The study we performed here allowed us to assess the direct cost associated with stroke management in the Neurology and Cardiology Departments of the Libreville University Hospital Center in Gabon. It provides new insights as of the direct costs of patient care from the government insurance perspective and for the years 2018 and 2019. Data collection was done by reviewing patient records in the aforementioned two departments. Thus, 313 complete patient records were screened in our study for the indicated period.
Our study indicated that the total cost of stroke management was 175,011,562 CFA francs (266.78 euros) with an average expense per patient that was found to be 559,142 CFA francs (852.35 euros). Out of this grand total amount of 175,011,562 CFA francs, the government medical insurance was responsible for paying 74,427,501 CFA francs (113,456.56 euros) to the hospital for qualified patients while the 25,896,661 CFA francs (39,476.62 euros) remaining balance was to be paid as copayment by patients. Insured patients paid on average 147,140FCFA (224.30 euros) per patients while uninsured patients paid on average 545,163 CFA francs (831.04 euros). On average, expenses incurred by uninsured patients are 3.7 times higher than expenses paid by government insure patients
As per analysis of patient records, we found that the actual occupancy of the hospital room and usage of utilities including electricity, generated the highest expense for case managements during hospitalization of stroke patients. On average, that expense per patient was 210,479 CAF francs (320.85euros). Hospitalization costs were immediately followed by imaging examinations with an average cost per patient of 207,169 CFA francs (315.81euros). The two billing items represented 37.6% and 37.10% of the total stroke management burden for our study period, respectively.
The high cost of hospitalizations could be explained by the length of patient stay in wards which was 10.52 days on average per patient. In the CHUL context, hospital costs took into account room and board. Thus, a long hospital stay was an important determinant of cost increase in stroke management. This result is consistent with those reported by several other independent authors and described in the literature [8,9,10].
In imaging examinations, CT scan ranks first with 41.06% of expenses. This could be explained by the systematic recommendation a CT scan as a routine procedure included in the diagnosis of strokes. As early as 1990, The Royal College of Physicians of London recommended a cerebral tomographic examination for all patients with sudden focal neurological deficit [11].
In laboratory testing, the blood electrolyte test represents 20.38% and HIV serology, 20.02% of the total expenses associated with to the costs of laboratory tests.
While insured patients paid out of pocket on average 147,140 CFA francs (224.30 euros), the government medical insurance paid to the hospital an average of 422,883FCFA (644.64 euros) per patient for the management of each insured stroke patient. On average per insured patient, imaging examinations costed 63,157 CFA francs (96.27 euros), followed by hospitalization fees with an average expenditure of 42,954 CFA francs (65.48 euros). The balance per patient due by the insurance for these two items were 152,915 CFA francs (233.10) and 171,818 CFA francs (261.92), respectively. The average hospitalization fees incurred by the insurance was higher than that of imaging examinations. This could be justified by the fact that some medical procedures such as MRIs, Angio MRIs and CT scans are only covered by insurance at 50% while hospitalizations are supported by the insurance at 80% of the total cost.
Comparing the costs of stroke management performed by other groups in other countries seems a challenging task because disparities are tremendous between countries as realities of these health systems are so different across countries. Many countries, especially those in Subsaharan Africa face multiple problems in their health system including the lack of technical and modern infrastructures and also the limited human resource specialized in the management of this pathology. Nevertheless, our study is consistent with other studies in that stroke management is shown to be very expensive for both patients who sometimes support the cost of their care alone, and for states through government funded health insurance. Studies on the direct costs of care for stroke patients give us an idea of the burden of this medical condition in both developing and developed countries.
The costs of stroke management, although clumped in one single treatment center, are comparable to those recorded in some African countries and those in Europe. A study conducted in Cameroon on 208 patients hospitalized for stroke with the diagnosis confirmed by CT scan, revealed an average cost per patient of 621,795 CFA francs (947.86) [12]. A one-year study for a sample of 78 patients in Benin showed an average cost per patient of 316,810 CFA francs (482.94 euros). This cost, while slightly below the cost we found in our study could be explained by the sample size and duration of the study. Indeed, our study included 4 times more patients than the study in Benin and covered a period of two years while the study in Benin cover only one year. Furthermore, in the same study performed in Benin, the highest expenditure item was attributed to paraclinical explorations (34.3% of the total expenditure) and ranked costs of hospitalizations in third place [13]. In our study however, hospitalizations show the generate the highest costs compared to all other aspects. The average length of hospital stay is clearly a factor associated with the increased cost of stroke management.
In Senegal, the study of Touré et al. revealed an overall cost of stroke management of 32,614,442 CFA francs (49,717.14 euros), for 383 patients hospitalized for stroke. The average cost per patient was shown to be 78,426 CFA francs (119.55 euros) [14]. This cost included salary and wages, which may explain the difference observed in our study that did not take into account that aspect. In our study, this burden was carried by government which is in charge of salary and wages across the country and it cannot be dissociated. The highest expenditure item in the Touré et al. study was hospitalizations, which accounted for 57.8% of total expenditure. This is in line with our study where we show that hospitalizations occupied 37.6% of the total expenses, making it the highest expense of all.
The cost of stroke is very high around the world. In many cases, in spite of the fact that medical insurance covers part of the cost, the remainder balance is sometimes much higher than the purchasing power of patients, making this condition extremely burdensome for many populations. In Gabon, that situation is even worst given the low purchasing power of average citizens and the extremely low salaries and wages Gabonese workers receive. For insured patients, the average copayment was 147,140 CFA francs (224.30 euros) while the minimum wage in the country is set at 150,000 CFA francs (228.65 euros). As consequence, there is almost no different between the economic burden incurred by insured patients and the minimum wage in Gabon. For the uninsured patient, the cost of stroke management is 3 times higher than the minimum wage. That observation echoes the assertion of Callixte Kuate-Tegueu et al., who found that the cost of stroke management in Cameroon is 17 times higher than the minimum wage in that country [12], making stroke management unbearable for uninsured families of stroke patients. In Benin, Thierry Adoukonou et al., reported in their study that the cost of stroke management was 1.03 times the gross domestic product (GDP) per inhabitant [13].