In this paper, I will set out to provide an understanding of stroke and its impact or costs on the afflicted individual and his or her caregivers. These costs include physical, psychological, social and healthcare costs. Key findings that are available in Singapore about stroke and the consequences on the afflicted will be presented. Through an understanding of the condition, important recommendations on improving the wellbeing of the people who are at risk are presented. Preventive measures promoted by the government are seen as critical in bringing down cases of a health condition that is noticeably increasing in the population over the years.
Stroke is one of the leading causes of death and disability in many countries. It was reported that, in 2013, there were nearly 25.7 million stroke survivors worldwide, but 6.5 million deaths resulting from stroke. 113 million disability-adjusted life-years (DALYs) were lost because of stroke, and 10.3 million new cases of strokes were found (Feign, et al., 2015). The numbers are expected to rise especially among youths (Béjot, Delpont, & Giroud, 2016). In Singapore, stroke is the fourth leading cause of death, with an approximate death rate of 40.4/100 000 in 2006, a prevalence of 3.65% and an incidence of 1.8/1000. It is among the top ten causes of hospitalization. It is also estimated that the total cost of hospital care for acute stroke per patient is about US$5000 (Venketasubramaniam, 2017). The amount is particularly significant if patients are from lower-income groups. This does not include the costs of after-hospital care at home. This thus highlights the gravity of the situation in terms of costs.
According to the Ministry of Health (2009), cardiovascular diseases were responsible for one-fifth of the total disease and injury burden in Singapore in 2010. It was identified that stroke was one of the main contributors of the cardiovascular burden. The burden also falls on the government which provides subsidies to reduce costs for the patient. It is noted that this shared burden was the largest in treating patients with cardiovascular and stroke problems. These two conditions took up 30% of the total shared burden among the elderly (MOH, 2009). This is despite the fact that there is widely available subsidized healthcare for primary level and hospital care, and rehabilitative services. Due to these concerns with costs, a national stroke support group has also been established (Venketasubramaniam, et al., 2017).
So what causes stroke? A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue (Venketasubramaniam, et al., 2017). Stroke is an emergency where treatment options necessitate a need to act fast. It is important to quickly access the hospital as this is a prerequisite to be treated. Other modalities of stroke care include management of complications, rehabilitation, and prevention of recurrence. There are many factors that contribute to stroke, and this which includes gender, race, ethnicity, and heredity. Others factors like hypertension, diabetes mellitus, cardiac diseases, hyperlipidaemia, obesity, smoking, and consumption of alcohol are also identified (O’Donnell, et al., 2010).
Another concern will be the healthcare costs for a stroke patient. Such costs increase along with the increasing number of stroke cases. With the ageing population, the burden of stroke is expected to increase dramatically in the years to come, posing challenges to the healthcare system and society (Venketasubramaniam, et al., 2017). Therefore, a proper management plan incorporating high-quality clinical care coupled with research would be essential.
Stroke is most often seen in the elderly male, and with worldwide aging populations (Teh, et al., 2018), is often associated with greater care needs. Furthermore, studies have also shown that the prevalence of stroke survivors in Singapore is relatively high when compared to other Asian countries (Teh, et al., 2018).
Depending on the severity of stroke, there are several effects of stroke on patients which include weaknesses that affect the whole side of the body or arm or just one leg. This leads to balance and coordination problems, even though his or her muscles may be strong enough to perform the activities (Healthhub, 2018).
In addition, there may be speech and articulation issues and this may cause others to have difficulties understanding the stroke patients. Stroke may cause memory, attention, thinking and other learning difficulties. Many stroke patients also have difficulties in swallowing. Many times, the food may be trapped in the mouth as patient may have difficulties in coordinating his or her tongue (Healthhub, 2018). Therefore, care is needed to make sure patients will not have any aspiration. Stroke patients may also have difficulty in controlling their bladder and passing motion, thus, patients may end up needing diapers (Healthhub, 2018). Stroke patient may also feel the financial burden not only on himself but also on his caregivers for example long term rehabilitation, medication and attending appointments. Thus, with all the disabilities, it is very common that stroke patients may end up getting into depression. Therefore, they become emotionally unstable. Patients have been noted to have feelings of confusion, shock, helplessness, grief, guilt, frustration, and anger, and all these lead to depression (Low, et al., 1999) as they may feel there is no quality of life.
While caregivers themselves have to cope with the devastating effects that stroke has on their loved ones, an increasing amount of demands is made on them. The caregivers may need to provide emotional support or assist the patient in activities of daily living. Consequently, this leads to many challenges when caring for a stroke patient. Although caregiving has also a positive aspect for the family members, the burden of informal care emphasises the need for new methods of enacting sustainable long-term care. In addition, the burden of care experienced by family caregivers including physical, physiological, social and healthcare costs, is the dominant factor for the caregiver to consider in the caregiving process.
Many stroke survivors are painfully aware of the effects of the stroke on their loved ones, and feel that they have become a burden. Studies have also reported that, for many caregivers, providing care was demanding and had a significant impact on their own physical health, leading to great physical and mental tiredness (Draper, 2007). Such fatigues was due to their relative’s need for constant care or supervision or the constant travel to and from hospital to visit the patients (Draper, 2007). The co-existence of longstanding conditions that reduced the patient’s independence further increased caregivers’ physical tiredness (Draper, 2007).
Moreover, in an Asian country like Singapore, many elderly patients still live with their family members. Thus, it is expected that there will be a substantial increase in burden and reliance on family members for their daily needs especially if they are disabled. Thus, there is a need to extend and improve existing services given to stroke survivors and to caregivers. Therefore, the government’s role is crucial in developing strategies to meet the health care needs of individuals with stroke.
Adopting the Wagner Chronic Model (2009) as shown above, health-care practices to improve the health of stroke patients can shift fundamentally from acute and reactive care, to one that is organized, structured, planned, patient-centred and proactive. This is done through a combination of effective multidisciplinary team care and planned interactions with patients. There are vital elements of the model which include strengthening the provider–patient relationship and improving health outcomes through self-management support, effective use of community resources, integrated decision support for professionals, and the use of patient registries and other supportive information technology (Wagner, 2009).
By providing caregivers and patients with support, this may not only improve their own health but also the quality of life of the stroke patients. Furthermore, minimising the stress of the family is crucial in the course of rehabilitation and support for the patient after stroke. There have been intervention programs which have been developed in Singapore, and these include education, support services, behavioural and psychotherapeutic techniques, self-help groups, and respite care to mobilise networks, creating new sources of support to decrease conflicts and enhance the quality of support (Cheah, et al., 2001). Various interventions have also been developed to support family members and to improve their involvement in the care process. Visits by a specialist outreach nurse and a stroke family care worker help the caregiver to understand the requirements and issues related to caring for such patients, as well as how they themselves can seek the required support. Long-term counselling is also provided for caregivers to address underlying emotional, physical and mental issues they may have.
In Singapore itself, primary healthcare is provided by a chain of polyclinics which constitute 20% of such care, with the remaining 80% comprises of private general practice clinics (MOH, 2009). Singaporeans with acute stroke are generally admitted to the “restructured” hospitals or, less commonly, to private general hospitals (Venketasubramanian, 2008). Care at public facilities is heavily subsidised by the government. Therefore, the increased emphasis on primary care and prevention is an outcome that may give heart to policymakers trying to work out how to pay for ballooning healthcare costs which is an enduring focal point in the country’s Budget. In Budget 2017, $10 billion was allocated for healthcare expenditure, and the amount is expected to go up to at least $13 billion by 2020 (MOH, 2017).
A critical development to address the issues facing stroke victims and their caregivers was the establishment of the Singapore National Stroke Association (SNSA). It is an organisation meant to support not only the patients but also their caregivers. It was registered under the Societies Act in December 1996, and was granted Charity Status in November 1998. SNSA is a member of the National Council of Social Service since March 1999. This organisation was established to better understand the needs of the stroke survivors and caregivers in Singapore.
There is a very strong community support for stroke patients and their caregivers. When the caregivers face problems in managing their condition, they could be referred to professional/volunteer services who assist in helping the stroke survivors. For example, volunteers visit patients in the hospital to reach out to them and give them encouragement and a listening ear (SNSA, 2018). In SNSA, activities are conducted to bring the stroke survivors and their caregivers together. These activities include bowling, participating in social activities, offering emotional support to one another, and sharing common challenges and knowledge about stroke.
The aim of SNSA is primarily to be a platform for both stroke survivors and caregivers to meet informally. SNSA also provides management, prevention, and awareness programmes in the community. There are many talks presented to the public and, a website with comprehensive information on stroke and its prevention has been developed (SNSA, 2018). Furthermore, an app was also created for the “Stroke Patient”. It is designed specifically for patients recovering from a stroke, their families and their friends. It helps to explain strokes, available treatments and the hospital care process. The app, created by a team of stroke specialists, provides easy-to-understand information on strokes and emergency stroke treatments (SNSA, 2018).
Despite many advances made in preventing and managing stroke, many still suffer from stroke which seems to be a prevalent and a burdensome condition particularly among elderly patients. Is it because of the ageing population or is it because there is minimal approach to reach out to the patients with underlying diseases that cause stroke? In an article by Lenfant (2003), it was noted that Health-care delivery often focuses on acute problems and only on short-term solutions, without the initiation of chronic professional treatment or the active involvement of chronically ill patients. Therefore, it is vital that health-care delivery should also focus on helping patients in self-management and self-empowerment. Improved outcomes could result for patients. There is evidence that interventions that result in improved disease control also help in reducing total health care costs for patients with chronic illnesses (Goetzel, et al., 2005).
There was an activity launched by NTUC Health launched in collaboration with SNSA in October 2014. It was called the LIFE After Stroke programme. Its goal was to improve the well-being and value of life for stroke patients in society. The programme utilises the “Learn, Interact, Flourish and Engage (L.I.F.E.)” elements through self-empowerment, deep interactions, peer support, group activities and excursions, group workouts monitored by therapists, and instructive talks by doctors, nurses, allied health professionals and stroke survivors (SNSA, 2018). This activity was important to better empower patients in understanding and managing their health.
It is also crucial that that an introduction of a multidisciplinary team in developing and implementing a disease management programme be promoted. The team should include doctors, nurses, pharmacists, therapists, case managers, and administrators. The team could establish its aims and move forward on what needs to be done, how it should be done, who would do it, and how much it would cost. The team must also anticipate the barriers to change. The same team could help evaluate the success of the programme on the basis of agreed performance and outcome indicators. Having clinician leaders and providing them with accountability and resources is crucial in getting their support and ownership of the programme.
In addition, in a study by Langhorne & Duncan, (2001), it was indicated that an organised multidisciplinary inpatient rehabilitation was important and it was associated with decreased mortality, and, increased independency and institutionalisation. This means that it was crucial that all stroke patients should receive the most appropriate rehabilitation to enhance their recovery and minimise their disability.
In a study by Kuo et al. (2012), there was also a development of an information technology (IT)-mediated home-based healthcare model designed to improve the effectiveness of caring for stroke patients who require chronic, home care. This system helped physicians, patients, and their families to more efficiently detect the occurrence of recurrent stroke. This model was integrated into the healthcare industry to improve the effectiveness of self-care in chronic care, especially for BP control. This model helped to effectively monitor the risk of stroke occurrence when patients are at home and instantly provide an emergency transfer.
Besides, one of the leading causes of stroke is hypertension. Most hypertension stays insufficiently controlled (Green, et al., 2008). In another study by Green et al (2008), it was noted that a “web-based health monitoring with a pharmacy-intervened healthcare model” provides people with detailed information on self-care and helps them achieve the goal of proper BP control.
Therefore, in Singapore, we could implement similar or web-based designs or an app that could help patients and their caregivers to monitor not only their stroke reoccurrence but also diseases that lead to stroke. This would be beneficial to reduce the prevalence and help them to better manage their condition. Besides, since there is an increasing number of patients who are also prescribed a large amount of long-term medications, having the multi-discipline team monitoring the patient’s medication will further enhance and reduce considerable wastage of medicine and also reduce the patient’s burden including costs. Collaboration and cooperation among the multidisciplinary parties will help ensure a successful and sustainable programme for the stroke patients.
Other recommendations, which include creating awareness among at-risk patients who suffer from diabetes, hypertension, and hyperlipidaemia, may help in the long term in preventing stroke.
This topic highlights the fact that both changes in the care delivery and quality of care is important in managing stroke patients and their caregiver. These findings are crucial especially since there is currently an increasing prevalence of stroke patients. New applications of information technology to self-empower patients and their caregiver will help in managing and preventing stroke rather than leaving the burden to the healthcare system. Moreover, better collaboration and cooperation among the members of the multidisciplinary team is crucial in the redesign and implementation of the disease management programs. This could contribute to more comprehensive and efficient quality of care. In addition, the individual and the caregivers have reduced burden in terms of healthcare costs and physical, physiological and social issues.
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