Abstract
BACKGROUND: Stroke is a leading cause of death and disability, placing a significant burden on survivors and their families. To address the lack of African-specific data, we investigated the cost of stroke management and the recovery of health-related quality of life in the post-discharge period in Mozambique. METHODS: A prospective, cost-of-illness study examining the direct and indirect costs of acute stroke presentations to a first referral urban public hospital in Maputo, Mozambique (June-December 2019). Direct costs were derived from medical records to estimate the cost of hospital care. Indirect costs were derived from interviews using a semi-structured questionnaire administered to patients or their caregivers during the index hospitalization and 28-days post-discharge to estimate additional expenditure and loss of productivity due to disability which varied by employment status (informal, formal, pensioner and unemployed). Health-related quality-of-life was assessed at 28-days post stroke using the EQ-5D-3L questionnaire. Cost analysis was conducted from a societal perspective and reported in $USD. RESULTS: 50 of 80 patients admitted with an acute stroke were consecutively recruited during the study period. Median age was 61 (IQR 38-68) years, 56% were women and 44% presented with a hemorrhagic stroke. Median length of stay in the hospital was 7.0 (IQR 4.0 to 8.0) days. Within 28-days post-discharge 20% patients had died. Estimated total direct cost of hospital care for 50 patients (hospital days, medication, and investigations) was $36,315.28, the median cost per patient was $721.45 (IQR 582; $790). Estimated direct non-medical costs per patient during hospitalization median $12,59 (IQR, 8.19; 16.39) and mean $13.62 (SD 8.02). In the first 28 days after discharge the non-medical cost was: $32.04 (IQR, 19,01; 49.83) and mean $41.37 (SD, 36.11). Overall, loss of productivity was very high in informal employment and quality of life in survivors severely compromised. The mean EQ-5D index and VAS scores of stroke patients were 0.514 (SD, 0.298), and 49.39 (SD, 20.95), respectively. Anxiety/depression 92.5% and Pain/discomfort 82.5% were the most frequently reported issues. CONCLUSION: The economic cost of stroke in low-income sub-Saharan African countries such as Mozambique is substantially high, with considerable out-of-pocket spending, poor survival rate and a compromised health-related quality-of-life. Health system reforms designed to mitigate the individual to societal burden imposed by stroke are required.