Introduction
Health expenditure is defined as “consumption of a resource with the primary objective of promoting, restoring, and maintaining health”, with the inclusion of spending by all levels of government and non-government entities, such as private health insurers and individuals.1,2 Globally, health expenditure has grown substantially from 3.5 trillion United States dollars (USD) in 1995 to 8.0 trillion USD in 2016 and is projected to continue increasing in the next three decades at a rate of 1.84% annually.3 There are a myriad of factors contributing to the growth of health expenditure, spanning socio-demographics (eg, population size and age structure, urbanization); economy (eg, financial resources and price growth); technology (eg, technological advancement, investment in research and development); lifestyle and environment (eg, obesity, greenhouse gas emissions); epidemiological transition and changing patterns of diseases (eg, upward trends in non-communicable diseases); delivery of healthcare (eg, improved access to health services); and administration and design of the health sector (eg, share of public and private spending, health insurance development).4 The substantial and continued growth of health expenditure has become a major challenge for financial sustainability within and beyond the health sector worldwide.4,5
Of the global total health expenditures, curative care in hospital settings accounts for the greatest share; this finding is consistent across low-, middle- and high-income countries.6 Evidence suggests that inappropriate utilization of hospital services, such as emergency department (ED) visits for non-urgent complaints and unnecessary hospitalization, plays a prominent role in driving up healthcare costs.7–9 It is estimated that only 10% of healthcare demands require hospital-related services, while the remaining 90% can be managed through primary health care (PHC).10 PHC is commonly identified as a “gateway” to the wider health system, which addresses the health needs of all populations at the community level.11 Research has suggested that strong PHC is associated with various benefits, including fewer unnecessary hospital admissions and lower healthcare costs.11
Initiatives using a PHC approach have been trialed extensively, with a mixed evidence base regarding their effectiveness on the acute sector. For example, a systematic review compared hospital-at-home interventions and in-hospital stay for patients with chronic diseases, and reported a significantly reduced risk of readmission yet a significantly greater length of treatment in the intervention group.12 Another systematic review examining the effectiveness of community-based interventions for childhood asthma found that multicomponent interventions are associated with a significant reduction in asthma-related ED visits and hospitalizations.13 While there is a heterogeneous collection of interventions, they are predominantly led by doctors and nurses.
Allied health (AH), along with medicine and nursing, is an integral pillar of PHC. Allied health professionals (AHPs) are equipped with essential and unique skills to provide wide-ranging health services, where they engage with clients in decision-making and support them in establishing and achieving goals that enhance functional capacity, support safe and independent community living, and maintain or improve quality of life.14 However, little is known about the impact of interventions led by AHPs on the acute sector due to a limited evidence base. To address this knowledge and research gap, the review team conducted a systematic review to synthesize contemporary evidence regarding the effectiveness of community-based AH services on the acute sector and the perspectives of relevant stakeholders in this context. That review employed a mixed methods approach and identified a substantial body of evidence that indicates community-based AH may alleviate the pressures on the acute sector, with overwhelmingly positive experiences and benefits reported by patients and their carers. The paper has been published.15
Healthcare stakeholders, such as policymakers and healthcare planners, rely on a combination of effectiveness and efficiency evidence to inform their decision-making. This enhances appropriate deployment of scarce resources to areas with the greatest potential for positive impact.16,17 Economic evaluations, which involve a comparative analysis of alternative courses of action in terms of costs and effects, are an essential approach to determining the efficiency of a health intervention.16 They are generally divided into two categories: full economic evaluations and partial economic evaluations. Full economic evaluations are characterized by comparison of two or more alternative interventions while accounting for both costs and effects, making them the optimal approach and the preferred type for both multipurpose systematic reviews and clinical practice guidelines. By contrast, partial economic evaluations do not fulfill these criteria; however, they may be employed when knowledge is limited.18 The type of economic evaluation is influenced by the unit used to measure effects. For example, cost-effectiveness analysis (CEA) is used when effects are expressed in natural units (eg, number of symptom events observed); whereas in cost–benefit analysis, effects are expressed in monetary terms.16,18
In the context of community-based AH, economic evaluations would complement the current evidence regarding effectiveness and stakeholders’ perspectives, leading to a more insightful understanding of the impact and enhanced resource allocation decisions among healthcare stakeholders. The evolving healthcare context, such as post-pandemic healthcare reforms and changing workforce and service delivery models, further amplifies the necessity for this study. Therefore, the aim of this review was to evaluate the economic impact of these community-based, AHP-led services on acute care utilization. The primary outcomes of interest for this review were the: (a) costs of at least one type of acute care utilization identified in the previous paper;15 and (b) cost-effectiveness of AHP-led services regarding acute care. The secondary outcomes of interest included total healthcare and/or non-healthcare costs associated with the management of target condition(s). Given the emerging evidence in this field, and the outcomes of interest, both full and partial economic evaluations were included in this review to facilitate a comprehensive understanding.
Methods
This systematic review, as a subset of the previous review, utilized the same methods described in detail in the first paper.15 This section presents a brief summary of the methods, along with a detailed description of the approaches related to the assessment of economic evaluations.
The conduct and reporting of this review were in accordance with the Preferred Reporting Items for a Systematic review and Meta-Analysis (PRISMA) 2020 statement19 (Table S1). The Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement20 was also followed for the reporting of items relevant to economic evaluations (Table S2).
Eligibility Criteria
Primary research studies meeting the previously described eligibility criteria in terms of Population and Exposure,15 as well as the eligibility criteria specific to economic evaluations in terms of Outcome and Study type, were included. Table 1 presents a detailed overview of the inclusion and exclusion criteria.
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Table 1 Inclusion and Exclusion Criteria
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Information Sources and Search Strategy
In summary, systematic searches of relevant bibliographic databases (MEDLINE, Embase, EmCare, PsycINFO, CINAHL [Cumulative Index to Nursing and Allied Health Literature] complete, and the Cochrane Library), online databases and theses repository (ProQuest Central, ProQuest Dissertations & Theses Global, and Trove), and Google and Google Scholar were conducted in September and October 2023. Citation searching was also conducted through examining the reference lists of included studies and relevant reviews. In line with the previous review,15 the search strategy was underpinned by three concepts: AH profession, Service type/Setting, and Outcome. Examples of search terms and subject headings used for each concept included: AH profession (allied health OR physiotherap* OR Allied Health Personnel/OR Physical Therapists/); Service type/Setting (primary healthcare OR community-based OR Community Health Services/); Outcome (hospitalization* OR “length of stay” OR Patient Admission/). Full search syntaxes were reported previously.15 All searches were limited to English language and studies from 2010 onward. The searches were undertaken by one reviewer (EJT).
Study Selection Process
The study selection process was described in detail elsewhere.15 Overall, title and abstract screening and full-text screening were conducted by four independent reviewers, with one reviewer (EJT) screened all records and three reviewers (SK, PM and LI) screened the records in duplicate. As an added step, following the selection of studies that met all inclusion criteria, a fifth reviewer (CP) independently checked approximately 50% of the eligible studies (6 out of 12), to enhance the accuracy of study selection for this review. Any inconsistencies were resolved through discussion.
Risk of Bias Assessment
In line with the previous review,15 a modified version of McMaster Critical Appraisal Tool for quantitative studies21 and McGill Mixed Methods Appraisal Tool for the randomized controlled trail (RCT) with nested quality study22 were used to assess the risk of bias of the included studies. Additionally, the Consensus on Health Economic Criteria List (CHEC-list)23 was used to assess the methodological quality of the economic evaluations. The CHEC-list was chosen as it is designed for appraisal of trial-based economic evaluations and is widely considered to be subject to more rigorous scrutiny than many other checklists.24
The CHEC-list consists of 19 assessment criteria regarding study details, methodology, the identification, measurement and valuation of costs and outcomes, statistical analysis, and conclusions. Each criterion was rated as “yes” or “no”. A scoring system was employed, where each “yes” was given 1 point and each “no” was scored 0 point. The final score for each study was computed as a percentage to represent the level of quality, with ≥75% being high, 51–74% being moderate, and ≤50% being low quality.25 Five independent reviewers were involved. One reviewer (EJT) critically appraised all included studies using both tools; four reviewers (CP, SK, PM and LI) double-checked approximately 25% (n = 3/12), with three (SK, PM and LI) using the modified McMaster Critical Appraisal Tool for quantitative studies (n = 1 per reviewer) and one reviewer (CP) using the CHEC-list (n = 3). Any inconsistencies were discussed and resolved between two reviewers (EJT and CP/SK/PM/LI).
Data Extraction
A customized data extraction form developed in Microsoft Excel (version 2402, Microsoft Corporation) was used to extract relevant data, including citation details and information related to PEO [Population, Exposure, Outcome], as described previously,15 along with economic evaluation characteristics. Five independent reviewers contributed to the process. One reviewer (EJT) conducted data extraction from all included studies; four reviewers (CP, SK, PM and LI) double-checked approximately 25% (n = 3/12), with three (SK, PM and LI) checking PEO-related data (n = 1 per reviewer) and one reviewer (CP) checking data relevant to economic evaluations (n = 3). Any inconsistencies were discussed and resolved between two reviewers (EJT and CP/SK/PM/LI).
Data Synthesis and Analysis
Study interventions and comparators were coded using the same approach described previously.15 The study outcomes were coded into seven categories based on their characteristics, including ED visit cost, hospital admission/hospitalization cost, combined costs (ie, totaled costs of ED visit and hospital admission/hospitalization), cost-effectiveness regarding acute care, total healthcare costs, total non-healthcare costs, and other integrated costs (ie, sum of healthcare and non-healthcare costs).
Mean cost per person in individual studies were converted to Australian dollars (AUD) using the online Campbell & Cochrane Economics Methods Group – Evidence for Policy and Practice Information – Center (CCEMG-EPPI-Center) Cost Converter (version 1.7),26 whereby the cost data was adjusted from their original cost currency and price year to AUD 2024 based on the International Monetary Fund (IMF) dataset for purchasing power parity (PPP) values. Where the price year was not reported, the year of publication was used. For the studies that reported cost per group, mean cost per person was manually calculated based on the reported total costs and participant numbers. Statistical significance could not be assessed for these studies, due to reliance on aggregated data, which precludes individual-level testing.
The cost-effectiveness plane was used as a tool to analyze and graphically represent the data related to the cost-effectiveness of AH services regarding acute care. The plane consists of four quadrants, with X-axis measuring the change in mean effect per person and Y-axis measuring the change in mean cost per person. The change in mean effect was estimated as the difference in all acute care admissions (ED and hospital admissions) or hospital LOS between the intervention and comparison group or pre- and post-implementation. The unit of measure for effect was reported as number of participants, admissions or bed days across the included studies. Where reported, the mean effect per person was either derived directly from the study or manually calculated based on the reported total effects/percentages and participant numbers. The effects in individual studies were reported previously.15 Similarly, the change in mean cost was estimated as the difference in the costs for all admissions or hospital LOS and the cost of the intervention between the intervention and comparison group or pre- and post-implementation. Where the intervention cost was not reported or could not be manually calculated, it was regarded as having zero cost when calculating the total cost per person. This is due to limitations associated with estimating the true intervention cost, including lack of reported data for essential cost components, and substantial variations in input data across jurisdictions and types of AH services. Studies were omitted from the cost-effectiveness plane if: (a) the mean effect was not reported or could not be manually calculated;27,28 (b) pre-post or between-group difference was not evaluated;29 or (c) the mean cost deviated substantially from other values.30 Table S3 outlines the effects and their units of measure, as well as the costs and associated methods of obtaining estimates for individual studies.
Narrative synthesis was performed to summarize outcomes and describe patterns of costs and cost-effectiveness across the included studies.31 This approach was selected as meta-analysis was not feasible to render a meaningful overarching conclusion, considering the heterogeneity of the included studies, in terms of target populations/conditions, types of AH services, comparators, units of measure for effects, and methods for obtaining acute care costs.31
Results
The database searches yielded a total of 11,093 records. After removing 3,092 duplicates, 8,001 records were screened for title and abstract relevance. From this, 7,872 records were further excluded as they did not meet the eligibility criteria. The subsequent 129 records, along with another 162 records identified via other methods were retrieved for full-text screening. Of these, 279 studies were deemed ineligible based on intervention (n = 192) (eg, involvement of doctors and nurses),32,33 outcome (n = 69) (eg, did not measure acute care utilization associated costs,34 reported a potential cost saving based on a general cost estimate with minimal detail,35 no separate reporting of acute care costs),36 setting (n = 15) (eg, unspecified setting,37 not limited to primary care and community-based settings),38 study design (n = 2), and duplicate (n = 1). Therefore, a total of 12 studies were included in this review (Figure 1).
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Figure 1 PRISMA flow diagram.
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Study Characteristics
All studies were quantitative research with various designs, including RCT (n = 3),28,39,40 pre-post (n = 2),41,42 retrospective cohort (n = 2),29,43 secondary analysis of RCT (n = 2),27,44 controlled interrupted time series (n = 1),30 prospective cohort (n = 1),45 and RCT with nested qualitative study (n = 1).46 The studies were published between 2011 and 2023 and were from eight countries, including the United States (US) (n = 3),29,30,43 Australia (n = 2),42,44 the United Kingdom (UK) (n = 2),27,46 Finland (n = 1),40 Israel (n = 1),28 Norway (n = 1),41 Sweden (n = 1),45 and the Netherlands (n = 1)39 (Table 2).
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Table 2 General Study Characteristics
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A range of community-based AH services targeting different populations and conditions were explored across the included studies (Table 2). The type of AH services was generally grouped in multidisciplinary and single disciplinary. Two to five professions were included in multidisciplinary AH services, involving various healthcare workers including dietitians, exercise specialists, medical social workers, occupational therapists (OTs), physiotherapists/physical therapists (PTs), and speech-language pathologists (SLPs). The type of multidisciplinary AH services included home-based rehabilitation with telemonitoring guidance39 and early supported discharge with continued rehabilitation at home.45 The former targeted participants who were at low-to-moderate cardiac risk and was delivered at least three times per week for a duration of 12 weeks with each training session lasting between 45 and 60 minutes;39 the latter focused on stroke patients and involved various AHP visits, with mean frequencies ranging from one to 14.45
Four AH professions led single disciplinary AH services, including physiotherapy (or physical therapy), nutrition and dietetics, social work, and exercise physiology. Of these, six studies examined various physiotherapy services targeting different populations and conditions. These included exercises for heart failure patients,27 recently discharged elderly44 and pre-frail and frail elderly,40 primary care referral of low back pain (LBP) to physiotherapy,29 a telephone assessment and advice service for musculoskeletal problems,46 and telerehabilitation for chronic obstructive pulmonary disease (COPD) patients.41 Each session lasted between 2027,44 and 90 minutes46 with frequencies up to six times per week44 for a duration of eight weeks27 to 12 months.40,44 The nutrition and dietetics services focused on an individualized intensive nutritional intervention for community-dwelling elderly at nutritional risk28 and a meal delivery service combined with medical nutrition therapy for chronically ill and nutritionally at-risk individuals.30 The nutritional counseling lasted between 30 and 45 minutes, with a frequency of five sessions;28 while meals were delivered three times daily, seven days a week.30 One study focused on a social work service involving a transitional care program for high acute care utilizers, who received the service for 35 days after hospital discharge.43 Another study included an exercise physiologist (EP) or a PT supervised exercise targeting elderly with fall-related concerns or a history of falling.42 The intervention was delivered twice per week for 12 weeks, with each session lasting between 60 and 90 minutes; this was followed by six months of optional exercise maintenance.42 These single disciplinary AH services were primarily provided at the participants’ homes.
Overall, the sample size across included studies ranged from 1041 to 2,249.46 All studies focused on participants aged 18 years and over, with the majority included people aged 50 years and over. Collectively, the participants aged between 24 and 93 years45 (Table 2).
All studies used a trial-based analytic approach, with eight studies reporting partial economic evaluations27–30,41,43–45 and four presenting full economic evaluations.39,40,42,46 The eight partial economic evaluations were cost analyses, with only three reporting a health system perspective.27,44,45 The remaining five studies did not report on the perspective of the evaluation. Among the four full economic evaluations, two studies reported a cost-utility analysis (CUA),39,40 one focused on both cost-consequence analysis and CUA,46 and another study performed both CUA and CEA.42 While one study did not report on the perspective,40 the other three adopted a societal perspective.39,42,46 Across the 12 studies, time horizons ranged between 180 days43 and five years,27 with 12 months being the most commonly reported duration.30,39,41,44,45 While most studies did not report discounting, three stated that discounting was not required due to the short time horizon.39,42,46 All studies specified their currency unit, including US dollar (n = 4),28–30,43 Australian dollar (n = 2),42,44 euro (n = 2),39,40 British pound (n = 2),27,46 Norwegian krone (n = 1),41 and Swedish krona (n = 1).45 Of these, seven studies further reported the price year or the year of conversion,27,39,40,42,44–46 ranging between 200946 and 2020/21.42 While none of the partial economic evaluations conducted uncertainty analysis, all full economic evaluations described approaches for uncertainty analysis (Table 3).
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Table 3 Characteristics and Key Findings of Economic Evaluations
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Methodological Quality
The study-level risk of bias assessments and the methodological quality assessments of economic evaluations are presented in Tables S4–S6. With regard to general risk of bias, the quality scores ranged between 69% and 100%. All quantitative studies clearly indicated the purpose of the research and described the justification of the need for their research. While all of them justified the sample size, one study did not describe the sample in detail.42 The reliability and/or validity of the outcome measures were addressed in six studies.27,28,39–41,45 Apart from the studies with an observational design, all but one30 described their interventions in detail. Of those including more than one study arm, only three studies clearly indicated that contamination was avoided,28,30,44 and none scored for avoidance of cointervention. All but one27 reported results in terms of statistical significance, while another41 did not describe analysis method(s). All studies reported dropouts, with the exception of those involved a secondary analysis or conducted retrospectively (scored as “not applicable”).27,29,30,42,43 Clinical importance was discussed across the included studies, with appropriate conclusions presented.
The RCT with nested qualitative study46 addressed all criteria related to the qualitative and quantitative (RCT) components. The study also provided rationale for utilizing the mixed methods approach, effectively integrated different components, addressed the inconsistencies and divergences between qualitative and quantitative data.
With regard to the methodological quality of economic evaluations, the scores ranged from 26% to 100%, suggesting the quality varied between low and high. In particular, six studies were rated as low,27–30,41,43 three studies were rated as moderate,40,44,45 and a further three studies were rated as high quality.39,42,46 In terms of study details, the research question was clearly defined across the included studies. All but one study42 clearly described study populations, while the majority provided a detailed description of competing alternatives.27–30,39,40,43–46 In terms of methodology, the economic study design was considered to be appropriate among the full economic evaluations.39,40,42,46 All studies chose the time horizon appropriately. Five studies explicitly stated and justified their chosen perspective.27,39,42,45,46 In terms of costs and outcomes, less than half of the included studies identified all important and relevant costs and outcomes based on the chosen perspective and the research question.39,42,44–46 Four studies did not report intervention costs.28,30,41,44 While nine studies measured the costs appropriately in physical units with valid sources/instruments,27,28,39,40,42–46 only two studies explicitly addressed the validity of the outcome measures.39,46 Six studies reported sources of valuation for costs and their reference years,39,40,42,44–46 and four described the method of outcome valuation.39,40,42,46 In terms of statistical analysis, only two full economic evaluations performed an appropriate incremental analysis.42,46 Further, only three studies stated and justified discounting39,42,46 and four studies analyzed uncertainty.39,40,42,46 Conclusions were supported by the data reported across all studies. Over half of the studies discussed generalizability of the results.28–30,39,42,44,46 All but one41 reported the existence or absence of conflicts of interest of study researcher(s) and funder(s), as well as discussing ethical and distributional aspects.
Findings from Multidisciplinary AH Services
Two studies39,45 evaluated the economic impact of multidisciplinary AH services on the acute sector, in comparison to other intervention and usual care. Both reported changes in at least two primary outcome domains, including cost-effectiveness regarding acute care (n = 2), hospital admission/hospitalization cost (n = 2), and ED visit cost (n = 1). For secondary outcomes, while both studies reported a change in total healthcare costs, only one study further revealed changes in total non-healthcare costs and other integrated costs. Table 3 outlines key findings of the included studies; Table S7 presents detailed outcomes extracted from individual studies; and Table S8 shows a breakdown of the changes in effects and costs for evaluating cost-effectiveness.
Primary Outcome – Cost-Effectiveness Regarding Acute Care
Both studies were plotted on the cost-effectiveness plane, showing mixed findings (Figure 2). Kraal et al39 suggested that the AH service was cost-saving but less effective compared to other intervention. The breakdown of the mean difference in effect and cost highlighted that the intervention was associated with an increase in hospital admissions but a decrease in associated cost (Table S8). By contrast, Tistad and von Koch45 found that the AH service was more effective but costly than usual care due to high intervention cost (Table S8).
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Figure 2 Cost-effectiveness plane for multidisciplinary AH services. Estimates in the northwestern quadrant indicate the intervention is less effective and more costly; estimates in the southwestern quadrant indicate the intervention is less effective and less costly; estimates in the southeastern quadrant indicate the intervention is more effective and less costly; estimates in the northeastern quadrant indicate the intervention is more effective and more costly. Key: ∆, change. Abbreviations: AA, all admissions; AH, allied health; HL, hospital length of stay.
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Primary Outcome – Hospital Admission/Hospitalization Cost
Both Kraal et al39 and Tistad and von Koch45 suggested a cost saving in favor of the AH service, with one39 further suggesting the finding being statistically non-significant. Specifically, Kraal et al39 indicated a lower cost of AUD 424 per person during the one-year study period, when comparing telemonitoring guided home-based cardiac rehabilitation with an outpatient clinic-based mode [other intervention]. Similarly, Tistad and von Koch45 found that early supported discharge with continued home-based rehabilitation was associated with lower recurrent inpatient care and rehabilitation costs (AUD 3,808 and AUD 801 per person, respectively) than conventional rehabilitation [usual care] for patients during the first year after stroke onset, leading to an overall cost saving of AUD 4,608 per person.
Primary Outcome – ED Visit Cost
In contrast to the cost savings related to hospitalizations, Kraal et al39 reported a higher, non-significant cost of AUD 28 per person in the intervention group, compared to the comparison group at the one-year follow-up.
Secondary Outcome – Total Healthcare Costs
Despite varied use of healthcare resources between the two studies, both revealed non-significant cost savings in favor of the AH service.39,45 Kraal et al39 assessed the combined costs of healthcare visits, healthcare admissions, medication use and interventions, and reported a cost saving of AUD 1,033 per person at the one-year follow-up. Consistently, Tistad and von Koch45 found a cost saving of AUD 6,324 per person, when compared the total costs of all healthcare services, in terms of inpatient care and rehabilitation, specialized outpatient care and rehabilitation, and primary care, between the AH service and the comparator over 12 months after stroke.
Secondary Outcome – Total Non-Healthcare Costs
In addition to total healthcare costs, Kraal et al39 also estimated total non-healthcare costs during the one-year study period, consisting of paid and unpaid absenteeism. The study identified a non-significant cost saving of AUD 6,453 per person in favor of the intervention.
Secondary Outcome – Other Integrated Costs
From a societal perspective (ie, the sum of total healthcare and non-healthcare costs with presenteeism), Kraal et al39 further identified a non-significant cost saving of AUD 14,423 per person favoring the home-based cardiac rehabilitation.
Findings from Single Disciplinary AH Services – Physiotherapy
Six studies assessed the economic impact of physiotherapy services on the acute sector.27,29,40,41,44,46 All reported a difference in at least one primary outcome domain, including hospital admission/hospitalization cost (n = 5), ED visit cost (n = 4), cost-effectiveness regarding acute care (n = 4), and combined costs (n = 1). For secondary outcomes, three studies identified changes in total healthcare costs, two reported changes in total non-healthcare costs, and a further two revealed changes in other integrated costs. Both within- and between-group comparisons were described within relevant outcome domains. For between-group comparisons, the impact of the physiotherapy service was compared with usual care and other intervention (Tables 3, S7 and S8).
Primary Outcome – Cost-Effectiveness Regarding Acute Care
Four studies were plotted on the cost-effectiveness plane, presenting mixed findings (Figure 3). In comparison to usual care, two studies suggested that the physiotherapy service was less effective and costed more,40,44 while one study found the intervention was slightly less effective but cost-saving.46 For the latter study, the breakdown of the mean difference in effect and cost highlighted that the AH service was associated with no difference in hospital admissions and a decrease in associated cost (Table S8). For pre-post comparison, Zanaboni et al41 showed that the implementation of the physiotherapy service was more cost-effective (intervention costs not reported).
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Figure 3 Cost-effectiveness plane for physiotherapy services. Estimates in the northwestern quadrant indicate the intervention is less effective and more costly; estimates in the southwestern quadrant indicate the intervention is less effective and less costly; estimates in the southeastern quadrant indicate the intervention is more effective and less costly; estimates in the northeastern quadrant indicate the intervention is more effective and more costly. Key: ∆, change; *, intervention costs not reported. Abbreviations: AA, all admissions; HL, hospital length of stay; m, months.
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Primary Outcome – Hospital Admission/Hospitalization Cost
Collectively, five studies demonstrated mixed findings regarding hospital admission/hospitalization cost. Of these, one study29 examined costs associated with the timing and content of the physiotherapy service; the remaining studies assessed between-group differences, including two reported positive findings favoring the comparator,40,44 one found a positive finding favoring the physiotherapy service,46 and another reported mixed findings.27
Fritz et al29 estimated within-group changes by comparing the timing (delayed versus early) and content (adherent versus nonadherent) of physiotherapy for LBP management during the 18-month follow-up. The study identified greater costs for both surgical/injection and inpatient nonsurgical procedures among participants who received delayed physiotherapy, compared to those with early physiotherapy (AUD 3,400 and AUD 326 per person, respectively), leading to an overall increase in cost of AUD 3,726. On the other hand, adherent physiotherapy was associated with a total cost saving of AUD 980 per person than nonadherent physiotherapy, resulting from a lower cost of AUD 1,017 for surgical/injection procedures but a greater cost of AUD 37 for inpatient nonsurgical procedures.29
In comparison to usual care, two studies40,44 identified a greater cost in the intervention group, albeit one study40 suggested no significant between-group difference; conversely, two other studies27,46 indicated a cost saving in the intervention group. While Farag et al44 discovered that recently discharged elderly receiving home-based exercise spent AUD 1,671 more per person during the 12-month study period, Suikkanen et al40 found a higher cost of AUD 2,459 per person among pre-frail and frail elderly receiving home-based physical exercise for the same duration. The latter study further highlighted the enduring elevated cost at 24 months, with a difference of AUD 2,118 per person.40 By contrast, Salisbury et al46 evaluated a telephone assessment and advice service for musculoskeletal problems and reported a cost saving of AUD 48 per person at the six-month follow-up. Consistently, Cowie and Moseley27 found a cost saving of AUD 8,065 per person of delivering a home-based exercise training versus usual care in heart failure patients over five years. However, when the intervention was compared with hospital-based training [other intervention], a greater cost of AUD 1,286 per person was discovered during the five-year study period.27
Primary Outcome – ED Visit Cost
Collectively, four studies identified mixed findings regarding ED visit cost. Of these, one study29 focused on within-group change; the remainder evaluated between-group differences, with two suggesting positive findings favoring the comparator,40,46 and another reporting a positive finding favoring the AH service.44
Fritz et al29 compared the timing and content of the physiotherapy service and reported cost savings of AUD 2 per person for delayed versus early physiotherapy, and AUD 8 per person for adherent versus nonadherent physiotherapy at the 18-month follow-up.
Three studies discussed differences between the physiotherapy service and usual care.40,44,46 Salisbury et al46 found a greater cost of AUD 3 per person in the intervention than the control group at the six-month follow-up. This finding was supported by Suikkanen et al,40 in which higher costs were associated with the intervention at both the 12-month and 24-month follow-ups (AUD 178 and AUD 279 per person, respectively), despite statistical significance not being achieved. By contrast, Farag et al44 reported a cost saving of AUD 8 per person in favor of the intervention during the 12-month study period.
Primary Outcome – Combined Costs
Zanaboni et al41 compared the difference in COPD-related hospital costs (a combination of hospital admissions, visits and LOS) between six months before and six months after implementation of a home-based telerehabilitation. The study suggested a cost saving of AUD 1,401 per person post-implementation, as a result of fewer hospital visits and shorter LOS.
Secondary Outcome – Total Healthcare Costs
Collectively, three studies discovered mixed findings regarding total healthcare costs. Of these, one study29 assessed within-group change; the other two estimated between-group differences, with one suggesting mixed findings,27 and another reporting a positive finding favoring the comparator.46
Fritz et al29 investigated within-group change in total LBP-related healthcare costs, including imaging procedures, doctor visits, surgical/injection procedures, inpatient nonsurgical procedures, ED visits, prescription medication, and other LBP-related costs, over the 18-month study period. The study found that delayed physiotherapy incurred a significantly greater cost of AUD 5,343 per person, compared to early physiotherapy; whereas adherent physiotherapy led to a significant cost saving of AUD 2,610 per person, compared to nonadherent physiotherapy.
Salisbury et al46 compared the physiotherapy service with usual care regarding total costs of healthcare resource use relevant to the management of musculoskeletal conditions, in terms of primary and community care, hospital care, and the use of the service. The study found a higher non-significant cost of AUD 21 per person at the six-month follow-up.46 By contrast, Cowie and Moseley27 focused on totaled costs of hospital admissions and interventions, and reported a cost saving of AUD 7,520 per person favoring the intervention during the five-year study period. However, when the home-based exercise training was compared with other intervention, there was a greater cost of AUD 1,217 per person.27
Secondary Outcome – Total Non-Healthcare Costs
Two studies identified mixed findings regarding total non-healthcare costs, when compared the physiotherapy service with usual care. Salisbury et al46 estimated the cost of lost production associated with time off work and usual activities by patients and their carers, and found a non-significant cost saving of AUD 109 per person favoring the intervention over six months. By contrast, Farag et al44 reported that participants who received the home-based exercise experienced higher total costs for social support services during the 12-month study period, with a difference being AUD 752 per person.
Secondary Outcome – Other Integrated Costs
Two studies further evaluated between-group differences in other integrated costs, including total direct and indirect costs to patients and their families, or use of healthcare and social services.40,46 Both suggested positive findings favoring usual care. While Salisbury et al46 reported a non-significant difference of AUD 238 per person regarding total costs to patients and their carers at the six-month follow-up, Suikkanen et al40 found differences of AUD 24,245 and AUD 10,447 per person at the 12-month and 24-month follow-ups, respectively, with the 12-month difference showing statistical significance.
Findings from Single Disciplinary AH Services – Nutrition and Dietetics
Two studies estimated the economic impact of nutrition and dietetics services on the acute sector.28,30 Both reported a cost difference in hospital admission/hospitalization cost; one study also examined cost-effectiveness regarding acute care, and changes in total healthcare costs. Both within- and between-group comparisons were described within relevant outcome domains. For between-group comparisons, the impact of the nutrition and dietetics service was compared with other intervention and usual care. Both studies did not report intervention costs (Tables 3, S7 and S8).
Primary Outcome – Cost-Effectiveness Regarding Acute Care
Based on the pre-post change in hospital admissions and cost, Gurvey et al30 suggested that the implementation of the AH service was more cost-effective. This study was not plotted on the cost-effectiveness plane due to a substantial deviation from other cost values.
Primary Outcome – Hospital Admission/Hospitalization Cost
Both Endevelt et al28 and Gurvey et al30 reported a cost saving in favor of the AH service, with one28 further suggesting the finding being statistically non-significant. Specifically, Gurvey et al30 reported a reduced cost of AUD 132,065 per person in chronically ill and nutritionally at-risk individuals during the six months after receiving a meal delivery service combined with medical nutritional therapy, compared to the six months prior. Endevelt et al28 compared an individualized intensive nutritional intervention to medical treatment combined with an educational booklet [other intervention] and standard care [usual care] for malnourished community-dwelling elderly, and indicated cost savings of AUD 1,120 and AUD 879 per person, respectively, during the six-month follow-up.
Secondary Outcome – Total Healthcare Costs
Gurvey et al30 further examined within-group change regarding total healthcare costs and revealed a cost saving of AUD 89,804 per person during the six months following implementation, compared to before implementation.
Findings from Single Disciplinary AH Services – Social Work
One study43 evaluated the impact of a psychosocial transitional care program for high hospital service utilizers, with both within- and between-group changes in cost-effectiveness regarding acute care, hospital admission/hospitalization cost, ED visit cost, and total healthcare costs being estimated. For between-group comparison, the social work service was compared with the matched control group receiving standard care [usual care] (Tables 3, S7 and S8).
Primary Outcome – Cost-Effectiveness Regarding Acute Care
The pre-post change at 30 days and the between-group differences at both 30 and 180 days were plotted on the cost-effectiveness plane (Figure 4). Collectively, mixed findings were identified. In comparison to pre-implementation, Weerahandi et al43 suggested that the implementation of the AH service was more cost-effective. This was supported by the between-group comparison at 30 days. However, the intervention became more costly and slightly less effective at 180 days.
 |
Figure 4 Cost-effectiveness plane for social work and exercise physiology services. Estimates in the northwestern quadrant indicate the intervention is less effective and more costly; estimates in the southwestern quadrant indicate the intervention is less effective and less costly; estimates in the southeastern quadrant indicate the intervention is more effective and less costly; estimates in the northeastern quadrant indicate the intervention is more effective and more costly. Key: ∆, change. Abbreviations: AA, all admissions; d, days; HL, hospital length of stay.
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Primary Outcome – Hospital Admission/Hospitalization Cost
Weerahandi et al43 identified mixed findings regarding 30- and 180-day readmission costs. For pre-post comparison, the study identified cost savings of AUD 31,073 and AUD 45,019 per person for 30- and 180-day readmission, respectively, after the implementation of the social work service. Similarly, a cost saving of AUD 2,758 per person at 30 days was found in the intervention group, compared to usual care. However, the cost saving was not sustained at 180 days, as the intervention group incurred a higher cost of AUD 1,055 than the comparison group.
Primary Outcome – ED Visit Cost
In line with the previous outcome domain, mixed findings were also discovered for 30- and 180-day ED visit costs.43 The within-group comparison demonstrated cost savings of AUD 51 and AUD 134 per person for 30- and 180-day ED visit, respectively, after the implementation of the social work service. By contrast, the costs associated with ED visits were greater in the intervention group than the comparison group at both 30 and 180 days (AUD 50 and AUD 62 per person, respectively).
Secondary Outcome – Total Healthcare Costs
Weerahandi et al43 further estimated the combined costs of ED visits, hospitalizations and the intervention. When compared to pre-implementation, cost savings of AUD 30,995 and AUD 45,009 per person were found at 30- and 180-day post-implementation, respectively. Consistently, a cost saving of AUD 2,582 per person at 30 days was found in the intervention group, compared to usual care. However, the cost saving was not sustained at 180 days, with the intervention group experiencing a higher cost of AUD 1,262 per person.
Findings from Single Disciplinary AH Services – Exercise Physiology
One study42 investigated within-group changes in cost-effectiveness regarding acute care, hospital admission/hospitalization cost, and other integrated costs following a structured, supervised exercise for elderly in local senior exercise parks (Tables 3, S7 and S8).
Primary Outcome – Cost-Effectiveness Regarding Acute Care
The cost-effectiveness plane indicated that the implementation of the AH service was more cost-effective than pre-implementation (Figure 4).42
Primary Outcome – Hospital Admission/Hospitalization Cost
Brusco et al42 found a cost saving of AUD 5,724 per person during the six-month post-implementation period, compared to the six-month period prior to participation, albeit statistical significance was not achieved.
Secondary Outcome – Other Integrated Costs
The study also estimated the combined costs of health and services utilizations, productivity loss and the intervention, and revealed a non-significant cost saving of AUD 5,070 per person post-implementation.42
Summary of Evidence
Drawing from a moderate body of research evidence that encompasses various study designs, types of economic evaluations, and methodological quality, this review discovered mixed findings regarding the economic impact of community-based AH services in three aspects. For acute care costs, the majority of included studies showed some level of cost savings associated with the AH service, in terms of ED visit and/or hospital admission/hospitalization costs (Figure 5). For cost-effectiveness regarding acute care, a greater proportion of the evidence suggested that the AH service is more cost-effective, or at least demonstrates potential cost-effectiveness depending on the cost-effectiveness threshold (ie, cost-saving but less effective, or more effective but costly) (Figure 6). However, this evidence base was formed from a smaller cohort of the included studies (n = 9). For total healthcare and non-healthcare costs, most studies revealed cost savings favoring the AH service, albeit with varied use of healthcare and community/social support resources and from diverse economic perspectives (Figure 7). Likewise, the evidence was based on a smaller proportion of the included studies (n = 9).
 |
Figure 5 Overview of acute care costs. Color code: Green, cost saving favoring the AH service; Red, cost saving favoring the comparator. Key: ***, high methodological quality of economic evaluation; **, moderate methodological quality of economic evaluation; *, low methodological quality of economic evaluation. Abbreviations: AH, allied health; d, days; m, months; MD, multidisciplinary; SD, single disciplinary; vs, versus.
|
 |
Figure 6 Overview of cost-effectiveness regarding acute care (all admissions and hospital LOS). (a) cost-increasing and less effective; (b) cost-increasing and no difference in effect; (c) cost-increasing and more effective; (d) no difference in cost and less effective; (e) no difference in cost and no difference in effect; (f) no difference in cost and more effective; (g) cost-saving and less effective; (h) cost-saving and no difference in effect; (i) cost-saving and more effective. Abbreviations: LOS, length of stay; n; number of studies. Note: Weerahandi et al 2015 was counted three times: for the between-group comparisons at 30 days and 180 days and for the pre-post comparison at 30 days, due to the changes in effects and costs across different quadrants.
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 |
Figure 7 Overview of total healthcare and non-healthcare costs. Color code: Green, cost saving favoring the AH service; Red, cost saving favoring the comparator. Key: ***, high methodological quality of economic evaluation; **, moderate methodological quality of economic evaluation; *, low methodological quality of economic evaluation. Abbreviations: AH, allied health; d, days; m, months; MD, multidisciplinary; SD, single disciplinary; vs, versus.
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Collectively, there are two key aspects to be considered when interpreting these findings. First, the methodological flaws related to general study designs and economic evaluations, such as small sample size, limited reporting of items relevant to economic evaluations (eg, perspective, method of outcome valuation, discounting, and sensitivity analysis), issues with partial economic evaluations (eg, lack of incremental analysis), and inadequate reporting of psychometric properties of the outcome measures and avoidance of contamination and co-interventions. Second, the heterogeneity of the evidence base, in terms of target populations/conditions, types of AH services, economic perspectives, data collection and analysis approaches, and outcomes, which challenged robust comparisons.
Discussion
Decisions underpinned by evidence that primarily focuses on the effectiveness of a health intervention may lead to inefficient, even wasteful practice and policy approaches. In the context of community-based AH, while the previous review15 suggested a potential positive impact on acute care utilization with wide acceptance among consumers, little is known about their economic outcomes. This systematic review aimed to address this gap. A moderate body of evidence, consisting of 12 studies, was identified. The findings revealed mixed evidence regarding the impact of community-based AH on acute care costs and cost-effectiveness. The mixed evidence base was also observed for the secondary outcomes of total healthcare and non-healthcare costs. For both primary and secondary outcomes, there was a considerable proportion of the evidence indicating trends towards cost savings and cost-effectiveness favoring the AH service. However, most findings were formed from a smaller cohort of studies, suggesting a limited evidence base.
The mixed findings regarding the impact of community-based AH on acute care costs resonate with, and add to, the current body of evidence on community-based health services. For example, a systematic review47 examined the effectiveness and related costs of nurse-led case management for community-dwelling patients with heart failure on reducing unplanned hospital admissions and LOS. The review reported mixed findings, including no significant difference between case management and usual care, and cost savings favoring the intervention.47 Another integrative review48 assessed the impact of community nurse-led interventions on hospital use among elderly, and found cost savings associated with the intervention.
Based on the changes in acute care costs and effects, cost-effectiveness was further examined to determine if community-based AH provides good value for money. Overall, a greater proportion of the evidence showed that the AH service was more cost-effective than the comparator. This was driven by the number and the magnitude of cost savings associated with hospital admissions and LOS, coupled with the beneficial effects on utilization. This is not surprising as hospital LOS is a key driver of the consumption of hospital resources.49 Another three included studies also partially contributed to the cost-effectiveness evidence base. Specifically, two studies39,46 found cost savings with reduced effects, suggesting a potential reduction in hospital LOS and/or diagnostic severity. Another study45 showed a greater effect but at a higher cost, which was driven up by the intervention cost. The AH service in this study may gradually demonstrate cost-effectiveness in the longer term, as the upfront intervention costs are less diluted by discounting over a short time horizon, potentially outweighing the cost savings.50 However, whether these interventions are considered cost-effective depend on society’s willingness to pay for perceived benefits, or their willingness to accept reduced effects for a cost saving.
Cost-effectiveness was not assessed in all of the included studies, as some27,28 did not explicitly report a measure of effect. Therefore, the evidence base in this review is limited. This is in line with other reviews investigating cost-effectiveness of AH services in general (eg,51–53). Nevertheless, this review adds value to the existing body of literature from two key perspectives. First, unlike other reviews that have evaluated a single AH service among a specific population (eg, physiotherapy for chronic conditions54 or following total hip replacement,51 occupational therapy for cognitive and/or functional decline,52 and nutrition therapy for type 2 diabetes53), this review focuses on the diverse nature of AH in one healthcare setting (ie, PHC). The collection of literature can shed light on the economic benefits of AH through different lenses. Second, this review has a particular interest in short-term effects (ie, ED visits, hospital admissions, and LOS), as opposed to long-term effects that have been commonly reported in other reviews (eg, quality-adjusted life year [QALY], and number of falls).51,52,54 While long-term cost-effectiveness is important for health interventions, like AH, that target life-long consequences including morbidity and disability, short-term cost-effectiveness is equally important to demonstrate the impact at different levels and across multiple sectors.
Total healthcare and non-healthcare costs that are directly or indirectly related to the management of the target condition(s) were another key aspect assessed in this review. Collectively, the findings were mixed, albeit most studies revealed cost savings favoring the AH service. The varied use of healthcare and community/social support resources, and the adoption of various economic perspectives are likely contributors to the heterogeneous evidence base. Given the diverse scope of practice of AH professions, it is unsurprising to discover considerable variability in target populations with varying needs in the management of their conditions. This likely leads to the different use of healthcare and non-healthcare resources. Healthcare costs can vary significantly across jurisdictions, due to differences in health systems, such as economic policies, healthcare pricing and insurance coverage, and costs of resources.55 Non-healthcare costs resulting from productivity loss, transportation, and use of community/social support resources can be influenced by factors including availability and accessibility of the needed services.55 Depending on the economic perspective, healthcare and non-healthcare costs can also vary substantially. For example, out-of-pocket payments constitute a considerable proportion of the overall costs from the patient’s perspective; whereas from the healthcare provider’s perspective, they have minimal impact on the overall costs.
In this review, only half of the included studies explicitly indicated an economic perspective, including three that adopted a societal perspective, and a further three reported from a health system perspective. Adoption of a societal perspective in economic evaluations has been recommended across several international guidelines and some AH literature, as it considers a broad scope of costs that affect a wide range of relevant stakeholders.52,54,56 However, Sittimart et al56 argued that there is no one-size-fits-all approach, the selection of the “right” perspective is influenced by the context (eg, policymakers’ and stakeholders’ views, availability of resources and data) and intended use of the analysis (eg, the research question).56
A consistent message stemming from community-based health service as well as AH literature is the lack of or limited availability of cost data (eg,47,48,52,53,57), posing a significant challenge in drawing unequivocal conclusions on the economic benefits. This is supported by the findings from this systematic review. While the previous review15 identified a substantial body of evidence on the effectiveness of community-based AH on acute care utilization, less than 20% of the included studies described relevant cost data. Furthermore, most studies were not specifically designed as economic evaluations. Measuring outcomes and costs is one of the four domains used to assess a country’s alignment with value-based health care.58 Therefore, routine collection, sharing, and analysis of health outcome and cost data and other relevant information is essential to the creation of value.58
Strengths and Limitations
This review has several strengths. First, it followed best practice standards in the conduct and reporting of systematic reviews (ie, PRISMA). As recommended by van Mastrigt et al,18 the CHEERS 2022 statement was also used for reporting items relevant to economic evaluations. Another strength was the inclusion of both full and partial economic evaluations with various perspectives, which facilitated a comprehensive synthesis of results from the existing literature. However, there are some limitations to consider when interpreting, applying and generalizing the findings. First, the imprecise and complex nature of gray literature searching and the focus on studies published in English may be associated with publication and language biases. Second, the methodological flaws related to general study designs and economic evaluations among the included studies may lead to imprecise measures and the introduction of bias. Due to limited reporting of relevant information in several included studies, the data assumptions and accuracy of data conversions, including estimations of mean cost and effect per person, intervention costs and currency conversion, may underestimate the true costs and effects associated with the interventions. Additionally, classification of AH professions varies across different jurisdictions, as there is currently no universally agreed definition of AH.59 Consequently, the findings may not be generalizable to all AH professions (eg, medical imaging, optometry, music/art therapy, etc). Furthermore, eight countries were included in this review, all of which were developed countries in the Western world. Therefore, the generalizability of the findings may be limited to other countries, especially developing countries.
Implications for Practice, Policy, and Future Research
Based on the findings from this review, a number of key implications for practice, policy, and future research emerge. Given the trends towards the economic benefits of community-based AH, ongoing investment in, and support for, AHP-led services are needed to complement other health services in the PHC sector. This may alleviate the pressures on acute care facilities and more broadly, promote financial sustainability within the health sector. The development and implementation of standardized mechanisms for routine collection, sharing, and analysis of relevant health outcome and cost data is imperative to strengthen future cost-effectiveness analysis. This requires not only health informatics infrastructure but also supportive policies and regulations, and organizational capabilities. To better inform future resource allocation decisions, it is recommended that economic evaluations be incorporated into routine practice when evaluating AH services. While the societal perspective is deemed as the most comprehensive approach to evaluating economic outcomes, future research should select the evaluation perspective based on the specific context and research question. A key issue in the studies included in this review was the limited reporting of all relevant data. Therefore, future economic evaluations could use current guidelines, such as the CHEERS 2022 statement,20 to facilitate standardized reporting. This would enhance the methodological quality of economic evaluations in the field of AH. Furthermore, the findings from an economic evaluation are often limited to a specific setting or country. Therefore, it is important to assess the transferability (ie, the extent to which the results can be extrapolated from one setting or context to another) of economic evaluations when applying or generalizing the findings.18 This can be achieved by using one of the checklists identified by Goeree et al.60
Conclusion
PHC plays a crucial role in keeping people well in the community and reducing the need for acute services. AH is an integral pillar of PHC. Community-based AH services have demonstrated their potential to alleviate the pressures on acute care utilization, with wide acceptance among consumers. However, decisions on resource allocation are underpinned by both effectiveness and efficiency perspectives. This review addresses the efficiency of community-based AH on the acute sector. Overall, the findings suggest trends towards the economic benefits of community-based AH, highlighting their potential to reduce the strain on the acute sector and the wider health system. However, the evidence base informing this review was limited. The findings present opportunities for future investment and ongoing research in services led by AHPs. Incorporation of economic evaluations into routine practice, standardized mechanisms for data collection, sharing and analysis, and use of existing tools in the conduct and reporting of economic evaluations are important aspects to consider as a means of strengthening the evidence base.
Abbreviations
AH, allied health; AHP(s), allied health professionals(s); AUD, Australian dollar; CCEMG-EPPI-Center, Campbell & Cochrane Economics Methods Group – Evidence for Policy and Practice Information – Center; CEA, cost-effectiveness analysis; CHEC-list, Consensus on Health Economic Criteria List; CHEERS, Consolidated Health Economic Evaluation Reporting Standards; COPD, chronic obstructive pulmonary disease; CUA, cost-utility analysis; ED, emergency department; EP, exercise physiologist; IMF, International Monetary Fund; LBP, low back pain; LOS, length of stay; OT(s), occupational therapist(s); PEO, Population, Exposure, Outcome; PHC, primary health care; PPP, purchasing power parity; PRISMA, Preferred Reporting Items for a Systematic review and Meta-Analysis; PT(s), physiotherapist(s)/physical therapist(s); RCT, randomized controlled trial; QALY, quality-adjusted life year; SLP(s), speech-language pathologist(s); UK, United Kingdom; US, United States; USD, United States dollar.
Data Sharing Statement
All relevant data are included in the article and Supplementary Materials; further inquiries can be directed to the corresponding author.
Funding
The first author (EJT) is a doctoral student and is supported by the Australian Government Research Training Program Scholarship. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Disclosure
The authors report no conflicts of interest in this work.
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