Stroke rehabilitation: effectiveness, benefits, and cost. Some practical considerations.

THE HIGH COST of health care delivery makes it mandatory for the physician to separate effective therapeutic measures from those which are costly yet of marginal benefit to the patient. This is particularly important in dealing with the treatment of chronic neurologic disorders, such as stroke, where the total medical costs involved in caring for a patient can be astronomical. Factors which can make it difficult for physicians to decide what sort of treatment to employ are: 1. Lack of carefully controlled clinical trials demonstrating the effectiveness and/or benefit of various therapeutic measures. 2. Lack of data on the total cost of chronic care. 3. Pressure from peers, patients, and families to "do everything possible" even if therapeutic intervention is of questionable value and is costly. Since vigorous treatment may not always return the patient to a reasonably happy and productive life, but may, instead, produce an unhappy, dependent, chronically disabled and isolated individual, the physician should consider the following guidelines in making therapeutic decisions: 1. What type of medical, surgical and rehabilitative treatment will be most effective! 2. Will the treatment be beneficial to the patient, his family, and/or society? 3. What is the actual cost of the treatment? Using stroke as a model of a major, chronically disabling, neurological disease, this editorial will review recent data on the effectiveness, benefit, and cost of one type of therapeutic intervention following an acute, cerebrovascular insult — stroke rehabilitation. Practical methods of maximizing a beneficial outcome while minimizing costs will be emphasized in an attempt to help the primary care physician select treatment which will provide the "best possible care" at the lowest cost.