title: Centralising and optimising decentralised stroke care systems: a simulation study on short-term costs and effects.
abstract: Centralisation of thrombolysis may offer substantial benefits. The aim of this study was to assess short term costs and effects of centralisation of thrombolysis and optimised care in a decentralised system.
  
  
  
  Using simulation modelling, three scenarios to improve decentralised settings in the North of Netherlands were compared from the perspective of the policy maker and compared to current decentralised care: (1) improving stroke care at nine separate hospitals, (2) centralising and improving thrombolysis treatment to four, and (3) two hospitals. Outcomes were annual mean and incremental costs per patient up to the treatment with thrombolysis, incremental cost-effectiveness ratio (iCER) per 1% increase in thrombolysis rate, and the proportion treated with thrombolysis.
  
  
  
  Compared to current decentralised care, improving stroke care at individual community hospitals led to mean annual costs per patient of $US 1,834 (95% CI, 1,823-1,843) whereas centralising to four and two hospitals led to $US 1,462 (95% CI, 1,451-1,473) and $US 1,317 (95% CI, 1,306-1,328), respectively (P < 0.001). The iCER of improving community hospitals was $US 113 (95% CI, 91-150) and $US 71 (95% CI, 59-94), $US 56 (95% CI, 44-74) when centralising to four and two hospitals, respectively. Thrombolysis rates decreased from 22.4 to 21.8% and 21.2% (P = 0.120 and P = 0.001) in case of increasing centralisation.
  
  
  
  Centralising thrombolysis substantially lowers mean annual costs per patient compared to raising stroke care at community hospitals simultaneously. Small, but negative effects on thrombolysis rates may be expected.
authors.affiliation: Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, P.O. Box 30001, 9700 RB, Groningen, The Netherlands. m.m.h.lahr@umcg.nl.
authors.forename: Maarten M H
authors.initials: MM
authors.lastname: Lahr
authors.affiliation: Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands.
authors.forename: Durk-Jouke
authors.initials: DJ
authors.lastname: van der Zee
authors.affiliation: Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
authors.forename: Gert-Jan
authors.initials: GJ
authors.lastname: Luijckx
authors.affiliation: Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
authors.forename: Patrick C A J
authors.initials: PC
authors.lastname: Vroomen
authors.affiliation: Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, P.O. Box 30001, 9700 RB, Groningen, The Netherlands.
authors.forename: Erik
authors.initials: E
authors.lastname: Buskens
mesh_terms: D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D004469:Economics, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data*; D017598:Efficiency, Organizational / Q000191:economics; D005843:Geography; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D009426:Netherlands; D017063:Outcome Assessment, Health Care / Q000191:economics / Q000706:statistics & numerical data; D020521:Stroke / Q000191:economics / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000191:economics / Q000379:methods*
keywords: Costs; Organisational model; Simulation models; Stroke; Thrombolysis