Abstract
Integrated care has emerged as a potential solution in advancing post-stroke care. Apart from ensuring the provision of comprehensive care to stroke patients, integrated care also fosters collaboration and coordination among diverse healthcare providers. As such, it is crucial to identify the best evidence of integrated care initiatives in real-world settings to support future care optimization. However, unlike other diseases or population groups where the scientific evidence of integrated care has been systematically summarized, there is currently a lack of synthesis of evidence for integrated care in stroke patients. Furthermore, considering the significant financial burden for discharged stroke patients, it becomes particularly pertinent to examine the cost-effectiveness of implementing innovations before their adoption. By synthesizing cost-effective evidence of integrated care, we can gain a clear vision of how to deliver integrated care cost-effectively for stroke.
This systematic review and meta-analysis aim to appraise the evidence on the cost-effectiveness impact of integrated care interventions on stroke survivor and their caregivers. Literature was searched, and trial-based studies evaluating the costs and effects of integrated care interventions were eligible for review. The principal effectiveness outcome extracted was quality-adjusted life-years (QALYs) gains of stroke patients. Secondary outcomes covered different domains, including patient's (1) physical disability; (2) daily activity functioning (ADL); (3) psychological health; (4) societal participation; (5) quality of life; as well as caregiver's (6) psychological health; (7) caregiving burden; (8) quality of life. Considering heterogeneity regarding cost data, a narrative structured synthesis was undertaken to assess the cost-effectiveness outcome.
There were 86,517 initial search results; 22 unique studies with 25 integrated care programs were identified. Integrated care interventions were categorized into 6 strategies: (1) early supported discharge (n=8), (2) care coordination (n=2), (3) integrated stroke services (n=3), (4) longer-term community reintegration (n=4), (5) home-based rehabilitation (n=3), (6) stroke unit/team care (n=5). The pooled results showed improvements in patients’ ADL, and physical and psychological health outcomes for integrated care compared to the control group, with significant effects being reported for ADL scores (SMD 0.133 [95% CI 0.025; 0.241]). 17 programs achieve meaningful improvements in patient/caregiver outcomes and are cost-saving/effective. Three strategies—early supported discharge, care coordination, and long-term community reintegration—were consistently identified as ‘Top’ across many outcome domains.
Integrated care for post-stroke recovery is very likely to be cost-effective. The development of a stroke care system with continued and long-term support for post-discharge stroke survivors is of significance.
This review offers promising results about three types of integrated care strategies, with two appear to be cost saving: early supported discharge and care coordination strategies; and one that focused on enhancing community reintegration in the longer-term achieve high potential to be cost-effective.