1

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

Thank You