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Cost Effectiveness of Neurological Rehabilitation
Professor Anthony B Ward
North Staffordshire Rehabilitation Centre
Stoke on Trent, UK
ACUTE CARE
∼∼∼∼
ITU
Neurosurgery
Orthopaedics
Acute brain injury
Hospital
NEUROLOGICAL
REHABILITATION
INPATIENT UNIT
TERTIARY
UNIT
(e.g. neuro-
behavioural
unit)
REHABILITATION MEDICINE
SPECIALIST
COMMUNITY
SERVICES
Supported dischargeHospital at home
Early community rehabilitation
Community reintegrationEnhanced participation
DEA – supported return to work
Integrated care planningLong term support
Single point of contact
Join health and social service planning
Multi-agency care
Multi-disciplinary
multi-agency
Brain Injury Team
Neuropsychiatric
service
more
complex
needs
less
complex
needs
highly
complex
needs
DGH
wardA&E
Community
Collin C, Ward A B. ‘Rehabilitation Medicine 2011 & Beyond’.
RCP London. 2010
Acute spinal cord injury
Hospital
DGH
ward
REHABILITATION MEDICINE
∼∼∼∼
SUPRA-REGIONAL
SPINAL INJURY CENTRE
REHABILITATION
MEDICINE
SPECIALIST
COMMUNITY
SERVICES
Integrated care planningLong term support
Single point of contact
Join health and social service planning
Multi-agency care
Community reintegrationEnhanced participation
DEA – supported return to work
SPINAL INJURY CENTRE
specialist outpatient
follow-up
REHABILITATION
MEDICINE
INPATIENT SERVICE
∼∼∼∼
Neurological
rehabilitation unit
ACUTE CARE
∼∼∼∼
ITU
Neurosurgery Orthopaedics
A&E
Community
Supported dischargeHospital at home
Early community rehabilitation
Collin C, Ward A B. ‘Rehabilitation Medicine 2011 & Beyond’.
RCP London. 2010
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 care1
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 rehabilitation1
• Prompt response on ill effects of immobility & complications1, 2
• Educating ‘acute staff’ of areas where rehabilitation is of major benefit3
• Money spent on rehabilitation recovered with 5-9 fold savings4
• Rehabilitation in all phases of health condition effective & ?cost-effective4
• Community based programmes effective4
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 SocietyAfter 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.
Complexity
of caseloadPatients requiring rehabilitation
Level 1a: Tertiary services
High physical dependency
UKROC Data reporting requirements
Minimum dataset
Commissioning Currency
Level 2b: Local specialist
rehabilitation services
Level 3a: Other specialist
services (e.g. stroke rehab)
NON-SPECIALISED
Level 1
Multi-level weighted tariff 5 tier
SPECIALISED
Level 2a: Extended catchment -
Mixed caseload
Level 1b: Tertiary servicesPhysical / cognitive/behavioural
Level 2a
Multi-level weighted tariff 5 tier
Level 2b
3 or 5-tier tariff
Full Dataset
Full Dataset
Level 3b: Generic
rehabilitation services
None
NON-SPECIALIST
Data Definition BSRM 2010
Standard per diem HRG
rates (reference costs)
Costings ExampleModel base rate notional bed day cost £400
*Banding factor based on proportionate staff inputs for each complexity group derived from casemix analysis
Applied to the variable portion of the OBD costs
Bed day cost:
Base rate = £400
Variable
Portion
of cost
75 %
(= £300
in this example)
Banded
by RCS scores
Non-variable
portion of cost
25 %
(= £100
in this example)
Non -Banded
V. heavy (13-15)
Heavy (10-12)
Medium (7-9)
Low (4-6)
V low (0-3)
Complexity
group
1.9
1.5
1.0
0.75
0.5
Banding
Factor*
+
Banded
cost
=
£670
£520
£400
£325
£250
Costing
multiplier
2.062
1.600
1.231
1.000
0.769
x
5 bands of complexity
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-RCT-based literature) and potential for cost-benefits, recommend:
• Early intensive rehabilitation, starting as soon as possible after onset1-4
• Specialist programmes for all those with complex needs 5, 6
• Specialist vocational programmes for those with potential to return to work6,7
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. 58thWorld 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? 1st 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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