A Randomized Controlled Trial to Improve the Uptake of and Adherence to Outpatient Rehabilitation Services Among Stroke Patients

Background Stroke is the leading cause of long-term disability in Singapore. Stroke accounts for 9.1% of years of life lost (YLL) and 6.1% of disability-adjusted life years (DALYs). With a rapidly aging population, the burden of stroke is anticipated to grow correspondingly in the years to come. Stroke survivors with moderate or severe functional disabilities require long-term medical and social care, imposing financial and psychological burdens on the patients and their family members. Research indicates that intensive specialized stroke rehabilitation can improve post-stroke functional outcomes for a substantial portion of stroke patients. Extant studies also indicate that rehabilitation is cost-effective in both inpatient and outpatient settings, and can potentially lead to reductions in both sub-acute and long-term post-stroke healthcare costs. In addition, a longitudinal study on post-stroke patients in Singapore found that receiving outpatient rehabilitation service at day rehabilitation centers resulted in earlier functional recovery. However, despite the benefits associated with adherence to prescribed rehabilitation sessions, the uptake rate of and adherence to outpatient rehabilitation service in Singapore is low. Only 33% of stroke survivors who were recommended for post-discharge community-based rehabilitation actually took up the service. The low uptake rate also implies substantial potential avoidable disability among stroke patients in Singapore.

Significance According to a longitudinal survey on patients who were discharged from community hospital and recommended for post-discharge outpatient rehabilitation in Singapore, financial burden of rehabilitation services and the inconveniences of transportation are associated with the low attendance rates to outpatient rehabilitation.

Behavioral economic theory and empirical studies also suggest that the low rate of uptake and adherence, at least in part, is attributable to stroke patients' perceptions or uncertainty about the health benefits of rehabilitation. Stroke patients may make a decision to utilize ORS or not, based on incomplete information about the service attributes (e.g. service quality, social connectedness, and perceived benefits). Over time, patients and caregivers may update their perceived service attributes through information and education on stroke management or actual experiences. Hence, providing incentives to take up ORS and educational materials on post-stroke management will elevate the current uptake rate of ORS and long-term adherence.

The proposed study will be the first attempt in Singapore to test innovative ways of encouraging uptake of stroke ORS. It will systematically test promising economic strategies that might be effective and cost-effective in increasing the uptake of and adherence to the prescribed ORS. Given the high bed occupancy rate in public acute hospitals in Singapore, outpatient center-based rehabilitation service could be a more viable option than inpatient rehabilitation and more cost-effective in Singapore. It will provide evidence for future policy change in financing outpatient rehabilitation service and other long-term care services in Singapore and other countries experiencing similar problems.

Specific Aims & Hypothesis Stroke is the leading cause of long-term disability in Singapore, and the burden of stroke is posing challenges to the healthcare system and society. Previous international and regional research studies suggest that a substantial proportion of stroke patients can benefit from post-stroke rehabilitation services and achieve improved functional outcomes. However, despite government subsidies and Medisave coverage for outpatient rehabilitation, the uptake rate of outpatient rehabilitation service (ORS) among stroke patients is low.