Incentives for Uptake of and Adherence to Outpatient Stroke Rehabilitation Services: A Three-Arm Randomized Controlled Trial.

Abstract

ObjectiveTo determine if rehabilitation uptake and adherence can be increased by providing coordinated transportation (increased convenience) and eliminating out-of-pocket costs (reduced expense).DesignThree-arm randomized controlled trial Setting: Stroke units of two Singapore tertiary hospitals Participants: Singaporeans or permanent residents aged ≥21 years who were diagnosed with stroke and discharged home with physician's recommendation to continue outpatient rehabilitation.InterventionsA Transportation Incentives arm (T), which provides free transportation services, a Transportation & Sessions Incentives arm (T&S), offering free transportation and prescribed stroke rehabilitation sessions, and a control arm, Education (E), consisting of a stroke rehabilitation educational programme.Main outcome measuresThe primary study outcome was uptake of outpatient rehabilitation services (ORS) amongst post-stroke patients, and key pre-defined secondary outcomes being number of sessions attended and adherence to prescribed sessions.ResultsUptake rate of ORS was 73.0% for E (CI, 63.8%-82.3%), 81.8% for T (CI, 73.8%-89.8%), and 84.3% for T&S (CI, 76.7%-91.8%). Differences of T and T&S versus E were not statistically significant (p=0.22 and p=0.10, respectively). However, average number of rehabilitation sessions attended were significantly higher in both intervention arms: 5.50 (SD, 7.65) for T and 7.51 (SD, 9.52) for T&S versus 3.26 (SD, 4.22) for control arm (E) (p-value for T vs E =0.017; p-value for T&S vs E =0.000.) Kaplan-Meier analysis indicated that persistence was higher for T&S compared to E (p=0.029).ConclusionsThis study has demonstrated a possibility in increasing the uptake of and persistence to stroke ORS with free transportation and sessions. Incentivizing stroke survivors to take up ORS is a new strategy worthy of further exploration for future policy change in financing ORS or other long-term care services.