Rehabilitation in NZ and QE Health
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1 Rehabilitation in NZ and QE Health
2 Rehabilitation Rehabilitation is a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible The main types are physical, psychological, occupational. These can be combined in a multidisciplinary approach for moderate to severely affected people
3 NZ Population change
4 The big picture Standard and Poor's warns aging population will increase pension and healthcare costs to 20.9% of GDP by 2050 from 14.4% now Health Workforce NZ states that there will be a 100% increase in aged care needs by 2026 but only a 30% increase in resources The current healthcare model for aged care is unsustainable. Each Rest Home admission costs $40,000 per annum Need for elderly people to remain independent Rehabilitation fosters independence
5 Changing needs for rehabilitation There is currently no comprehensive rehabilitation system in New Zealand. Provision of, and access to services is fragmented and varies greatly between regions. The main funders of rehabilitation- the Ministry of Health, Accident Compensation Corporation and District Health Boards, all purchase different components of rehabilitation leading to the provision of varied and often inequitable services and therefore different outcomes for clients. The current rehabilitation workforce faces issues of recruitment and retention at all levels; from the unregulated workforce of caregivers, through allied health professionals to rehabilitation medicine specialists. Training in rehabilitation is limited and uptake is not currently adequate to meet the needs of a comprehensive system. Health Workforce NZ Rehabilitation Forecast Dec 2011
6 Why the poor state? Rehabilitation and aged care are not Public Funding Priorities 2012/13 DHB Health Targets Shorter stays in emergency departments Improved access to elective surgery Shorter waits for cancer treatment Increased immunisation Better help for smokers to quit More heart and diabetes checks
7 REHABILITATION WHAT IS IT AND DOES IT WORK?
8 Rehabilitation Rehabilitation is a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible The main types are physical, psychological, occupational. These can be combined in a multidisciplinary approach for moderate to severely affected people
9 Rehabilitation treatment pathways GP/Specialist Diagnosis as requiring rehabilitation QE Health focuses on this group 90% 9% 1% Mild pain and/or disability Moderate pain and/or disability Severe pain and/or disability Community low medium intensity programs Community medium intensity programs or rehabilitation clinic outpatient Rehabilitation clinic day/inpatient Not successful Consider rehabilitation clinic outpatient or day/inpatient if symptoms worsen Not successful Consider rehabilitation clinic day/inpatient Day/inpatient unsuccessful Consider permanent institutionalisation
10 Supporting Evidence (Very intensive Rehabilitation) Musculoskeletal - Back pain Guzman et al (BMJ 2002), Fairbanks et al (BMJ 2005), Rivero-Arias et al (BMJ 2005) (Chou et al. Spine 2009). Musculoskeletal rheumatoid arthritis (Hammond 2004). (Vlieland, J Rheum 1997). (Lambert, BMJ 1998). (Spiegel, Arthritis Rheum 1986; Anderson, J Rheum 1988; Helewa, Arthritis Rheum 1989). Musculoskeletal ankylosing spondylitis Masiero et al (J.Rheum 2011) Neurological Frazzita et al (Neurorehabil Neural Repair 2012) Parkinsons disease. Trend et al (Clin Rehabil ) Parkinsons disease. Cabrera Gomez (Int J MS Care. 2010) multiple sclerosis patients Piira et al (J Neurol Neurosurg Psychiatry 2010) Huntingdons disease. Zinza et al. (J Neurol Neurosurg Psychiatry 2010) Huntingdon s disease.
11 Outcomes Audit of QE Health patient records for 10 years between January 2001 to December 2010 Several health outcomes measures consistently collected over this time period Please see appendix for detail on the measures used All patients included (no a priori exclusions from analysis)
12 10 year audit (Approx 7 PPS patients per annum) Table 1) Demographics of QE Health treated population Time period 01/01/ /12/2010 National National Number of patients 2624 Diagnosis Pain 25% Number of rehabilitation visits 3214 Osteoarthritis 21% Rheumatoid Arthritis 15% Age Mean 59 Fibromyalgia 13% Median 60 Post Polio Syndrome 2% Mode 74 Other 23% Sex M 28% Data Availability Visits with pre and post outcomes data 89.7% F 72% Ethnicity Pakeha 83% Number of visits 1 visit 84% Maori 12% 2 visits 11% Islander 1% 3 visits 3% Asian 1% 4 visits 1% Other 3% 5 visits or more 0% Funding Lakes 16% Occupation Retired 38% BOP 22% Working 26% Waikato 13% Beneficiary 11% Midland 17% Housewife/Home person 10% Other DHB NZ 18% Other/NA 14% ACC 12% Private and Other 2%
13 Global Health Change in Wellness score (0=no change) between admission and discharge at QE Health A score between 0 (as good as dead) and 10 (full health) (Changes above 1.0 are clinically significant)
14 6 minute walk test Change in 6 minute walk test (0=no change) between admission and discharge at QE Health How many metres can you walk in 6 minutes? (Changes above 44m are clinically significant)
15 Getup and Go test Change in GetGo test (0=no change) between admission and discharge at QE Health Timing patients from waking to full activity. It is measured in minutes (Changes above 1.0 are clinically significant)
16 mean of Dataset$Change.McGill Pain Change in McGill Pain Score (0=no change) between admission and discharge at QE Health Negative scores signifying reduced pain are better (Negative changes greater Plot than of Means -4.0 are clinically significant) Fibromyalgia Osteo Arth Other Other Arth Pain Post polio Rheum Arth
17 How long does the treatment effect last? Currently under study Only 16% of patients return for a second visit Evidence from pain patients show treatment outcomes still strong at 12 months
18 QE Health rehabilitation analysis to 12 months in persistent pain patients
19 Average QEHS score (28 = minimum, 140 = maximum) Long term benefits across severity Different patient types benefit: ACC funded pain patients experience similar gains to DHB funded rheumatology patients Average QEHS score for MDPP patients (08/09 thru to 09/10) Avg QEHS Severe patients Admission Discharge 3 month follow up 6 month follow up 12 month follow up N = 43 severe patients with admission score < 90 Stage of patient in treatment cycle N = 41: Data for September review Severe patients have QEHQ < 90 at admission
20 QE as a microcosm of larger issues DHB focus on elective surgery and non rehabilitation services Publicly funded services declining Private demand increasing
21 What is QE Health today? Orthotics Specialist Clinics Physiotherapy Rehabilitation Occupational Therapy Gymnasium Spa Psychology Nursing care 60 staff employed
22 QE Health has its own recognised model of holistic care (HCPT)
23 QE: Historical rehabilitation service patterns QE Now - breakdow n of Rehabilitation prpgrammes $3,000,000 $2,500,000 $2,000,000 Private $1,500,000 $1,000,000 ACC DHB $500,000 $0 MIR* Light MIR AFP/Community rehab/hnya Gymnasium Heavy spa programmes** Light spa programmes Physiotherapy/OT outpatient services Spa one off services Programmes - in order of intensity
24 Sum of daypatients and inpatients QE as a microcosm of the larger picture: MIR rehabilitation in decline Total intensive rehabilitation patient numbers using QE Health per annum / / / / / / / / /12 Reporting year (ending June 30)
25 Why the change? Rheumatology has specialised on inflammatory conditions Osteoarthritic conditions no longer catered for Very large patient group left out In per cent of New Zealanders aged 15 and over were living with at least one type of arthritis which is equivalent to 660,000 people. By 2020 the prevalence of arthritis is expected to reach 16.9 per cent. RA is the second most common form of arthritis in New Zealand, affecting 3.5 per cent of the population. In 2008 this was equivalent to more than 149,000 people. Pain specialists are beginning to meet the unmet need. But very slowly as it is not on DHB priority list Source: Fit for Work: Musculoskeletal disorders and the NZ labour market. University of Lancaster 2012
26 Diverse fortunes smaller sub business growing 120 TOTAL GYM MEMBERSHIPS - July 2011 to current Mths GOLD 6 Mths 3 Mths 2 Mths Other Gold Membership increased to $299 Casual removed Spa Monthly Revenue , , ,000 60,000 TOTAL 6 Mths GOLD 6 Mths 3 Mths 2 Mths 1 Mth Casual Total Monthly Visits Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul % 33 50% 39 53% 41 52% 43 52% 41 53% 40 51% 31 40% 27 35% 29 35% 32 31% 39 40% 43 39% 13 25% 13 20% 12 16% 13 16% 13 16% 11 14% 12 15% 17 22% 21 27% 24 29% 36 35% 40 41% 44 40% 1 2% 1 2% 1 1% 0 0% 0 0% 1 1% 1 1% 1 1% 1 1% 0 0% 1 1% 3 3% 3 3% 3 6% 3 5% 5 7% 8 10% 6 7% 3 4% 2 3% 3 4% 2 3% 4 5% 11 11% 11 11% 14 13% Total 1 2% 2 3% 1 1% 2 3% 1 1% 0 0% 1 1% 0 0% 1 1% 0 0% 1 1% 0 0% 2 2% 13 25% 14 21% 15 21% 15 19% 19 23% 22 28% 22 28% 25 32% 25 32% 26 31% 23 22% 4 4% 4 4% Linear (Total) (18/7/12) 40,000 20,000 0 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12
27 French Spa curistes private health maintenance 2012/13 40% growth in numbers Average treatment length 1 week Daily spa therapies + physio, gym or rheumatology if required $1,000 per head average spend on QE therapies alone
28 The way forward No fast change expected on public funding approach Crisis is required prior to this Rehabilitation must survive and grow in a private market setting Medical spa services Dementia rehabilitation
29 A wider range of rehabilitation programs target for 2018 QE rehabilitation in future $3,000,000 $2,500,000 $2,000,000 Private $1,500,000 ACC DHB $1,000,000 $500,000 $0 MIR* Light MIR Gymnasium Heavy spa programmes** Physiotherapy/OT outpatient services AFP/Community rehab/hnya Light spa programmes Programme in order of intensity Spa one off services
30 Crisis brewing? What if the focus on surgery changes? Antimicrobial resistance poses a catastrophic threat. If we don t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can t be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection. Prof Dame Sally Davies; England s Chief Medical Officer; Annual Report 2011
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