ARE STROKE UNITS COST EFFECTIVE? EVIDENCE FROM A NEW ZEALAND STROKE INCIDENCE AND POPULATION-BASED STUDY

Transcription

1 ARE STROKE UNITS COST EFFECTIVE? EVIDENCE FROM A NEW ZEALAND STROKE INCIDENCE AND POPULATION-BASED STUDY Braden Te Ao, Ph.D. Centre for Health Services Research & Policy, University of Auckland, National Institute for Stroke & Applied Neurosciences, Auckland University of Technology

2 Acute stroke units for improving outcomes from stroke Stroke units Nationally Seven DHB s nationwide have stroke units Slow uptake on stroke units Stroke Guidelines Stroke units are recommended for hospitals Cost effectiveness Some studies suggests stroke units are cost effective, others not Black box intervention Great variation of cost/effectiveness measure More costly - Cost per day (NZ$2008) Stroke unit -NZ$1100 General Ward - NZ$850

3 Discharge delays One result Problems with moving through the system (bottlenecks) Delays in discharge Due to stroke patients waiting for transfer Over 65 years-can be done by a geriatrician Under 65 years-delays due to arguments between funding agencies Implications: Strains costly resources Reduced availability of beds on a stroke unit Reduced availability of beds in rehabilitation hospitals Worse outcomes from being discharged to residential care

4 Current study- Te Ao, Brown, Feigin & Anderson 2012 Natural experiment Auckland Region Community Stroke study (ARCOS) Prevalence study in Auckland, New Zealand (pop: 945,000) Follow up period for 1 year 1938 stroke sufferers 1495 first ever stroke Data collection during 2002 to 2003 Time of data collection-middlemore Hospital Had Stroke Unit(SU), but limited beds 53% of people admitted (into SU) Approach Use ARCOS data from Middlemore

5 Capacity constraint Stroke Unit beds are limited (12) If waiting time for discharge increases, fewer stroke unit beds are available Lowers probability of admission into Stroke Unit

6 Question: Are Stroke Units cost effective? How sensitive are the results to changes in waiting times for discharge? Costs Hospitalisations and health services during first year care Outcomes Identify pathways during first year Link endpoints at 28 days, 6 months and 12 months with utility scores (QALYs) Cost effectiveness Compare costs and outcomes for those treated in stroke unit vs. General Ward 6

7 Cost effectiveness model From ARCOS Place of discharge up to 1 year Home, Rest home or dead From literature Life expectancy at 12 months post stroke Home (NEMESIS) Rest Home Utility after stroke (Kalra et al, 2005) Home Rest Home (Tosteson et al, 1995) Quality Adjusted Life Years (QALYs) 7

8 Unit costs 8

9 Decision Model 9

10 Characteristics of sample 10

11 Predictors of Stroke Unit admission Dependent Admission to Stroke Unit Logistic regression Conclusion No consistent predictors: This is consistent with the anecdotal evidence suggesting thatadmissiontothestrokeunitwasdoneonthebasisofavailablebeds 11

12 Results: Summary of costs and health outcomes 12

13 Results: Incremental cost utility ratios 13

14 Sensitivity Analysis: Delays in Discharge 14

15 Summary : Stroke units for improving outcomes from stroke Stroke Units are cost effective ICURs below $20,000 (NZ$20k threshold???) Robust to changes in parameters Delays in discharge Interviews revealed barriers to flowing through system Result is to decrease access to rehab/entry into stroke units 15

16 COST OF TRAUMATIC BRAIN INJURY (TBI) IN NEW ZEALAND: WHAT CAN WE LEARN FROM COST-OF-ILLNESS STUDIES Braden Te Ao, Ph.D. National Institute for Stroke & Applied Neurosciences, Auckland University of Technology

17 Burden of TBI on Society TBI is a leading cause of disability and death in New Zealand incidence of TBI per 100,000 person-years was 790 cases 95% are mild and 35% did not seek immediate medical attention Economic burden of TBI worldwide Recent studies suggest substantial financial burden of TBI Some limitations Focused on those that were hospitalized Most severe injuries Incur higher direct costs 17

18 Current study Research objective To estimate the one year and lifetime societal cost due to TBI s in New Zealand in 2010 projected to 2020 Basic Approach Data Source -Brain Injury Outcomes New Zealand in the Community study (BIONIC) Detailed resource use for 725 incident cases TBI severity based on the Glasgow Coma Scale Incidence based cost of illness (COI) model Direct and indirect costs Focus on additional costs associated with TBI (not total costs) Projected to New Zealand population in 2010 (NZ census) 18

19 Cost of TBI Data collection From BIONIC- self reported health usage at 1, 6 and 12 months post TBI Personal cost (out of pocket costs) Rehabilitation & outpatient services Community health services Lost of productivity (i.e. loss of income due to injury) Equipment and home modification National Health Databases Hospitalizations (National Minimum Dataset) Identified by ICD-10 codes Linked by matching NHI (patient identifier) No fault personal accident insurance cover (ACC) 19

20 Cost calculation method Hospital costs calculated on diagnosis related groups (NMDS) Using Weighted Inlier Equivalent Separations (WIES) Resource use approach Resources units based (self-reported health usage) Costs based on resources units*year-specific unit price (market price) Descriptive Analyses including means and 95% confidence intervals [CI] will be used to determine the economic profile of TBI in NZ by levels of severity 20

21 Average cost per person Users (n=725) Resources per patient (N. of days or N. visits) Cost per category (NZD) % Mean Mean 95% CI Health care Emergency Department 42% $270 Initial hospitalisation 36% 2.6 $4,374 $3,024-$5,723 Hospital readmission 4% 6.5 $7,009 $2,893-$11,124 Outpatient care 6% 6.1 $2,669 $294-$5,043 Specialised Medical care 14% 9.6 $3,476 $2,405-$4,546 Allied Health care 18% 21.4 $6,289 $4,910-$7,667 General Practice 36% 9 $1,421 $1,238-$1,603 Nursing 4% 19.1 $3,366 $763-$5,967 Radiology 1% 3.8 $3,544 -$1,406-$8,494 Community Services 3% $31,735 $12,145-$51,323 Out of pocket expenses 4% $1,033 $196-$1,869 Other expense 100% $215 $211-$218 Total Direct medical costs per person 100% $5,749 $4,609-$6,889 Non health care (indirect) loss in productivity 17% $2,980 $2,402-$3,556 Total 1-year costs per person 100% 21 $6,259 $5,104-$7,413

22 Average cost per person by TBI severity ** P< 0.05 Mild TBI (GCS 13) Moderate/Severe TBI (GCS 12) % of all mild (n=691) Mean 95% CI % of all severe (n=34) Mean 95% CI Health care Emergency Department 41% $270 44% $270 Initial Hospitalisation 34% $2,813** $2,198-$3,427 88% $16,500** $6,188-$26,812 Hospital readmission 3% $5,623 $1,068-$10,177 12% $14,285 $3,740-$24,829 Outpatient care 6% $1,590 $865-$2,313 15% $11,300 -$17,343-$39,944 Specialised Medical care 14% $3,358 $2,227-$4,487 29% $4,604 $641-$8566 Allied Health care 17% $5,869 $4,523-$7,214 41% $9,854 $2,971-$16,737 General Practice 37% $1,430 $1,240-$1,619 32% $1,214 $552-$1,876 Nursing 4% $2,306 $802-$3,809 12% $9,988 -$15,801-$35,777 Radiology 1% $1,866 -$610-$4,341 3% $10,256 Community Services 3% $29,642 $9,916-$49,367 12% $42,197 -$71,142- $155,536 Out of pocket expenses 4% $1,137 $134-$2,140 15% $489 $218-$760 Other expense 100% $214 $210-$ % $226 $223-$228 Total Direct medical costs per 100% $4,528 $3,675-$5, % $30,563 $15,067-$45,058 person Non health care (indirect) loss in productivity 16% $2,940 $2,327-$ % $3,352 $1,370-$5,334 Total 1-year costs per person 100% $5,005** $4,142-$5, % $31,745** $16,114- $47,377

23 Lifetime cost methods On-going healthcare needs Moderate-severe disability (defined by Glasgow Outcome Scale) at 12 months post TBI 5% of all TBI (4% mild; 27% moderate/severe) Average direct cost per person * probability of having a moderate-severe disability Long-term productivity loss Decrease in income at 12months post TBI 3% of all TBI (3% mild; 6% moderate/severe) Value time lost from employment up to age 65 years was estimated for all adults Long term cost estimates were summed together with first year costs 23

24 Estimated lifetime costs per person Average costs per person 1-year costs On-going Long-term direct lost of medical care productivity (post (post 12 12months) months) Total lifetime costs* Mild TBI (n=691) $5,005 $519 $1,384 $6,908 Moderate/Severe TBI (n=34) $31,745 $21,724 $1,136 $54,605 Total (n=725) $6,259 $1,215 $1,350 $8,824 * Lifetime estimates based on short-term data 24

25 Total costs for New Zealand Cost estimates for New Zealand Current Burden 2010 Projected Burden 2020 Incidence (First ever TBI) One year direct healthcare cost $65,676,129 $78,189,847 One year indirect cost $5,688,474 $6,819,650 One year total cost $71,364,604 $85,009,497 Lifetime cost $103,342,853 $122,831,743 Prevalence (Recurrent TBI) One year direct healthcare cost $138,948,741 $168,045,754 One year indirect cost $12,118,102 $14,655,733 One year total cost $151,066,843 $182,701,487 Lifetime cost $218,284,240 $263,994,762 25

26 Interpretation: The cost of TBI in New Zealand in 2010 Per capita cost of $6,259 (US4,195; 3,231) in the first year Differs according to severity $5,005 (US3,355; 2,584) for Mild TBI $31,746 (US21,279; 16,390) for Moderate/Severe TBI Cost of Mild TBI is significantly lower than Moderate/severe TBI (P 0.05) Total cost of all Mild TBI are 3 times higher thanthat for Moderate/Severe TBI Urgent need to develop effective interventions to preventhigh cost TBI. 26

27 What is the added value of cost of illness studies? Health planning Identifying health and social service resources used Anticipate and budget for health services needed to detect and treat TBI Potential costs savings by providing information on the cost that can be averted through prevention Health policy Cost information can inform whether new methods of testing or treating are cost effective 27

28 Further recommendations The need for a longitudinal study to observe longterm outcomes Caregiver/informal care Caregiver time and expenses are clearly significant costs to those living at home Identify disparities and inequalities in accessing health services (unmet needs) Identifying resources being utilised Identifying extra resources the people may need 28