The Economic Impact of the Multifaceted Stroke 1-2-0 Educational Campaign in China

doi:10.21203/rs.3.rs-4912045/v1

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Research Article

The Economic Impact of the Multifaceted Stroke 1-2-0 Educational Campaign in China

https://doi.org/10.21203/rs.3.rs-4912045/v1

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Background

Stroke prehospital time is exceptionally long in China. The multifaceted Stroke 1-2-0 Amplifying Version Engagement (SAVE) intervention has substantially reduced onset-to-door time for patients with acute stroke in Shanghai, China. This study aimed to assess the implementation and downstream healthcare costs associated with the educational program.

Methods

Data were extracted anonymously from the hospital information systems for all ischemic stroke patients admitted to the hospital from 2016 to 2019. Cost data from different years were converted into 2019 Chinese Yuan (CNY) using a 5% discount rate. We used a multivariate generalized linear model (GLM) with log-link to examine the campaign's impact on LOS and costs.

Results

The SAVE intervention was estimated to cost CNY 1,768,067 for Xinzhuang County from October 2016 to December 2019. Most costs (59.64%) were for the mass media broadcast. 2830 stroke patients met the inclusion criteria, including 490 in the pre-campaign and 2,340 in the post-campaign period. Following the multifaceted SAVE intervention, the mean (SD) LOS decreased from 9.48 (3.80) days to 8.80 (3.55) days. The mean (SD) hospitalization costs per patient dropped from ¥21950.72 (10410.74) to ¥19262.50 (12772.81) CNY (P < .01). In the GLM model, the campaign was associated with reduced LOS (Table; β coefficient [95% CI]: -0.070 [-0.11 to -0.030]; P < 0.01) and hospitalization costs (β coefficient [95% CI]: -0.11 [-0.17 to -0.053]; P < 0.01).

Conclusions

Our findings suggest that the SAVE intervention generated economic savings through its effect on reducing LOS, which could be explained by improved intravenous thrombolytic therapy. Innovative ways of delivering educational materials, e.g., via digital health, will need to be explored by lowering costs for personnel and mass media.

Stroke remains a leading cause of death globally; it is also ranked as the number one cause of death and disability in some low- and middle-income countries (LMICs), particularly in China.¹ Stroke death and disability are attributable to two primary barriers: failure to identify and failure to rescue.² Reperfusion therapy by intravenous thrombolysis or endovascular mechanical thrombectomy improves the likelihood of disability-free recovery after acute ischemic stroke (AIS) but should be initiated within 6 hours of stroke onset.^{3,4 5} The use of reperfusion therapy remains very low (< 10%) in China, partly due to poor awareness and significant prehospital delay, many people are disabled or even die without receiving any time-sensitive reperfusion therapy.^6–8 Recent data indicated that the median stroke onset-to-door time was around 24 hours in China. Super long stroke onset-to-door delay should be considered a global crisis, especially in LMICs.⁸ Hence, reducing prehospital delay by improving layperson’s symptom recognition is urgently needed.^9,10 To improve stroke knowledge, the Stroke 1-2-0 tool was developed to help laypersons identify stroke warning signs, by adapting FAST to the local emergency phone number of 1-2-0 in China.¹¹

The community-based educational campaigns are an important strategy to promote stroke recognition tools and shorten the prehospital time in some high-income countries. Still, such programs are scarcely available in LMICs.¹² To promote the Stroke 1-2-0 tool, we designed a multilevel educational program entitled “Stroke 1-2-0 Amplifying Version Engagement (SAVE)”, which aims to encourage immediate action when any stroke symptoms occur and improve stroke outcomes in China.¹³ In the pilot study covering Xinzhuang County of Shanghai, the SAVE intervention demonstrated promising effectiveness in reducing prehospital time.¹⁴ However, limited data is available on the implementation costs and their downstream healthcare costs, further impedes the adoption of health educational programs.¹² Hence, this study aimed to fill gaps in the literature by comprehensively assessing the costs and resources needed to develop and execute the stroke educational program in China. This study also evaluated the economic impacts of SAVE intervention on healthcare utilization and costs.

Study design

The effects of the SAVE intervention, in terms of the 3-hour hospital arrival rate, have been published elsewhere.¹⁴ Following the previously published study,¹⁴ data were extracted anonymously from the hospital information systems for all ischemic stroke patients admitted to the hospital from January 1, 2016, to December 31, 2019.¹⁴ The SAVE intervention was implemented on October 1, 2016; the pre-campaign period was defined as January 2016 to September 2016 and the post-campaign period was from defined as November 2016 to December 2019. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cohort studies.¹⁵

Ethics approval

This study was reviewed and approved by the ethics committees of the Institutional Review Boards of Minhang Hospital of Fudan University.

Overview of Save Intervention

The SAVE intervention was introduced to Xinzhuang, Shanghai using a multifaceted outreach campaign implementation strategy, including broadcasting videos, printed materials, local news, and face-to-face community education, which has been reported elsewhere.¹⁴ In brief, the SAVE intervention included: (1) The television campaign ran through free media advertising on the local TV Channel. The one-minute animated video, which was endorsed by the Chinese Stroke Association (CSA),¹⁶ was broadcast six times per day. (2) The radio campaign ran through free radio advertising on the local station. The radio advertisement was broadcast six times per day. (3) The newspaper advertised the Stroke 1-2-0 pictures in the local newspaper. (4) The public poster campaign distributed 30,000 brochures to residents each year. (5) face-to-face education sessions were offered by primary physicians every week.

Sample selection

As described previously,¹⁴ AIS patients who met the following criteria were included in the analysis: 1) diagnosed with ischemic stroke, which was confirmed with computed tomography or magnetic resonance image; 2) hospital admission within two days of stroke onset; and 3) lived in Xinzhuang during the campaign. Patients were excluded if they 1) had stroke onset within hospitals; 2) had dementia or psychological disorders; 3) had missing data on demographics, NIHSS score, date and time of symptom onset, and length and cost of hospital stay.

Healthcare utilization and costs

The relative difference in length of stay (LOS) and costs for AIS patients admitted to the hospital in pre- and post-SAVE was used to determine the potential impacts of SAVE intervention on healthcare utilization and cost.¹⁷ The LOS and costs were estimated as the mean LOS and total hospitalization costs per admission due to AIS. We retrieved the sum of the costs for each AIS patient admitted to the hospital, including nursing, medical services, laboratory tests, and prescription drugs. Because the use of intravenous thrombolytic therapy was significantly improved following the SAVE intervention, the costs for intravenous thrombolytic therapy were not included in the analysis.

Cost of SAVE intervention

To measure the implementation cost of SAVE, we employed a micro-costing approach to quantify the resources needed to develop and implement the SAVE programs, following the recommendation for economic evaluations for implementation studies.^18–20 From the healthcare system's perspective, direct cost data were collected for October 2016-December 2019. We quantified the quantity and unit cost from logistical and expenditure reports, further clarified by discussions with project staff and physicians. Total intervention costs included personnel costs (e.g., salary, benefits), travel, materials (e.g., posters), facilities, and campaign costs (e.g., planning, designing and executing media). The advertising fees, whether donated or subsidized by local communities, were based on fair market value.

We used the average annual income in Shanghai for personnel costs, with an additional 40% fringe benefit rate. The annual income was obtained from the National Burau of Statistics.²¹ For in-person educational sessions, 50 volunteer physicians were recruited and provided in-person educational sessions. The travel and training time for providing in-person educational sessions were based on the average income for full-time equivalent (FTE) healthcare providers. We also recruited ten project staff to distribute posters, brochures, and management (e.g., scheduling educational sessions). We used the average salary for community workers for project staff. Travel costs were determined from staff time and transportation modes.

Statistical analysis

Continuous variables are presented with mean and standard deviation (SD) and compared with student t-tests. Categorical variables are reported with frequencies and percentages and compared with chi-square tests. We also compared the length and hospital stay costs before and after the SAVE intervention. We employed a generalized linear model with a gamma distribution and log link to calculate the mean incremental effect of SAVE on LOS and total hospital costs after adjustment for potential confounders, including age, sex, stroke severity, cigarette smoking, alcohol drinking, prior history ischemic stroke or TIA, comorbidities. All analyses were conducted using SAS 9.4. Two-sided P < 0.05 was considered statistically significant. Cost data from different years were converted into the 2019 Chinese Yuan (CNY) using a 5% inflation rate.

Patient characteristics

From January 1 2016 to December 31 2019, among the 4,432 AIS patients who were admitted to the Minhang hospital, 137 patients were excluded because they had missing data on the stroke onset time or hospital arrival time, 43 patients were excluded because they had stroke onset while in hospital, 27 patients were excluded because they had dementia or psychological disorders, and 1,395 patients were excluded because they had missing data on costs or NIHSS score. Therefore, a total of 2,830 patients with stroke were included in the analysis. The flowchart of the sample selection process is shown in Fig. 1.

A total of 2,830 AIS patients were included in the analysis. 490 stroke patients were included in the pre-campaign period and 2,340 stroke patients were included in the post-campaign period. As shown in Table 1, there were no statistically significant differences in age (P = 0.577), sex (P = 0.093), alcohol drinking (P = 0.056), prior history of ischemic stroke or TIA (P = 0.076), the onset of stroke during the daytime (P = 0.064), and comorbidities between AIS patients in the pre-and post-campaign periods. Compared to the pre-campaign period, the post-campaign period had a higher proportion of AIS patients who had a mild stroke (75.64% vs 65.10%; P < .001).

Table 1

Characteristics of stroke patients in pre-campaign and post-campaign period
Characteristics	Pre-campaign	Post-campaign	P-value
	(n = 490)	(n = 2,340)
Age, years			0.577
18–44	13 (2.65%)	81 (3.46%)
45–64	155 (31.63%)	685 (29.27%)
65–75	137 (27.96%)	695 (29.70%)
75+	185 (37.76%)	879 (37.56%)
Sex			0.093
Female	202 (41.22%)	870 (37.18%)
Male	288 (58.78%)	1470 (62.82%)
Stroke severity			< .001
1 ≤ NIHSS ≤ 4	319 (65.10%)	1770 (75.64%)
5 ≤ NIHSS ≤ 14	149 (30.41%)	525 (22.44%)
NIHSS ≥ 15	22 (4.49%)	45 (1.92%)
Cigarette smoker	122 (24.90%)	620 (26.50%)	< .001
Alcohol drinker	59 (12.04%)	216 (9.23%)	0.056
Prior stroke or TIA	107 (21.84%)	430 (18.38%)	0.076
Medical conditions
Hypertension	328 (66.94%)	1473 (62.95%)	0.095
Diabetes mellitus	134 (27.35%)	658 (28.12%)	0.729
CH&SH	11 (2.24%)	58 (2.48%)	0.760
Atrial Fibrillation	44 (8.98%)	156 (6.67%)	0.069
Daytime onset	356 (72.65%)	1602 (68.46%)	0.036
Abbreviation: SD, standard deviation; TIA, Transient ischemic attack; CH, cerebral hemorrhage; SH, subarachnoid hemorrhage; NIHSS, National Institutes of Health Stroke Scale; PVD, Peripheral Vascular Disease. Daytime was defined as 6AM to 6 PM; tPA: Tissue plasminogen Activator.

Cost of SAVE intervention

The SAVE intervention was estimated to cost ¥1,768,067 CNY for Xinzhuang County from October 2016 to December 2019, with ¥516,453 CNY in 2017, ¥519,316 CNY in 2018, and ¥523,526 CNY in 2019 (Table 2). As shown in Fig. 2, most of the costs (59.64%) were for the mass media broadcast, including the advertising fee for local newspapers, TV, and radio stations. Other major cost drivers included the costs for personnel and travel (26.01%) and materials (6.70%).

Table 2

Implementation costs (CNY) of SAVE intervention*
Cost category	Implementation activity	2016 (Oct-Dec)	2017 (Jan-Dec)	2018 (Jan-Dec)	2019 (Jan-Dec)
Program activities	Training by experts	5,325	5,072	4,830	4,600
	Physician trainee expense	1,458	1,503	1,548	1,568
	Project staff/coordinator trainee expense	886	853	858	861
	Planning for implementation	53,251	—	—	—
	Facilities and equipment rental	892	910	879	949
Materials	Brochures	7,380	29,768	29,925	31,500
	Posters	1,476	5,954	5,985	6,300
Personnel and travel	In-person education by physicians	3,790	15,626	16,098	15,985
	Poster/brochure distribution by project staffs	27,929	107,572	108,202	108,529
	Transportation	1,655	5,833	6,224	6,240
	Management by project coordinators	2,793	10,757	10,820	10,853
Mass media	New advertisement	1,968	7,938	7,980	8,000
	Television broadcast	49,199	198,450	199,500	200,000
	Video Production	9,840	9,923	9,975	10,000
	Radio broadcast	24,600	99,225	99,750	100,000
	Audio Production	3,936	3,969	3,990	4,000
Facilities	Facilities and equipment rental	12,395	13,101	12,751	14,140
Total:		208,772	516,453	519,316	523,526
*Cost data were converted into 2019 Chinese Yuan (CNY) using a 5% inflation rate.

Healthcare utilization and costs

The mean (SD) LOS after the SAVE intervention was significantly shorter at 8.80 (3.55) days in the post-SAVE period compared to 9.48 (3.80) days in the pre-SAVE period (Fig. 3; P < .001). In the GLM model, the SAVE intervention was associated with reduced LOS (Table 3; β coefficient [95% CI]: -0.070 [-0.11 to -0.030]; P < 0.01). The adjusted incremental reduction in LOS was 0.69 days per hospital admission.

Table 3

Adjusted length and cost of hospitalization for ischemic stroke
Characteristics	Length of Stay			Hospitalization Costs
Characteristics	LSM	Adjusted β (95% CI)	P-value	LSM	Adjusted β (95% CI)	P-value
Stroke 1-2-0 campaign
Yes	2.25	-0.070 (-0.11 to -0.030)	< .01	9.98	-0.11 (-0.17 to -0.053)	< .01
No	2.32	0 [Reference]	—	10.10	0 [Reference]	—
Age
18–44	2.21	0 [Reference]	—	9.98	0 [Reference]	—
45–64	2.26	0.048 (-0.044 to 0.14)	0.303	10.05	0.074 (-0.066 to 0.21)	0.302
65–75	2.31	0.097 (0.005 to 0.19)	0.040	10.12	0.14 (0.001 to 0.28)	0.049
75+	2.35	0.13 (0.042 to 0.23)	< .01	10.01	0.036 (-0.11 to 0.18)	0.624
Sex
Male	2.30	0 [Reference]	—	10.11	0 [Reference]	—
Female	2.27	-0.038 (-0.070 to -0.006)	0.019	9.97	-0.14 (-0.19 to -0.089)	< .01
Stroke severity
1 < NIHSS ≤ 4	2.12	0 [Reference]	—	9.80	0 [Reference]	—
5 < NIHSS ≤ 14	2.27	0.28 (0.21 to 0.36)	< .01	9.98	0.18 (0.13 to 0.23)	< .01
NIHSS > 15	2.40	0.23 (0.16 to 0.30)	< .01	10.45	0.65 (0.55 to 0.75)	< .01
Cigarette smoker	2.28	-0.002 (-0.036 to 0.033)	0.919	10.02	0.047 (-0.052 to 0.10)	0.078
Alcohol drinker	2.28	0.004 (-0.048 to 0.056)	0.877	10.01	0.061 (-0.018 to 0.14)	0.132
Prior stroke or TIA	2.26	-0.043 (-0.081 to -0.005)	0.028	10.09	-0.091 (-0.15 to -0.030)	0.003
Medical conditions
Hypertension	2.28	-0.012 (-0.044 to 0.020)	0.446	10.07	-0.070 (-0.12 to -0.021)	< .01
Diabetes mellitus	2.30	0.032 (-0.001 to 0.065)	0.055	10.01	0.052 (0.009 to 0.10)	0.046
Atrial Fibrillation	2.28	-0.001 (-0.056 to 0.055)	0.984	10.03	0.024 (-0.062 to 0.11)	0.578
Daytime onset	2.28	-0.013 (-0.044 to 0.018)	0.416	10.02	0.030 (-0.018 to 0.078)	0.213
Abbreviation: TIA, Transient ischemic attack; NIHSS, National Institutes of Health Stroke Scale. Daytime was defined as 6 AM to 6 PM.

The mean (SD) hospitalization costs per admission dropped from ¥21950.72 (10410.74) to ¥19262.50 (12772.81) CNY (P < .01). In the GLM model, the SAVE intervention was associated with lower hospitalization costs (β coefficient [95% CI]: -0.11 [-0.17 to -0.053]; P < 0.01). The adjusted incremental reduction in hospitalization costs was ¥2,604 CNY per hospital admission.

Our findings suggest that the SAVE intervention generated economic benefits through its effect on reducing LOS, which could be explained by improved intravenous thrombolytic therapy for stroke patients.¹⁴ In addition, with shorter prehospital delay, stroke patients were less likely to have neurological deficits upon hospital admission, and hence, fewer healthcare resources were needed. Stroke educational campaigns effectively improve stroke knowledge and promote behavioural changes, but they generally require large, sustained funding.^10,12 Policymakers face challenges in balancing the rising healthcare burden with implementing educational campaigns. However, to our knowledge, few studies examined the economic impact of educational campaigns.²² Hence, our analysis provided crucial empirical evidence for future work that scales up the intervention in other regions of China.

This study provides important evidence on the cost of implementing the community-based campaign in China. On average, the annual cost of implementing the SAVE intervention was around ¥500,000 CNY in Shanghai, China. The advertising fees for mass media (e.g., newspaper, radio, and TV) were the major cost drivers, but these costs were donated by the local community. In addition, more than 25% of the total intervention cost was for personnel and travel, including salary and benefits. Even though physicians and project staff worked as volunteers, their personnel costs were also included in the analysis to obtain a more conservative estimate.

Our analysis also demonstrated the economic impacts of implementing the SAVE intervention. On average, the SAVE intervention was associated substantial reduction in hospitalization costs. In the post-campaign period, a total of 2,340 stroke patients were admitted to hospitals. With the ¥2,604 CNY estimated reduction in hospitalization costs per admission, the reduction in hospitalization costs is projected to be ¥6,093,360 CNY post-campaign period. At the same time, the total implementation costs of SAVE intervention are only ¥1,768,067 CNY during the same period. Hence, the estimated cost-savings were expected to be more than 4 million CNY for Xinzhuang, Shanghai. With over 2.4 million incident stroke cases annually across China, one of the savings in hospitalization would be more substantial if successfully implementing the educational campaign nationwide. Furthermore, considering the improved functional independence of stroke survivors, the educational campaign would have even more profound economic implications by reducing caregiver and society burdens.

Although Stroke recognition tools (e.g., F.A.S.T.) have been shown to improve stroke awareness, stroke early detection, and reduce prehospital delay for stroke^23–27, the effects of education campaigns were not sustainable, particularly after the COVID-19 pandemic. In fact, the United Kingdom relaunched the FAST campaign to reduce stroke burden in 2022 because of the prolonged prehospital time.²⁸ A potential explanation is due to the lack of effective and sustainable intervention strategies that are customized for different populations and settings.²⁹ Mass media campaigns are expensive, and their effects on behaviour change are still unknown.¹⁰ Traditional educational campaigns also require enormous resources for implementation, which is challenging for LMICs like China. Even though our findings suggested that the implementation costs could offset the implementation costs, it is still unknown whether the economic benefits are persistent over the long run. With the recent advancement in digital technology, therefore, innovative digital health education strategies should be developed to deliver digital media and digital products for stroke education. The current SAVE campaign is a community-based campaign, without targeting those at risk for stroke. Innovative strategies should be also developed to deliver interventions specific to those with higher risks of stroke.

This study has several strengths. First, this is the first empirical study in China to determine the implementation and downstream costs of educational campaigns in China, providing important evidence for future scaling up. The cost-effectiveness of mass media campaigns is a concern, and our study demonstrated that a well-designed educational campaign could reduce hospitalization costs and achieve potential cost-savings. Second, our study also categorized implementation costs into traditional categories, which will assist in planning future implementation strategies. For example, mass media and personnel are the main cost drivers, and digital health strategies should explored in future implementation studies.

This study has some limitations. First, the study only collected data from one hospital, the findings may not be generalizable to other settings. Second, the shorten in LOS may contribute to other factors, e.g., the healthcare reforms that limit the length of hospitalization. Therefore, future studies could employ a prospective study design with a control group (e.g., a randomized control trial). Third, the personnel costs were estimated based on the average salary rather than the actual salary earned by physicians and project staff.

Our findings suggest that the Stroke 1-2-0 campaign generated economic savings through its effect on reducing LOS, which could be explained by improved intravenous thrombolytic therapy. Innovative ways of delivering educational materials, e.g., via mobile App, will need to be explored by lowering costs for personnel and mass media.

Ethics approval and consent to participate:

This study was reviewed and approved by the ethics committees of the Institutional Review Boards of Minhang Hospital of Fudan University. The requirement for written informed consent from participants was waived by the Shanghai Ethics Committee for Clinical Research.

Consent for publication:

Not applicable.

Availability of data and materials:

The datasets used and/or analyzed during the present study are available from the corresponding author upon reasonable request.

Competing interests:

The authors declare that there are no conflicts of interest.

Funding:
Not applicable

Authors' contributions:

JY: conceptualization, methodology, formal analysis, writing original draft, and review & editing manuscript; YW: conceptualization, methodology, formal analysis, writing original draft, and review & editing manuscript; YL: review & editing manuscript; ZKL: review & editing manuscript; RL: review & editing manuscript; JZ: conceptualization, methodology, supervision, funding acquisition, project administration, and review & editing manuscript.

Acknowledgement:

We acknowledge the community volunteers and the doctors of the community hospital for promoting the Stroke 1-2-0 educational program in Minhang District.

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No competing interests reported.

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The Economic Impact of the Multifaceted Stroke 1-2-0 Educational Campaign in China

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Main text

Methods

Study design

Ethics approval

Overview of Save Intervention

Sample selection

Healthcare utilization and costs

Cost of SAVE intervention

Statistical analysis

Results

Patient characteristics

Cost of SAVE intervention

Healthcare utilization and costs

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1