Cost-effectiveness of Seven-days-per-week Rehabilitation Schedule for Acute Stroke Patients

doi:10.21203/rs.3.rs-1489462/v1

Background: Rehabilitation is an essential medical service for patients who have suffered acute stroke. Although the effectiveness of seven-days-per-week rehabilitation schedule has been studied in comparison with five- or six-days-per-week rehabilitation schedule, its cost-effectiveness has not been analyzed. In this research, to help formulate more cost-effective medical treatments for acute stroke patients, we analyzed the cost-effectiveness of seven-days-per-week rehabilitation for acute stroke from public health payer’s perspective, and public healthcare and long-term care payerʼs perspective in Japan.

Methods: Cost-effectiveness of seven-days-per-week rehabilitation for acute stroke patients was analyzed based on the result from a study using a Japanese database examining the efficacy of seven-days-per-week rehabilitation. Cost utility analysis was conducted by comparing seven-days-per-week rehabilitation with five- or six-days-per-week rehabilitation, with its main outcome incremental cost-effectiveness ratio (ICER) calculated by dividing estimated incremental medical and long-term care costs by incremental quality-adjusted life years. The incremental costs analyzed included medical costs and long-term care costs, estimated using the Japanese fee table and published sources. Analysis period was five years, and Markov modeling was used for the analysis.

Results: The ICER was $10,901/ QALY from public health payer’s perspective, lower than 5,000,000 Yen/ QALY (approximately US$43,055), which was the threshold used for the cost-effectiveness evaluation in Japan. The 7-day-per-week rehabilitation was dominant from public healthcare and long-term care payerʼs perspective. The result of sensitivity analysis showed that even when the lowest efficacy of was assumed, the ICER was $39,065/QALY.

Conclusion: The results indicated that seven-days-per-week rehabilitation for acute stroke rehabilitation was likely to be cost-effective, with a little uncertainty with uncertainty in patient outcome.

Acute stroke

Rehabilitation

Cost-effectiveness

Cost utility analysis

Rehabilitation is an essential medical service for patients recovering from acute stroke, and the effectiveness of stroke rehabilitation has been reported in the literature [1–4]. The American Heart Association and American Stroke Association have stated the importance of early initiation of stroke rehabilitation [5]. Some studies consider the relationship between frequency of stroke rehabilitation and clinical outcomes such as length of stay [6–8]. Matsui et al. reported that being hospitalized on Friday would make post-stroke severity significantly worse, indicating that difference in treatments between weekdays and weekdays could affect patient outcomes [9]. Kinoshita et al. compared a group of acute stroke patients using the Japan Rehabilitation Database (N = 3,072) who utilized rehabilitation services seven days per week, with another group comprising those who utilized these services for five or six days [10]. The results showed that patient severity was significantly lower in the group with seven-days-per-week schedule even after adjustment by related parameters, and therefore, better outcomes can be expected.

In Japan, the importance of considering cost-effectiveness of medical services is being realized, and in 2019, the cost-effectiveness evaluation commenced [11]. In a study by Murayama et al. in 2011, only 4 out of 25 subject hospitals in Japan were found to provide acute stroke patients with rehabilitation seven days a week [12]. It is possible that, currently, such hospitals are still not in majority. It is necessary to evaluate the cost-effectiveness of seven-days-per-week rehabilitation for acute stroke patients and consider optimal service fee in the national fee table to consider promoting that rehabilitation schedule. However, no study has considered its cost-effectiveness compared with a five- or six-days-per-week schedule. In this study, the cost-effectiveness of a seven-days-per-week rehabilitation schedule for acute stroke patients is analyzed to help formulate more cost-effective rehabilitation for acute stroke patients.

Scheme and Outcomes

The subjects were two groups of hypothetical 1,000 patients each, who had suffered from acute stroke in Japan. One patient group conventionally used rehabilitation services five or six days a week, and the other, for seven days a week, for 30 days after the onset of stroke in acute hospitals (five-/six-day group and seven-day group, respectively). The two groups were compared in the cost utility analysis, for which effectiveness of the seven-days-per-week rehabilitation was based on the study by Kinoshita et al [10]. The characteristic of patients were according to that study. The analysis period was five years after onset. The design of this study was shown in Fig. 1. In Japan, it was common for acute stroke patients to be admitted in an acute hospital, and after being discharged, in a convalescent hospital, for treatments such as rehabilitation. In the National fee schedule in Japan, additional fee for acute stroke rehabilitation can be charged for 30 days after onset [13]. Based on the information in the National fee schedule, it was assumed that the duration of stay in acute hospitals in this study is 30 days, and that in convalescent hospitals is up to 90 days (i.e.3 months) [14]. It was also assumed that the two groups differed in the frequency of rehabilitation services utilized in the acute stage, though there was no such difference in medical services they received in the convalescent stage [11] From the 4th month, the patients utilized long-term care services according to their severity, which was described later section (“Long-term care cost estimate” section).

The primary outcome for the cost utility analysis was the incremental cost-effectiveness ratio (ICER), which is commonly used for health technology assessment in many countries such as UK [15] and Japan [12]. ICER was estimated as incremental costs brought by a new treatment or medical service divided by incremental clinical outcomes. The ICER for this study was calculated using the Equation below. Quality-adjusted life years (QALY), a standard measure in health technology assessment, was used as a measure of clinical outcome [12]. Calculated ICERs were evaluated with the threshold of 5,000,000 yen/QALY (approximately US$43,055), in accordance with the one used in the cost-effectiveness evaluations in Japan [16].

$ICER=\frac{Costs in 7-day group-Costs in 5-or 6-day group}{QALY gained in 7-day group-QALY gained in 5-or 6- day group}$ Equation

In the Japanese medical system, universal rates are decided for each medical service, treatment, or drug in the national fee schedule [17]. The rate of co-payment differs depending on patient groups (e.g., 30% for most patients, 10% for patients aged 75 years or older, and no charge for welfare recipients), and the rest is paid by insurers and the government. In total, only 11% of the national medical expenditure is covered by patient co-payments. A large part is covered by the public budget, and the Guideline for Preparing Cost-Effectiveness Evaluation in Japan recommends that health technology assessment be conducted from the public health payer’s perspective, which basically includes medical costs including patient co-payments and payments by insurers and the government [11]. However, the guideline also states that long-term care costs can be included when the effect of public long-term care costs is important. Since this was the case with acute stroke, by which patients had severe sequela, our analysis was based both on the public health payer’s perspective, and public healthcare and long-term care payerʼs perspective. The latest national fee schedule, which was published in 2020 [13], was used. The costs and QALYs were discounted by 2% per year, according to the Japanese guideline [11]. After the analysis, the results were converted to US$ using the currency exchange rate as of March 10, 2022 (US$1 = 116.133 yen). The entire process was repeated 1000 times.

Patient severity estimate

Patient severity from the fourth to the 60th month was estimated using Markov modeling. The Markov model was a simulation model in which transition states and transition probabilities, as well as patients’ moves between the transition states at a Markov cycle (i.e., the frequency at which patients move), are defined. The Markov model has been applied to simulations of patients with various diseases [18, 19] and with stroke patients [20, 21]. In this study, three states—mRS0-2 (functionally independent), mRS3-5 (disabled), and mRS6 (death)—were defined. The Markov cycle was set as one month, and the model structure and the transition probabilities obtained in a previous study by Health Quality Ontario [22]

Data on patient severity at three month after the onset of stroke (initial probability) was obtained from a previous study by Kinoshita et al., which compared the two groups using the Japanese Rehabilitation Database (modified Rankin Scale (mRS) 012:mRS345:mRS6 = 43.3: 54.5: 2.2 for the seven-day group and mRS012:mRS345:mRS6 = 37.6:58.5:3.9 for the five-/six-day group) [10]. The study showed that patient severity was significantly lower in the group with seven-days-per-week schedule even after adjustment by related parameters. Patient severity was based on the modified Rankin Scale. Considering uncertainty in patient severity, two other scenarios were also set, changing the rate of patients with mRS0-2 severity. The rate of patients with mRS0-2 severity was set by calculating the risk ratio for mRS0-2 severity from the previous study [10], and by using the upper and lower edge of 95CI to determine the patient severity at three months (best scenario and worst scenario, respectively). The mRS stage distributions for the seven-day group were mRS0-2: mRS3-5: mRS6 = 47.4:50.4:2.2 in the best scenario, and mRS0-2: mRS3-5: mRS6 = 39.7:56.4:3.9 in the worst scenario. The patient severity at 90 days was randomly decided for each patient according to those initial probabilities. R ver. 3.5.2 was used for the simulation. After the simulation using the Markov model, patients were divided into finer mRS stages (from mRS 0 to 6) at each time cycle because differences could exist even in functionally independent patients or disabled patients. Patients at each mRS stage were divided into finer mRS grades with the proportion of mRS grades by Hattori et al. (mRS0:1:2 = 47:46:61, mRS3:4:5 = 66:65:45) [23]. Based on the estimated patient severity, QALYs and cost estimates were analyzed, as explained later. This entire process of estimating the severity were repeated 1000 times.

Medical cost

In this study, it was assumed that there was no difference in medical services provided to the seven-day and five-six-day groups, except for the number of rehabilitation services in the acute stage. No significant difference was found between the two groups in length of stay and treatments provided in the acute stage, such as administration of recombinant tissue plasminogen activator in the study by Kinoshita [10]. It was also assumed that medical costs after discharge from acute hospitals were not included in the analysis.

In the medical cost analysis, patients utilized rehabilitation services for 30 days after onset. The day of onset was randomly assigned to patients, from Sunday to Saturday, because the number of rehabilitation days were affected by what day of the week the stroke occurred.

In the Japanese medical system, the time required for rehabilitation services is 20 minutes per unit [11]. It was assumed that the number of rehabilitation units a patient utilizes per day was 4.3 [11], and was changed between 3 to 6, as sensitivity analysis. The national fee for per-unit rehabilitation service is $21.1. An additional fee of $2.58 per unit was charged for rehabilitation during the first 30 days, and there is another fee of $3.88 per unit during the first 14 days [11], which is charged when a full-time (or equivalent) rehabilitation physician is engaged. Since there were no data on proportion of hospitals that provide rehabilitation for acute stroke patients five to six days a week, it was assumed that all the patients in the five-/six-day group utilized rehabilitation services five days a week for a conservative cost estimate.

Long-term-care cost

It was assumed that long-term-care costs differed depending on patient severity. The Japanese long-term care system divides patients with care needs into seven levels based on their severity: Support level 1–2 and Care Needs level 1–5 [24]. The higher the level, the severer a patient is. Patients with Support level needs are less severe than those with Care Needs level. First, the estimated patient severity in the form of mRS stages was transformed into severity in the form of long-term-care needs (the seven levels), according to a previous study [25] (Table 1). For example, to estimate long-term-care costs, patients with mRS1 disability were assigned to Support level 1. Patients with mRS4 were assigned to Care Needs level 2 or 3, and patients with mRS5 were assigned to Care Needs level 4 or 5, according to the proportion of the patients in each Care Needs level in the previous survey by the Ministry of Health Labor and Welfare [26] (i.e.Care level 2:3 = 3,578:2,300, Care level 4:5 = 1,932:1,873). The rate of service utilization was defined by patient severity under the premise that, the severer a patient, the more care services she/he is likely to be utilized (Table 1) [24]. Data on long-term-care costs were calculated according to a previous study by Yamaga and Ikeda, in which the costs were estimated based on a survey by the Ministry of Health Labor and Welfare by dividing the amount of total long-term expenditure at each Care Needs level by the number of patients in each Care Needs level [27] (Table 1).

Table 1

QOL utility, care needs level, utilization rate of long-term care services, and long-term care costs used in the simulation
	mRS0	mRS1	mRS2	mRS3	mRS4	mRS5	mRS6
QOL utility (SD) [30]	0.89 (0.114)	0.797 (0.084)	0.65 (0.074)	0.588 (0.067)	0.363 (0.073)	0.092 (0.08)	0 (0)
Care needs level [32]		Support level 1	Support level 2	Care level1	Care level 2 or 3*	Care level 4 or 5*
Utilization rate of long-term care services [30]	0	0.216	0.915	0.985	1	1	0
Long-term care costs based on care needs level ($/month) [32]		249	427	915	Level 2 1238 Level 3 1812	Level 4 2174 Level 5 2504
*Patients are assigned to the either of the 2 Care Level according to the proportion of the patients shown in Comprehensive Survey of Living Conditions [33] (Care level 2:3 = 3,578:2,300, Care level 4:5 = 1,932:1,873)

mRS: modified Rankin Scale, QOL: Quality of life

Table legend: Table 1 shows the parameter inputs for each mRS grade used in the analysis.

QALY estimation

The patients were assigned quality of life (QOL) utility according to their mRS grades. Data on QOL utility for each mRS stage was obtained from the study by Hattori, which was conducted on Japanese subjects [23]. The QOL utility was randomly generated under the assumption that the values were normally distributed, and utility values were generated for each patient, with the average and standard deviation as shown in Table 1.

Sensitivity Analysis

To consider the uncertainty of cost-effectiveness, sensitivity analysis was conducted. The number of rehabilitation units per day was changed from 3 to 6. Medical costs and long-term care costs were respectively changed from 0.9 time to 1.1 times since these costs were universal, and the revision rates are approximately 1% overall every 2 years. Therefore, drastic changes in medical costs and long-term care costs were not expected. The discount rate was changed from 0–4%, according to the Japanese guideline [12]. Finally, the patient severity at the third month was changed according to the study by Kinoshita et al [9], as it was stated in the previous section (i.e.best scenario and worst scenario).

Medical cost and long-term-care cost

In the base case, the average medical cost for rehabilitation at the acute stage per patient was $3,286 for the seven-day group, and $2,348 for the five-/six-day group. When the number of rehabilitation units were changed from 3 to 6, the medical costs were $2,292 to $4,5985 for the seven-day group, and $1,408 to $3,399 for the five-/six-day group.

Average long-term-care costs per patient for the 5 years were $43,290, $41,564, and $43,765 for the seven-day group in the base scenario, best scenario, and worst scenario, respectively. Long-term-care costs for the five-/six-day group was $44,617.

From public healthcare and long-term care payerʼs perspective, the average total incremental costs per patient were $-388, $-2,213, and $87 in the base scenario, best scenario, and worst scenario, respectively (Table 2).

Incremental QALYs

The average gained QALYs were 1.855, 1.898, and 1.787 for the seven-day group in the base scenario, best scenario, and worst scenario, respectively. The gained QALYs for the five-/six-day group was 1.765. The incremental QALYs for the 5 years were 0.089, 0.133, and − 0.022 in the base scenario, best scenario, and worst scenario, respectively (Table 2).

Incremental cost-effectiveness ratio

From public healthcare payerʼs perspective, ICERs were $10,901/QALY, $7,047/QALY, and $39,065/QALY in the base scenario, best scenario, and worst scenario, respectively (Table 2). The probabilities of 7-day rehabilitation being cost-effective with the threshold of $43,055 were 93.4%, 99.0%, 49.7% in the base scenario, best scenario, and worst scenario, respectively.

From public healthcare and long-term care payerʼs perspective, the seven-day group was dominant in the base scenario and in the best scenario. ICER in the worst scenario was $3,569/QALY (Table 2). The ICER plots for each scenario with the threshold were shown in Fig. 2. The probabilities of 7-day rehabilitation being cost-effective with the threshold of $43,055 were 97.2%, 99.7%, and 70.8% in the base scenario, best scenario, and worst scenario, respectively. The ICER plots for each scenario with the threshold were shown in Fig. 3.

Table 2

Results of each scenario
scenario	medical cost	long-term care cost	gained QALY	only medical cost included		medical and long-term care cost included
scenario	medical cost	long-term care cost	gained QALY	ICER ($/QALY)	probability of being cost-effective	ICER ($/QALY)	probability of being cost-effective
base scenario	3286	43290	1.86	10901	93.4%	Dominant	97.2%
Δfrom five-/six-day group	938	-4108	0.09
best scenario	3286	41565	1.90	7047	99.0%	Dominant	99.7%
Δfrom five-/six-day group	938	-5833	0.13
worst scenario	3286	43765	1.79	39065	49.7%	3569	70.8%
Δfrom five-/six-day group	938	-3633	0.02
five-/six-day group	2349	44617	1.77

Table legend: Table 2 shows the results of each scenario on medical cost, long-term care cost, QALY, and ICER.

Sensitivity Analysis

The results of sensitivity analysis from public healthcare payerʼs perspective were shown in Fig. 4-a. When the inputs of the discount rate were changed, the ICERs moved from $8,242/QALY to $10,158/QALY. When the inputs of the number of rehabilitation units were changed, the ICERs moved from $9,961/QALY to $13,376/QALY. When the inputs of medical costs were changed, the ICERs moved from to $9,511/QALY to $11,625/QALY.

The results of sensitivity analysis from public healthcare and long-term care payerʼs perspective were shown in Fig. 4-b. Seven-days-per-week rehabilitation stayed dominant even when the values of parameters were changed, expect for patient severity.

This study analyzed the cost-effectiveness of providing rehabilitation to acute stroke patients seven days per week. The ICER at 60 months was $10,901/QALY with the 93.4% probability of ICER being lower than $43,055/QALY from public healthcare payerʼs perspective. Therefore, excellent cost-effectiveness of seven-days-per-week rehabilitation was expected. Kinoshita et al. analyzed the effectiveness of providing rehabilitation seven days per week by comparing the seven-day and five-/six-day groups. Their result was confirmed by including a large number of patients and by adjusting the odds ratio with various factors such as patient demographic information, time to admission after onset, and administration of recombinant tissue plasminogen activator [9]. This study clarified the economic aspects of a seven-days-per-week rehabilitation schedule for acute stroke patients.

The medical and long-term care system in Japan is guided by the national fee schedules [13]; thus, the cost analysis can be applied throughout the country. In this study, it was assumed that medical costs did not differ between the two groups, except for the frequency of rehabilitation. This result of excellent cost-effectiveness can be attributed to the fact that implementing a seven-days-per-week rehabilitation schedule does not cost much.

Long-term-care costs were lower for the seven-day group. The ICER was also better from public healthcare and long-term care payerʼs perspective. The result was attributed to the improved patient severity. Our result indicated that stroke patients can benefit from being assigned to lower care-needs levels, and subsequently, lower long-term care costs, by utilizing seven-days-per-week rehabilitation in the acute stage. The effect on patients suffering from post-stroke disability usually lasts for a lifetime. In Japan, approximately 26.9% of all long-term-care expenditure is attributed to stroke [26]. Therefore, it is important to conduct cost-effectiveness analysis including long-term care costs of stroke treatments.

This research covered a sensitivity analysis considering uncertainty in the distribution of patient severity. The results showed that its cost-effectiveness mostly remained at the high level. The value of ICER was $39,065/QALY, below the threshold in the worst case from public healthcare payerʼs perspective, indicating that seven-days-per-week rehabilitation for acute stroke patients was cost-effective even in the worst case. However, the probability of ICER being lower than the threshold was 70.8% from public healthcare and long-term care payerʼs perspective, and 49.7% from public healthcare payerʼs perspective. This result indicates that although providing seven-days-per-week rehabilitation for acute stroke patients is likely to be cost-effective, there is a little uncertainty according to the fluctuation in the patient outcomes. To address the uncertainty, further study is needed to clarify the characteristic of patients for which seven-days-per-week rehabilitation is cost-effective.

Murayama et al reported that only 4 out of 25 subject hospitals were found to provide acute stroke patients with rehabilitation seven days a week [9]. Initiating the seven-days-per-week rehabilitation schedule incurs costs for personnel (i.e., physicians, providers, and so on) who work on weekends or holidays, and administration costs, which can be a restraint for hospitals. The results of this study will be of importance in considering the optimal national fee in terms of cost-effectiveness and promoting the seven-days-per-week rehabilitation schedule. However, although costs for providing rehabilitation seven days a week could be an obstacle from its implementation for hospitals, its cost-effectiveness from hospitals’ perspective is still unclear. Future research should focus on analysis from the perspective of hospitals.

This study analyzes the cost-effectiveness of the seven-days-per-week rehabilitation schedule for acute stroke patients to encourage the consideration of providing more cost-effective stroke treatments. Although the results here showed that seven-days-per-week rehabilitation was likely to be cost-effective, this study has several limitations. First, this analysis is based on one database study by Kinoshita et al [10], even though the study has large number of Japanese samples, and the efficacy of seven-days-per-week rehabilitation was evaluated after adjustment with related parameters. Despite this limitation, the results of this study are of great importance when high-evidence study such as randomized controlled trials does not exist for this topic. Second, since this study was from the healthcare payer’s perspective, this study did not consider opportunity costs; Yamaga et al. measured the cost of illness of stroke in Japan and included opportunity costs in their analysis [25]. Next, though there should be differences in the number of rehabilitation units among hospitals, the relationship between rehabilitation time and patient severity has not been clear. Although a positive relationship between rehabilitation time and patient outcomes has been reported in the post-acute stage [28–29], there is no consensus about the acute stage [30]. Some studies report that, by increasing intensity of rehabilitation in the acute stage, post-stroke severity in patients would be improved [3–4]; however, Lauro et al. reported no significant effect of the same [31]. If the relationship is clarified, more detailed analysis on cost-effectiveness can be made available. Lastly, cost structures are different globally. Therefore, even though our methods are applicable to other countries, analyses should be conducted according to each country's system.

This study examined the provision of cost-effective treatments for acute stroke patients, focusing on the cost-effectiveness of seven-days-per-week rehabilitation schedule. The estimated ICER was $10,901/QALY, which was lower compared with the threshold of 5,000,000 yen/QALY (approximately U S$43,055) from public healthcare payerʼs perspective, and seven-days-per-week rehabilitation schedule was dominant from public healthcare and long-term care payerʼs perspective. The results indicates that seven-days-per-week rehabilitation is likely to be cost-effective, with a little uncertainty in its cost-effectiveness according to uncertainty in patient outcome. These results would be of prime importance when further studies are conducted from the perspective of hospitals.

CER, Incremental Cost-effectiveness Ratio; QALY, Quality-adjusted Life Years; mRS, modified Rankin Scale; QOL, Quality of Life

Ethic approval and consent to participate: Not Applicable

Consent for publication: Not Applicable

Availability of data and materials: The dataset(s) supporting the conclusions of this article is(are) included within the article.

Competing interests: The authors declare that they have no competing interests

Funding: Not Applicable

Authors’ contributions: Y.M, K.A, T.O, T.T, K.F, K.Y, K.H,K.A made substantial contributions to the conception and design of the work. Y.M and J.T made substantial contributions to the acquisition of data and the analysis. K.A and T.O made substantial contributions by providing advice from clinical perspective. Y.M drafted the work, and K.A, T.O, J.T, T.T, K.F, K.Y, K.A substantially revised it. All authors read and approved the final manuscript.

Acknowledgement: We would like to thank Editage (www.editage.jp) for English language editing.

Biernaskie J, Chernenko G, Corbett D.Efficacy of Rehabilitative Experience Declines with Time after Focal Ischemic Brain Injury. J Neurosci. 2004; 24: 1245-54.
Liu N, Cadilhac DA, Andrew NE, Zeng L, Li Z, Li J et al. Randomized controlled trial of early rehabilitation after intracerebral hemorrhage stroke: Difference in outcomes within 6 months of stroke. Stroke. 2014; 45: 3502-07.
Kwakkel G, Wagenaar RC, Twisk JW, Lankhorst GJ, Koetsier JC. Intensity of leg and arm training after primary middle-cerebral- artery stroke: a randomised trial. Lancet 1999; 354: 191-96.
Langhorne P, Wagenaar R, Partridge C. Physiotherapy after stroke: more is better?. Physiotherapy Research International 1996; 1:75-88.
Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC et al. Guidelines for Adult Stroke Rehabilitation and Recovery: a guideline for healthcare professionals From the American Heart Association/American Stroke Association. Stroke. 2016; 47: e98-169.
Brusco NK, Shields N, Taylor NF, Paratz J. A saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: A randomised controlled trial. Aust J Physiother. 2007; 53: 75-81.
Disotto-Monastero M, Chen X, Fisch S, Donaghy S, Gomez Manuel. Efficacy of 7 days per week inpatient admissions and rehabilitation therapy. Archives of Physical Medicine and Rehabilitation. 2012; 93: 2165-69.
Peiris CL, Shields N, Brusco NK, Watts JJ, Taylor, NF. Additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: A randomized controlled trial. BMC Med. 2013; 11:198.
Matsui H, Hashimoto H, Horiguchi H, Yasunaga H, Matsuda S. An exploration of the association between very early rehabilitation and outcome for the patients with acute ischaemic stroke in Japan: a nationwide retrospective cohort survey. BMC Health Serv Res. 2010; 20(10):213.
Kinoshita S, Momosaki R, Kakuda W, Okamoto T, Abo M. Association Between 7 Days Per Week Rehabilitation and Functional Recovery of Patients With Acute Stroke: A Retrospective Cohort Study Based on the Japan Rehabilitation Database. Archives of Physical Medicine and Rehabilitation. 2017; 98: 701-06.
The Central Social Insurance Medical Council. Guideline for Preparing Cost-Effectiveness Evaluation to the Central Social Insurance Medical Council Ver 2.0. 2019.https://c2h.niph.go.jp/tools/guideline/index.html　Accessed on March 5, 2022.
Murayama Y, Inoue I, Member for Voluntary Hospitals of Japan Society. Effect of the 2008 revision of rernuneation for medical services on rehabilitation in an acute hospital. Sagyoryoho. 2011; 30: 717-726. (In Japanese)
The ministry of Health, Labour, and Welfare. Annunciation No.43, amended on March fifth. 2020. Available athttps://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000188411_00027.html　. (Accessed on March 10, 2022) (In Japanese).
The Ministry of Health, Labour, and Welfare. Patient Survey 2014. Available athttps://www.mhlw.go.jp/toukei/saikin/hw/kanja/17/index.html(Accessed on March 10, 2022) (In Japanese)
National Institute of Health and Care Excellence. The guideline manual. 7 Assessing cost effectiveness. 2022. Available athttps://www.nice.org.uk/process/pmg6/chapter/assessing-cost-effectiveness (Accessedon March 10, 2022)
Ogura H, Komoto S, Shiroiwa T et al. Exploring the Application of Cost-Effectiveness Evaluation in the Japanese National Health Insurance System. Int J Technol Assess Health Care. 2019;35(6):452-60.
The Ministry of Health Labour and Welfare.　An Outline of the Japanese Medical System. 2022. Available athttps://www.mhlw.go.jp/english/policy/health-medical/health-insurance/index.html　 (Accessedon March 10, 2022)
Wong LY,Toh MP,Tham LW. Projection of prediabetes and diabetes population size in Singapore using a dynamic Markov model.J Diabetes.2017;9:65-75.
Ramos M,Lamotte M,Gerlier L,Svangren P,Miquel-Cases A,Haughney J. Cost-effectiveness of physical activity in the management of COPD patients in the UK.Int J Chron Obstruct Pulmon Dis 2019; 14:227-239.
Cassarly C,Martin RH,Chimowitz M,Peña EA,Ramakrishnan V,Palesch YY. Comparison of multistate Markov modeling with contemporary outcomes in a reanalysis of the NINDS tissue plasminogen activator for acute ischemic stroke treatment trial.PLoS One 2017; 12: e0187050.
Pizzo E,Dumba M,Lobotesis K. Cost-utility analysis of mechanical thrombectomy between 6 and 24 hours in acute ischemic stroke.Int JStroke 2019; 1747493019830587.
Xie X, Lambrinos A, Chan B, Dhalla IA, Krings T, Casaubon LK et al. Mechanical thrombectomy in patients with acute ischemic stroke: a cost-utility analysis. CMAJ Open 2016;4(2):E316-25.
Hattori N, Hirayama T, Katayama Y. Medical Care for Chronic-Phase Stroke in Japan. 2012; 52: 175-180.
Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare. Long-Term Care Insurance System of Japan. 2016. Available athttps://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-elderly/dl/ltcisj_e.pdf (Accessedon March 10, 2022)
Yamaga M, Ikeda S. Cost of illness after stroke. Journal of the International University of Health and Welfare. 2016; 21:82-92. (In Japanese)
The Ministry of Health Labour and Welfare. Comprehensive Survey of Living Conditions, long-term care. Avaiable at　https://www.mhlw.go.jp/toukei/list/20-21.html (Accessedon March 10, 2022)
The Ministry of Health Labour and Welfare. Survey of Long-term Care Benefit Expenditures, 2017. Available athttps://www.mhlw.go.jp/toukei/list/45-1.html (Accessedon March 10, 2022)
Miyai I,Sonoda S,Nagai S Takayama K, Inoue Y, Kakehi A et al. Resultsof new policies for inpatient rehabilitation coverage in Japan.Neurorehabil Neural Repair 2011; 25: 540-7.
Nagai S, Sonoda S, Miyai I, Kakehi A, Goto S, Takayama Y et al. Relationship between the intensity of stroke rehabilitation and outcome: A survey conducted by the Kaifukuki Rehabilitation Ward Association in Japan (second report).Jpn J Compr Rehabil Sci 2011; 2:77-81.
Japan Stroke Association. Japanese Guidelines for the Management of Stroke 2015 (supplement in 2017). Available athttp://www.jsts.gr.jp/img/guideline2015_tuiho2017.pdf (Accessed on April 22, 2019) (In Japanese).
Lauro AD, Pellegrino L, Savastano G, Ferraro C, Fusco M, Balzarano F et al. A randomized trial on the efficacy of intensive rehabilitation in the acute phase of ischemic stroke. J Neurol 2003; 250(10):1206-08.

No competing interests reported.

Cost-effectiveness of Seven-days-per-week Rehabilitation Schedule for Acute Stroke Patients

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Materials And Methods

Results

Sensitivity Analysis

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1