To evaluate the impact of the COVID-19 pandemic on inpatient stroke care costs in a 23 hospital, integrated University Hospitals System Stroke Program (UHSSP).  

Since 2008, the UHSSP implemented system-wide clinical practice guidelines and analytics to optimize high-value stroke care by improving quality and reducing unnecessary costs of care.  

All stroke hospital discharges for DRGs 64-66 at 12 UHSSP hospitals were analyzed for volume, case mix index (CMI), inpatient total direct costs (TDC) including length of stay (LOS), ICU LOS, diagnostics, imaging, lab, OR, Pharmacy, supply and direct contribution margin (DCM) using EPSi™ and quality using GWTG- Stroke® and STATIT piMD™.  The data encompassed three waves: 2017 (baseline), 2019 (2 years into a high-reliability initiative), and through 2q2022 (2 years into the pandemic). 

For all medically managed stroke at the academic hub, the average TDC, CMI and positive DCM all increased (by +15%, +0.07, and +0.5% respectively) in 2019 over baseline in 2017.  However, in 2q2002 over 2019, there was a significant increase in TDC, not scaled to the increase in CMI, and associated with a significant reduction in the positive DCM (by +63%, +0.06, and -61% respectively).  The increased costs were driven by increased ICU LOS (ratio of ICU LOS vs non-ICU LOS +37%, from 2.05 to 2.8-fold) associated with nursing shortages and shifting step-down care to the ICU, and anticoagulant reversal agents accounting for a growth of 37% to 56% of all pharmacy costs.  The same pattern was seen analyzing all hospitals in aggregate. 

The inpatient stroke costs have increased significantly since the pandemic, resulting in many health systems now operating in a deficit.  Analyses have focused on pharmacy, labor and supply costs.  This report identifies an unanticipated significant cost related to prolonged ICU LOS resulting from nursing staffing shortages.