American Heart Association's Quality and Outcomes Research Scientific Sessions
American Heart Association's Quality and Outcomes Research Scientific Sessions
April 09, 2018
4 min read

Depression affects outcomes, costs after stroke, MI

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Depression increased annual health care expenditures and health resource utilization and worsened outcomes in patients with MI or stroke, according to data presented at the American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions.

“There is a lot of room for improvement in the screening of ASCVD patients for depression, as this could improve health care efficiency and ultimately health outcomes among these individuals,” Victor Okunrintemi, MD, MPH, research fellow at Baptist Health South Florida in Coral Gables, told Cardiology Today.

Depression, atherosclerotic CVD

Okunrintemi and colleagues analyzed data from 19,840 patients from the 2004-2015 Medical Expenditure Panel Survey with atherosclerotic CVD who represented 18.3 million U.S. adults. The Patient Health Questionnaire-2 was used to stratify patients by depression risk.

A high risk for depression was seen in 8.6% of patients.

Compared with patients with low risk for depression, those with high risk had higher out-of-pocket and overall health care expenditures, more emergency room visits and hospitalizations, poor patient satisfaction and poorer perception of their health status.

Furthermore, non-depressed atherosclerotic CVD patients at a high risk for depression were also more likely to have significantly worse health-related quality of life, higher chance of poor perception of their health status (OR 1.83; 95% CI, 1.5-2.23) and poor patient-provider communication (OR 1.29; 95% CI, 1.18-1.42), when compared with atherosclerotic CVD patients who already have a diagnosis of depression.

“The results from this study show that non-depressed ASCVD patients at high risk for depression have worse patient experience when compared with those who already have depression,” Okunrintemi said in an interview. “This is probably because a lot of these high-risk patients might be depressed, but the diagnosis is missed and untreated, hence worsening health outcomes. Routine screening of ASCVD patients at follow up outpatient visits may be an appropriate approach to reduce the under diagnoses of depression among these individuals.”

Increased expenditures, utilization for MI

In a separate study, Okunrintemi and colleagues reviewed data from the 2006-2015 Medical Expenditure Panel Survey of patients with MI. Depression was seen in 1,381 patients, who represented 1.42 million people. Those free from depression (n = 6,702) represented 7.16 million patients.

The mean age of patients from both groups was 65 years, and 63% were men.

Compared with patients without depression, those diagnosed with depression were more likely to be hospitalized (OR = 1.54; 95% CI, 1.29-1.83) and visit the ED (OR = 1.43; 95% CI, 1.21-1.69). These patients also had significantly greater mean annual expenditures than those without depression ($20,648 vs. $14,343; P < .001).

Annual overall health care expenditures were $4,381 higher in patients with depression vs. those without. Patients with depression also had $402 higher out-of-pocket health care expenses compared with those without depression.

“As a quality improvement measure to increase health care efficiency, routine depression screening at follow-up visits may be appropriate, especially among these high-risk populations,” Okunrintemi and colleagues wrote.

Outcomes with pre-stroke depression

Patients with depression before a stroke had an increased risk for functional decline after ischemic stroke discharge and worse outcomes compared with those without depression, according to a presentation by Shreyansh Shah, MD, assistant professor of neurology at Duke University School of Medicine.

Shreyansh Shah, MD
Shreyansh Shah

“The findings from this study are hugely significant for patients recovering from stroke, physicians treating them and caregivers of stroke patients,” Shah told Cardiology Today. “It highlights the fact the in order to make a good recovery from stroke, it is very important that everyone realizes how important is to treat the depression associated with it.”

In this study, Shah, Emily O’Brien, PhD, assistant professor in population health sciences at Duke University, Adrian Hernandez, MD, MHS, vice dean for clinical research and professor of medicine at Duke University School of Medicine, director of Health Services Outcomes Research and faculty associate director of Duke Clinical Research Institute, and colleagues analyzed patient-reported outcome measures from 1,617 patients from the PROSPER study.

The modified Rankin Scale was assessed after discharge for stroke, 3 months and 6 months. Other outcome measures that were reviewed at 3 and 6 months included EuroQol-5D-3L, Patient Health Questionnaire-2, EuroQol Visual Analog Scale, Fatigue Severity Scale and Stroke Impact Scale-16.

Patient medical history was used to identify patients with pre-stoke depression.

Pre-stroke depression was seen in 11.4% of patients. Those identified with pre-stroke depression were more likely to be women, white and have more CV risk factors compared with those without depression.

Although both groups had similar functional status and stroke severity, those with pre-stroke depression had worse patient-reported outcome measures at 3 and 6 months.

Patients with pre-stoke depression had higher odds of functional decline (OR = 1.56; 95% CI, 1-2.42) 3 to 6 months before discharge, with a greater negative effect of stroke on their health and life. These patients were also more likely to report severe fatigue while recovering from stroke compared with those without pre-stroke depression (OR at 6 months = 2.31; 95% CI, 1.55-3.45).

“At that time, there is a significant lack of data regarding what is the most effective therapy, either medical or behavioral, for treating depression in patients who had stroke,” Shah said in an interview. “There is a huge need for randomized controlled clinical trials to identify more effective ways for treating depression in stroke patients.” – by Darlene Dobkowski


Okunrintemi V, et al. Presentation 240.

Okunrintemi V, et al. Presentation 241.

Shah S, et al. Presentation 17. All presented at: American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions; April 6-7, 2018; Arlington, Va.

Disclosures: Okunrintemi and Shah report no relevant financial disclosures.


Editor’s Note: This article was amended on April 10, 2018 to reflect updates to the data.