Cost-effectiveness of occupational therapy for older adults: a protocol for an updated systematic review

Abstract

Introduction

The ageing populations in developed countries are a global concern, with increasing numbers of older adults facing physical, cognitive and psychological challenges, resulting in reduced quality of life and higher healthcare costs. Healthcare expenditure worldwide has been on the rise, especially among older adults, emphasising the importance of enabling independent living while reducing healthcare costs. Occupational therapy holds promising outcomes in promoting functional independence and enhancing the quality of life for older adults, but research on its cost-effectiveness remains limited. This systematic review aims to evaluate the recent evidence on the cost-effectiveness of occupational therapy interventions for older adults from a pragmatic perspective.

Methods and analysis

This systematic review will cover full economic evaluations, including cost-effectiveness, cost-utility and cost–benefit analyses, by reviewing randomised and cluster randomised controlled trials. The participants will be aged over 65 years without disease or disability restrictions. Primary outcomes will be assessed using functional status and quality-of-life assessments. Studies published before July 2023 will be searched in PubMed, Web of Science and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, with no language restrictions.

Ethics and dissemination

Ethical approval is not required for this literature-based systematic review. The study’s findings will update the evaluation of occupational therapy’s cost-effectiveness in older adults and will be made public by publishing them in scholarly journals.

PROSPERO registration number

CRD42023453558.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study aims to evaluate the cost-effectiveness of occupational therapy from a pragmatic perspective.

• The primary outcomes of functional status and quality-of-life assessments will be used to calculate the incremental cost-effectiveness ratio.

• The systematic review protocol will be reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines, enhancing transparency and reproducibility.

• The review may face challenges in identifying a substantial number of high-quality studies on the cost-effectiveness of occupational therapy interventions for older adults, as previous literature suggests a scarcity of such evaluations.

• The exclusion of non-English publications may introduce language bias and potentially miss relevant studies.

Introduction

The ages of the populations of developed countries are increasing worldwide,¹ and the increasing number of older adults is a concern in all developed nations. Ageing is associated with declining physical, cognitive and psychological functions, which lead to difficulties in activities of daily living, decreased quality of life and increased healthcare costs.^{2 3} Total healthcare expenditure worldwide has been steadily increasing since 1995, reaching US$8.0 trillion in 2016, and is estimated to eventually increase to US$15.0 trillion in 2050.⁴ Healthcare expenditure per capita among older adults (65 years and older) was higher than that among younger age groups, and this trend was observed in several high-income countries, including USA, Canada, Germany and Japan.⁵ Therefore, it is important to allow older adults to live independently while simultaneously lowering their overall healthcare expenditure.

'A previous systematic review revealed that certain exercise programmes could reduce the rate and risk of falls and that home safety interventions delivered by occupational therapists were effective for fall prevention, particularly among people who were at a higher risk of falling.⁶ Furthermore, fall prevention strategies were cost-effective during the interventions used in the included studies, as well as during the participants’ remaining lifetime.⁶ The benefits of exercise promotion among older adults in extending independent living can offset their costs.⁷ In addition, physical rehabilitation is effective for long-term care residents, helping them remain independent and perform activities of daily living without significant adverse events.⁸ It has also been suggested that the cost-effectiveness of physical rehabilitation is reasonable, as improving the physical condition of older adults may eventually reduce the need for hospitalisation and intensive personal care.⁸ However, the evidence required to determine the most effective interventional approach for physical rehabilitation is insufficient.⁸ Particularly, regarding increasing healthcare expenditure among older adults, it is crucial to investigate and evaluate interventional rehabilitation strategies that are both efficacious and cost-effective.

Occupational therapy is a promising intervention for promoting functional independence and enhancing quality of life in older adults. Occupational therapists use meaningful activities related to a person’s beliefs, values and needs,⁹ and have the skills and knowledge to help older adults remain active in their daily lives. Additionally, they can identify personally significant activities that may enhance motivation and purpose, although the meaning of engaging in activities varies among individuals.^{10 11} This may result in a greater demand for occupational therapy targeted at older adults.

Thus, occupational therapy is an essential healthcare component for older adults; however, research regarding its cost-effectiveness is still in its infancy stage. A review of the quality of published economic evaluations regarding occupational therapy found that although the number of evaluations had increased, it was still less than that in other fields; additionally, only three of nine published studies were considered high quality.¹²

This systematic review aims to provide an updated evaluation of the cost-effectiveness of occupational therapy in older adults in recent years, as previously conducted by Nagayama et al.¹³ Thus, this systematic review will evaluate the current empirical evidence regarding the cost-effectiveness of occupational therapy for older adults from a pragmatic perspective.

Methods

The planned study will be conducted between 1 August 2023 and 31 May 2024. The protocol of this systematic review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines.¹⁴

Inclusion criteria

Types of studies

In this systematic review, specific inclusion criteria concerning the types of studies to be considered will be established. The criteria will emphasise the inclusion of three primary forms of comprehensive economic evaluations: cost-effectiveness, cost-utility and cost–benefit analyses, which will be conducted within the framework of randomised controlled trials (RCTs) and cluster RCTs. Each selected study will undergo a meticulous and rigorous assessment, involving a detailed scrutiny of the full text. The evaluation will focus extensively on the methodology section, ensuring the identification of studies that specifically execute cost-effectiveness, cost-utility and cost–benefit analyses within the stipulated parameters of RCTs and cluster RCTs.

Types of participants

Participants aged over 65 years and without restrictions due to disease or disability will be considered. We will aim to include a broad spectrum of potential participants for this systematic review, without imposing restrictions related to participant residence types, such as in-hospital, nursing home and home-based settings. Our intention will be to ensure an inclusive approach that welcomes diverse participant backgrounds and living arrangements, allowing for a comprehensive analysis across varied contexts.

Types of interventions

This study will include both individual and group occupational therapy interventions that target physical, sensory, psychological and cognitive functions; activities of daily living; environmental factors; use of assistive devices and primary caregiver counselling, as classified by the International Classification of Functioning, Disability and Health. No restrictions will be placed on the intervention and follow-up periods. The therapies provided in the control groups of the studies included should comprise therapies other than occupational therapy, usual interventions or no intervention. Our approach will involve categorising the collected studies into distinct periods during the final phase of the analysis. This decision will facilitate the aggregation of studies during the data collection phase without imposing temporal constraints.

Regarding the calculation of cost-effectiveness, our strategy will entail plotting the study outcomes on a cost-effectiveness plane and conducting subsequent analysis accordingly. This method will enable us to evaluate and visually represent the cost-effectiveness of interventions across different temporal segments, thereby accommodating potential variations in time-related factors.

Outcome measurements

The primary outcomes for this systematic review include the calculation of the incremental cost-effectiveness ratio (ICER) derived from functional status assessments, such as the Functional Independence Measure, and evaluations of quality of life using tools such as EuroQol-5D across the reviewed studies. Additionally, we aim to compute and incorporate quality-adjusted life-years where feasible. Our approach involves conducting separate analyses for each distinct outcome measure. As previously mentioned, we will graphically represent the data on the cost-effectiveness plane to visually appraise the cost-effectiveness of interventions for each specific outcome. In instances where a study under review has already computed the ICER or provided pertinent cost-effectiveness data, we will incorporate the findings into our analysis. However, in cases where ICER is not explicitly available, we are committed to calculating it by dividing the incremental cost by the incremental effect for the respective outcome measures.

Exclusion criteria

This systematic review will exclude study protocols, conference proceedings, commentary papers, comparisons between the two types of occupational therapy, model-based economic evaluations and partial economic evaluations. Studies without full-text access will also be excluded.

Data sources and search strategies

The PubMed, Web of Science and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases searched from inception until August 2023, and only the articles published before July 2023 will be included. We conducted a preliminary PubMed search and developed keywords based on the results using synonyms for ‘older adults’, ‘occupational therapy’, ‘cost-effective’ and ‘clinical trial’. A search strategy was initially developed for PubMed using a combination of controlled vocabulary (eg, MeSH) and free-text terms. Subsequently, this strategy was adapted for alignment with other databases. The reference lists of relevant articles were also be manually searched (see online supplemental appendix 1). Two authors (TK and HN) will conduct a comprehensive literature search across multiple digital databases, including PubMed, Web of Science and CINAHL, as well as among unpublished trials registered on ClinicalTrials.gov and the UMIN Clinical Trials Registries. No language restrictions were imposed on the search.

Study selection

All retrieved studies will be imported into Rayyan software, and duplicate studies will be omitted. Two authors (TK and HN) will independently screen the titles and abstracts in accordance with the inclusion and exclusion criteria and perform crosschecks. The full text of studies will be reviewed for their eligibility according to the inclusion criteria. The full-text articles will be retrieved and reviewed independently by the same authors (TK and HN). These authors (TK and HN) will download the full texts of all possible relevant studies for further independent assessments and crosschecks. Disagreements will be resolved through team discussions or consultations with a third reviewer (JU).

Data extraction

Study characteristics and details will be extracted from each selected study with reference to previous studies.¹⁵ For all studies, authors, years, countries, populations, primary results and general conclusions will be extracted using a standardised data extraction form. Discrepancies between reviewers will be resolved through a review of the source documents and discussions until a consensus is reached. The primary outcome data will be entered into and calculated using the Review Manager V.5.4 software (Cochrane Collaboration).

Risk-of-bias (quality) assessment

Two authors (TK and HN) will systematically evaluate the risk-of-bias in each trial using the Cochrane risk-of-bias assessment tool. These evaluations will consider the following domains: adequacy of the randomisation methodology; sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data and selective outcome reporting; and other potential sources of bias. If the scores of the two authors are different, the item in question will be discussed, and, if necessary, a third reviewer will reconduct the evaluation. After discussions to resolve inconsistencies, a final consensus score will be derived for each quality domain. Review Manager 5.4 software will be used to create a risk-of-bias diagram.

Additionally, the quality of the economic evaluation methodology will be assessed using the Evers Consensus on Health Economic Criteria list.¹⁶ Using this checklist, each study will be assessed based on whether it reports on the 19 recommended criteria (eg, appropriate valuation of outcomes, sensitivity analysis and appropriate economic study design). For each criterion, a study will be assigned 1 point if it appropriately addresses the criterion and 0 point if it does not. According to the instructions on the checklist, all criteria are weighted equally.

Data synthesis strategy

The data will be analysed qualitatively through the characterisation of the characteristics and outcomes of the included studies.

The results will be presented in a narrative synthesis format, encompassing a description of the participant’s characteristics, intervention details, outcomes and cost-effectiveness. Finally, each of the included studies will be plotted on a cost-effectiveness plane to visualise the cost-effectiveness of occupational therapy for older adults.

Patient and public involvement

As this study constitutes a systematic review of existing literature, the patients and public were not directly involved. However, we will address this gap by conducting an extensive literature review and will include patient-reported outcomes and insights gathered from a diverse range of healthcare professionals who closely interact older adults, which will significantly contribute to framing our research question and refining the study objectives.

Ethics and dissemination

We confirm that ethical approval was not required for this systematic review, as per the guidelines of our institution’s Institutional Review Board, who waived the requirement for approval.

Discussion

This systematic review endeavours to update and comprehensively evaluate the cost-effectiveness of occupational therapy in older adults. By incorporating the outcomes of previous systematic reviews that focused on distinct populations such as individuals with mental health issues and with cognitive and functional decline, as well as those requiring acute and subacute care, this study aims to extend the understanding of cost-effective interventions tailored to the needs of older adults.

Previous systematic reviews regarding the cost-effectiveness of occupational therapy have reported on individuals with mental health issues, cognitive and/or functional decline and adults requiring acute and subacute care.^17–19

For patients with mental health problems, supported employment—specifically, individual placement and support—has demonstrated cost-effectiveness in multiple contexts. Furthermore, occupational therapy, when integrated with the treatment of major depression, has been shown to be cost-effective. Moreover, an advanced supported employment programme was found to be cost-effective.¹⁷

Systematic or multicomponent occupational therapy interventions have shown economic benefits in individuals with cognitive and/or functional decline. Interventions that incorporated multiple consultation sessions and targeted improvements in the home environment, individual abilities and caregiver skills were found to be the most efficacious and cost-effective.¹⁸

For adults requiring acute and subacute care, the following interventions demonstrated superior efficacy and cost-effectiveness compared with that observed among those requiring usual care: delivery of structured activities of daily living retraining during the post-traumatic amnesia phase for individuals with traumatic brain injury; occupation-based interventions for individuals poststroke; virtual rehabilitation following a stroke; acute discharge planning and adjusting the challenge–skill balance in rehabilitation for individuals with musculoskeletal, spinal or cerebral diseases. Additionally, the combination of occupational therapy and physiotherapy interventions before and after hip replacement surgery has also been shown to be cost-effective.¹⁹

However, it should be noted that all these systematic reviews highlighted limitations such as the small number of studies available and variability in study quality.

In our previous systematic review investigating the cost-effectiveness of occupational therapy interventions in older adults, we found that cost-effective occupational therapy comprised setting client-centred goals, focusing on meaningful occupations and thoroughly educating therapists on the intervention protocol.¹³ Given the reported inaccuracies in transparency and reproducibility within the current literature on healthcare economic evaluations, updating our understanding through a systematic review and conducting bias assessments for each paper would be crucial in addressing these issues and advancing the field.²⁰ Our present systematic review may substantiate these findings by presenting additional information that augments the existing knowledge in this area, thereby enhancing the evidence for the cost-effectiveness of occupational therapy interventions in older adults. The findings may inform decision makers and healthcare providers of the value of occupational therapy as an intervention that can help promote functional independence and enhance the quality of life of older individuals.^{21 22}

While we acknowledge that this study has methodological limitations, the results of this systematic review may provide a good foundation for future research. Studies evaluating the economic value of occupational therapy are urgently needed, and similar economic perspectives and results should be considered for comparisons.^{19 23–25}

Moreover, this updated review aims to shed light on how the cost-effectiveness of occupational therapy may vary based on different factors such as living arrangements, duration of therapy and specific intervention modalities. The expected outcome of this study is a nuanced understanding of how these varying factors influence the cost-effectiveness of occupational therapy in older adults, providing a distinctive advantage.²⁴ By exploring these differences, we anticipate drawing a more comprehensive picture of the economic impact and efficiency of occupational therapy interventions, further enhancing the insights gained from our previous review.¹³ This approach will not only offer an updated perspective but also serve as an advantage by delineating the nuanced impacts that diverse living arrangements and varying intervention durations can have on the cost-effectiveness of occupational therapy for older adults.

Ethics statements

Patient consent for publication

Not applicable.