Economic Evaluation of Adult Rehabilitation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials in a Variety of Settings

Utilization of early supported discharge and outpatient rehabilitation services following inpatient stroke rehabilitation

BACKGROUND

Studies examining factors associated with patient referral to early supported discharge (ESD)/outpatient rehabilitation (OPR) programs and utilization of ESD/OPR services after discharge from inpatient stroke rehabilitation (IPR) are scarce. Accordingly, we examined utilization of ESD/OPR services following discharge from IPR and patient factors associated with service utilization.

METHODS

Stroke patients discharged from IPR facilities in Alberta between April 2014 and March 2016 were included and followed for one year for ESD/OPR service utilization. Multivariable linear and negative binomial regressions were used to examine association of patients' factors with ESD/OPR use.

RESULTS

We included 752 patients (34.4% of 2,187 patients discharged from IPR) who had 40,772 ESD/OPR visits during one year of follow-up in the analysis. Mean and median ESD/OPR visits were 54.2 and 36 visits, respectively. Unadjusted ESD/OPR visits were lower in females and patients aged ≥ 60 years but were similar between urban and rural areas. After adjustment for patient factors, patients in urban areas and discharged home after IPR were associated with 83.5% and 61.9%, respectively, increase in ESD/OPR visits, while having a right-body stroke was associated with 23.5% increase. Older patients used ESD/OPR less than their younger counterparts (1.4% decrease per one year of older age). Available factors explained 12.3% of variation in ESD/OPR use.

CONCLUSION

ESD/OPR utilization after IPR in Alberta was low and varied across age and geographic locations. Factors associated with use of ESD/OPR were identified but they could not fully explain variation of ESD/OPR use.

Self-management Programs Within Rehabilitation Yield Positive Health Outcomes at a Small Increased Cost Compared With Usual Care: A Systematic Review and Meta-analysis

OBJECTIVE

To determine if self-management programs, supported by a health professional, in rehabilitation are cost effective.

DATA SOURCES

Six databases were searched until December 2023.

STUDY SELECTION

Randomized controlled trials with adults completing a supported self-management program while participating in rehabilitation or receiving health professional input in the hospital or community settings were included. Self-management programs were completed outside the structured, supervised therapy and health professional sessions. Included trials had a cost measure and an effectiveness outcome reported, such as health-related quality of life or function. Grading of Recommendations, Assessment, Development, and Evaluations was used to determine the certainty of evidence across trials included in each meta-analysis. Incremental cost-effectiveness ratios were calculated based on the mean difference from the meta-analyses of contributing health care costs and quality of life.

DATA EXTRACTION

After application of the search strategy, two independent reviewers determined eligibility of identified literature, initially by reviewing the title and/or abstract before full-text review. Using a customized form, data were extracted by one reviewer and checked by a second reviewer.

DATA SYNTHESIS

Forty-three trials were included, and 27 had data included in meta-analyses. Where self-management was a primary intervention, there was moderate certainty of a meaningful positive difference in quality-of-life utility index of 0.03 units (95% confidence interval, 0.01-0.06). The cost difference between self-management as the primary intervention and usual care (comprising usual intervention/therapy, minimal intervention [including education only], or no intervention) potentially favored the comparison group (mean difference=Australian dollar [AUD]90; 95% confidence interval, -AUD130 to AUD310). The cost per quality-adjusted life year (QALY) gained for self-management programs as a stand-alone intervention was AUD3000, which was below the acceptable willingness-to-pay threshold in Australia per QALY gained (AUD50,000/QALY gained).

CONCLUSIONS

Self-management as an intervention is low cost and could improve health-related quality of life.

Cost modelling rehabilitation in the home for reconditioning in the Australian context

BACKGROUND

Inpatient rehabilitation services are challenged by increasing demand. Where appropriate, a shift in service models towards more community-oriented approaches may improve efficiency. We aimed to estimate the hypothetical cost of delivering a consensus-based rehabilitation in the home (RITH) model as hospital substitution for patients requiring reconditioning following medical illness, surgery or treatment for cancer, compared to the cost of inpatient rehabilitation.

METHODS

Data were drawn from the following sources: the results of a Delphi survey with health professionals working in the field of rehabilitation in Australia; publicly available data and reports; and the expert opinion of the project team. Delphi survey data were analysed descriptively. The costing model was developed using assumptions based on the sources described above and was restricted to the Australian National Subacute and Non-Acute Patient Classification (AN-SNAP) classes 4AR1 to 4AR4, which comprise around 73% of all reconditioning episodes in Australia. RITH cost modelling estimates were compared to the known cost of inpatient rehabilitation. Where weighted averages are provided, these were determined based on the modelled number of inpatient reconditioning episodes per annum that might be substitutable by RITH.

RESULTS

The cost modelling estimated the weighted average cost of a RITH reconditioning episode (which mirrors an inpatient reconditioning episode in intensity and duration) for AN-SNAP classes 4AR1 to 4AR4, to be A$11,371, which is 28.1% less than the equivalent weighted average public inpatient cost (of A$15,820). This represents hypothetical savings of A$4,449 per RITH reconditioning substituted episode of care.

CONCLUSIONS

The hypothetical cost of a model of RITH which would provide patients with as comprehensive a rehabilitation service as received in inpatient rehabilitation, has been determined. Findings suggest potential cost savings to the public hospital sector. Future research should focus on trials which compare actual clinical and cost outcomes of RITH for patients in the reconditioning impairment category, to inpatient rehabilitation.

Efficacy of therapeutic exercise on activities of daily living and cognitive function among older residents in long-term care facilities: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

This study aimed to systematically analyze the efficacy of therapeutic exercise on activities of daily living (ADL) and cognitive function among older residents in long-term care facilities.

DATA SOURCES

PubMed, Cochrane Central of Register Trials, Physiotherapy Evidence Database, OTseeker, and Ichushi-Web were searched from inception until December 2018.

STUDY SELECTION

Databases were searched to identify randomized controlled trials (RCTs) of therapeutic exercise for long-term care facility residents aged 60 years and older, focusing on ADL and cognitive function as outcomes.

DATA EXTRACTION

Two independent reviewers extracted the key information from each eligible study. Two reviewers independently screened and assessed all studies for eligibility, extracting information on study participants, details of interventions, outcome characteristics, and significant outcomes. Any discrepancies were resolved by a third reviewer.

DATA SYNTHESIS

A total of 11 RCTs with 1,280 participants were eligible for analyses. Therapeutic exercise had a significant benefit on ADL (standard mean difference [SMD] = 0. 22, 95% confidence interval [CI]: 0.02, 0.42, p = 0.03)]. Subgroup analyses indicated that interventions were conducted ≥ 3 days per week [SMD = 0.42, 95% CI 0.02, 0.82, p = 0.04]. For cognitive function, group exercise and ≥ 3 days/week of intervention had a significant benefit (group exercise: mean difference [MD] = 3.36, 95% CI 0.91, 5.80, p = 0.007; ≥ 3 days/week of intervention: MD = 2.28, 95% CI 0.07, 4.49, p = 0.04).

CONCLUSIONS

Therapeutic exercise conducted 3 or more days per week may be effective for improving ADL and cognitive function among older residents in long-term care facilities. This meta-analysis suggested that group exercise for cognitive functions was effective. However, the effective method of intervention delivery for ADL was unclear.

Barriers, enablers and acceptability of home-based care following elective total knee or hip replacement at a private hospital: A qualitative study of patient and caregiver perspectives

Background

To facilitate implementation of home-based care following an elective total knee or hip replacement in a private hospital, we explored patient and caregiver barriers and enablers and components of care that may increase its acceptability.

Method

Thirty-one patients (mean age 71 years, 77% female) and 14 caregivers (mean age 69 years, 57% female) were interviewed. All themes were developed using thematic analysis, then categorised as barriers or enablers to uptake of home-based care or acceptable components of care. Barrier and enabler themes were mapped to the Theoretical Domains Framework.

Results

Eight themes emerged as barriers or enablers: feeling unsafe versus confident; caregivers’ willingness to provide support and patients’ unwillingness to seek help; less support and opportunity to rest; positive feelings about home over the hospital; certainty about anticipated recovery; trusting specialist advice over family and friends; length of hospital stay; paying for health insurance. Five themes emerged as acceptable components: home visits prior to discharge; specific information about recovery at home; one-to-one physiotherapy and occupational therapy perceived as first-line care; medical, nursing and a 24/7 direct-line perceived as second-line care for complications; no one-size-fits-all model for domestic support. Theoretical domains relating to barriers included emotion (e.g., feeling unsafe), environmental context and resources (e.g., perceived lack of physiotherapy) and beliefs about consequences (e.g., unwillingness to burden their caregiver). Theoretical domains relating to enablers included beliefs about capabilities (e.g., feeling strong), skills (e.g., practising stairs), procedural knowledge (e.g., receiving advice about early mobility) and social influences (e.g., caregivers’ willingness to provide support).

Conclusions

Multiple factors, such as feeling unsafe and caregivers’ willingness to provide support, may influence implementation of home-based care from the perspectives of privately insured patients and caregivers. Our findings provide insights to inform design of suitable home-based care following joint replacement in a private setting.

Older patients with active cancer have favorable inpatient rehabilitation outcomes

OBJECTIVES

To investigate the characteristics and rehabilitation outcomes of older patients with active cancer (OPAC) undergoing post-acute inpatient rehabilitation (IR), and to evaluate which clinical factors are associated with poor rehabilitation outcomes.

MATERIALS AND METHODS

This is a retrospective study of patients aged ≥65 with active cancer undergoing IR following acute hospitalization at our tertiary hospital centre (N = 330). We collected data on patient, malignancy, and hospitalization characteristics, and IR outcomes including function, mobility, discharge destination, and mortality. Multivariate stepwise logistic regression was used to identify independent associations with the composite outcome of death within three months or discharge to long-term care (LTC).

RESULTS

Patient mean age was 80.1 ± 7.2 years. The most common malignancies were colon (30.9%) and hematologic (16.1%). Most patients were hospitalized urgently (64.8%) and underwent surgery (72.4%). From IR admission to discharge, patients ambulating independently increased from 14.0% to 52.0%. Discharge destination was to the community (80.4%), to LTC (7.6%), and transfer to an acute ward (7.2%), while 4.8% died during IR. One-year survival was 62.1%. The composite outcome was met by 24.8% of patients with multivariate logistic regression revealing independent associations (p < 0.05) with high baseline dependency, metastatic disease, low mobility score on IR admission, complications during acute care, and ≥ 75th percentile values for lactate dehydrogenase and alkaline phosphatase.

CONCLUSION

OPAC have favorable IR outcomes including high rate of community discharge, function and mobility gains, and lower mortality rates when compared with previously studied cancer rehabilitation populations. We identified several clinical markers associated with the composite outcome, which can guide post-acute discharge planning in patients with an unclear prognosis.

Modified Constraint-Induced Movement Therapy at Home-Is It Possible? Families and Children's Experience

Modified constraint-induced movement therapy (mCIMT) is efficient at improving upper limb non-use. The experiences of families and children with mCIMT could allow researchers to understand how it influences their day-to-day life and to improve the function of the affected upper limb without altering family life and avoiding frustration. In this qualitative study, we aimed to collect the experiences of parents and their children (aged 4-8 years) who did mCIMT at home regarding the application of low-intensity modified constraint-induced movement therapy to improve the affected upper limb functionality in infantile hemiplegia with moderate manual ability. Individual semi-structured interviews were performed to obtain insights into their experience with mCIMT. The experiences of parents and children were described in thematic sections. Eight children with hemiplegia (six years, standard deviation, SD: 1.77) and their parents were asked about their experiences after applying 50 h of mCIMT at home. Three main themes emerged from the children's interview data: (1) the experience of wearing the containment in the modified constraint-induced movement therapy (CIMT) intervention, (2) the reaction to performing the therapy at home with his/her family, and (3) learning of the affected upper limb. In the parents' interview data, there were two main themes: (1) the difficulty of executing an intensive therapy protocol (mCIMT: 50 h) at home and (2) the feeling of not wanting to finish the intervention. The experiences of the parents and their children regarding mCIMT allowed us to understand the facilitators and barriers that affect the execution of mCIMT at home, and this understanding allows us to improve its future application.

The future of rehabilitation in the United Kingdom National Health Service: Using the COVID-19 crisis to promote change, increasing efficiency and effectiveness

THE PROBLEM

Rehabilitation services in the UK are inadequate, with insufficient capacity or flexibility to meet the needs of patients after Covid-19.

HISTORY

Rehabilitation developed in a piecemeal way, focused on specific problems: spinal cord injury, burns, polio, stroke, back pain, equipment and adaptations etc. Rehabilitation is also provided using other names (e.g. intermediate care). Patients with complex needs do not fit easily within this system.

SYSTEM FAILURE

After Covid-19, patients have problems that cross existing condition-specific and/or treatment-specific services. Covid-19 has exposed the lack of any coherent organisational principle underlying development or commissioning of rehabilitation services. Consequently, in order to have their needs met, patients either have to engage with two or more separate services or they receive good management for some problems and sub-optimal management for other problems.

THE GOALS

The multitude of small specific services need to coalesce into an integrated service able to meet all the needs of any patient referred. Second, rehabilitation needs to be fully integrated into all healthcare services.

A SOLUTION

The purpose of healthcare is to 'improve our health and well-being . . . to stay as well as we can to the end of our lives'. (NHS constitution) All healthcare services need to consider patients holistically, giving equal attention to disease, disability, and distress. Rehabilitation, acute care, mental health and palliative care services need to work in parallel to achieve this purpose. Healthcare providers, supported by commissioners and rehabilitation experts, could achieve structural and organisational change, meeting the needs of patients.

Quality of reporting of economic evaluations in rehabilitation research: a systematic review

BACKGROUND

The quality of reporting of health economic evaluations for rehabilitation services has been questioned, limiting the ability to provide accurate recommendations for health decisions.

PURPOSE

To document current overall reporting quality of the published literature for economic evaluations of rehabilitation services using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and to identify factors that could influence the quality of reporting.

DATA SOURCES

Electronic literature searches were performed using MEDLINE and the NHS Economic Evaluations Database via the Cochrane Library.

STUDY SELECTION

Prospective rehabilitation economic evaluation articles from 2013 to 2020 were selected.

DATA EXTRACTION

Data were extracted by one reviewer and independently verified by a second reviewer.

DATA SYNTHESIS/RESULTS

Title and abstracts of 3,454 papers were reviewed. 204 papers were selected for a full text screening. From those, 129 potential papers were identified to be included in this study.

LIMITATIONS

Only two databases were used in data collection, and papers were selected from 2013 to 2020 only.

CONCLUSIONS

Inconsistent reporting in health economic evaluations of rehabilitation services has continued, despite the availability of the CHEERS checklist. The methods of the analyzed studies were frequently under-reported, thereby creating challenges in determining whether the results reported were valid.IMPLICATIONS FOR REHABILITATIONVariable quality of reporting has been identified in rehabilitation research assessing cost-effectiveness.To grow as an area of expertise, the field of rehabilitation must produce research demonstrating its cost-effectiveness.Both rehabilitation clinicians and funders would benefit from full and transparent information to identify optimal solutions for effective and efficient care.

Cost-utility analysis of home-based cardiac rehabilitation as compared to usual post-discharge care: systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Determining cost-utility differences between home-based cardiac rehabilitation (HBCR) on the one hand, and usual post-discharge care (UC) on the other, can improve resource-allocation in healthcare settings.

AREAS COVERED

In June 2019, PubMed, Web of Science, Scopus, and Cochrane library were searched for randomized controlled HBCR trials. Standardized mean differences (SMDs) of cost and quality-adjusted life years (QALYs) between HBCRs and UCs were calculated using random effect models. Heterogeneity was assessed by inconsistency index (I2) and publication bias by funnel plot and Egger's regression test. Thirteen articles, representing 2,992 participants, were deemed representative for final analysis. In the meta-analysis, a significant difference with respect to QALYs favored HBCR, while no significant cost difference was observed between HBCR and UC. However, subgroup-analysis of trials with different follow-up durations revealed somewhat different results, and HBCR was found to be significantly better with regard to both cost and QALYs for patients with heart failure. Cost-utility analysis categorizing interventions as 'dominant', 'effective', 'doubtful', and 'dominated', found HBCRs dominant.

EXPERT OPINION

Although HBCR tended to be superior compared to UC in this review, larger and more robust trials addressing specific patients groups are needed for definitive results.

Application of Low-Intensity Modified Constraint-Induced Movement Therapy to Improve the Affected Upper Limb Functionality in Infantile Hemiplegia with Moderate Manual Ability: Case Series

OBJECTIVE

To assess the functionality of the affected upper limb in children diagnosed with hemiplegia aged between 4 and 8 years after applying low-intensity modified Constraint-Induced Movement Therapy (mCIMT).

METHODS

Prospective case series study. A mCIMT protocol was applied for five weeks, with two hours of containment per day. The study variables were quality of movement of the upper limb, spontaneous use, participation of the affected upper limb in activities of daily living, dynamic joint position, grasp-release action, grasp strength, supination and extension elbow movements. Four measurements were performed, using the quality of upper extremity test (QUEST) scale, the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) Evaluation, a hand dynamometer and a goniometer.

RESULTS

The sample was composed of eight children with moderate manual ability. Statistically significant differences were detected in all the studied variables (p < 0.05) between the pre-treatment and post-treatment results (Week 0-Week 5), except for upper limb dressing, putting on splints and buttoning up. In the first week, the changes were statistically significant, except for protective extension, grasp strength, grasp-release and all functional variables (level of functionality and participation of the patient's upper limbs) in the SHUEE Evaluation (p > 0.05). The greatest increase occurred in spontaneous use from Assessment 1 to Assessment 4 (p = 0.01), reaching 88.87% active participation in bimanual tasks. The quality of movement of the upper limb exhibited a significant value due to the increase in dissociated movements and grasp (p = 0.01).

CONCLUSION

A low dose (50 h) of mCIMT increased the functionality of children diagnosed with congenital hemiplegia between 4 and 8 years of age with moderate manual ability.

A cohort study of the effects of multidisciplinary in-patient primary care in older adults

PURPOSE

To evaluate short and long-term effects of a multifactorial and multidisciplinary in-patient municipality intervention including training of activities of daily living, cardiovascular exercise, resistance training and social activities on quality-of-life, need-of-care, and physical function in older adults at risk of further functional decline.

METHOD

A cohort study including data collected rigorously during 3.5 years at an in-patient municipality rehabilitation center in Aalborg, Denmark. Patients received a multifactorial and multidisciplinary intervention. Outcomes were quality-of-life (EQ5D), weekly need-of-care hours, and test of physical functioning (sit-to-stand, 6-min walking test, tandem balance).

RESULTS

Data was collected from 532 patients (63.3% women). The median [5; 95 percentiles] age was 79 [55; 92] years with a length-of-stay of 21 [8; 55] days. The mean (95% CI) EQ5D index score showed a clinically relevant improvement from admission 0.46 (0.44; 0.48) to discharge 0.69 (0.67; 0.71) and there was no decline 6-month postdischarge 0.67 (0.64; 0.70). The weekly need-of-care decreased significantly by 7.2 (6.6, 7.9) h from a mean of 9.8 h before admission to 2.6 h 6-month postdischarge. Sit-to-stand improved from 6.3 (6.0; 6.7) to 9.3 (8.9; 9.6) repetitions, 6-min walking test from 147 (138; 156) to 217 (207; 227) m, and tandem balance from 20.7 (19.8; 21.6) to 25.2 (24.8; 26.2) s.

CONCLUSION

Our results were remarkable and highlight that a well-structured multifactorial and interdisciplinary intervention with a clear aim and inclusion criteria related to functional decline may lead to long-term clinically relevant improvements in functionally declining older adults. Future studies should, however, explore similar interventions in comparable populations preferably in randomized controlled designs.

The stroke exercise preference inventory is feasible to use in a community rehabilitation setting

Exploring exercise preferences may help people to adhere to exercise programs by promoting customized programs to suit the person's choices and concerns. We investigated if the Stroke Exercise Preference Inventory, a questionnaire designed to explore stroke survivors' preferences for exercise and potential barriers, was feasible to use, and whether it assisted physiotherapists to design ongoing exercise programs in a mixed diagnostic convenience sample attending community rehabilitation. Physiotherapy staff interviewed 42 participants, and sought feedback about the questionnaire. Participant responses for exercise preferences and perceived barriers were then summarized. The questionnaire was quick to administer, readily understood, and considered relevant to consider when discussing options for exercise. Clinicians reported the questionnaire was useful for 48% (20/42) of participants, as it engaged the participant, clarified their preferences and allowed problem solving of potential barriers to exercise. Participants expressed strong preferences to be challenged, and to receive supervision and support. Preferences regarding environmental and social context of exercise varied widely. Difficulty getting started was the most common barrier reported. The Stroke Exercise Preference Inventory was feasible to use with a mixed diagnostic group during community rehabilitation, and provides structure to explore preferences and barriers to exercise. It remains to be tested whether use of the questionnaire promotes adherence to exercise programs.

Referral patterns of stroke rehabilitation inpatients to a model system of outpatient services in Ontario, Canada: a 7-year retrospective analysis

Background

While several studies have tracked the care paths of patients in the early phases of stroke recovery, studies examining the transition from inpatient to outpatient rehabilitation are lacking. Examining this transition allows for improved understanding and refinement of the process whereby patients are referred and admitted to programs. The objective of this study was to examine the referral patterns of stroke rehabilitation inpatients to outpatient stroke therapy services, their demographics, and clinical profile.

Methods

This study examined patients who: (1) were admitted to an inpatient stroke rehabilitation unit between January 1, 2009 and March 1, 2016, (2) had a stroke diagnosis, (3) had an inpatient length of stay of > 1 day, and (4) lived within the geographical boundaries of the South West Local Health Integration Network which allowed them access to both hospital-based and home-based stroke rehabilitation outpatient programs. Patient data was collected from the National Rehabilitation Reporting System, as well as three hospital outpatient administrative databases. These databases were cross-referenced to determine each patient’s pathway. Those referred to an outpatient therapy program, and those who attended the outpatient programs, were compared to those who were not, and did not, respectively.

Results

1497 inpatients were included in the analysis. Upon discharge, 1037 (69.3%) of patients had an outpatient clinic, follow-up appointment scheduled; of those, 902 (87.0%) patients attended at least one outpatient clinic visit. 891 (59.5%) were referred to one of the interdisciplinary outpatient stroke rehabilitation programs; of those, an outpatient therapy program was attended by 80.9% of patients (n = 721). Of those receiving outpatient therapy services, the number of patients attending the in-hospital versus home-based program were equal, 360 and 361 individuals, respectively.

Conclusion

This study allows for a better understanding of the transition between inpatient and outpatient stroke care. There is a paucity of this type of information in stroke rehabilitation literature to date. This study acts as a starting point in improving rehabilitation planning across the continuum of care.

Cost-effectiveness of a high-intensity rapid access outpatient stroke rehabilitation program

A common strategy to improve cost-effectiveness in healthcare is to offer outpatient care instead of in-hospital care. Toronto Rehabilitation Institute developed an outpatient high-intensity fast-track (FT) stroke rehabilitation program aimed at discharging inpatient stroke rehabilitation patients earlier or bypassing inpatient rehabilitation altogether. This cost-effectiveness analysis compares FT rehabilitation within 1 week of discharge with no FT in a single healthcare payer system. Patient costs and outcomes over a 12-week time horizon were included. Using individual-level FT data from April 2015 to March 2016, incremental cost-effectiveness ratios (ICERs) (with 95% confidence interval) were estimated using regression. Subgroup analysis was completed for patients entering FT directly from inpatient rehabilitation and acute stroke care. Uncertainty was assessed using a cost-effectiveness acceptability curve with a range of willingness-to-pay values ($0-1000 per inpatient day saved). ICER (95% confidence interval) estimate for patients entering FT from inpatient rehabilitation was $404 ($270-620) per inpatient day saved. ICER estimate for direct from acute care admissions was $37 ($20-55) per day saved. At willingness-to-pay of $698 (cost of one alternate level of care day in acute care awaiting rehabilitation), the probability of FT being cost-effective was 99.2 and 100% for patients from inpatient rehabilitation and acute stroke care, respectively. From a single healthcare payer perspective, FT is a cost-effective method of providing appropriate rehabilitation intensity for stroke patients early on, and likely to provide savings to the healthcare system upstream through fewer days awaiting rehabilitation admission.

Assessing the impact of a home-based stroke rehabilitation programme: a cost-effectiveness study

Background: Stroke is often a severe and debilitating event that requires ongoing rehabilitation. The Community Stroke Rehabilitation Teams (CSRTs) offer home-based stroke rehabilitation to individuals for whom further therapy is unavailable or inaccessible. The objective of this study was to evaluate the cost-effectiveness of the CSRT programme compared with a "Usual Care" cohort. Methods: We collected data on CSRT clients from January 2012 to February 2013. Comparator data were derived from a study of stroke survivors with limited access to specialised stroke rehabilitation. Literature-derived values were used to inform a long-term projection. Using Markov modelling, we projected the model for 35 years in six-month cycles. One-way, two-way, and probabilistic sensitivity analyses were performed. Results were discounted at 3% per year. Results: Results demonstrated that the CSRT programme has a net monetary benefit (NMB) of $43,655 over Usual Care, and is both less costly and more effective (incremental cost = -$17,255; incremental effect = 1.65 Quality Adjusted Life Years [QALYs]). Results of the probabilistic sensitivity analysis revealed that incremental cost-effectiveness of the CSRT programme is superior in 100% of iterations when compared to Usual Care. Conclusions: The study shows that CSRT model of care is cost-effective, and should be considered when evaluating potential stroke rehabilitation delivery methods. Implications for Rehabilitation Ongoing rehabilitation following stroke is imperative for optimal recovery. Home-based specialised stroke rehabilitation may be an option for individuals for whom ongoing rehabilitation is unavailable or inaccessible. The results of this study demonstrated that home-based rehabilitation is a cost-effective means of providing ongoing rehabilitation to individuals who have experienced a stroke.

Additional Physical Therapy Services Reduce Length of Stay and Improve Health Outcomes in People With Acute and Subacute Conditions: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

To update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, and are safe and cost-effective for patients with acute or subacute conditions.

DATA SOURCES

Electronic database (AMED, CINAHL, EMBASE, MEDLINE, Physiotherapy Evidence Database [PEDro], PubMed) searches were updated from 2010 through June 2017.

STUDY SELECTION

Randomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay, or cost-effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review.

DATA EXTRACTION

Data were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale, and the Grading of Recommendation Assessment, Development, and Evaluation approach was applied to each meta-analysis.

DATA SYNTHESIS

Postintervention data were pooled with an inverse variance, random-effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate-quality evidence that additional physical therapy services reduced length of stay by 3 days in subacute settings (mean difference [MD]=-2.8; 95% CI, -4.6 to -0.9; I²=0%), and low-quality evidence that it reduced length of stay by 0.6 days in acute settings (MD=-0.6; 95% CI, -1.1 to 0.0; I²=65%). Additional physical therapy led to small improvements in self-care (SMD=.11; 95% CI, .03-.19; I²=0%), activities of daily living (SMD=.13; 95% CI, .02-.25; I²=15%), and health-related quality of life (SMD=.12; 95% CI, .03-.21; I²=0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in subacute rehabilitation.

CONCLUSIONS

Additional physical therapy services improve patient activity and participation outcomes while reducing hospital length of stay for adults. These benefits are likely safe, and there is preliminary evidence to suggest they may be cost-effective.

Improving the rehabilitation of older people after emergency hospital admission

PURPOSE

Older adults are at risk of functional decline during emergency hospital admissions. This review aims to understand which exercise-based interventions are effective in improving function for older adults who experience unplanned admissions.

METHODS

Database searches identified randomised control trials (RCTs) comparing exercise-based interventions with usual hospital care. The primary outcome was functional status measured by activities of daily living (ADL) scores. Secondary outcomes were length of hospital stay (LOS), mortality and readmissions. Sub-group meta-analyses were conducted on interventions delivered in-hospital only compared with interventions provided both in hospital and after discharge.

RESULTS

After reviewing 8365 studies, nine were eligible for inclusion. Seven were included in the meta-analysis. Participants from five countries had a mean age of 79 years (1602 participants). Usual care varied considerably and the interventions showed heterogeneity, with different combinations of strengthening, resistance, high-intensity or mobility exercises. There were limited descriptions of exercise intervention delivery and participant adherence. There is low-quality evidence supporting exercise interventions that have both in-hospital and post-discharge components (3 trials, SMD 0.56 (-0.02, 1.13)). Trials involving only in-hospital interventions were inconclusive for functional gains (5 trials, SMD -0.04 (-0.31, 0.22)).

CONCLUSIONS

Exercise-based rehabilitation for older patients after emergency hospitalisation improves functional ability if the intervention starts in hospital and continues after discharge. No conclusions can be made regarding the effective exercise 'dose' or content.

IMPLICATIONS

Understanding the components of exercise interventions will improve service planning and delivery. Further studies are needed to understand the effective 'dose' and content of exercise for hospitalised older adults.

A protocol for a systematic review of economic evaluation studies conducted on neonatal systemic infections in South Asia

BACKGROUND

Neonatal systemic infections and their consequent impairments give rise to long-lasting health, economic and social effects on the neonate, the family and the nation. Considering the dearth of consolidated economic evidence in this important area, this systematic review aims to critically appraise and consolidate the evidence on economic evaluations of management of neonatal systemic infections in South Asia.

METHODS

Full and partial economic evaluations, published in English, associated with the management of neonatal systemic infections in South Asia will be included. Any intervention related to management of neonatal systemic infections will be eligible for inclusion. Comparison can include a placebo or alternative standard of care. Interventions without any comparators will also be eligible for inclusion. Outcomes of this review will include measures related to resource use, costs and cost-effectiveness. Electronic searches will be conducted on PubMed, CINAHL, MEDLINE (Ovid), EMBASE, Web of Science, EconLit, the Centre for Reviews and Dissemination Library (CRD) Database, Popline, IndMed, MedKnow, IMSEAR, the Cost Effectiveness Analysis (CEA) Registry and Pediatric Economic Database Evaluation (PEDE). Conference proceedings and grey literature will be searched in addition to performing back referencing of bibliographies of included studies. Two authors will independently screen studies (in title, abstract and full-text stages), extract data and assess risk of bias. A narrative summary and tables will be used to summarize the characteristics and results of included studies.

DISCUSSION

Neonatal systemic infections can have significant economic repercussions on the families, health care providers and, cumulatively, the nation. Pediatric economic evaluations have focused on the under-five age group, and published consolidated economic evidence for neonates is missing in the developing world context. To the best of our knowledge, this is the first review of economic evidence on neonatal systemic infections in the South Asian context. Further, this protocol provides an underst anding of the methods used to design and evaluate economic evidence for methodological quality, transparency and focus on health equity. This review will also highlight existing gaps in research and identify scope for further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017047275.

Healthcare resource utilization and clinical outcomes associated with acute care and inpatient rehabilitation of stroke patients in Japan

Objective

To investigate healthcare resource utilization and changes in functional status in stroke patients during hospitalization in an acute hospital and a rehabilitation hospital.

Design

Retrospective cohort study.

Setting

One acute and one rehabilitation hospital in Japan.

Participants

Patients who were admitted to the acute hospital due to stroke onset and then transferred to the rehabilitation hospital (n = 263, 56% male, age 70 ± 12 years).

Main outcome measures

Hospitalization costs and functional independence measure (FIM) were evaluated according to stroke subtype and severity of disability at discharge from the acute hospital.

Results

Median (IQR) costs at the acute hospital were dependent on the length of stay (LOS) and implementation of neurosurgery, which resulted in higher costs in subarachnoid hemorrhage [$52 413 ($49 166-$72 606) vs $14 129 ($11 169-$19 459) in cerebral infarction; and vs $15 035 ($10 920-$21 864) in intracerebral hemorrhage]. The costs at the rehabilitation hospital were dependent on LOS, and higher in patients with moderate disability than in those with mild disability [$30 026 ($18 419-$39 911) vs $18 052 ($10 631-$24 384)], while those with severe disability spent $25 476 ($13 340-$43 032). Patients with moderate disability gained the most benefits during hospitalization in the rehabilitation hospital, with a median (IQR) total FIM gain of 16 (5-24) points, compared with a modest improvement in patients with mild (6, 2-14) or severe disability (0, 0-5).

Conclusions

The costs for in-hospital stroke care were substantial and the improvement in functional status varied by severity of disability. Our findings would be valuable to organize efficient post-acute stroke care.

Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data

QUESTIONS

Among people receiving inpatient rehabilitation after stroke, does additional weekend physiotherapy and/or occupational therapy reduce the length of rehabilitation hospital stay compared to those who receive a weekday-only service, and does this change after controlling for individual factors? Does additional weekend therapy improve the ability to walk and perform activities of daily living, measured at discharge? Does additional weekend therapy improve health-related quality of life, measured 6 months after discharge from rehabilitation? Which individual, clinical and hospital characteristics are associated with shorter length of rehabilitation hospital stay?

DESIGN

This study pooled individual data from two randomised, controlled trials (n=350) using an individual patient data meta-analysis and multivariate regression.

PARTICIPANTS

People with stroke admitted to inpatient rehabilitation facilities.

INTERVENTION

Additional weekend therapy (physiotherapy and/or occupational therapy) compared to usual care (5 days/week therapy).

OUTCOME MEASURES

Length of rehabilitation hospital stay, independence in activities of daily living measured with the Functional Independence Measure, walking speed and health-related quality of life.

RESULTS

Participants who received weekend therapy had a shorter length of rehabilitation hospital stay. In the un-adjusted analysis, this was not statistically significant (MD -5.7 days, 95% CI -13.0 to 1.5). Controlling for hospital site, age, walking speed and Functional Independence Measure score on admission, receiving weekend therapy was significantly associated with a shorter length of rehabilitation hospital stay (β=7.5, 95% CI 1.7 to 13.4, p=0.001). There were no significant between-group differences in Functional Independence Measure scores (MD 1.9 points, 95% CI -2.8 to 6.6), walking speed (MD 0.06 m/second, 95% CI -0.15 to 0.04) or health-related quality of life (SMD -0.04, 95% CI -0.26 to 0.19) at discharge.

DISCUSSION

Modest evidence indicates that additional weekend therapy might reduce rehabilitation hospital length of stay.

CLINICAL TRIAL REGISTRATION

ACTRN12610000096055, ACTRN12609000973213. [English C, Shields N, Brusco NK, Taylor NF, Watts JJ, Peiris C, et al. (2016) Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data.Journal of Physiotherapy62: 124-129].

Systematic overview of economic evaluations of health-related rehabilitation

BACKGROUND

Health related rehabilitation is instrumental in improving functioning and promoting participation by people with disabilities. To make clinical and policy decisions about health-related rehabilitation, resource allocation and cost issues need to be considered.

OBJECTIVES

To provide an overview of systematic reviews (SRs) on economic evaluations of health-related rehabilitation.

METHODS

We searched multiple databases to identify relevant SRs of economic evaluations of health-related rehabilitation. Review quality was assessed by AMSTAR checklist.

RESULTS

We included 64 SRs, most of which included economic evaluations alongside randomized controlled trials (RCTs). The review quality was low to moderate (AMSTAR score 5-8) in 35, and high (score 9-11) in 29 of the included SRs. The included SRs addressed various health conditions, including spinal or other pain conditions (n = 14), age-related problems (11), stroke (7), musculoskeletal disorders (6), heart diseases (4), pulmonary (3), mental health problems (3), and injury (3). Physiotherapy was the most commonly evaluated rehabilitation intervention in the included SRs (n = 24). Other commonly evaluated interventions included multidisciplinary programmes (14); behavioral, educational or psychological interventions (11); home-based interventions (11); complementary therapy (6); self-management (6); and occupational therapy (4).

CONCLUSIONS

Although the available evidence is often described as limited, inconsistent or inconclusive, some rehabilitation interventions were cost-effective or showed cost-saving in a variety of disability conditions. Available evidence comes predominantly from high income countries, therefore economic evaluations of health-related rehabilitation are urgently required in less resourced settings.

Usual Clinical Practice for Early Supported Discharge after Stroke with Continued Rehabilitation at Home: An Observational Comparative Study

INTRODUCTION

Based on randomised controlled trials, evidence exists that early supported discharge (ESD) from the hospital with continued rehabilitation at home has beneficial effects after stroke; however, the effects of ESD service in regular clinical practice have not been investigated. The purpose of the current study was to compare ESD service with conventional rehabilitation in terms of patient outcomes, caregiver burden at 3 and 12 months and the use and costs of healthcare during the first year after stroke.

MATERIAL AND METHODS

This study was a subgroup analysis of a longitudinal observational study of patients who received care in the stroke unit at Karolinska University Hospital in Sweden. Patients who met the inclusion criteria for ESD in previous experimental studies were included. The patients were referred to available rehabilitation services at discharge, and comparisons between those who received ESD service (the ESD group, n = 40) and those who received conventional rehabilitation (the NoESD group, n = 110) were performed with regard to independence in activities of daily living (ADL), the frequency of social activities, life satisfaction, and caregiver burden and the use and costs of healthcare during the first year after stroke.

RESULTS

At 3 and 12 months, no differences were observed with regard to patient outcomes; however, ESD was associated with a lower caregiver burden (p = 0.01) at 12 months. The initial length of stay (LOS) at the hospital was 8 days for the ESD group and 15 days for the NoESD group (p = 0.02). The median number of outpatient rehabilitation contacts was 20.5 for the ESD group (81% constituting ESD service) and 3 for the NoESD group (p<0.001). There was no difference between the groups with regard to overall healthcare costs.

CONCLUSIONS

ESD service in usual clinical practice renders similar health benefits as conventional rehabilitation but a different pattern of resource use and with released capacity in acute stroke care.

Is cost effectiveness sustained after weekend inpatient rehabilitation? 12 month follow up from a randomized controlled trial

Background

Our previous work showed that providing additional rehabilitation on a Saturday was cost effective in the short term from the perspective of the health service provider. This study aimed to evaluate if providing additional rehabilitation on a Saturday was cost effective at 12 months, from a health system perspective inclusive of private costs.

Methods

Cost effectiveness analyses alongside a single-blinded randomized controlled trial with 12 months follow up inclusive of informal care. Participants were adults admitted to two publicly funded inpatient rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus additional Saturday rehabilitation. Incremental cost effectiveness ratios were reported as cost per quality adjusted life year (QALY) gained and for a minimal clinical important difference (MCID) in functional independence.

Results

A total of 996 patients [mean age 74 years (SD 13)] were randomly assigned to the intervention (n = 496) or control group (n = 500). The intervention was associated with improvements in QALY and MCID in function, as well as a non-significant reduction in cost from admission to 12 months (mean difference (MD) AUD$6,325; 95% CI −4,081 to 16,730; t test p = 0.23 and MWU p = 0.06), and a significant reduction in cost from admission to 6 months (MD AUD$6,445; 95% CI 3,368 to 9,522; t test p = 0.04 and MWU p = 0.01). There is a high degree of certainty that providing additional rehabilitation services on Saturday is cost effective. Sensitivity analyses varying the cost of informal carers and self-reported health service utilization, favored the intervention.

Conclusions

From a health system perspective inclusive of private costs the provision of additional Saturday rehabilitation for inpatients is likely to have sustained cost savings per QALY gained and for a MCID in functional independence, for the inpatient stay and 12 months following discharge, without a cost shift into the community.

Trial registration

Australian and New Zealand Clinical Trials Registry November 2009 ACTRN12609000973213.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0822-3) contains supplementary material, which is available to authorized users.

Effectiveness of constraint-induced movement therapy on upper-extremity function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

Objective:

To systematically examine the research literature on the effectiveness of constraint-induced movement therapy on improving arm function in children with cerebral palsy, and to assess the association between the study effect size and the characteristics of the patients and intervention protocol.

Data sources:

A systematic literature search was conducted in PubMed, PsycINFO, Cochrane, CINAHL, Web of Science, and TRIP Database up to May 2014.

Review methods:

Studies employing randomized controlled trial design, children with cerebral palsy, comparing constraint-induced movement therapy with another intervention with a focus on arm function, and upper-extremity measures were included in this review. Methodological quality was evaluated using the Physiotherapy Evidence-based Database (PEDro) scale.

Results:

The literature search resulted in 27 randomized controlled trial studies with good methodological quality that compared constraint-induced movement therapy with other intervention therapy. Overall, constraint-induced movement therapy provided a medium beneficial effect ( d = 0.546; p < 0.001) when compared with conventional therapy. For the subgroup analyses, presence of a dose-equivalent comparison group, intervention location, and time of follow-up were significant factors. Studies examining constraint-induced movement therapy effect without a dose-equivalent comparison group showed a large effect in children with cerebral palsy, but studies with a dose-equivalent group only showed a small effect. Children who received home-based constraint-induced movement therapy had a better improvement in arm function than those who received constraint-induced movement therapy elsewhere.

Conclusion:

The research literature supports constraint-induced movement therapy as an effective intervention to improve arm function in children with cerebral palsy.

Are weekend inpatient rehabilitation services value for money? An economic evaluation alongside a randomized controlled trial with a 30 day follow up

BACKGROUND

Providing additional Saturday rehabilitation can improve functional independence and health related quality of life at discharge and it may reduce patient length of stay, yet the economic implications are not known. The aim of this study was to determine from a health service perspective if the provision of rehabilitation to inpatients on a Saturday in addition to Monday to Friday was cost effective compared to Monday to Friday rehabilitation alone.

METHODS

Cost utility and cost effectiveness analyses were undertaken alongside a multi-center, single-blind randomized controlled trial with a 30-day follow up after discharge. Participants were adults admitted for inpatient rehabilitation in two publicly funded metropolitan rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus an additional rehabilitation service on Saturday. Incremental cost utility ratio was reported as cost per quality adjusted life year (QALY) gained and an incremental cost effectiveness ratio (ICER) was reported as cost for a minimal clinically important difference (MCID) in functional independence.

RESULTS

996 patients (mean age 74 (standard deviation 13) years) were randomly assigned to the intervention (n = 496) or the control group (n = 500). Mean difference in cost of AUD$1,673 (95% confidence interval (CI) -271 to 3,618) was a saving in favor of the intervention group. The incremental cost utility ratio found a saving of AUD$41,825 (95% CI -2,817 to 74,620) per QALY gained for the intervention group. The ICER found a saving of AUD$16,003 (95% CI -3,074 to 87,361) in achieving a MCID in functional independence for the intervention group. If the willingness to pay per QALY gained or for a MCID in functional independence was zero dollars the probability of the intervention being cost effective was 96% and 95%, respectively. A sensitivity analysis removing Saturday penalty rates did not significantly alter the outcome.

CONCLUSIONS

From a health service perspective, the provision of rehabilitation to inpatients on a Saturday in addition to Monday to Friday, compared to Monday to Friday rehabilitation alone, is likely to be cost saving per QALY gained and for a MCID in functional independence.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry November 2009 ACTRN12609000973213.