1 Cost Effectiveness of Neurological Rehabilitation Professor Anthony B Ward North Staffordshire Rehabilitation Centre Stoke on Trent, UK
more complex needs ACUTE CARE ITU Neurosurgery Orthopaedics Neuropsychiatric service NEUROLOGICAL REHABILITATION INPATIENT UNIT highly complex needs TERTIARY UNIT (e.g. neurobehavioural unit) A&E less complex needs DGH ward Hospital Acute brain injury Supported discharge Hospital at home Early community rehabilitation Community reintegration Enhanced participation DEA supported return to work Community REHABILITATION MEDICINE SPECIALIST COMMUNITY SERVICES Multi-disciplinary multi-agency Brain Injury Team Collin C, Ward A B. Rehabilitation Medicine 2011 & Beyond. RCP London. 2010 Integrated care planning Long term support Single point of contact Join health and social service planning Multi-agency care
ACUTE CARE ITU Neurosurgery Orthopaedics REHABILITATION MEDICINE INPATIENT SERVICE Neurological rehabilitation unit A&E DGH ward REHABILITATION MEDICINE SUPRA-REGIONAL SPINAL INJURY CENTRE Acute spinal cord injury SPINAL INJURY CENTRE specialist outpatient follow-up Supported discharge Hospital at home Early community rehabilitation Community reintegration Enhanced participation DEA supported return to work Hospital Community REHABILITATION MEDICINE SPECIALIST COMMUNITY SERVICES Collin C, Ward A B. Rehabilitation Medicine 2011 & Beyond. RCP London. 2010 Integrated care planning Long term support Single point of contact Join health and social service planning Multi-agency care
Specialised Rehabilitation Complex issues Variable goals, variable outcomes Benefits seen not always in health care independence Multi-professional activity is one profession more effective/cost-effective than another? Team and individual competencies & professional boundaries do they matter?
Rehabilitation Effectiveness Evidence-based treatments Relevant outcomes Service efficacy Practice-based evidence Resource utilisation Cost-effectiveness
Rehabilitation Effectiveness Evidence-based treatments Relevant outcomes Service efficacy Practice-based evidence Resource utilisation Cost-effectiveness
Measurement Problems Outcomes dependent on team activities & treatment algorithm Separating impact of one intervention E.g. contribution of ITB over physical treatments? Longer initial hospital stays appear bad, but result in long term savings in cost of care 1 Turner-Stokes L. Brain Injury 2007; 21 (10): 1015-1021.
Are We Measuring the Right Things? Activities/QUALYs Northwick Park Dependency score (NPDS) Prediction of dependency Northwick Park Care Needs assessment (NPCNA) Detection of changes Retrospective analysis of 297 patients following severe TBI FIM vs. Barthel vs. NPDS/NPCNA NPDS/NPCNA detected changes associated with substantial care savings, especially in high dependency patients Floor effects of FIM negative Turner-Stokes L, Paul S, Williams H. JNNP 2006
Rehabilitation Medicine Works Well recognised benefits for early rehabilitation 1 Prompt response on ill effects of immobility & complications 1, 2 Educating acute staff of areas where rehabilitation is of major benefit 3 Money spent on rehabilitation recovered with 5-9 fold savings 4 Rehabilitation in all phases of health condition effective &?cost-effective 4 Community based programmes effective 4 1. Verplancke D, Snape S, Salisbury CF, Jones PW, Ward AB. Clin Rehabil 2005; 19 (2): 117-125. 2. Didier JP. Springer Verlag; 2004. p476. Paris: p 476. 3. Krauth C, et al. Gesundheitsökonomische Evaluation von Rehabilitationsprogrammen im Förderschwerpunkt Rehabilitationswissenschaften Rehabilitation 2005; 44: pp e46-e56. 4. Gutenbrunner C, Ward AB, Chamberlain MA. The White Book on PRM in Europe. J Rehabil Med 2007; Suppl.1: S69.
Benefits of RM Reduces complications e.g. physical effects of neurological injury, immobility, etc. Optimises patients physical & social functioning Identifies cognitive & emotional aspects of TBI even in absence of physical sequelae Improves chances of independent living at home & return to work Concentrates therapy More therapy input associated with shorter hospital stays & improved outcomes Right environment & skill mix of trained therapists Turner-Stokes L. Clinical Rehabilitation 2002; 16 (Suppl. 1): 1-60. Stroke Units Trialists Collaboration. British Medical Journal 1997; 314: 1151-1159. Bernspang B, Asplund K, Erikson S, Fugl-Meyer AR. Stroke 1987; 18: 1081-1086. Indrevidavik B, et al,. Stroke, 22: 1026-1031.
Participation in Society After Rehabilitation Reduction in care Social benefits Getting out of house Personal & family relations Independence Community mobility Driving Use of assistive technology Occupational Work Informal/voluntary Collin C, Ward A B. Rehabilitation Medicine, 2011 & Beyond. RCP London. 2010
Rehabilitation Effectiveness Evidence-based treatments Relevant outcomes Service efficacy Practice-based evidence Resource utilisation Cost-effectiveness
UK Rehabilitation Outcomes Consortium Measures activity in rehabilitation units Developed in collaboration with Australian system Learning from international models Develop cost-effectiveness model Turner-Stokes L, Poppleton R, Williams H, et al. Disability & Rehabilitation 2012; 34 (22): 1900-1906.
Data Definition BSRM 2010 UKROC Data reporting requirements Full Dataset Full Dataset Commissioning Currency Level 1 Multi-level weighted tariff 5 tier Level 2a Multi-level weighted tariff 5 tier SPECIALISED Level 1a: Tertiary services High physical dependency Level 1b: Tertiary services Physical / cognitive/behavioural Level 2a: Extended catchment - Mixed caseload Minimum dataset Level 2b 3 or 5-tier tariff NON-SPECIALISED Level 2b: Local specialist rehabilitation services None Standard per diem HRG rates (reference costs) NON-SPECIALIST Level 3a: Other specialist services (e.g. stroke rehab) Level 3b: Generic rehabilitation services Complexity of caseload Patients requiring rehabilitation
Costings Example Model base rate notional bed day cost 400 5 bands of complexity Bed day cost: Base rate = 400 Complexity group V. heavy (13-15) Heavy (10-12) Medium (7-9) Low (4-6) V low (0-3) Variable Portion of cost 75 % (= 300 in this example) Banded by RCS scores x Banding Factor* 1.9 1.5 1.0 0.75 0.5 + Non-variable portion of cost 25 % (= 100 in this example) Non -Banded = Banded cost 670 520 400 325 250 Costing multiplier 2.062 1.600 1.231 1.000 0.769 *Banding factor based on proportionate staff inputs for each complexity group derived from casemix analysis Applied to the variable portion of the OBD costs
Cost Benefits after Stroke Rehabilitation Direct costs of treating stroke patients Spasticity vs. without spasticity Retrospective analysis of 232 patients treated over 1 year Mean age 73 years, M:F 52:48 Mean cost spasticity vs. No spasticity $84,195 $21,845 (p <0.001) Conclusion Direct costs for 12 month stroke survivors 4x higher Lundström E, et al. Stroke 2010; 41 (2): 319-324
Costs of Care for Adults Informal care costs 4 times higher than formal costs Informal care costs significantly higher for those with sudden onset conditions & hidden/ mixed impairments Healthcare costs significantly associated with Sudden onset condition Greater dependency in activities of daily living Longer condition duration Greater dependency significantly associated with increased social care costs Jackson D, McCrone P, Turner-Stokes L. Jnl. Rehab Med 2013; 45 (7): 653-661.
Rehabilitation Effectiveness Evidence-based treatments Relevant outcomes Service efficacy Practice-based evidence Resource utilisation Cost-effectiveness
Strongest Recommendations for Cost Benefits (GRADE Classification) Basis of research evidence available (from both RCT- & non-rctbased literature) and potential for cost-benefits, recommend: Early intensive rehabilitation, starting as soon as possible after onset 1-4 Specialist programmes for all those with complex needs 5, 6 Specialist vocational programmes for those with potential to return to work 6,7 1. Turner-Stokes L, et al. Cochrane Review: Multi-disciplinary rehabilitation for ABI in adults of working age. 2008; Issue 4. 2. Turner-Stokes L. J Rehabil Med 2008;40(9):691 701. 3. Cope N, Hall K. Arch Phys Med Rehabil 1982; 63(9):433 7. 4. Engberg AW, Liebach A, Nordenbo A. Acta Neurol Scand 2006;113(3):178 84. 5. 58 th World Health Assembly, Doc A58/17. Geneva: WHO, 2005. 6. Black DC. Working for a healthier tomorrow. London: TSO, 2008. 7. Waddell G, et al. Vocational Rehabilitation: What works, for whom, and when? 1 st edn. London: TSO; 2008.
Conclusion Cost-effectiveness elusive Cannot compare against no treatment These patients are already expensive! Enough evidence to show effectiveness of treatments Need to have right tools to demonstrate both But, also need better practice based efficacy standards Once decision made to treat, cost benefit from goal specific treatment Some treatments cost-effective Rehabilitation probably cost-effective, but more data needed
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