Abstract

In the UK, more than 100,000 strokes occur each year, and this is expected to rise to over 2.1 million by 2035. Life after stroke services aim to support peoples physical and emotional state, are complimentary to rehabilitation and take a non-medical holistic approach to living well after a stroke. This rapid review aimed to identify evidence on the cost-effectiveness of life after stroke services, and the impact of these interventions on health or social care resource use. The review included evidence from 12 studies (7 economic evaluations and 5 randomised controlled trials), published between January 2000 and August 2024.

The economic evaluations assessed a number of interventions to support stroke survivors, their families and caregivers. Two of the randomised controlled trials were partial economic evaluations, reporting on cost and resource use data related to training caregivers, and an arts and health-based intervention. The other three trials reported on resource use but not cost data, and assessed family support interventions, and a telehealth intervention to assist stroke survivors and their carers. There was a lack of evidence on the cost-effectiveness of life after stroke as a comprehensive service. However, this review identified evidence on the cost-effectiveness and resource utilisation of specific interventions within these services.

Findings include that a community-based Individual Management Program for post-stroke survivors was cost-effective from a societal perspective at 24-month follow-up. A carer training intervention, delivered whilst the stroke patient was in hospital, was associated with a reduction in health and social care resource use when evaluated at a single hospital. However, this intervention was not cost-effective when rolled out and assessed across multiple hospitals. Other findings included that a combination of speech and language therapy with voluntary support services had a lower cost per session compared to NHS speech and language therapy alone. Family support organiser interventions for stroke survivors and carers were associated with reduced healthcare utilisation. To fully understand the effectiveness and cost-effectiveness of life after stroke interventions, research is needed to assess potential long-term impacts. A reduction in resource use may be associated with cost savings and reduced burden on the NHS. However, an increase in health care and social care use may also be appropriate due to better signposting or identification of peoples’ needs. Evidence is also needed on the cost-effectiveness of supporting stroke survivors in returning to the workforce. Many of the sample sizes in the included studies lacked ethnic diversity. Stroke trials need strategies to achieve equity of access. This review focused on evidence of cost-effectiveness and resource utilisation. Decisions relating to policy and practice should also consider evidence on clinical effectiveness and patient preferences.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The authors were funded for this work by the Health and Care Research Wales Evidence Centre, itself funded by Health and Care Research Wales on behalf of Welsh Government

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Data Availability

All data produced in the present study are available upon reasonable request to the authors

AbbreviationsADLActivities of Daily LivingAQoL-4DAssessment of Quality of Life-Four DimensionsAUDAustralian DollarsCCACost-Consequence AnalysisCDMChronic Disease ManagementCIConfidence IntervalCSNATCarer Support Needs AssessmentCSRIClient Service Receipt InventoryCUACost Utility AnalysisDISCSDepression Intensity Scale CirclesEQ-5D-5LEuroQol-5 Dimensions-5 LevelsFADFamily Assessment DeviceFACQFamily Appraisal of Caregiving QuestionnaireFAIFrenchay Activities IndexFITTFamily Intervention: Telephone TrackingFSOFamily Support OrganiserGDSGeriatric Depression ScaleGHQ-12General Health Questionnaire-12HADSHospital Anxiety and Depression ScaleHISDS-IIIHead Injury Semantic Differential ScaleHRQoLHealth Related Quality of LifeICERIncremental Cost Effectiveness RatioIMPIndividual Management ProgramJBIJoanna Briggs InstituteLASLife After StrokeLOSLength of StayLSCTCLondon Stroke Carer Training CourseNEADLNottingham Extended Activities of Daily LivingNICENational Institute for Health and Care ExcellenceOECDOrganisation for Economic Co-operation and DevelopmentPCSPerceived Criticism ScaleQALYQuality Adjusted Life YearRCTRandomised Controlled TrialRNLIReintegration to Normal Living IndexRSESRosenberg Self-Esteem ScaleSCCStroke Care CoordinatorSDStandard DeviationSEStandard ErrorSIPSOSubjective Index of Physical and Social OutcomeSISStroke Impact ScaleSLTSpeech and Language TherapySMFStandard Medical Follow-upSRUStroke Rehabilitation UnitTIATransient Ischaemic AttackUCUsual CareVASVisual Analogue ScaleWEMWBSWarwick-Edinburgh Mental Well-being ScaleWTPWillingness to PayGlossaryEconomic evaluationan assessment of the costs and effects of alternate healthcare interventions. The aim of an economic evaluation is to help decision makers maximise the level of health benefits relative to the finite resources available.Health and Social Care resource use or utilisationrefers to the use of healthcare resources by end users (patients) and intervention deliverers. This can take the form of contacts with health professionals across health and social care, medicines or healthcare consumables used. In economic evaluations, resource use is collected, and costs are assigned to them to identify the costs an intervention places on the healthcare system.Cost-effectiveness analysiscosts are compared with a treatment’s common therapeutic goal, expressed in terms of one main outcome measured in natural units (e.g., improvement in blood pressure or cholesterol level). These outcomes are typically condition-specific, meaning comparison within conditions is possible, but difficulty arises in comparing between conditions.Cost-utility analysisa method of evaluation that measures health benefits in preference-based, non-monetary units such as Quality Adjusted Life Years (QALYs) or Disability Adjusted Life Years (DALYs). These units are helpful for economic evaluation as they are generic and can be applied across conditions, allowing for comparison between conditions.Full economic evaluationis an economic evaluation that compares both the costs and effects of alternate healthcare interventions. The examples of cost-effectiveness and cost-utility above reflect full economic evaluations as they analyse both costs and outcomes of interventions.Partial economic evaluationis an economic evaluation that does not compare both the costs and effects of alternate healthcare interventions. A common partial economic evaluation is a cost-analysis that presents the costs of interventions only, with no consideration of effects. Partial economic evaluations are sometimes conducted within or alongside randomised controlled trials. However, the conduct of partial economic evaluations are not limited to randomised controlled trial study designs, with alternatives including economic evaluations alongside natural experiments or economic modelling studies which often utilise sources of data from previous literature in addition to or instead of collecting primary data.Randomised controlled triala study in which a number of similar people are randomly assigned to 2 (or more) groups to test a specific drug, treatment or other intervention. One group (the intervention group) has the intervention being tested, the other (the comparison or control group) has an alternative intervention, a dummy intervention (placebo) or no intervention at all. The groups are followed up at set time periods to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. Randomised controlled trials are the highest standard of research trials as their design helps to reduce biases that may impact the findings.Randomised controlled trials with partial economic evaluationsare a study type that follows the randomised controlled trial methodology. Randomised controlled trials with cost comparisons collect information on the costs associated with the interventions studied to allow for comparison across alternate interventions not just based on clinical effect but also costs.Within-trial economic evaluationis a full economic evaluation of the costs and effects of healthcare interventions that are being studied as part of a clinical trial. The primary aim of clinical trials is typically a measurement of clinical effect of administering an intervention (e.g., change in blood pressure). These clinical effects of the intervention are then assessed together with the costs of the intervention in the economic evaluation.Cost-consequence analysisIs a form of partial economic evaluation that presents the disaggregated costs and outcomes of an intervention.Statistical significancea statistically significant result is one that is deemed to be down to a true effect rather than random chance. It is a way to determine if a relationship between variables is caused by something other than chance.