Background: Stroke remains one of the leading causes of morbidity and mortality in Australia. The objective of this study was to estimate the current and future cost burden of ischemic stroke (IS) in Australia. Method: First, the annual chronic management cost per person following IS were derived for all people aged ≥30 years discharged from a public or private hospital in Victoria, Australia between July 2012 and June 2017 (with follow-up data until June 2018 [n = 34,471]). Then extrapolated the data from from Victoria to the whole Australian population aged between 30 years and 99 years to project the total healthcare costs following IS (combination of acute event and chronic management cost) over a 20-year period (2019–2038) using a dynamic multistate life table model. Data for the dynamic model were sourced from the Victorian Admitted Episodes Dataset (VAED) and supplemented with other published data. Result: The estimated annual total chronic management cost following IS was 13,525 Australian dollars (AUD) per person (95% CI: AUD 13,380, AUD 13,670) for cohorts in the VAED between July 2012 and June 2017. The annual chronic management cost was estimated to decline following IS. The highest cost was incurred in the first year of follow-up post-IS (AUD 14,309 per person) and declined to AUD 9,776 in the sixth year of follow-up post-IS. The total healthcare cost for people aged 30–99 years was projected to be AUD 47.7 billion (95% UI: AUD 44.6 billion, AUD 51.0 billion) over the 20-year period (2019–2038) Australia-wide, of which 91.3% (AUD 43.6 billion) was attributed to chronic management costs and the remaining 8.7% (AUD 4.2 billion) were due to acute IS events. Conclusion: IS has and will continue to have a considerable financial impact in the next 2 decades on the Australian healthcare system. Our estimated and projected cost burden following IS provides important information for decision making in relation to IS.

Stroke caused 6.5 million deaths and 143 million disability adjusted life years worldwide in 2019 [1]. With this disease burden, stroke is the second leading cause of death and the third leading cause of lost disability adjusted life years [1, 2]. In Australia, the Stroke Foundation reported that 445,000 people were living with stroke, 27,400 people had their first stroke, and 8,700 people died due to stroke in 2020 [3]. Stroke also has a profound impact on the Australian workforce, with people who experience a stroke often exiting the workforce or experiencing marked disability [4, 5].

Stroke also imposes a considerable economic burden. Globally, stroke was estimated to cost USD 891 billion (1.12% of the global GDP) in 2019 [6]. In Australia, the economic cost of stroke was estimated to be 6.2 billion Australian dollars (AUD) in 2020 [3]. The total cost of cardiovascular disease (CVD) was projected to exceed AUD 62 billion from 2020–2029 [5]. However, detailed projections of the cost burden of ischemic stroke (IS), the most common form of stroke, have not been explored in Australia.

Previous cost projections for CVD in Australia have been based on the Australian National Health Survey [4, 5, 7]. The accuracy of cost projections using these data is dependent on the granularity of clinical data for the specific health conditions, which is lacking for stroke. To address this gap, we used a large Victorian Admitted Episodes Dataset (VAED) to analyze patient-level data for all people aged ≥30 years discharged from hospitals following IS in Victoria, Australia [8, 9].

The objectives of this study were to (1) to estimate the total annual chronic management costs per person for people who survived an IS between 2012 and 2017, stratified by age group, sex, comorbidities, socioeconomic disadvantage, and follow-up time and (2) to project acute event cost of IS and chronic management cost following IS for the Australian population aged between 30 and 99 years, over a 20-year period (2019–2038). By projecting a long-term cost burden of IS, we would understand the implication of the disease and provide the opportunity to plan ahead for prevention strategies to reduce the health and cost of burden of IS.

Methods for Estimating the Current Cost Burden of Ischemic Stroke

Data Sources

The study population for estimating the chronic management cost following IS (chronic management cost from here forward) was people in the VAED aged ≥30 years who were discharged from a public or private hospital after an IS (n = 34,471) between July 1, 2012 and June 30, 2017 (with data to June 30, 2018) [8, 9]. People were followed until death or end of follow-up (June 30, 2018), whichever came first. Admission with IS was defined as an admission with a primary diagnosis recorded in the VAED as IS (ICD 10-AM code I63-I64 [9, 10]). This dataset was linked to the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS), and National Death Index (NDI) [9]. Services data were derived from the MBS, medication dispensing data from the PBS, readmission data from the VAED, and date of death from the NDI [9].

A healthcare perspective was adopted in the current study and costs relevant to this perspective were derived from multiple sources. Chronic management costs included medication costs from PBS (see online suppl. Fig. S1; for all online suppl. material, see https://doi.org/10.1159/000538564), diagnostic procedures and investigations cost from MBS (see online suppl. Fig. S2), and all-cause hospital admission costs from the VAED (with cost estimates from the National Hospital Cost Data Collection [NHCDC] report between 2012/13 and 2017/18; see online suppl. Fig. S3). All costs were adjusted to 2019 AUD using the health price index [11].

Exposures

Chronic management costs were stratified by age group, sex, diabetes status, hypertension status, socioeconomic status, and year of follow-up [9]. Socioeconomic status was measured using the Index of Relative Socioeconomic Disadvantage (IRSD), developed by Australian Bureau of Statistics (ABS) [9, 12]. We split areas into quintiles (relative to the entire population), the first quintile being the most socioeconomically disadvantaged area and the fifth quintile being the least [4, 9, 12]. An IRSD was assigned to each admission based on the last known postcode before admission for IS [9].

Statistical Analysis

Costs were estimated using generalized linear models (GLMs) with a gamma outcome distribution and a power-1 link function, weighted by person-years of follow-up. First, univariable models were fit to estimate the total chronic management cost by age (where age was the midpoint of each age group [in 5-year intervals] and parameterized with spline effects), diabetes status, hypertension status, IRSD, and year of follow-up. A multivariable model was then fit to estimate the adjusted total chronic management cost adjusted for all variables listed above. Estimated costs were presented as annual cost per person with the respective stratification group accompanied by the 95% confidence intervals.

Methods for Projecting the Future Cost Burden of Ischemic Stroke

Model Overview

A dynamic multistate life table model, a stochastic process that allows individuals to move between a finite number of states overtime with attached transition probabilities [13, 14], was constructed to project the cost burden of IS for the Australian population aged between 30 and 99 years over 2 decades (2019–2038) in yearly cycles. The main outcomes from the model included total healthcare costs, a combination of acute event cost of IS and chronic management cost following IS.

Model Structure

The model used to project the cost burden (Fig. 1) has been described in detail elsewhere and adapted to the current study [15, 16]. Briefly, the model included four health states: “alive with no-IS,” “alive with new IS,” “alive after surviving IS (i.e., post-IS),” and “death.” Death could be due to causes other than IS (i.e., “Death other”), due to IS (“fatal IS”), or death after surviving the first IS (“Death Post-IS”).

Fig. 1.

Structure of the multistate life table model and associated transition probabilities. IS, ischemic stroke; ℓ, 1-year period; λ, ischemic stroke incidence rate; µother, mortality rate for people without ischemic stroke (i.e., other mortality); µpost-IS, post-IS all-cause mortality rate; pfatal, proportion of fatal ischemic stroke; ratesum, λ+ µother; tpsum, 1-exp(-ratesum × ℓ); ratesum, the sum of incidence rate of ischemic stroke and mortality rate for people without ischemic stroke (i.e., other mortality); tpsum, transition probability of ratesum.

Fig. 1.

Structure of the multistate life table model and associated transition probabilities. IS, ischemic stroke; ℓ, 1-year period; λ, ischemic stroke incidence rate; µother, mortality rate for people without ischemic stroke (i.e., other mortality); µpost-IS, post-IS all-cause mortality rate; pfatal, proportion of fatal ischemic stroke; ratesum, λ+ µother; tpsum, 1-exp(-ratesum × ℓ); ratesum, the sum of incidence rate of ischemic stroke and mortality rate for people without ischemic stroke (i.e., other mortality); tpsum, transition probability of ratesum.

Close modal

Population

The base population included in the dynamic multistate life table model was the Australian population aged between 30 years and 99 years in 2018 derived from the Australian Bureau of Statistics (ABS) (see online suppl. Table S1) [17]. Including ages younger than 30 years has significant reidentification risks and so was excluded from our linked dataset. Moreover, stroke events below age 30 years are not a common occurrence [18]. This population was then aged in yearly cycles from 2019 to 2038. Throughout the projection time, Australian residents (once they aged from 29 to 30 years at the beginning of each cycle) and migrants entered the model [19].

Data Source

The VAED was the primary source of input data for the dynamic model (described above). A healthcare perspective was also adopted in the dynamic multistate life table model. Acute event costs related to admission to hospital with the diagnosis of IS were sourced from NHCDC version 10 round 24 for 2019–20 (see online suppl. Table S2) [20]. These acute event costs were assumed to be incurred by people with incident IS events (i.e., nonfatal IS and fatal IS events). Acute event costs related to IS were assumed to be constant regardless of age and sex. We applied a conservative assumption in the base case: that only half of the people with fatal IS would incur an acute event cost [4, 5].

Chronic management cost was based on the predicted single-year age follow-up cost for cohorts with IS in the VAED (see online suppl. Table S3). All costs in projections were adjusted to 2019 AUD using the health price index [11].

Estimating Transition Probabilities for the Dynamic Multistate Life Table Model

GLMs were used to estimate the single year-age prevalence of IS, incidence rate of IS, proportion of fatal IS, non-IS mortality rate, and post-IS mortality rate stratified by sex and have been described in detail in a previous publication [15, 16]. Input data for the GLM were primarily sourced from cohorts in the VAED. The estimated rates were converted to transition probabilities before used in the dynamic model to project the Australian population in each health state and the cost burden of IS (i.e., we projected the cost burden of IS to the Australian population using the VAED input data).

Outcomes

After populating the transition probabilities described above (Fig. 1) in the dynamic multistate life table model, outcomes necessary for the cost projection were captured: specifically, acute event cost, chronic management cost, and total healthcare cost. For all projected costs, a 5% annual discounting was applied in the base case. Projected costs were presented by age group and year, stratified by sex, at a population level.

Sensitivity and Scenario Analysis

Monte Carlo simulation with 1,000 iterations was performed to derive the 95% uncertainty intervals (UI) for key cost outcomes from the dynamic model. Distributions used for each parameter are described in online supplementary Table S4. Scenario analyses were also performed including: (a) varying the discount rate (0% and 3%), (b) assuming all people with fatal IS incur acute event cost, and (c) changing the duration of projection from 20 years to 10 years (2019–2028). All analyses were performed using Stata version 18.0 (StataCorp, USA).

Annual Chronic Management Costs following Ischemic Stroke

There were 34,471 people (54.6%) with 72,774-person years of follow-up discharged with a diagnosis of IS between July 1, 2012 and June 30, 2017 (Table 1). The adjusted total annual chronic management cost per person was estimated to be AUD 13,525 (95% confidence intervals: AUD 13,380, AUD 13,670) (Table 1). The estimated cost per person decreased with alongside years of follow-up. However, no major cost difference was observed across socioeconomic disadvantage quintile. For crude estimates of admission cost, medication cost, and MBS cost, see online supplementary Table S5. Results of the crude estimates had the same trend as the adjusted total chronic management cost estimates.

Table 1.

Estimated chronic management cost following IS for cohorts in the Victorian admitted episode dataset

VariableNPerson-yearsTotal chronic cost per person, AUD*Total chronic cost per person, AUD*
unadjustedLBUBadjusted**LBUB
Overall 34,471 72,774 13,030 12,897 13,164 13,525 13,380 13,670 
Sex 
 Male 18,826 40,502 13,382 13,200 13,566 13,780 13,582 13,978 
 Female 15,645 32,271 12,588 12,395 12,781 13,192 12,976 13,408 
Age 
 30–39 years 571 1,372 9,494 8,737 10,251 11,299 10,241 12,357 
 40–49 years 1,625 4,011 9,665 9,320 10,011 10,717 10,289 11,145 
 50–59 years 3,376 8,299 10,675 10,387 10,962 11,398 11,075 11,721 
 60–69 years 6,286 14,912 13,229 12,930 13,528 13,527 13,217 13,837 
 70–79 years 9,276 20,545 14,501 14,236 14,766 14,453 14,189 14,717 
 ≥80 years 13,337 23,635 13,320 13,125 13,513 13,855 13,644 14,065 
Hypertension 
 Yes 29,609 61,713 13,775 13,621 13,930 13,870 13,712 14,027 
 No 4,862 11,060 8,873 8,637 9,108 10,798 10,450 11,146 
Diabetes 
 Yes 9,740 19,452 16,853 16,522 17,184 16,740 16,404 17,077 
 No 24,731 53,321 11,636 11,498 11,775 12,235 12,082 12,388 
IRSD quintile 
 1 (most disadvantaged) 6,412 13,338 13,308 13,080 13,535 13,128 12,896 13,361 
 2 6,127 12,878 13,455 13,305 13,604 13,397 13,242 13,553 
 3 6,320 13,356 13,534 13,396 13,673 13,546 13,400 13,691 
 4 7,635 15,946 13,626 13,463 13,791 13,721 13,545 13,896 
 5 (least disadvantaged) 6,724 14,016 13,708 13,497 13,920 13,876 13,647 14,106 
Follow-up 
 Year 1 34,471 27,130 13,883 13,720 14,046 14,309 14,136 14,482 
 Year 2 22,582 19,020 12,567 12,432 12,702 13,083 12,938 13,227 
 Year 3 15,629 12,805 11,479 11,311 11,647 12,057 11,875 12,238 
 Year 4 10,238 8,098 10,565 10,359 10,770 11,184 10,959 11,410 
 Year 5 6,141 4,396 9,784 9,549 10,020 10,432 10,171 10,693 
 Year 6 2,742 1,324 9,112 8,855 9,369 9,776 9,489 10,064 
VariableNPerson-yearsTotal chronic cost per person, AUD*Total chronic cost per person, AUD*
unadjustedLBUBadjusted**LBUB
Overall 34,471 72,774 13,030 12,897 13,164 13,525 13,380 13,670 
Sex 
 Male 18,826 40,502 13,382 13,200 13,566 13,780 13,582 13,978 
 Female 15,645 32,271 12,588 12,395 12,781 13,192 12,976 13,408 
Age 
 30–39 years 571 1,372 9,494 8,737 10,251 11,299 10,241 12,357 
 40–49 years 1,625 4,011 9,665 9,320 10,011 10,717 10,289 11,145 
 50–59 years 3,376 8,299 10,675 10,387 10,962 11,398 11,075 11,721 
 60–69 years 6,286 14,912 13,229 12,930 13,528 13,527 13,217 13,837 
 70–79 years 9,276 20,545 14,501 14,236 14,766 14,453 14,189 14,717 
 ≥80 years 13,337 23,635 13,320 13,125 13,513 13,855 13,644 14,065 
Hypertension 
 Yes 29,609 61,713 13,775 13,621 13,930 13,870 13,712 14,027 
 No 4,862 11,060 8,873 8,637 9,108 10,798 10,450 11,146 
Diabetes 
 Yes 9,740 19,452 16,853 16,522 17,184 16,740 16,404 17,077 
 No 24,731 53,321 11,636 11,498 11,775 12,235 12,082 12,388 
IRSD quintile 
 1 (most disadvantaged) 6,412 13,338 13,308 13,080 13,535 13,128 12,896 13,361 
 2 6,127 12,878 13,455 13,305 13,604 13,397 13,242 13,553 
 3 6,320 13,356 13,534 13,396 13,673 13,546 13,400 13,691 
 4 7,635 15,946 13,626 13,463 13,791 13,721 13,545 13,896 
 5 (least disadvantaged) 6,724 14,016 13,708 13,497 13,920 13,876 13,647 14,106 
Follow-up 
 Year 1 34,471 27,130 13,883 13,720 14,046 14,309 14,136 14,482 
 Year 2 22,582 19,020 12,567 12,432 12,702 13,083 12,938 13,227 
 Year 3 15,629 12,805 11,479 11,311 11,647 12,057 11,875 12,238 
 Year 4 10,238 8,098 10,565 10,359 10,770 11,184 10,959 11,410 
 Year 5 6,141 4,396 9,784 9,549 10,020 10,432 10,171 10,693 
 Year 6 2,742 1,324 9,112 8,855 9,369 9,776 9,489 10,064 

N, number of people with IS; IS, ischemic stroke; IRSD, Index of Relative Socioeconomic Disadvantage; LB, lower bound of the confidence interval (2.5%); UB, upper bound of the confidence interval (97.5%); AUD, Australian dollar.

*Total chronic management cost is the composite of hospital admission cost, medication cost, and MBS cost.

**Total chronic management cost adjusted for age, sex, hypertension, diabetes, Index of Relative Socioeconomic Disadvantage, and follow-up time.

Projection of the Cost Burden of Ischemic Stroke for the Australian Population Using a Dynamic Model

IS was projected to cost the Australian healthcare system AUD 4.2 billion (95% UI: AUD 3.9 billion, AUD 4.4 billion) in acute event cost, AUD 43.6 billion (95% UI: AUD 40.5 billion, AUD 46.8 billion) in chronic management cost, and AUD 47.7 billion (95% UI: AUD 44.6 billion, AUD 51.0 billion) in total healthcare cost between 2019 and 2038 (see Tables 2-4; Fig. 2; online suppl. Table S6-S15). The projected costs were consistently higher for male population, and age group 70–79 years had the highest total healthcare cost burden in both sexes.

Table 2.

Projected acute event cost of IS by age group for the Australian population aged 30–99 years over the 20-year period (2019–2038)

Projected acute cost of IS for male population
age group, yearsN*acute cost, AUDLBUB
30–39 8,539 61,464,670 49,120,313 75,581,671 
40–59 16,606 118,076,107 94,680,763 143,494,480 
50–59 30,845 221,442,449 179,003,669 269,628,466 
60–69 57,120 406,148,462 327,935,464 490,579,020 
70–79 89,295 617,696,096 502,234,608 744,413,912 
80–89 91,325 599,273,884 487,636,800 724,303,064 
90–99 42,064 261,384,324 212,474,570 315,306,240 
Total 335,794 2,285,486,080 2,168,809,984 2,401,386,496 
Projected acute cost of IS for male population
age group, yearsN*acute cost, AUDLBUB
30–39 8,539 61,464,670 49,120,313 75,581,671 
40–59 16,606 118,076,107 94,680,763 143,494,480 
50–59 30,845 221,442,449 179,003,669 269,628,466 
60–69 57,120 406,148,462 327,935,464 490,579,020 
70–79 89,295 617,696,096 502,234,608 744,413,912 
80–89 91,325 599,273,884 487,636,800 724,303,064 
90–99 42,064 261,384,324 212,474,570 315,306,240 
Total 335,794 2,285,486,080 2,168,809,984 2,401,386,496 
Projected acute cost of IS for female population
age group, yearsN*acute cost, AUDLBUB
30–39 3,965 28,607,640 22,557,979 35,592,405 
40–49 8,704 61,823,006 49,518,137 76,405,956 
50–59 18,225 130,731,593 105,168,078 158,793,773 
60–69 38,557 273,104,642 221,256,645 329,906,120 
70–79 69,228 474,054,692 383,805,840 573,259,936 
80–89 85,600 559,114,204 456,587,292 674,316,832 
90–99 53,628 338,790,073 275,527,626 409,622,792 
Total 277,907 1,866,225,792 1,772,427,648 1,966,444,800 
Projected acute cost of IS for female population
age group, yearsN*acute cost, AUDLBUB
30–39 3,965 28,607,640 22,557,979 35,592,405 
40–49 8,704 61,823,006 49,518,137 76,405,956 
50–59 18,225 130,731,593 105,168,078 158,793,773 
60–69 38,557 273,104,642 221,256,645 329,906,120 
70–79 69,228 474,054,692 383,805,840 573,259,936 
80–89 85,600 559,114,204 456,587,292 674,316,832 
90–99 53,628 338,790,073 275,527,626 409,622,792 
Total 277,907 1,866,225,792 1,772,427,648 1,966,444,800 
Projected total acute cost of IS
age group, yearsN*acute cost, AUDLBUB
30–39 12,504 90,072,310 71,678,292 111,174,076 
40–49 25,310 179,899,113 144,198,900 219,900,436 
50–59 49,070 352,174,042 284,171,747 428,422,239 
60–69 95,677 679,253,104 549,192,109 820,485,140 
70–79 158,523 1,091,750,788 886,040,448 1,317,673,848 
80–89 176,925 1,158,388,088 944,224,092 1,398,619,896 
90–99 95,692 600,174,397 488,002,196 724,929,032 
Total 613,701 4,151,711,872 3,941,237,632 4,367,831,296 
Projected total acute cost of IS
age group, yearsN*acute cost, AUDLBUB
30–39 12,504 90,072,310 71,678,292 111,174,076 
40–49 25,310 179,899,113 144,198,900 219,900,436 
50–59 49,070 352,174,042 284,171,747 428,422,239 
60–69 95,677 679,253,104 549,192,109 820,485,140 
70–79 158,523 1,091,750,788 886,040,448 1,317,673,848 
80–89 176,925 1,158,388,088 944,224,092 1,398,619,896 
90–99 95,692 600,174,397 488,002,196 724,929,032 
Total 613,701 4,151,711,872 3,941,237,632 4,367,831,296 

N, number of people; IS, ischemic stroke; LB, lower bound of the UI (2.5%); UB, upper bound of the UI (97.5%); AUD, Australian dollar.

*Number of people for acute event cost projection is based on the number of people with nonfatal IS and half of the people with fatal IS.

Table 3.

Projected chronic management cost following IS by age group for the Australian population aged 30–99 years over the 20-year period (2019–2038)

Projected chronic cost of IS for male population
age group, yearsN*chronic cost, AUDLBUB
30–39 192,027 685,852,392 503,574,516 918,534,824 
40–49 288,481 1,165,478,320 1,030,170,624 1,307,068,472 
50–59 477,909 2,502,448,752 2,298,408,896 2,702,892,816 
60–69 768,686 5,421,760,992 5,091,463,904 5,737,755,360 
70–79 1,010,809 7,821,678,208 7,407,053,632 8,217,754,752 
80–89 838,522 5,894,644,896 5,564,180,864 6,212,039,136 
90–99 310,927 1,869,169,344 1,683,183,676 2,057,153,292 
Total 3,887,361 25,361,033,216 23,584,743,424 27,139,971,072 
Projected chronic cost of IS for male population
age group, yearsN*chronic cost, AUDLBUB
30–39 192,027 685,852,392 503,574,516 918,534,824 
40–49 288,481 1,165,478,320 1,030,170,624 1,307,068,472 
50–59 477,909 2,502,448,752 2,298,408,896 2,702,892,816 
60–69 768,686 5,421,760,992 5,091,463,904 5,737,755,360 
70–79 1,010,809 7,821,678,208 7,407,053,632 8,217,754,752 
80–89 838,522 5,894,644,896 5,564,180,864 6,212,039,136 
90–99 310,927 1,869,169,344 1,683,183,676 2,057,153,292 
Total 3,887,361 25,361,033,216 23,584,743,424 27,139,971,072 
Projected chronic cost of IS for female population
age group, yearsN*chronic cost, AUDLBUB
30–39 127,146 568,696,976 432,265,068 751,063,320 
40–49 181,956 896,544,704 788,058,484 1,019,391,680 
50–59 307,839 1,779,468,680 1,612,065,816 1,959,822,912 
60–69 516,843 3,788,365,248 3,503,555,680 4,082,349,280 
70–79 717,631 5,442,741,280 5,107,483,200 5,777,803,264 
80–89 673,811 4,149,221,536 3,929,309,152 4,366,865,184 
90–99 335,047 1,606,438,036 1,468,405,716 1,741,681,656 
Total 2,860,274 18,231,476,224 16,880,318,464 19,653,042,176 
Projected chronic cost of IS for female population
age group, yearsN*chronic cost, AUDLBUB
30–39 127,146 568,696,976 432,265,068 751,063,320 
40–49 181,956 896,544,704 788,058,484 1,019,391,680 
50–59 307,839 1,779,468,680 1,612,065,816 1,959,822,912 
60–69 516,843 3,788,365,248 3,503,555,680 4,082,349,280 
70–79 717,631 5,442,741,280 5,107,483,200 5,777,803,264 
80–89 673,811 4,149,221,536 3,929,309,152 4,366,865,184 
90–99 335,047 1,606,438,036 1,468,405,716 1,741,681,656 
Total 2,860,274 18,231,476,224 16,880,318,464 19,653,042,176 
Projected total chronic cost of IS
age group, yearsN*chronic cost, AUDLBUB
30–39 319,173 1,254,549,368 935,839,584 1,669,598,144 
40–49 470,437 2,062,023,024 1,818,229,108 2,326,460,152 
50–59 785,748 4,281,917,432 3,910,474,712 4,662,715,728 
60–69 1,285,529 9,210,126,240 8,595,019,584 9,820,104,640 
70–79 1,728,440 13,264,419,488 12,514,536,832 13,995,558,016 
80–89 1,512,333 10,043,866,432 9,493,490,016 10,578,904,320 
90–99 645,974 3,475,607,380 3,151,589,392 3,798,834,948 
Total 6,747,635 43,592,509,440 40,465,061,888 46,793,013,248 
Projected total chronic cost of IS
age group, yearsN*chronic cost, AUDLBUB
30–39 319,173 1,254,549,368 935,839,584 1,669,598,144 
40–49 470,437 2,062,023,024 1,818,229,108 2,326,460,152 
50–59 785,748 4,281,917,432 3,910,474,712 4,662,715,728 
60–69 1,285,529 9,210,126,240 8,595,019,584 9,820,104,640 
70–79 1,728,440 13,264,419,488 12,514,536,832 13,995,558,016 
80–89 1,512,333 10,043,866,432 9,493,490,016 10,578,904,320 
90–99 645,974 3,475,607,380 3,151,589,392 3,798,834,948 
Total 6,747,635 43,592,509,440 40,465,061,888 46,793,013,248 

N, number of people; IS, ischemic stroke; LB, lower bound of the UI (2.5%); UB, upper bound of the UI (97.5%); AUD, Australian dollar.

*Number of people for chronic management cost projection is based on the number of people with prevalent IS at the beginning of each cycle.

Table 4.

Results of scenario analyses for projected acute events, chronic management, and total healthcare cost of IS for Australian population aged 30–99 years

Scenario analyses for male population
outcomeN*estimate, AUDLBUB
20-year projection 
5% discount 
 Acute cost 335,794 2,285,486,080 2,168,809,984 2,401,386,496 
 Chronic cost 3,887,361 25,361,033,216 23,584,743,424 27,139,971,072 
 Total cost** 4,223,155 27,646,519,296 25,833,517,056 29,457,049,600 
3% discount 
 Acute cost 335,794 2,723,932,928 2,584,737,280 2,861,869,056 
 Chronic cost 3,887,361 29,847,025,664 27,722,297,344 31,954,952,192 
 Total cost** 4,223,155 32,570,959,872 30,433,611,776 34,724,315,136 
0% discount 
 Acute cost 335,794 3,652,385,536 3,465,677,312 3,836,702,464 
 Chronic cost 3,887,361 39,265,337,344 36,416,839,680 42,068,631,552 
 Total cost** 4,223,155 42,917,720,064 40,085,282,816 45,785,636,864 
All fatal ISa 
5% discount 
 Acute cost 354,442 2,334,798,592 2,216,359,424 2,451,623,424 
 Chronic cost 3,887,361 25,361,033,216 23,584,743,424 27,139,971,072 
 Total cost 4,241,803 27,695,831,040 25,882,763,264 29,505,820,672 
10-year projection 
5% discount 
 Acute cost 144,787 1,262,084,992 1,197,319,424 1,325,804,672 
 Chronic cost 1,874,286 15,221,680,128 14,236,811,264 16,264,923,136 
 Total cost** 2,019,073 16,483,765,248 15,470,993,408 17,528,274,944 
Scenario analyses for male population
outcomeN*estimate, AUDLBUB
20-year projection 
5% discount 
 Acute cost 335,794 2,285,486,080 2,168,809,984 2,401,386,496 
 Chronic cost 3,887,361 25,361,033,216 23,584,743,424 27,139,971,072 
 Total cost** 4,223,155 27,646,519,296 25,833,517,056 29,457,049,600 
3% discount 
 Acute cost 335,794 2,723,932,928 2,584,737,280 2,861,869,056 
 Chronic cost 3,887,361 29,847,025,664 27,722,297,344 31,954,952,192 
 Total cost** 4,223,155 32,570,959,872 30,433,611,776 34,724,315,136 
0% discount 
 Acute cost 335,794 3,652,385,536 3,465,677,312 3,836,702,464 
 Chronic cost 3,887,361 39,265,337,344 36,416,839,680 42,068,631,552 
 Total cost** 4,223,155 42,917,720,064 40,085,282,816 45,785,636,864 
All fatal ISa 
5% discount 
 Acute cost 354,442 2,334,798,592 2,216,359,424 2,451,623,424 
 Chronic cost 3,887,361 25,361,033,216 23,584,743,424 27,139,971,072 
 Total cost 4,241,803 27,695,831,040 25,882,763,264 29,505,820,672 
10-year projection 
5% discount 
 Acute cost 144,787 1,262,084,992 1,197,319,424 1,325,804,672 
 Chronic cost 1,874,286 15,221,680,128 14,236,811,264 16,264,923,136 
 Total cost** 2,019,073 16,483,765,248 15,470,993,408 17,528,274,944 
Scenario analyses for female population
outcomeN*estimate, AUDLBUB
20-year projection 
5% discount 
 Acute cost 277,907 1,866,225,792 1,772,427,648 1,966,444,800 
 Chronic cost 2,860,274 18,231,476,224 16,880,318,464 19,653,042,176 
 Total cost** 3,138,180 20,097,701,888 18,717,356,032 21,533,816,832 
3% discount 
 Acute cost 277,907 2,225,428,224 2,113,488,384 2,344,225,792 
 Chronic cost 2,860,274 21,363,894,272 19,774,619,648 23,039,969,280 
 Total cost** 3,138,180 23,589,322,752 21,958,443,008 25,287,385,088 
0% discount 
 Acute cost 277,907 2,986,756,352 2,836,346,624 3,144,748,288 
 Chronic cost 2,860,274 27,922,399,232 25,815,638,016 30,125,182,976 
 Total cost** 3,138,180 30,909,155,328 28,745,469,952 33,136,762,880 
All fatal ISa 
5% discount 
 Acute cost 298,428 1,920,384,000 1,824,006,144 2,021,768,832 
 Chronic cost 2,860,274 18,231,476,224 16,880,318,464 19,653,042,176 
 Total cost 3,158,701 20,151,861,248 18,773,114,880 21,588,303,872 
10-year projection 
5% discount 
 Acute cost 119,203 1,026,808,000 975,428,352 1,083,188,480 
 Chronic cost 1,416,582 11,235,134,464 10,394,008,576 12,113,448,960 
 Total cost** 1,535,785 12,261,942,272 11,428,127,744 13,133,842,432 
Scenario analyses for female population
outcomeN*estimate, AUDLBUB
20-year projection 
5% discount 
 Acute cost 277,907 1,866,225,792 1,772,427,648 1,966,444,800 
 Chronic cost 2,860,274 18,231,476,224 16,880,318,464 19,653,042,176 
 Total cost** 3,138,180 20,097,701,888 18,717,356,032 21,533,816,832 
3% discount 
 Acute cost 277,907 2,225,428,224 2,113,488,384 2,344,225,792 
 Chronic cost 2,860,274 21,363,894,272 19,774,619,648 23,039,969,280 
 Total cost** 3,138,180 23,589,322,752 21,958,443,008 25,287,385,088 
0% discount 
 Acute cost 277,907 2,986,756,352 2,836,346,624 3,144,748,288 
 Chronic cost 2,860,274 27,922,399,232 25,815,638,016 30,125,182,976 
 Total cost** 3,138,180 30,909,155,328 28,745,469,952 33,136,762,880 
All fatal ISa 
5% discount 
 Acute cost 298,428 1,920,384,000 1,824,006,144 2,021,768,832 
 Chronic cost 2,860,274 18,231,476,224 16,880,318,464 19,653,042,176 
 Total cost 3,158,701 20,151,861,248 18,773,114,880 21,588,303,872 
10-year projection 
5% discount 
 Acute cost 119,203 1,026,808,000 975,428,352 1,083,188,480 
 Chronic cost 1,416,582 11,235,134,464 10,394,008,576 12,113,448,960 
 Total cost** 1,535,785 12,261,942,272 11,428,127,744 13,133,842,432 
Scenario analyses for total population
outcomeN*estimate, AUDLBUB
20-year projection 
5% discount 
 Acute cost 613,701 4,151,711,872 3,941,237,632 4,367,831,296 
 Chronic cost 6,747,635 43,592,509,440 40,465,061,888 46,793,013,248 
 Total cost** 7,361,335 47,744,221,184 44,550,873,088 50,990,866,432 
3% discount 
 Acute cost 613,701 4,949,361,152 4,698,225,664 5,206,094,848 
 Chronic cost 6,747,635 51,210,919,936 47,496,916,992 54,994,921,472 
 Total cost** 7,361,335 56,160,282,624 52,392,054,784 60,011,700,224 
0% discount 
 Acute cost 613,701 6,639,141,888 6,302,023,936 6,981,450,752 
 Chronic cost 6,747,635 67,187,736,576 62,232,477,696 72,193,814,528 
 Total cost** 7,361,335 73,826,875,392 68,830,752,768 78,922,399,744 
All fatal ISa 
5% discount 
 Acute cost 652,870 4,255,182,592 4,040,365,568 4,473,392,256 
 Chronic cost 6,747,635 43,592,509,440 40,465,061,888 46,793,013,248 
 Total cost 7,400,504 47,847,692,288 44,655,878,144 51,094,124,544 
10-year projection 
5% discount 
 Acute cost 263,990 2,288,892,992 2,172,747,776 2,408,993,152 
 Chronic cost 3,290,868 26,456,814,592 24,630,819,840 28,378,372,096 
 Total cost** 3,554,858 28,745,707,520 26,899,121,152 30,662,117,376 
Scenario analyses for total population
outcomeN*estimate, AUDLBUB
20-year projection 
5% discount 
 Acute cost 613,701 4,151,711,872 3,941,237,632 4,367,831,296 
 Chronic cost 6,747,635 43,592,509,440 40,465,061,888 46,793,013,248 
 Total cost** 7,361,335 47,744,221,184 44,550,873,088 50,990,866,432 
3% discount 
 Acute cost 613,701 4,949,361,152 4,698,225,664 5,206,094,848 
 Chronic cost 6,747,635 51,210,919,936 47,496,916,992 54,994,921,472 
 Total cost** 7,361,335 56,160,282,624 52,392,054,784 60,011,700,224 
0% discount 
 Acute cost 613,701 6,639,141,888 6,302,023,936 6,981,450,752 
 Chronic cost 6,747,635 67,187,736,576 62,232,477,696 72,193,814,528 
 Total cost** 7,361,335 73,826,875,392 68,830,752,768 78,922,399,744 
All fatal ISa 
5% discount 
 Acute cost 652,870 4,255,182,592 4,040,365,568 4,473,392,256 
 Chronic cost 6,747,635 43,592,509,440 40,465,061,888 46,793,013,248 
 Total cost 7,400,504 47,847,692,288 44,655,878,144 51,094,124,544 
10-year projection 
5% discount 
 Acute cost 263,990 2,288,892,992 2,172,747,776 2,408,993,152 
 Chronic cost 3,290,868 26,456,814,592 24,630,819,840 28,378,372,096 
 Total cost** 3,554,858 28,745,707,520 26,899,121,152 30,662,117,376 

N, number of people; IS, ischemic stroke; LB, lower bound of the 95% UI (2.5%); UB, upper bound of the 95% UI (97.5%); AUD, Australian dollar.

*Number of people for acute event cost projection is based on the number of people with nonfatal IS and half of the people with fatal IS.

Number of people for chronic management cost projection is based on the number of people with prevalent IS at the beginning of each cycle.

Number of people for total healthcare cost projection is the sum of people considered for acute events and chronic management cost projection.

**Total cost is the sum of acute events cost and chronic management cost (i.e., total healthcare cost).

aAssuming for all fatal IS events happened after hospitalization in the dynamic model.

Fig. 2.

Projected total healthcare cost of IS for Australian population aged between 30 and 99 years over 20 years (2019–2038) stratified by sex. AUD, Australian dollar.

Fig. 2.

Projected total healthcare cost of IS for Australian population aged between 30 and 99 years over 20 years (2019–2038) stratified by sex. AUD, Australian dollar.

Close modal

Scenario Analyses

Scenario analyses are presented in Table 4. Reducing the base case annual discount rate from 5% to 3% and 0% increased the projected total healthcare cost by 17.6% and 54.6%, respectively. Considering all people with fatal IS in the dynamic model to incur acute event cost increased the projected acute event cost by 2.5% and the total healthcare cost by 0.2%. Decreasing the projection period from 20 years (2019–2038) to 10 years (2019–2028) reduced the projected total healthcare cost by 39.8%.

The overall annual chronic management cost following IS per person was estimated to be AUD 13,525 for people with IS in the VAED between 2012 and 2017. Our dynamic model projected that between 2019 and 2038, the total healthcare cost would be AUD 47.7 billion. Of these, 91.3% (AUD 43.6 billion) were attributed to chronic management costs and the remaining 8.7% (AUD 4.2 billion) for acute IS events.

Chronic management cost was estimated to decline over the course of follow-up. This trend could mainly be explained by admission related costs where the highest cost was incurred in the first-year post-IS follow-up (AUD 9,596 per person) and declined in the subsequent follow-up years to reach AUD 6,175 per person in the sixth-year post-IS follow-up (see online suppl. Table S5). Another deriver of high follow-up cost in the first-year post-IS follow-up was inclusion of MBS cost that could be driven by rehabilitation in the first few months following index IS [21]. Stratification by socioeconomic disadvantage has shown no major difference in the chronic management cost.

Projections from the dynamic model highlight the considerable cost burden that IS could impose in the coming decades. Our findings further corroborate the previous study by Marquina et al. [5] that projected the cost burden of CVD in Australia between 2020 and 2029 [5]. The study reported that the healthcare cost of CVD (including both myocardial infarction and stroke) would be AUD 61.9 billion [5], of which, the chronic cost was attributed to 75% (AUD 46.7 billion) of the total healthcare cost [5]. In comparison, our study projected that the total healthcare cost associated with IS would be around AUD 28.7 billion, 92% (AUD 26.5 billion) of which was attributed to chronic management cost over a 10-year period (2019–2028).

Our estimated current and projected cost burden of IS underline the importance of prevention strategies in curbing the burden of IS. Previous studies demonstrated that primary prevention strategies solely aimed at finding people at risk of IS were ineffective in reducing the disease burden [22, 23]. Hence, priorities should shift toward population-wide primary prevention approaches that reduce exposure to risk factors across a lifespan of the whole population and consequently reduce costs related to acute events [6, 24, 25]. Secondary prevention strategies play a crucial role in reducing the recurrence of IS and improving survival poststroke [26, 27], and strengthening secondary prevention strategies is warranted to reduce the chronic management cost of IS.

The main strength of this study is the use of the VAED. This dataset has a large and representative cohort of people with IS from which to derive costs from via linkage. Additionally, the utilization of a dynamic model in our study accounts for demographic changes overtime, incident cases, and migration while projecting the healthcare cost burden of IS.

Nevertheless, there are a number of limitations that are worth mentioning. Acute event cost was assumed to be similar regardless of age and sex in the dynamic model due to lack of detailed individual level costing data.

Another limitation is related to input data used in the dynamic model. Rates and proportions were assumed to remain stable throughout the projection time. This conventional approach would likely overestimate the projected nonfatal and fatal IS and years of life lived with IS, which in turn were used in projecting the healthcare cost. Previous studies showed that conventional approaches overestimated the burden of coronary heart disease as compared to trend-based approaches that consider recent decline in coronary heart disease mortality [28, 29]. Thus, our cost projection would likely change with the underlying rates and probabilities considered to build the model.

Further, there may be issues of generalizability with our results. The cost estimates were derived from a single state in Australia, while our projections used data from the whole of Australia, thereby assuming that the Victorian population and healthcare systems are comparable to other states in Australia, which may not be the case.

Our study also has not considered the productivity loss due to IS. Therefore, our estimated and projected cost burden of IS would have been even higher if productivity loss was considered.

IS will cost the Australian healthcare system around AUD 47.7 billion. Findings from our study further affirm the importance of reprioritizing population-wide primary prevention strategies and strengthening secondary prevention strategies to reduce the burden of IS in Australia.

The authors would like to acknowledge the Victorian Department of Health as the source of VAED data for this study, the Centre for Victorian Data Linkage (Victorian Department of Health) for the provision of data linkage, and the AIHW for provision of access to the NDI. Data acquisition and management were supported by the Dementia Australia Yulgilbar Innovation Award.

This study was approved by the Australian Institute of Health and Welfare Ethics Committee (EO2018/4/468) and Monash University Human Research Ethics Committee (14339). We have received a waiver for informed consent to access data.

The authors have stated explicitly that there are no conflicts of interest in connection with this article.

T.B.A. is supported by Monash Graduate Research Scholarship and Monash International Tuition Fee Scholarship. J.I. has received funding from AstraZeneca and Amgen for projects unrelated to this study. A.L. is supported by a Commonwealth Research Training Program (RTP) scholarship. J.S.B. was supported by an NHMRC Boosting Dementia Research Leadership Fellowship and has received grant funding or consulting funds from the NHMRC, Medical Research Future Fund, Victorian Government Department of Health and Human Services, Dementia Australia Research Foundation, Yulgilbar Foundation, Aged Care Quality and Safety Commission, Dementia Centre for Research Collaboration, Pharmaceutical Society of Australia, Society of Hospital Pharmacists of Australia, GlaxoSmithKline Supported Studies Programme, Amgen, and several aged care provider organizations unrelated to this work. All grants and consulting funds were paid to the employing institution. J.I.M. and Z.A. were supported by the National Health and Medical Research Council (NHMRC) Ideas Grants Application ID: 2012582. The funder had no input into the design of the study or decision to submit for publication.

T.B.A.: conceptualization(equal); formal analysis (equal); methodology (lead); software (equal); visualization (equal); writing – original draft (lead); and writing – review and editing (equal). J.I.: conceptualization (support); writing – review and editing (equal); and supervision (support). A.L.: writing – review and editing (equal); formal analysis (support); and software (support). J.S.B.: writing – review and editing (equal). J.I.M.: conceptualization (lead); formal analysis (equal); methodology (lead); software (equal); visualization (equal); writing – review and editing (equal); and supervision (equal). Z.A.: conceptualization (lead); methodology (lead); visualization (support); writing – review and editing (equal); supervision (lead); and resources (lead).

Additional Information

Jedidiah I. Morton and Zanfina Ademi share last authorship.

The access data can be requested from the data custodians (Centre for Victorian Data Linkage and AIHW) via an application process.

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