STRATEGIC INVESTMENT TO INCREASE UTILIZATION OF STROKE REHABILITATION SERVICES: INSIGHTS FROM A SYSTEM DYNAMICS MODEL

Purpose: Despite evidence that intensive post-stroke rehabilitation can reduce mortality, increase post-stroke functional outcomes, and lower long-term care costs; the utilization of post-stroke rehabilitation is low. In the SE Asian city-state of Singapore, approximately 20 percent of stroke patients who are referred to post-stroke rehabilitation actually utilize the service. The aim of this study was to use the modeling methodology of System Dynamics (SD) to evaluate the cost-effectiveness of various nationwide policies in improving the uptake of post-stroke rehabilitation and the quality of life of stroke patients. 

Method: We constructed a SD computer simulation model to capture states and events following stroke. This includes rehabilitation, post-stroke functional status stratified by use of rehabilitation, recurrent stroke event, and long term survival of stroke patients based on functional status for a representative, synthetic population of Singaporeans aged 15 years and older. We parameterized the model using inputs from the literature, Singapore national health surveys, and local cohort data. Parameters for which data was unavailable were estimated via model calibration to match Singapore demographics and stroke trends. The model focuses on key factors that are influential in rehabilitation uptake and adherence: out-of-pocket costs, difficulties with transportation to/from rehabilitation centers, and lack of perceived value of rehabilitation in improving quality of life. Under different hypotheses of production functions for post-stroke rehabilitation uptake (i.e., assumptions about the relative impact of investment on the use of post-stroke rehabilitation), the model enabled us to calculate the expected total costs and public health gains of any nationwide policy designed to increase the uptake of post-stroke rehabilitation over any time frame.

Result: Taking into account the cost of long-term care and investment in post-stroke rehabilitation uptake, optimal (100 percent) uptake of post-stroke rehabilitation over a period of 20 years generates total savings of $1137 million and 75916 incremental quality-adjusted life years compared to the absence of post-stroke rehabilitation. Sensitivity analysis reveals that cost-effectiveness varies with quality-of-life estimates, survival and cost.

Conclusion: Post-stroke rehabilitation appears to be a cost-saving investment for the nation in improving stroke survivors’ quality of life. Investments designed to increase the uptake of post-stroke rehabilitation services offer the potential for substantial down-line social cost savings, and policymakers may want to promote such investments in Singapore and similar countries.