Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals

 

Survivors don't give a damn about cost, THEY WANT TO KNOW; DOES THIS GET ME RECOVERED? Are the funders that blitheringly stupid?

Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals

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https://doi.org/10.1016/j.rehab.2024.101824Get rights and content

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Highlights

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  First cost-effectiveness analysis of different stroke rehabilitation pathways.

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  Inpatient unit followed by a community clinic was the most cost-effective pathway.

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  Day hospital followed by a community clinic was also a cost-effective pathway.

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  Cost-effectiveness analysis is consistent with stroke evidence-based practice.

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  The incremental cost-effectiveness ratios are coherent between both perspectives.

Abstract

Background

Stroke burden challenges global health, and social and economic policies. Although stroke recovery encompasses a wide range of care, including in-hospital, outpatient, and community-based rehabilitation, there are no published cost-effectiveness studies of integrated post-stroke pathways.

Objective

To determine the most cost-effective rehabilitation pathway during the first 12 months after a first-ever stroke.

Methods

A cohort of people in the acute phase of a first stroke was followed after hospital discharge; 51 % women, mean (SD) age 74.4 (12.9) years, mean National Institute of Health Stroke Scale score 11.7 (8.5) points, and mode modified Rankin Scale score 3 points. We developed a decision tree model of 9 sequences of rehabilitation care organised in 3 stages (3, 6 and 12 months) through a combination of public, semi-public and private entities, considering both the individual and healthcare service perspectives. Health outcomes were expressed as quality-adjusted life years (QALY) over a 1-year time horizon. Costs included healthcare, social care, and productivity losses. Sensitivity analyses were conducted on model input values.

Results

From the individual perspective, pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective, followed by pathway 1 (Rehabilitation Centre » Community Clinic). From the healthcare service perspective, pathway 3 was the most cost-effective followed by pathway 7 (Outpatient Hospital » Private Clinic). All other pathways were considered strongly dominated and excluded from the analysis. The total 1-year mean cost ranged between €12104 and €23024 from the individual's perspective and between €10992 and €31319 from the healthcare service perspective.

Conclusion

Assuming a willingness-to-pay threshold of one times the national gross domestic product (€20633/QALY), pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective strategy from both the individual and healthcare service perspectives. Rehabilitation pathway data contribute to the development of a future integrated care system adapted to different stroke profiles.

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Keywords

Pathway

Stroke

Rehabilitation

Outcomes

Cost-analysis

Health policy

Abbreviations

C

Outpatient Community Clinic

H

Outpatient Day Hospital

HB

Home-based Rehabilitation

ICER

Incremental Cost-Effectiveness Ratio

MMSE

Mini Mental State Examnation

mRS

modified Rankin Scale

N

Nursing Home

NHS

National Health System

NIHSS

National Institute of Health Stroke Scale

P

Outpatient Private Clinic

QALY

Quality-Adjusted Life Year

RC

Rehabilitation Inpatient Centre

UL

Long-Term Inpatient Unit

UM

Medium-term Inpatient Unit

US

Short-term Inpatient Unit

WHO

World Health Organization

WTP

willingness-to-pay

Introduction

Stroke rehabilitation should be intensive, timely, and multidisciplinary, with coordinated transfers between settings, and effective interfacing with social and community care [1]. However, post-stroke care is considered disorganized and fragmented even in the best health systems [2], and many survivors express dissatisfaction [3]. There are no universally agreed best practices across European countries, where different health service structures and payment systems often lead to inconsistent care pathways, type, and quality of therapies [4,5].

Stroke defies worldwide health, social and economic policies, as a global leading cause of mortality and disability [6]. By 2047 there will be an additional 40,000 incident stroke cases (+3 %) and 2.58 million prevalent stroke cases (+ 27 %) [7], and the corresponding economic burden will increase [8]. Approximately 3 to 4 % of total health expenditures in Western countries are allocated to stroke [9]. In 2017, 32 European countries spent €60 billion on stroke care, of which 45 % was for health care, 8 % for social care, 47 % for direct and indirect productivity losses. Of the €27 billion spent on stroke healthcare, only 18 % was spent on rehabilitation [10].

Despite recovery from a stroke being an arduous journey that takes months or years [11] and covers a whole spectrum of care, including in-hospital, outpatient, and community-based rehabilitation [12], there are no published cost-effectiveness studies of integrated post-stroke pathways [13]. Our previous work showed 9 different rehabilitation pathways, that suggested heterogeneity, inefficiency, and inequalities, followed by a heterogeneous satisfaction level [14].

In the last years, there has been a call to design new care settings that ensure greater consistency and effectiveness to meet the targets set for 2030 by the Action Plan for Stroke [4]. The extent of the challenge, combined with limited healthcare budgets emphasizes the need for an evidence-based and cost-effective analysis that contributes to post-stroke decision-making [15], bridging the gap between clinical guidelines, organizational models, and the provision of care.

This study evaluated the cost-effectiveness of post-stroke rehabilitation pathways using high-quality individual participant-level data. It aimed to (i) determine the cost structure of each pathway and ii) determine the most cost-effective rehabilitation post-stroke care pathway from the perspective of the individuals with stroke and that of the healthcare service.

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