Malaysian Stroke Patients Bear Most Long-Term Care, Disability Costs: Galen

55% of post-stroke survivors require partial or complete dependence on a caregiver; 35% regain full independence post-stroke treatment – Galen Centre’s White Paper on stroke.

KUALA LUMPUR, Dec 2 – Stroke management is estimated to cost Malaysia over one-fifth of a billion ringgit annually, or RM213 million, based on an expected 40,000 stroke admissions per year.

According to the Galen Centre for Health and Social Policy’s recently published White Paper on stroke titled “Advancing and Optimising Acute Stroke Care in Malaysia”, the projected lifetime economic burden for stroke patients diagnosed in Malaysia in 2016 was about US$1.36 billion (RM6.23 billion). 

The estimated lifetime treatment cost for each ischemic and hemorrhagic stroke patient was RM36,400 (USD$8,607) and RM37,757 (USD$8,928), respectively.

Stroke has been among the top five principal causes of hospitalisation in Malaysia from 2012 to 2019. The medical condition occurs when there is a blocked artery leading to reduced blood flow and oxygen supply to the brain (ischaemic stroke) or burst blood vessel (haemorrhagic stroke).

The Galen Centre pointed out that much of existing cost data for stroke care in Malaysia referred specifically to direct medical expenditure. 

The health think tank, citing a 2015 study published in the Singapore Medical Journal on the cost of post-stroke outpatient care in Malaysia, noted that stroke patients and their families tend to bear most of the costs related to disability and long-term care (including rehabilitation and nursing care), logistics (for example, mileage and parking), meals, and health aids and equipment, following hospital discharge for their acute condition.

“In one case, travelling to the hospital for therapy and consultations was found to form the bulk of crippling costs borne by the individual and their family.”

The 2015 research, as cited by the Galen Centre, highlighted that stroke severity influenced the cost of outpatient care in Malaysia following a stroke.

Patients who experienced more severe strokes required more medical support and nursing assistance, attended outpatient therapy more frequently, and were more likely to seek alternative therapies. 

They spent approximately 60 per cent of their total expenses on attendant care and medical equipment purchases. 

Only 14 per cent of the total cost was for medical expenses, including consultation, medication, and rehabilitation. This was largely due to heavily subsidised medical services of up to 98 per cent in public hospitals in Malaysia.

The Galen Centre noted that post-stroke survivors are often burdened with multiple underlying health conditions, citing the National Stroke Registry that found more than half of patients (55 per cent) required partial or complete dependence on a caregiver. Just over a third, or 35 per cent, regained full independence post-stroke treatment.

Four In Ten Stroke Patients In Malaysia Aged Under 60

The Galen Centre’s White Paper on stroke highlighted an “escalating” incidence of stroke cases in Malaysia, citing estimates that there are more than 40,000 strokes in the country every year, causing at least 11,680 lives lost, or 10.7 per cent of total deaths.

Disturbingly, 40 per cent of stroke patients in Malaysia are aged below 60 years, the Galen Centre found. “Young” stroke, or stroke that afflicts those between 19 and 50 years old, comprised 16 per cent of hospitalised patients. 

Estimates by the Institute for Health Metrics and Evaluation showed that stroke represents the third leading cause of mortality in Malaysia.

The Global Burden of Disease Report 2016 projected that stroke would become the second leading cause of mortality in Malaysia, with one in four Malaysians expected to suffer from it, by 2040.

Combined with analysis from the “Monitoring Stroke Burden in Malaysia” project, the latest edition of the registry (2009-2016) found that on average, 92 stroke admissions occurred daily across health care facilities nationwide, said the Galen Centre.

More than half of stroke patients in Malaysia are male. Almost 32 people die due to stroke daily. In one case, 23 per cent of hospitalisation cases were patients with a history of recurrent stroke, said the Galen Centre.

Ischaemic stroke incidence in Malaysia has increased annually by 29.5 per cent and haemorrhagic stroke by 18.7 per cent. The number of stroke incidences continues to increase, as can be observed by a three-fold increment trend from the year 2010 to 2014.

“With increasing numbers of stroke patients, especially those needing hospitalised care, the cost of stroke management is most likely to rise,” said the Galen Centre.

According to the think tank, the major risk factor for stroke in Malaysia is hypertension at 70 per cent, followed by diabetes (41 per cent) and high cholesterol (24 per cent), similar to Singapore, Thailand, Indonesia, and India.

Patients with atrial fibrillation were found to suffer from severe stroke, increased complications, poor functional outcomes, and higher mortality, said the Galen Centre. Atrial fibrillation occurs when the heart’s upper chambers (atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions. This reduces the heart’s efficiency and performance. 

Major Improvements Needed In Care Pathways For Stroke Management

The Galen Centre suggested several measures to improve care pathways for stroke management, such as increasing patient education to improve identification of stroke by relatives and family members; early accurate diagnosis and timely treatment after prompt referral to an appropriate medical facility; and increasing the availability of and improving existing rehabilitation services.

The think tank called for an increase in the number of neurologists and multidisciplinary health care professionals who can treat stroke and administer thrombolysis needs. Thrombolysis, or thrombolytic therapy, works by dissolving dangerous clots in blood vessels, improving blood flow, and preventing damage to tissues and organs.

Stroke services in Malaysia, the Galen Centre noted, currently suffer from both a limited number of interventional radiologists as well as related radiology facilities. This poses significant barriers to being able to offer thrombectomies as the treatment of first choice, particularly in government hospitals. 

Thrombectomy is a surgery to remove a blood clot from inside an artery or vein.

The Galen Centre said neuro-interventionalist training programmes should be conducted to increase the number of specialists readily available for care of hyperacute patients.

Thirdly, the think tank called for increased availability of thrombolytic therapy, noting that this is only provided 24/7 in 10 public hospitals across the country. 

“As ‘time is brain’, this availability must be extended to other health facilities to ensure that efficacious treatments provided early in the chain of care are able to minimise disability and avoid future suffering, as well as reducing the economic costs in societies with higher ageing populations. It is also preferable that such services are provided through 24-hour, 7 days’ a week stroke care service,” said the Galen Centre.

“New initiatives such as the RESQ (Regional Emergency Stroke Quick Response Unit) further strengthen the availability of such services, but remain limited in geographical coverage.”

Currently, the RESQ is available at 28 hospitals in Malaysia.

Acute stroke care should be decentralised, as the Galen Centre called for at least one “stroke ready” hospital per state that provides 24-hour, 7 days’ a week service through an acute stroke unit (ASU). 

“District hospitals are frequently unutilised and could be used to deliver appropriate stroke care during the early critical period,” said the Galen Centre.

ASUs, with trained clinical personnel and updated treatment such as endovascular treatment (EVT)/ intravenous thrombolysis (IVT), and reperfusion therapy have improved the clinical outcome of stroke patients over the past few years. 

The Galen Centre said each hospital should have a stroke care team to better triage acute stroke patients at emergency medicine departments, allowing for more effective early intervention in acute ischaemic stroke cases, as well as timely decisions of appropriate options where possible.

“The Sarawak General Hospital’s piloting of its acute stroke unit demonstrated the benefits of having such a facility with clear, measurable and improved outcomes.”

The Galen Centre urged the government to redesign stroke care delivery in remote areas, highlighting the lack of designated stroke beds and the absence of stroke care units to provide IV thrombolysis and thrombectomy. 

In addition, the think tank said adequate rehabilitation centres should be provided for post-stroke care.

“As more people survive stroke, there is a greater focus on this part of the care pathway, as part of strategies to improve quality of life, and reduce ill health. People should be able to return to their homes and even work if they wish to do so.”

In conclusion, the Galen Centre noted that although acute stroke care in Malaysia has seen improvements and developments in recent years, the challenge remains in being able to provide high quality and effective treatment utilising existing resources via a patient-centred approach.

“Addressing the gap in the provision of acute stroke services, particularly ensuring that efficacious treatment is available and provided during the critical first 4.5 hours, will save lives, improve outcomes, and reduce the overall cost of stroke, both to society and to the economy,” said the Galen Centre.

“Malaysia has within its means and the opportunity to transform people’s outcomes and experiences of stroke. Better survival outcomes for stroke patients are possible.”

SC-MY-02518, Dec 2022

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