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Systematic review of economic evidence on stroke rehabilitation services

Published online by Cambridge University Press:  02 March 2005

Bruce K. Brady ,
Lynda McGahan  and
Becky Skidmore
Bruce K. Brady
Affiliation:
Canadian Coordinating Office for Health Technology Assessment (CCOHTA)
Lynda McGahan
Affiliation:
Canadian Coordinating Office for Health Technology Assessment (CCOHTA)
Becky Skidmore
Affiliation:
Canadian Coordinating Office for Health Technology Assessment (CCOHTA)
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Abstract

Objectives: Given the resource-intensive nature of stroke rehabilitation, it is important that services be delivered in an evidence-based and cost-efficient manner. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of three rehabilitation services after stroke: stroke unit care versus care on another hospital ward, early supported discharge (ESD) services versus “usual care,” and community or home-based rehabilitation versus “usual care.”

Methods: A systematic literature review of cost analyses or economic evaluations was performed. Study characteristics and results (including mean total cost per patient) were summarized. The level of evidence concerning relative cost or cost-effectiveness for each service type was determined qualitatively.

Results: Fifteen studies met the inclusion criteria: three on stroke unit care, eight on ESD services, and four on community-based rehabilitation. All were classified as cost-consequences analysis or cost analysis. The time horizon was generally short (1 year or less). The comparators and the scope of costs varied between studies.

Conclusions: There was “some” evidence that the mean total cost per patient of rehabilitation in a stroke unit is comparable to care provided in another hospital ward. There is “moderate” evidence that ESD services provide care at modestly lower total costs than usual care for stroke patients with mild or moderate disability. There was “insufficient” evidence concerning the cost of community-based rehabilitation compared with usual care. Several methodological problems were encountered when analyzing the economic evidence.

Keywords

Cerebrovascular accidentRehabilitationEconomicsReviewMeta-analysis

Information

Type
GENERAL ESSAYS
Information
International Journal of Technology Assessment in Health Care , Volume 21 , Issue 1 , January 2005 , pp. 15 - 21
Copyright
© 2005 Cambridge University Press

OBJECTIVES

The evaluation of stroke rehabilitation services poses a challenge for economists, given the long-term and variable nature of disability after stroke, the associated multiple outcomes, and the variety of elements comprising the different services. This study reviews the evidence on the relative cost and cost-effectiveness of rehabilitation interventions after stroke, including stroke unit (SU) care, early supported discharge (ESD) services, and community-based rehabilitation.

Details of the systematic reviews of the clinical and economic evidence of these stroke rehabilitation services can be found in a report (15) published by the Canadian Coordinating Office for Health Technology Assessment (CCOHTA). To parallel the clinical review, we performed a literature search of economic studies for a fourth comparison: the impact of different intensities (duration) of rehabilitation therapies after stroke. However, no studies for this intervention met the inclusion criteria.

METHODS

We performed a systematic review to summarize and then appraise the economic evidence, based on the steps outlined in CCOHTA's guidelines for authors (1).

Study Selection Criteria

Study type: Primary studies that were either an economic evaluation or a cost analysis (collectively referred to as “economic studies”) were included. An economic evaluation was defined as the comparative analysis of two or more alternatives, in terms of costs and consequences. It includes four types of analyses: cost minimization, cost effectiveness, cost utility, and cost benefit. A cost analysis was defined as a comparison of the costs of alternatives at the microlevel. Studies that only assessed resource use (e.g., length of stay, or LOS) were excluded, unless unit costs were indicated.

Population: Patients of all ages with a clinical definition of stroke (focal neurological deficit caused by cerebrovascular disease) were included.

Interventions and comparators:

  • i care in an SU, including rehabilitation (with specialized teams of physicians and professional staff caring exclusively for stroke patients) versus care on a general medical ward or a geriatric ward;
  • ii ESD services (releasing patients from hospital earlier than usual, using organized interdisciplinary teams to support patients at home) versus usual care; and
  • iii rehabilitation in the community (hospital-based outpatient therapy clinics or home-based therapy that aims to prevent admission to hospital) versus usual care.

Usual care in (ii) and (iii) included all comparators defined in the study.

Literature Search Strategy

Published literature was identified through a cross-database search of relevant DIALOG databases. We performed parallel searches on AgeLine, CINAHL, PubMed, The Cochrane Library, and the Health Economic Evaluations Database. Searches were limited to literature published from January 1995 (1990 for PubMed) onward, with results incorporated up to July 31, 2002. Gray literature was obtained through searching specialized rehabilitation databases and Web sites of health technology assessment and related agencies. Clinical trial registries were also searched.

Data Extraction

Two reviewers independently selected studies; any disagreement was resolved through consensus. One reviewer extracted relevant information from the selected studies using a standardized form.

Data Synthesis

A qualitative approach summarizing the characteristics and results of the selected studies was used for data synthesis. The results of the studies were not pooled quantitatively, given the variation in study characteristics. Information on mean total cost per patient, the direction and magnitude of total costs (relative to the comparator), and statistical significance were tabulated.

The level of evidence concerning the relative cost or cost-effectiveness for each service type was determined subjectively by weighing several factors: the number of studies, the consistency of cost trends, the “robustness” of results (including statistical significance and results of sensitivity analysis), and the methodological quality of studies. No formal assessment of methodological quality was done; however, the limitations and transparency (in terms of fulfilling the data extraction form items) of each study were noted. Higher quality studies were given more weight. The economic evidence for each service type was graded as “good,” “moderate,” “some,” or “insufficient.”

RESULTS

Search Results

Fifteen primary studies met the inclusion criteria: three on SU care (6;9;13), eight on ESD services (2;3;5;10;12;14;17;18), and four on community-based rehabilitation (4;7;16;20).

Study Characteristics and Methodological Quality

Table 1 summarizes characteristics of the fifteen studies. All studies were classified as “cost-consequence analysis” or “cost analysis” (although some were labeled differently by their authors). Eleven were set in Europe (six in the United Kingdom), two in Australia, and one each in Canada and Hong Kong. The time horizon of the studies was generally short (1 year or less), although one had a lifetime horizon. Eleven studies were based on the health outcomes, resource use, and costs of specific trials (for details on health outcomes, refer to the clinical review in the CCOHTA report). In three studies, data from several sources were used in a model. More than half of the studies conducted sensitivity analyses; some studies also stratified results according the degree of disability (e.g., descriptive level, activities of daily living or Barthel Index score, or ward of discharge).

The scope of costs (hence, “study perspective”) varied between studies. Some studies used a health service payer perspective; others also captured the costs of social services or institutional care. Five studies also captured societal elements, including the direct costs incurred by patients and the indirect costs incurred by informal caregivers.

Economic Results

The results of the economic studies are summarized in Table 1.

(i) SU care versus care on another hospital ward

All three studies (6;9;13) of SU care were set in Europe, included patients with various disability levels, and captured the costs of community and outpatient care in the analysis. The intervention in the study by Claesson et al. (6) was an acute SU linked with continued care in geriatric SUs when a long rehabilitation period is needed. The SU data in the Hagenmeyer et al. (9) study was derived from Scandinavian randomized controlled trials, in which the SU uses early mobilization and interdisciplinary rehabilitation.

All three studies showed that SU care had slightly lower costs than rehabilitation on other hospital wards. The cost of SU care was 11 percent lower (no significant difference, or NS) in the Claesson study. In the Hagenmeyer study, both total direct (lifetime) costs, as well as societal costs (which include the cost of lost productivity), were 3 percent lower in SU care compared with conventional care (statistical significance not reported, or NR). (The societal costs are only reported in the full German-language study (8).) Two studies (6;9) indicated that lower SU costs for nursing care were partly offset by higher outpatient costs. The Claesson study found that informal care costs were lower (NS) in SU care and indicated the gap would likely increase after 1 year. The study by Major and Walker (13) indicated there were limitations to the data on LOS but that “it seems reasonable to conclude that, within the randomized trials, stroke unit care did not increase length of stay and may have reduced it.”

Several strengths in these studies were noted. The lifetime analysis of the Hagenmeyer (8) study considered long-term consequences (including the higher incidence and costs of recurrent stroke due to increased survival of SU patients) and the cost data were based on larger trials. Also, no inconsistencies in health outcomes were uncovered between the three studies and the results of the CCOHTA clinical review (e.g., better survival for SU care).

(ii) ESD services versus usual care

The studies of ESD services were set in Australia (two) (2;3), Canada (one) (17), Hong Kong (one) (12), Sweden (two) (10;18), and the United Kingdom (two) (5;14). All but one evaluated home-based care; the study by Hui et al. (12) evaluated rehabilitation in a day hospital. The comparator was “conventional” rehabilitation (defined as a mixture of services) in six studies and hospital rehabilitation in two (10;14). All studies were based on data from single trials except the study by Anderson et al. (3), which used data from a meta-analysis. All studies had a health service or health and social services perspective, although some also collected data on informal caregiver burden or costs.

Two studies of high methodological quality, the studies by Beech et al. (5) and Anderson et al. (3) involved many participants with a follow-up of 1 year. Both used good costing methods. Four studies (2;14;17;18) were of medium quality, as they were smaller trials that lasted 3 months to 1 year.

The six higher quality studies (2;3;5;14;17;18) reported a trend toward modestly lower costs for ESD services compared with usual care, ranging from 4 percent to 30 percent. The difference in costs was statistically significant in only the study by Teng et al. (17). Four of the higher quality studies reported that lower ESD costs were robust in sensitivity analysis.

The two lower quality studies, Holmqvist et al. (10) and Hui et al. (12), showed ESD services had higher costs than usual care. Little weight was given to these studies, as the Holmqvist study was a small, dated, nonrandomized pilot study and the Hui study was dated and evaluated rehabilitation in a day hospital.

All studies of home-based care reported that LOS in hospital was lower in the home-based group, consistent with the findings in the CCOHTA report's clinical section. In three studies (5;14;17), lower costs were offset by higher community care or social services costs.

The six higher quality studies suggest “moderate” evidence of modestly lower costs of ESD services compared with usual care but there are several qualifications:

  1. Service variation: It is difficult to generalize the findings, given the mixture of comparators in the eight studies. For example, the comparator in the Teng (17) study was a mixture of inpatient and outpatient rehabilitation, private care and home care; some patients received no rehabilitation. The duration of home rehabilitation in the eight studies also varied from 4 weeks to 4 months.
  2. Patient characteristics: In most studies, the patients had mostly mild to moderate disability. Therefore, the results of the trials may be relevant only to this group. There was also conflicting evidence on the relative costs of ESD services according to the degree of disability. The study by Anderson et al. (2) found greater cost savings (a statistically significant difference, or SD) for less disabled patients in the ESD group, whereas the study by McNamee et al. (14) found that the better functioning patients in the ESD group had higher costs (SD) than those in the comparator group.
  3. Readmissions: There was conflicting evidence on the impact of ESD services on hospital readmissions. The studies by Anderson et al. (2) and Holmqvist et al. (10) found higher readmissions in the ESD services group (due to one severely disabled patient in the latter study), the Beech study found readmissions to be similar, and the Teng study found readmissions were lower in the ESD services group. Teng found that readmissions accounted for much of the cost difference between the ESD services and comparator groups.
  4. Informal care: The degree to which ESD services shift costs and burden from the health service to informal caregivers is unclear. The study by Anderson et al. (2) found informal costs were higher for ESD services (NR), whereas the study by von Koch et al. (18) found the costs to be lower (NS) for patients in the ESD services group. The Teng study reported that informal caregivers of patients receiving ESD services were less burdened (NS), although the patients generally had mild disabilities. A study by Holmqvist et al. (11) reported no significant difference in time spent by family caregivers.

(iii) Rehabilitation in the community versus usual care

Findings of the four studies of home-based rehabilitation showed conflicting results. The study by Gladman et al. (7) reported the cost of rehabilitation in the community was 27 percent higher (NR) than in a day hospital or outpatient rehabilitation. The study by Roderick et al. (16) also reported that the cost of rehabilitation in the community was higher by 26 percent (NS) than rehabilitation in a day hospital. Both studies were set in the United Kingdom and captured health and community or social services.

A prospective cohort study by Andersson et al. (4) found the cost of home-based rehabilitation was comparable (NS) to the cost of hospital-based rehabilitation after 12 months of follow-up. The study, which was set in Sweden, captured the costs of acute care, rehabilitation, home-help services, and nursing home care. The Andersson and Roderick studies found costs were shifted from the hospital to home-help or social services.

The Young and Forster study (20), which focused on physiotherapy in the United Kingdom, reported that the median direct cost of home physiotherapy was 38 percent lower (SD) than rehabilitation in a day hospital. Sensitivity analysis showed the cost results were robust. The Young and Forster study reported there was no significant difference in lost caregiver leisure time, caregiver stress, and community support.

No conclusion can be drawn about the relative cost of rehabilitation in the community given the limitations and conflicting results of these four studies. Comparators varied between studies and statistical significance was not found or reported in three studies (4;7;16). The Young study evaluated physiotherapy only and was small, dated, and of short duration. The results of the Gladman study were dated and dependent on ward of discharge and assumptions about the cost of the ambulance service. There was possible bias against community rehabilitation in the Andersson and Gladman studies due to the greater dependence of patients in the home-based group than the comparator at baseline. Also, the impact of community rehabilitation on informal caregivers is unclear (only the Young study considered the time spent by informal caregivers).

CONCLUSIONS

The three SU studies provide “some” evidence that the cost of SU rehabilitation is comparable to that in a conventional hospital ward, although one review (19) warned that smaller hospitals may have too few acute stroke patients to make stroke-specific services viable. There was “moderate” economic evidence that the cost of ESD services was modestly lower than for usual care, although this finding is qualified by caveats concerning the heterogeneity of the care “packages,” the limited applicability of the results to more disabled patients, and the uncertain impact of ESD services on hospital readmission and informal caregivers. No conclusions could be drawn about community-based rehabilitation given the limitations and conflicting results of the studies, and two studies (7;16) suggested that a range of options be provided for stroke patients discharged from the hospital.

Some problems made comparisons of service costs difficult:

  • Design of studies: including the difficulty in blinding trials, the inclusion of nonrandomized trials, the short duration (all but one were 1 year or less), underpowered trial sizes, the lack of statistical analysis (seven studies did not measure or report on precision), and the exclusion of informal caregiver costs.
  • Study heterogeneity: including the variety of comparators evaluated (in many studies, this variety was a mixture of different types of services), differences in the scope of costs captured (most excluded the costs of informal care), and uncertainty about the similarity of rehabilitation service “packages” with the same label.
  • Generalizability: findings applied to a portion of the stroke population (those with moderate to mild stroke severity), some older studies may not reflect current medical practice (data in six studies pre-date 1997), and reservations about generalizing results to settings where unit costs differ or where care is organized differently, in terms of staffing structures and the types and amounts of therapies used.

These limitations indicate a need for well-designed, adequately powered, and longer term studies that include a range of ages and severity levels and capture all consequences and costs, including those associated with hospital readmissions, long-term care, and informal care. Using quality-adjusted life years to measure the multiple outcomes would facilitate resource allocation through cost-utility analysis. Furthermore, there should be better reporting within studies, including a clearer description of the elements of stroke rehabilitation services and a separation of resource use from unit costs to allow for pooling of results and assigning different unit costs.

POLICY IMPLICATIONS

Drawing firm and “generalizable” policy implications from the economic evidence on stroke rehabilitation services is complicated for several reasons. These reasons include the inherent differences in rehabilitation service “packages,” difficulties with generalizing economic study results across settings, as well as other limitations of the primary studies included in this review. However, this review of the available evidence suggests that there is moderate evidence that ESD services provide care at modestly lower total costs than usual care for stroke patients with mild or moderate disability.

CONTACT INFORMATION

Bruce K. Brady, MA, MSc, Health Economist (); Lynda McGahan, MSc, Research Officer (), HTA Directorate, Canadian Coordinating Office for Health Technology Assessment (CCOHTA), 600-865 Carling Avenue, Ottawa, Ontario K1S 5S8, Canada

Becky Skidmore, MLS, Information Specialist (), Corporate Services Directorate, Canadian Coordinating Office for Health Technology Assessment (CCOHTA), 600-865 Carling Avenue, Ottawa, Ontario K1S 5S8, Canada

Funding, literature searching, and administrative assistance were provided by the Canadian Coordinating Office for Health Technology Assessment (CCOHTA).

Bruce Brady, Lynda McGahan and Becky Skidmore disclosed no conflicts of interest. The authors gratefully acknowledge Hussein Noorani of CCOHTA for leading the CCOHTA project on stroke rehabilitation services, of which the economic review summarized here was one component.

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Figure 0

Primary Economic Studies of Stroke Rehabilitation Services