OBJECTIVES:

Individuals residing in rural and small communities have inadequate access to timely stroke care resulting in a higher mortality rate. While some interventions are effective in improving healthcare access, it is unknown whether these interventions are cost-effective. We aim to systematically review cost-effectiveness of organisational stroke care interventions addressing geographical inequalities.

METHODS:

We searched PubMed and Embase for articles published between 2012 and 2022 examining the cost-effectiveness of organisational stroke care interventions in rural and small communities using a pre-defined search strategy. Two independent reviewers screened for eligible studies and performed the data extraction. The individual studies were narratively synthesised.

RESULTS:

A total of 15 studies met the inclusion/exclusion criteria and covered multiple facets of stroke care including mobile stroke, tele-stroke, and decentralisation of stroke care. Four out of five studies on tele-stroke were cost-effective compared to standard care. Four studies investigated mobile stroke units (MSUs) and showed mixed result. While a cost consequence analysis showed MSU costed more than standard care, another study showed benefit cost ratio of MSU was greater than one. Cost effectiveness increased with less number of specialists. Of five studies investigating transferring interventions, prehospital severity-triaging or dispatching neuro-specialist from hub hospitals to nearby hospitals were dominantly cost-effective. Secondary transfer of emergency stroke patients with helicopter in rural areas was cost-effective under standard willingness to pay thresholds. Decentralising stroke care incurred marginally higher costs but slightly improved the thrombolysis rate.

These studies included both short-term and lifetime horizons; with two using a societal,one using a payer and 11 using a healthcare perspective. Study outcomes included incremental cost per quality-adjusted life years, disability-adjusted life year, deaths averted, and severe disability cases prevented.

CONCLUSIONS:

Implementing tele-stroke and prioritising transfers of appropriate patients to primary stroke centres or dispatching specialists offer cost-effective ways to improve stroke delivery in rural and small communities.