ARTICLE IN PRESS

The Cost-Effectiveness of a Stroke Unit in Providing Enhanced

Patient Outcomes in an Australian Teaching Hospital

Shaun Zhai, MBChB,* Fergus Gardiner, BMSc, MBA, PhD(c),†,‡ Teresa Neeman, PhD,§
Brett Jones, BN,‖ and Yash Gawarikar, MBBS, MD†,§

Background: Stroke is one of the leading causes of disability and mortality.

Patients who receive organized inpatient care in a stroke unit (SU) have better
clinical outcomes. However, evidence on the cost analysis of an SU is lacking.
The objective of this study was to assess the performance and analyze the
cost-effectiveness of an SU. Methods: A retrospective observational study was
conducted comparing the acute stroke patient care in a 6-month period before
and after the establishment of an acute SU at Calvary Hospital in 2013-2014. Results:
There were 103 patients included in the pre-SU period, as compared to 186
patients in the post-SU period. In the pre- and post-SU groups, 54 and 87
patients, respectively, had ischemic stroke, with significant trends in improved
morbidity and mortality in the post-SU group (P = .01). The average length of
stay (LOS) for patients was reduced from 9.7 days to 4.6 days in the post-SU
group (P = .001). There was a reduction of cost per admission from $6382
Australian dollars (AUD) with conventional ward care as compared to $6061
(AUD) with SU care. Conclusion: This study confirmed that the establishment of
an SU not only improves treatment outcomes but also shortens LOS, thereby achiev-
ing cost-effectiveness. Key Words: Stroke—stroke unit—length of stay—cost-
effectiveness—stroke management—Australia.
© 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Introduction The financial cost of stroke is substantial and amounts

Stroke is a common and a potentially debilitating con-
dition. It is the second leading cause of mortality and
the third leading cause of morbidity.1,2 One in six people
will have a stroke during their lifetime.3 In Australia, cur-
rently, there are around 470,000 people living with this
condition; this is projected to reach 709,000 people in 2032.4
From the *St Vincent’s Hospital, Sydney, Australia; †Calvary Hos-
pital, Bruce, Canberra, Australia; ‡Charles Sturt University, Bathurst,
Australia; §Australian National University, Canberra, Australia; and
‖The Canberra Hospital, Canberra, Australia.
Received March 29, 2017; revision received May 8, 2017; accepted
May 17, 2017.
Address correspondence to: Fergus Gardiner, BMS, MBA, PhD(c),
Calvary Hospital, Bruce, Canberra, Australia. E-mail: gus_gardiner@
hotmail.com.
1052-3057/$ - see front matter
© 2017 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.05.025
to $5 billion (AUD) per annum in Australia.5
Stroke unit (SU), which is an organized inpatient service
for stroke patients provided by a multidisciplinary team
specializing in stroke management, has become an im-
portant part of stroke care.6 From its inception approximately
4 decades ago,7 there have been increasing evidence to
suggest the efficacy of SU in reducing mortality and mor-
bidity in acute stroke patients by about 20%.8-10 Acute SUs
are generally considered more costly than conventional
care in a general hospital ward.11 However, there is limited
literature associated with reviewing the financial costs of
an SU compared with conventional hospital care.
This study was designed to measure patient out-
comes before and after the SU implementation at an
Australian teaching hospital. This included demograph-
ic information, medical investigations, treatments, patient
outcomes, and health economics. To the researchers’ knowl-
edge, this research focus has not been completed before.
This study has been designed to corroborate previous
research findings to show that SUs improve patient

Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2017: pp ■■–■■ 1
 ARTICLE IN PRESS
2 S. ZHAI ET AL.
outcomes, and, more importantly, to concurrently analyze
the financial cost of the operation of an SU in real life,
thereby assessing its cost-effectiveness. It was hypoth-
esized that the SU will provide a cost-effective improvement
in patient outcomes. It was hoped that this study may
provide further justification on the implementation of SUs
in the Australian health system.
Methods
The researchers conducted an observational study,
comparing stroke patients who have been admitted to
Calvary Public Hospital, Canberra, before and after the
establishment of the local SU from October 2013 to October
2014 (52 weeks). The hospital ethics committee approv-
al was received for data collection, analysis, and publication
(reference number 24-2014).
The pre-SU patients were identified retrospectively
by matching International Classification of Diseases-10
(ICD-10) codes for cerebrovascular diseases (ICD-10:
I60-I69). On reviewing physical and electronic clinical
records, patient files were retrieved and their diagnoses
reviewed. Specifically, investigators evaluated all pre-
and post-SU clinical notes to ensure the accuracy of the
diagnosis. The investigators adjudicated cases where the
ICD-10 coding was incorrect based on clinical documen-
tation, imaging, and other investigation findings. The
disease characteristics, investigations, treatment, and
outcomes were recorded. The data of the post-SU pa-
tients were collected prospectively by the stroke neurologists
and stroke nurse specialist.
Study Population
The SU is on a dedicated ward in the hospital and has
4 beds equipped with continuous cardiac monitoring.
There is a computed tomography (CT) scanner and a
magnetic resonance imaging (MRI) scanner on site for
neuroimaging support. The SU is staffed by a stroke neu-
rologist, a stroke nurse specialist, and specially trained
nurses. The SU also receives input from the allied health
team for speech therapy, dietary therapy, occupational
therapy, and physiotherapy. The SU was established on
April 28, 2014; therefore patients presented to Calvary
Hospital in the 6-month period between October 28, 2013
and April 27, 2014 were referred to as the pre-SU group,
whereas for the 6 months between April 28, 2014 and
October 27, 2014, it was referred to as the post-SU group.
In the post-SU period, all stroke patients were admitted
to the SU in the first instance. Once stabilized the patient
could be discharged directly from the SU or stepped down
to a conventional ward. The stroke service provided the
entire acute care.
In the pre-SU period, stroke patients were treated by
various general physicians (internists). These physicians
often had various specialty interests (but not neurology).
Under these physicians, there was a registrar and a resident
or intern doctor. The neurologist may have been con-
sulted for the patient’s care during the admission; however,
this practice was highly variable. A general ward phys-
iotherapist, occupational therapist, or a speech therapist
was involved in the patient care, upon referral from the
treating team.
Patients were eligible for inclusion in the study if they
had any type of stroke, including hemorrhagic or isch-
emic, as well as transient ischemic attacks (TIAs) (defined
as <24 hours neurologic deficit caused by a focal lesion
in areas including the brain, the retina, and the spine).
In the post-SU phase, as data were prospectively re-
corded, any presentation that resembled a stroke with
subsequent admission to the SU was included. For some
of the stroke-like presentations, an alternative diagnosis
than stroke was identified eventually. These were clas-
sified as stroke-mimics and were included in the analysis.
If the patient was transferred to another facility after pre-
senting briefly to Calvary Hospital (i.e., less than 24 hours)
and was not admitted to the local SU, they were ex-
cluded from the study. Patients who were transferred to
Calvary Hospital from another health institution for re-
habilitation or placement purposes after a stroke were
also excluded.
Study Endpoints
The primary endpoint for the study was to compare
the modified Rankin Scale (mRS) at 90 days after the stroke
in pre- and post-SU patients. Patients were identified ret-
rospectively by ICD-10 code, and as such, the 90-day mRS
outcomes were obtained via the following measures:
• Neurology/stroke follow-up clinic at 90 days;
• If patients were inpatients at day 90 either for the
same admission, for rehabilitation purposes, or for
readmission purposes, their mRS scores were evalu-
ated based on clinical notes;
• If patients had died within a 90-day period;
• If patients came for a clinic appointment and the
clinical documentation was adequate for an mRS
evaluation;
• Delayed follow-up visits, with patient recollection
of their neurologic status at the 90-day mark after
a stroke.
The main secondary endpoint was to compare the
length of stay (LOS) and the in-hospital cost of each stroke
patient during the pre- and post-SU periods. Other sec-
ondary endpoints included the timeliness and completeness
of investigations, adherence to best medical therapy,
thrombolysis rates, and allied health involvement. Out-
comes at discharge from the stroke service (stroke service
is different from SU, it includes whole period patient in
hospital for SU and subsequent conventional ward care)
and nosocomial infections were also analyzed. The dis-
charge destination involved the patient’s transfer location
upon departure from the stroke service. In regard to the
 ARTICLE IN PRESS
COST-EFFECTIVENESS OF A STROKE UNIT 3
pre-SU patients, the physical discharge of the patients Table 1. Baseline age characteristics of all patients under
from their treating team was regarded as the equivalent stroke service (stroke-mimic patients included)
data point.
Nosocomial infections were grouped into 3 categories: Pre-SU Post-SU (n = 186)
pneumonia, urinary tract infections (UTIs), and others. (n = 103) (all types)
Others often included cannula-associated infections,
Mean (SD) 75.5 (12.8) 68.3 (15.7)
cellulitis, etc. All infective events were reviewed and ad- Median 77 70
judicated by the investigator. If the patient had a new Min 31 18
lung infiltrate plus clinical evidence that the infiltrate is Max 98 95
of an infectious origin, which fulfills at least 2 of the 4 IQR 25/75 69/84 57/80
criteria, including the new onset of fever, purulent sputum,
leukocytosis, and decline in oxygenation, then a diag- Abbreviations: IQR, interquartile range; Max, maximum; Min,
nosis of pneumonia was made. If the clinical criteria were minimum; SD, standard deviation; SU, stroke unit.
not fully met, then the diagnosis was at the discretion
of the treating physician.12 For the diagnosis of a UTI, Table 2. Baseline age characteristics of ischemic stroke
the patient had to have a positive urinalysis or a urine patients only
culture, with the presence of symptoms.13 If the treating
physician initiated a course of antibiotic treatment based Pre-SU (n = 54) Post-SU (n = 87)
on clinical evidence or suspicion, which did not fulfill (ischemic stroke) (ischemic stroke)
the above criteria, then these events were grouped as
“others” in the nosocomial infection analysis. Mean (SD) 75.5 (10.9) 72.3 (15.7)
Median 76 75
Statistical Analysis Min 45 24
Max 98 95
EPI Info 7.0 software (Centers for Disease Control and IQR 25/75 68/84 64/84
Prevention, Atlanta, GA) was used for the data acquisi-
tion of all patients in the study. Prespecified characteristics Abbreviations: IQR, interquartile range; Max, maximum; Min,
minimum; SD, standard deviation; SU, stroke unit.
of each patient were recorded in our Stroke Study da-
tabase. Ordinal regression was used to compare mRS
outcomes in ischemic stroke patients between the 2 periods.
Average hospital length of stay between the 2 periods 76 and 75, respectively; interquartile range (IQR 25/75)
was compared using a linear model, adjusting for type. was 68/84 and 64/84. Of the pre-SU patients, 56.3% were
Subgroup analyses by type were performed post hoc. In- male, compared to 56.6% in the post-SU group.
vestigation rates, treatments, infection rates, and destination As shown in Table 3, in the pre-SU group, types of
following hospital discharge were compared between events were divided into TIA 38.8%, ischemic stroke
periods using Pearson chi-squared tests. SPSS version 23.0 52.4%, hemorrhagic stroke 6.8%, and stroke mimic 1%.
software (IBM SPSS Statistics for Windows, IBM Corp., In the post-SU phase, the types of events were TIA
Armonk, NY) was for all statistical modeling. Observed 28.0%, ischemic stroke 46.8%, hemorrhagic stroke 2.7%,
difference were considered significant if P < .05. and stroke mimic 22.0%.

Results
There were 112 patients identified in the pre-SU period, Table 3. Percentage and frequency of types of events for all
and subsequently 9 were excluded. In the post-SU period, patients under stroke service before and after the stroke
197 patients were recorded and 11 were excluded. The unit establishment
majority (90%) of excluded cases were transfers from
another facility for rehabilitation or placement pur- Post-SU
poses. The remaining exclusions included missing data Pre-SU (n = 186)
(N = 1) and duplicated record (N = 1). There were 103 (n = 103) (all types)
patients included in the pre-SU group compared to 186 % (number) % (number)
in the post-SU group. The mean age (and the standard
Type of TIA 38.8 (40) 28.0 (52)
deviation) was 75.5 (12.8) in pre-SU patients and 68.3 (15.7)
events Ischemic stroke 52.4 (54) 46.8 (87)
in the post-SU group (Table 1). In the pre- and post-SU
Hemorrhagic stroke 6.8 (7) 2.7 (5)
groups, 54 and 87 patients had ischemic stroke, respec- Stroke mimic 1.0 (1) 22.0 (41)
tively. When comparing ischemic stroke patients only, the Undetermined 1.0 (1) .5 (1)
mean age was 75.5 in the pre-SU group and 72.3 in the
post-SU group, as shown in Table 2. The median age was Abbreviations: SU, stroke unit; TIA, transient ischemic attack.
 ARTICLE IN PRESS
4 S. ZHAI ET AL.

Figure 1. Modified Rankin Scale at 90 days of pre- and post-SU ischemic stroke patients.

Study Outcomes days in the SU, and a further 1.9 days on the conven-
tional ward. The total cost per stroke patient amounted
The ordinal analysis of the functional status of stroke
to $6061 (AUD) for the post-SU period. This is in com-
patients, in terms of mRS, at 90 days, demonstrated a
parison to the total amount of $6382 (AUD) for the cost
significant trend favoring a better outcome in the post-
per stroke patient with conventional medical ward care
SU period (P = .01) (Fig 1). Ninety days after initial stoke,
considering the average LOS of 9.7 days (Table 5).
70% of all patients were followed-up to determine their
Other secondary endpoint measurement can be divided
functional status and mortality data. There were no sig-
into 3 categories: investigations, therapeutics, and imme-
nificant differences between the follow-up rate between
diate outcomes. There were significantly more MRI
the pre- and post-SU groups.
and CT angiogram scans of the brain carried out in the
There was a significant improvement in the LOS of
post-SU group; 74.7% versus 48.5% for the former (P < .001)
stroke patients from 9.7 days in the pre-SU group com-
and 71.5% versus 4.9% for the latter (P < .001) (Table 6).
pared with 4.6 days in the post-SU group (P = .001). During
There was a nonsignificant reduction in CT head acqui-
the post-SU phase, stroke patients spent on average 2.7
sition in the same period. The door to CT acquisition time
days in the SU (median 2, range 1-13, standard devia-
(from the patient presenting to the emergency depart-
tion 2.4). Subgroup analysis of the LOS data showed that
ment doorstep to obtaining a CT scan) had been reduced
the improvement was predominant in TIA (3.8 days
from 135 to 89 minutes (P = .004). When comparing the
pre-SU and days 1.7 post-SU, P = .16) and ischemic stroke
completion rate of secondary preventative investigations,
patients (13.8 days pre-SU and 5.9 days post-SU, P < .001)
there was a significant improvement in multiple areas. These
(Table 4). The average cost of patient care on a normal
included the increased carotid imaging from 75.7% to 89.3%
medical ward amounted to approximately $660 (AUD)
(P = .007), cardiac monitoring from 43.7% to 100% (P < .001),
per patient day, whereas the cost averaged $1317 (AUD)
per day on the SU mainly due to higher staffing ratio
and resource distribution. Despite the significantly higher Table 5. Breakdown of total cost per patient admission with
cost of care in the SU, the duration of stroke patients’ conventional ward care versus stroke unit care
admission was substantially shorter—an average of 2.7
Conventional Stroke
ward care unit care
Table 4. Average length of stay (LOS) for pre- and $ (AUD) $ (AUD)
post-SU patients
Nursing $1611.5 $1824.9
Days—mean (SE) Pre-SU Post-SU P value Medical staff $808.7 $895.5
Allied health $721.6 $601.8
TIA 3.8 (.93) 1.7 (.13) .18 Imaging $737.6 $1041.5
Ischemic stroke 13.8 (2.24) 5.9 (.57) <.001 Pathology $978.9 $366.2
Hemorrhagic stroke 11.7 (4.89) 13.2 (5.76) 1.0 Pharmacy $386.5 $531.1
Stroke mimic 2.4 (.55) Miscellaneous $1137.5 $799.7
All strokes 9.7 (1.35) 4.6 (.37) .001 Total cost per admission $6382 $6061
Cost per admission day $660 $1317
Abbreviations: SE, standard error; SU, stroke unit; TIA, transient
ischemic attack. Abbreviation: AUD, Australian dollar.
 ARTICLE IN PRESS
COST-EFFECTIVENESS OF A STROKE UNIT 5
Table 6. Completion rate and timeliness of CT and MRI Table 8. Treatment (pharmacologic and nonpharmacologic)
imaging for all strokes/TIAs for ischemic stroke patients

Pre-SU (%) Post-SU (%) Pre-SU (%) Post-SU (%)

(n = 101) (n = 144) P value (n = 54) (n = 87) P value

CT head 99.0 96.8 .43 Pharmacologic

Door to CT 134.9 (IQR 89.0 (IQR .004 Thrombolysis 3.7 12.6 .13
time (min) 57-162) 39-123) Antiplatelet 62.8 66.9 .58
MRI head 48.5 74.7 <.001 Anticoagulation 24.5 21.6 .55
CT angiogram 4.9 71.5 <.001 NOAC 65.6 78.4
(proportion of all
Abbreviations: CT, computed tomography; IQR, interquartile range; anticoagulant use)
MRI, magnetic resonance imaging; SU, stroke unit; TIAs, transient Antihypertensive 66.3 77.1 .08
ischemic attacks. Statin 64.9 82.0 .003
Nonpharmacologic
Speech pathologist 39.2 87.0 <.001
fasting glucose and lipid profile (pathology testing was Physiotherapist 35.3 53.9 .04
processed at the hospital’s accredited laboratory: ACT Pa- Occupational 15.4 38.9 .004
thology) from 39.8% to 94.1% (P < .001) (Table 7). therapist
The pharmacologic treatment involved thrombolysis in
the hyperacute phase and secondary prevention in the Abbreviations: NOAC, new oral anticoagulant; SU, stroke unit.
longer term. More post-SU patients received thromboly-
sis although the trend was not significant, (12.6% versus
Table 9. Discharge destinations for stroke patients
3.7%; P = .13). As demonstrated in Table 8, statins were
significantly more likely to be prescribed in the post-SU, Pre-SU (%) Post-SU (%)
whereas there was trend to suggest higher likelihood of (n = 61) (n = 92)
treatment with antiplatelet or antihypertensive agent.
However, the proportion of long-term anticoagulant Deceased 15.0 9.8
use was unchanged in the 2 groups. Allied health input, High-level nursing home 10.0 0
including the involvement of speech pathologist, phys- Low-level nursing home 1.7 0
Hospital transfer 11.7 16.3
iotherapist, and occupational therapist was universally
Inpatient rehabilitation 18.3 25.0
improved in the post-SU as well among established strokes,
Outpatient rehabilitation 0 1.1
including ischemic and hemorrhagic types. Home with support 10.0 6.5
At the time of hospital discharge, as shown in Table 9, Home without support 33.3 41.3
of all the established stroke patients, pre-SU death rate
was 15.0%, high level nursing home 10.0%, low level Abbreviation: SU, stroke unit.
nursing home 1.7%, home with support 10.0%, home
without support 33.3%, hospital transfer 11.7%, inpa-
tient rehabilitation 18.3%. In the post-SU group, death and higher function upon discharge in the post-SU phase.
was 9.8%, home with support 6.5%, home without support Nosocomial infections were less frequent in the post-SU
41.3%, hospital transfer 16.3%, and inpatient rehabilita- period, 9.2% versus 23.8% (P = .03) (Table 10). Subgroup
tion 25.0%. There was a trend toward lower mortality analysis revealed that pneumonia from all causes
(including aspiration) was less common in the post-SU
patients, 2.2% compared to 11.5% (P = .03).
Table 7. Completeness of secondary preventative
investigations for ischemic stroke/TIA patients

Pre-SU (%) Post-SU (%) Table 10. Nosocomial infection rates for stroke patients
(n = 94) (n = 139) P value
Pre-SU Post-SU
Carotid imaging 75.7 89.3 .004 (%) (%) P value
Cardiac monitoring 43.7 100 <.001
Fasting blood sugar 39.8 94.1 <.001 Nosocomial infection 23.8 9.2 .03
and lipids Pneumonia 11.5 2.2 .03
Transthoracic 65.1 64.0 .9 (including aspiration)
echocardiogram UTI 4.9 6.5 .9

Abbreviations: SU, stroke unit; TIA, transient ischemic attack. Abbreviations: SU, stroke unit; UTI, urinary tract infection.
 ARTICLE IN PRESS
6 S. ZHAI ET AL.

Discussion providing cost-effective care for more stroke patients. This

may have wider implications in the Organization for Eco-
Our study has demonstrated that by adopting an SU
nomic Co-operation and Development countries where
model of care, mortality and morbidity can be signifi-
there are many similarities in the economic and social
cantly improved for patients at 90 days. These findings
indexes shared with Australia.
are consistent with current literature in stroke care.10 In
In this study, there were significantly more stroke (and
our study, there had been a notable improvement in the
stroke-like) presentations in the post-SU phase, even after
key performance indicators of stroke care, including the
discounting stroke-mimic cases which accounted for ap-
timeliness in the acquisition of CT imaging, as well as
proximately one fifth of the post-SU cohort. The increase
the completion rate of CT angiogram and MRI of the head.
in number can be predominantly attributed to an in-
There was an increased adherence to the investigations
crease in ischemic stroke patient load, as there were 88
and treatment for secondary prevention recommended
post-SU patients as opposed to 54 pre-SU ones. Due to
by the Australian National Stroke Foundation.14
the establishment of the SU, there were more interhospital
The main significance of this study was the appraisal
transfers in the post-SU phase (a net increase of 19 pa-
of the cost-effectiveness of an SU. Due to the special-
tients). Another reason could be the increased recognition
ized organization of an SU and the staffing of dedicated
of milder ischemic strokes due to the increased use of
health professionals, the expectation is that an SU would
MRI investigations. Some of these patients would oth-
be more costly to run than a general ward model.11 The
erwise be diagnosed as TIAs without neuroimaging. The
average cost of a patient cared for in our SU was $1317
increase in stroke diagnosis corresponded to a small drop
(AUD) per day, compared to $660 (AUD) on a conven-
in percentage of TIA diagnosis in the post-SU period. The
tional medical ward. However, by having a specialized
“upstaging” of diagnosis may have clinical implications
unit, we were able to demonstrate that the LOS can be
that are beyond the scope of this study, and this may
substantially reduced. In the post-SU phase, stroke pa-
warrant further research.
tients on average spent 2.7 days on the SU, and then
The main limitation of this study is due to its design
another 1.9 days on a general medical ward. This is com-
being an observational study. Biases, including recall bias,
parable to the median LOS of 5 days for stroke patients
may be introduced in data acquisition. All electronic and
in the Australian National Stroke Audit.15 The combined
physical notes were processed by the main author and
LOS had been reduced, resulting in significant cost saving.
the stroke nurse specialist to minimize interobserver varia-
Additionally, there were several other areas of stroke care
tions and ascertainment biases. Due to the nature of the
that were contributory toward improvement in the uti-
study, a significant number of patients could not be located
lization of resources. By carrying out CT angiogram of
or followed up after their hospital discharge. At 90 days
the cerebral and neck blood vessels at the outset along-
after the initial stroke, only 70% of all patients could be
side CT imaging of the brain, a significant number of
followed up for their functional status and mortality
carotid ultrasound scans were avoided. Similarly, Holter
data. However, there were no significant differences
monitoring was much less frequently requested due to
between the follow-up rate between the pre- and post-
the concurrent telemetric cardiac monitoring in the stroke
SU groups.
unit. Despite the higher average stroke unit cost per day
from a more sophisticated care pathway, due to the im-
Acknowledgments: We would like to thank the employees
proved efficiency and efficacy, overall the inpatient cost
and patients of the Calvary Public Hospital Bruce.
of a stroke patient care was comparable in the pre-SU
and post-SU periods.
As aforementioned, there is convincing evidence to References
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