Are Active Interventions for Caregivers of Stroke Patients Cost-Effective?

VBCN - May 2015 Volume 2, No 1 - Stroke
Rosemary Frei, MSc

Several studies have examined the costs associated with actively educating and supporting family caregivers of people who have had a stroke, yet provide only limited evidence that such interventions are cost-effective. That’s the bottom line of a new systematic review published in Clinical Rehabilitation (Heslin M, et al. Clin Rehabil. March 10, 2015. [Epub ahead of print]).

A team from the United Kingdom searched the English-language literature and found 10 relevant studies that had sufficient data to be included in their review. The 10 relevant studies had disparate designs, sites of patients recruited, interventions, and forms of analyses, and had predominantly white participants. Only 3 of these studies connected outcomes with cost data within a “formal” economic evaluation framework; 1 had a full economic analysis (Kalra L, et al. BMJ. 2004;328:1099; Patel A, et al. BMJ. 2004;328:1102; Pierce LL, et al. Disabil Rehabil. 2009; 31:1676-1684).

All 3 studies with economic evaluation showed that caregiver interventions are less costly and are associated with similar or better outcomes than nonintervention conditions. However, 2 of these studies used the same intervention—caregiver training—and the same data set (Kalra L, et al. BMJ. 2004;328:1099; Patel A, et al. BMJ. 2004;328:1102).

The paucity of full economic analyses led the team to conclude that well-designed, randomized, controlled trials are needed that focus solely on interventions for stroke-patient caregivers.

“It is difficult to draw firm conclusions on cost-effectiveness for informing clinical practice due to the variation in the types of interventions and comparators examined in different studies,” wrote lead author Margaret Heslin, PhD, Research Associate, Centre for the Economics of Mental and Physical Health, King’s College London, and her coauthors. “Similarly, a number of methodological limitations undermine the conclusions that can be drawn where evidence of relevance to the issue of intervention cost-effectiveness is reported.”

A 2008 review by the Cochrane Collaboration had examined the effectiveness of giving relevant information to stroke patients and their caregivers. The reviewers found just 1 published economic study, however, and therefore could not draw conclusions about the cost-effectiveness of such interventions. Dr Heslin and 3 of her colleagues conducted the systematic review to try to fill in that gap. The 10 studies they included focused on interventions either for caregivers exclusively or for both caregivers and patients. The interventions ranged from basic information-giving to active education, training, and skill-building.

The 1 study that provided a full economic analysis—including the calculation of cost per quality-adjusted life-year (QALY)—was a 1-year, randomized trial conducted in the United Kingdom that compared caregiver training to conventional care in a stroke-rehabilitation unit (Patel A, et al. BMJ. 2004;328:1102). The economic outcomes data were collected by participant self-report. The patients whose caregivers were in the intervention arm had significantly fewer inpatient days, and less physiotherapy and occupational therapy than those in the control group. Furthermore, the total healthcare and social-care costs for patients whose caregivers were in the intervention arm were significantly lower. The cost for QALY was similar in the 2 groups.

Investigators did not calculate the incremental cost-effective ratio because “the carer training was clearly the more desirable option, with both lower costs and better outcomes,” noted Dr Heslin and her coauthors.

Of the 2 other studies that included some economic analyses, one was the same study referenced in the 2008 Cochrane review (Kalra L, et al. BMJ. 2004;328:1099). It was conducted in the United Kingdom and involved the same intervention as the aforementioned study with full economic analysis. The third study was conducted in the United States and compared an intervention known as Caring Web to a nonweb intervention (Patel A, et al. BMJ. 2004;328:1102). Both found the intervention was associated with lower costs and better or equal patient outcomes compared with control conditions.

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Last modified: June 1, 2015
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