-AF stroke patients. 72
Increased hospitalisation, cost and recurrence with AF-related stroke
AF has been found to be associated with a 20% increase in the length of hospital stay and a 40% decrease in the likelihood of patients returning home compared to the absence of AF in surviving stroke patients. 72
As described in Chapter three, almost all AF-related strokes are cardioembolic; where the clot forms in the chambers of the heart from where it travels downstream in the blood to the vessels of the brain. Compelling research has shown that those who suffer cardioembolic strokes have a poorer clinical condition on admission to hospital, experience a longer stay and endure a worse recovery following discharge than those with non-cardioembolic stroke. 106 The same study also found that costs were higher. The average cost per patient of initial hospital care for cardioembolic stroke was €4,890 per patient, compared with €3,550 for non-cardioembolic stroke, representing an increase of almost 40%. 106
In addition to being more severe, cardioembolic strokes are associated with a higher risk of recurrence than other types of stroke. 60 The increased severity and risk of recurrence of strokes in patients with AF compared with other strokes suggests that these patients will experience a greater impairment in quality of life than patients without AF.
Case study: a carer’s perspective
“For the past 9 months my sister and I have been acting as full- time carers to our mother, who is bedridden following a stroke. She is unable to do anything for herself and needs 24-hour care in her own home, where she feels comfortable and safe. We have had to leave our husbands and our own homes to give mother our full support.
Full-time carers can lose their sense of identity and independence as their social life is curtailed. I am also concerned for my husband’s welfare.”
Case study: a child’s perspective
“The first time I saw Daddy again, he was sitting in a wheelchair tied on with a sheet so that he would not fall. His mouth was drooping and he was making funny noises which we could not understand. I was scared of him, I didn’t want to see him any more. I was ashamed of him... he does not remember much about it. He doesn’t look like Daddy any more.”
High economic cost
As explored in chapter two, strokes are extremely expensive, each one costing the NHS between £9,500 and £14,000. AF stokes are more severe 72 and consequently can be expected to account for a greater proportion of the more expensive strokes. This impact of AF becomes of considerable importance when considering that the cost of stroke to the UK economy has been estimated to be £2.4 billion, 61 and the cost of stroke to Europe is likely to be over €38 billion. 57
AF-related strokes cost more
In a clinical study that investigated the cost of different severities of stroke, it was found that the average cost of a severe stroke was more than three times higher than the average cost for a mild stroke. 48
There is also direct evidence for the increased cost of stroke in patients with AF. In one study, the average direct costs of stroke per patient were found to be over a third higher in patients with AF than in patients without AF. 62 The effect of AF on stroke-related inpatient costs was also recently analysed. The inpatient costs over just a three-month period were on average 8% higher for each patient with AF compared to patients without AF 196. As AF is estimated to be responsible for approximately between 15-20% of all strokes, 63 the increased cost of AF-related strokes compared with other strokes represents a significant economic burden.
Direct costs of AF to NHS are huge
All the above studies were focused on the economic burden of AF associated only with the elevated risk and severity of strokes. A study from the Office of Health Economics published in 2009 deliberately set out to evaluate the direct costs to the NHS of all AF. The study investigated the costs of AF alone, as well as the costs of secondary problems such as AF-related stroke and AF-related heart failure.
For 2008, it was calculated that AF accounted for 5.7 million days in hospital beds and a total direct cost to the NHS of £2.2 billion 61. AF patient days spent in hospital beds cost the NHS over £1.8 billion. Non-bed in-patient costs were £124 million and outpatient costs completed the total at £205 million.
Together with loss of time in employment and contribution to the community of the patient, and most probably also to those providing informal care, this amounts to a significant burden on society and on thousands of individuals.
Strong rationale for stroke prevention in patients with atrial fibrillation
In conclusion, patients with AF have a higher risk of stroke and suffer from more severe strokes than patients without AF. Thus, AF-related stroke imposes an even greater burden on individuals, carers, families, society and healthcare resources than stroke in patients without AF, providing a strong rationale for effective management of AF and prevention of stroke in this high-risk population.