The cost-effectiveness of life after stroke services and the impact of these services on health and social care resource use: a rapid review

The UK is expected to see a 60% increase in first-time strokes over the next 20 years. This translates to about 2.1 million stroke survivors living in the UK 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. While traditional cost-effectiveness analysis provides a valuable framework for evaluating healthcare interventions, it may not fully capture the individual experiences of stroke survivors or the broader impact on their ongoing recovery, wellbeing and the lives of their carers. Future research should seek to quantify the effects of life after stroke support on patients and carers. 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. Funding StatementThe 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. Report ContributorsO_ST_ABSReview TeamC_ST_ABSKalpa Pisavadia, Bethany Fern Anthony, Jacob Davies, Sofie Roberts, Rachel Granger, Llinos Haf Spencer, Elizabeth Gillen, Juliet Hounsome, Jayne Noyes, Deborah Fitzsimmons, and Rhiannon Tudor Edwards. Methodological AdviceRuth Lewis Evidence Centre TeamRuth Lewis, Adrian Edwards, Alison Cooper, Micaela Gal and Elizabeth Doe involved in Stakeholder engagement, review of report and editing. Public PartnerRobert Hall Stakeholder(s)Angela Contestabile, Heidi James, Lynn Preece, Llinos Wyn Parry, Katie Chappelle, Jonathan Hewitt. Evidence need submitted to the Evidence Centre: 30.10.2023 Initial Stakeholder Consultation Meeting: 29.04.24 Final Report issued: June 2025 The review should be cited as: Health and Care Research Wales Evidence Centre. A rapid review of cost-effectiveness of life after stroke services and the impact of these services on health and social care resource use_(RR0027). June 2025. DisclaimerThe views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The Health and Care Research Wales Evidence Centre and authors of this work declare that they have no conflict of interest. EXECUTIVE SUMMARYO_ST_ABSWhat is a Rapid Review?C_ST_ABSOur rapid reviews use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. Who is this Rapid Review for?This Rapid Review was conducted as part of the Health and Care Research Wales Evidence Centre Work Programme. The review question was suggested by representatives of the Stroke Association UK. Background / Aim of Rapid ReviewThe UK is expected to see a 60% increase in first-time strokes over the next 20 years. This translates to about 2.1 million stroke survivors living in the UK by 2035. Approximately 70,000 stroke survivors are currently living in Wales. Life after stroke services take a non-medical holistic approach to living well after a stroke and are complimentary to rehabilitation. Life after stroke services encompass services that aim to support peoples physical and emotional state. Some of these services are specific to communication and emotional support, providing tools and information, reassurance, coaching and peer support. Life after stroke services have the potential to reduce the cost burden to health and social care. 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 (it did not review the evidence on the clinical effectiveness or peoples lived experience of life after stroke services). Results of the Rapid ReviewThe evidence base: O_LIThe review included evidence from studies published between January 2000 and August 2024 (at the time when the searches were conducted). C_LIO_LIOf the 12 studies included, seven were economic evaluations, and five were randomised controlled trials reporting on cost and or resource use data only. C_LIO_LIThe seven economic evaluations assessed the following interventions: a needs assessment tool for caregivers (Patchwood et al, 2021); training for caregivers (Forster et al, 2013); an exercise and education reintegration programme for stroke survivors and their families (Harrington et al, 2010), a community-based Individual Management Program for post-stroke survivors (Orman et al, 2024); combined speech and language therapy and support services for stroke survivors and their families (van der Gaag and Brooks, 2008); peer-befriending for psychological distress (Flood et al, 2022), and a post-discharge structured assessment (Forster et al, 2015). C_LIO_LITwo randomised controlled trials were partial economic evaluations which reported on cost and resource use data. These studies specifically related to the following interventions: training caregivers (Kalra et al, 2004); and an arts and health-based intervention (Ellis-Hill et al, 2019). C_LIO_LIThe remaining three randomised controlled trials reported on resource use but not cost data and assessed family support organiser service (Mant et al, 2000; Tilling et al, 2005), and a telehealth support intervention designed to assist stroke survivors and their carers (Bishop et al, 2014). C_LI Key findings: O_LIThis review highlighted a lack of studies evaluating the cost-effectiveness of life after stroke as a comprehensive service as per the national stoke model, particularly when delivered as intended in a holistic multicomponent format. However, this review identified evidence on the cost-effectiveness and resource utilisation of specific interventions within these services, that support both stroke survivors and carers. C_LIO_LIA community-based Individual Management Program for post-stroke survivors was found to be cost-effective from a societal perspective at 24-month follow-up. C_LIO_LIA combination of speech and language therapy with voluntary support services had a lower cost per session than reported costs for equivalent NHS services However, cost-effectiveness was not assessed in this study C_LIO_LIA telehealth support intervention was associated with a reduction in healthcare utilisation. C_LIO_LIA caregiver training programme, delivered whilst the stroke patient was still 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 found to be cost-effective when rolled out and assessed across multiple hospitals. C_LIO_LIA community-based arts and health group intervention led to a reduction in outpatient contacts and home care worker contacts compared to usual care. C_LIO_LIA Family Support Organiser service was associated with a reduction in physiotherapy contact, but the use of other services were comparable with usual care. C_LIO_LIThe addition of a new post-discharge system to an existing community-based Stroke Care Coordinators service was not cost-effective from either a health or societal perspective when compared to the Stroke Care Coordinator usual practice. C_LIO_LIPeer-befriending was found to be more costly and less effective than usual care alone. C_LIO_LIThe use of a Carer Support Needs Assessment Tool (CSNAT) was not cost-effective compared to usual care. C_LIO_LIThe cost per patient of a community-based combined exercise and education reintegration programme was greater than that of the control group. C_LI Policy and Practice ImplicationsO_LIThere is some evidence that interventions such as Individual Management Programme; telehealth support, community-based arts and health group, Family Support Organiser, and caregiver training can be cost-effective or lead to a reduction in service utilisation. C_LIO_LIWhile the gold standard model of traditional cost-effectiveness analysis proves a robust and valuable framework for assessing the cost-effectiveness of healthcare interventions, it does not capture the individual impact on the recovery of a stroke survivor and the ongoing health and wellbeing of them or their family. C_LIO_LIThis review focused on evidence of cost-effectiveness and resource utilisation, which are helpful in the context of resource allocation for future roll-out of services, however, decisions relating to policy and practice must also consider the wider evidence base on clinical effectiveness and patient preferences going forward. C_LIO_LIAlthough a reduction in resource use may be associated with cost savings and reduced burden on the NHS, importantly, an increase in health care and social care use may also be appropriate due to better signposting or identification of peoples needs. C_LI Research Implications and Evidence GapsO_LIFurther research is needed on cost-effectiveness of life after stroke as a comprehensive service as per the national stoke model C_LIO_LITo fully understand the effectiveness and cost-effectiveness of life after stroke interventions, research is needed to assess potential long-term impacts. C_LIO_LIEvidence is needed on the cost-effectiveness of supporting stroke survivors in returning to the workforce. C_LIO_LIThe timing of life after stroke interventions appeared to be important in terms of how they are received by stroke survivors, their carers and their families. C_LIO_LIMany of the samples in the included studies lacked ethnic diversity. Stroke trials need strategies to achieve equity of access, given that a large portion of UK stroke admissions are from Black, Asian and minority ethnic communities (Office for National Statistics, 2021). C_LI Economic considerationsO_LIThe average cost to society per stroke survivor in the first year post-stroke in the UK is {pound}45,409. The key drivers of this cost are informal care and lost productivity costs (Stroke Association, 2020). Appropriate and timely post-stroke support for stroke survivors, their families and or caregivers could help alleviate some of this economic impact. C_LIO_LIStroke costs NHS Wales {pound}220 million per year. When considering a wider societal economic cost, this figure rises to {pound}1.6 billion per year. If current trends persist with no action taken, this figure is forecast to increase to {pound}2.8 billion per annum by 2035 (Welsh Government, 2024b). C_LI GlossaryEconomic evaluation: an 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 utilisation: refers 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 analysis: costs are compared with a treatments 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 analysis: a 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 evaluation: is 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 evaluation: is 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 trial: a 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 evaluations: are 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 evaluation: is 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 analysis: Is a form of partial economic evaluation that presents the disaggregated costs and outcomes of an intervention. Statistical significance: a 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.