the economics of stroke care in ontario -...
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The Economics of Stroke Care In
Ontario
Matthew Meyer
Research Coordinator – OSN & Lawson Health Research Institute
PhD Candidate – Schulich School of Medicine and Dentistry, Western University
2012 Vanier Canada Graduate Scholar – Canadian Institutes of Health Research
Ontario’s Stroke System –
What to Expect
For the average patient w stroke:
Acute LOS = 12.1 days
• 4 days ALC
Rehab LOS = 31.7 days
• 2 days ALC
• 8 weekend days
CCAC (if at all) = 3.9 rehab visits
• 20.5 days waiting
Total = 68 days (50% waiting)
Overview
1. Provincial Economic Evaluation
• Where are the opportunities?
2. Practical Implementation
• How can efficiencies be achieved?
3. Future Evaluation
• Adding regional context
The Impact of Moving to Stroke Rehabilitation Best Practices in
Ontario
http://ontariostrokenetwork.ca/pdf/The_impact_of_moving_to_stroke_rehabilitation_best_practices_in_Ontario_OSN
_Final_Report_Sept_14_2012.pdf
Objectives
Report on the potential economic impact of stroke rehabilitation recommendations made by the Rehabilitation and CCC Expert Panel
To identify areas where further evaluation and validation of assumptions is necessary
The Rehabilitation and Complex Continuing Care (RCCCEP) Expert Panel
• Formed in December 2010 as a component of the ER/ALC expert panel
• Phase I focused on how to best reduce ALC length of stay in Ontario’s healthcare system via better utilization of current resources
• Orthopedics and stroke were identified as priority populations
• The Ontario Stroke Network established a Stroke Reference Group to identify and recommend stroke rehabilitation best practices to the RCCCEP
• In June 2011, the panel released its phase I report outlining best-practice recommendations
Best Practice Recommendations
The following recommendations were selected for evaluation:
I. Timely transfer of appropriate patients from acute facilities to rehabilitation
• Ischemic strokes to rehabilitation by day 5
• Hemorrhagic strokes to rehabilitation by day 7
II. Provision of greater intensity therapy in inpatient rehabilitation
• 3 hours of therapy per day
• 7-day a week therapy
Best Practice
Recommendations..cont’d
III. Timely access to outpatient/community-based rehabilitation for appropriate patients
I. Early Supported Discharge with engagement of CCAC
II. Mechanisms to support and sustain funding for outpatient and/or community based rehabilitation
III. 2-3 outpatient or CCAC visits/ week for 8-12 weeks
IV. Ambulatory rehabilitation provided as necessary
IV. Ensuring that all rehabilitation candidates have equitable access to the rehabilitation they need
Ontario’s Stroke System –
Major Pathways
Stroke/ ER Acute
Admission
LTC
CCC
LTC
Comm. rehab Home
Outpatient rehab
Home
Inpatient rehab
Outpatient rehab
Home
Comm. rehab Home
Home
LTC
Outpatient rehab
Home
Comm. rehab Home
Home
Acute Care Recommendations
• Mean acute LOS for ischemic stroke and TIA = 5 days
• Mean acute LOS for hemorrhagic stroke = 7 days
• Elimination of all acute ALC bed days among these patients
Per Diem Acute Care Cost
Per diem acute LOS cost estimates in Ontario in FY 2010 are as follows 1*:
Ischemic stroke (ICD-10 codes I63,I64**) - $591.52
TIA (ICD-10 code G45.9) - $656.58
Hemorrhagic (ICD-10 codes I61,I62)- $576.64
*Excludes direct medical and laboratory costs
**I64 (unspecified stroke) - included as ischemic since mean per diem acute costs were closest to ischemic values.
Potential Acute Care Cost Impact
Potential for Impact:
~22,000 acute ALC bed days annually
~23,000 additional acute bed days
~$26M acute healthcare dollars
Inpatient Rehabilitation Recommendations
Recommendation:
II. Provision of greater intensity therapy in inpatient rehabilitation I. 3 hours of therapy per day
II. 7-day a week therapy
Assumptions:
• A staff:bed ratio of 1:6 for PT and OT will be needed to achieve 3 hours of therapy/day
• A ratio of 1:12 for SLP is sufficient given that not all patients require SLP services
Inpatient Rehabilitation
Assumptions*:
• Admitting patients to inpatient rehabilitation earlier will result in greater acuity during rehabilitation and may require longer rehab LOS than currently seen
However:
• Greater therapy intensity will improve the rate of functional recovery
• Weekend therapy will further improve the rate of functional recovery
• Improved access to outpatient and community rehabilitation will facilitate earlier transitions to the community
Inpatient Rehabilitation
• Inpatient rehabilitation estimates were calculated
separately by Rehabilitation Patient Group (RPG)2*
Motor = motor FIM score (-tub/shower transfer), Cognitive = cognitive FIM score
Inpatient Rehabilitation
Estimating the impact of improved efficiency: Greater Acuity: patients will be assumed to require the LOS of the next most severe group in rehabilitation (LOS estimates for group 1100 were calculated independently)
Greater intensity/weekend therapy: it will be assumed that the combination of 3-hr/day therapy 7-days a week will reduce overall rehabilitation LOS by 1 day for every week in rehabilitation (ie. a 14% reduction in overall LOS)
Outpatient/community rehab: it will be assumed that no patient will stay in inpatient rehabilitation with a FIM score greater than 100 and patients in RPG 1160 would receive their rehabilitation in the community
Inpatient Rehabilitation Cost Impact-Improved Efficiency
Cost/day for inpatient rehabilitation:
2008 rehabilitation per diem cost adjusted to 2011 values = $603/day
Inpatient Rehabilitation LOS Changes
RPG N
(2010/11)*
2010/11
LOS
(days)
Estimated
Bed Days
Consumed
with
FIM®>100
(2010/11)
Revised
LOS
Target
(no FIM®
>100)
(days)
Acuity-
Adjusted
LOS
Target
(days)
Best-
Practice
Expected
LOS
(days)
1160 229 15.0 3441 0 0 0
1150 441 21.3 6015 7.7 9.0 7.7
1140 358 23.8 5287 9.0 16.8 14.4
1130 568 29.4 7155 16.8 29.4 25.2
1120 782 34.9 4280 29.4 41.8 35.8
1110 689 43.4 1130 41.8 48.8 41.8
1100 354 52.7 1367 48.8 57.1 48.9
Inpatient Rehabilitation
Total Potential Impact:
• 16,927 rehabilitation bed days annually
~$10M healthcare dollars
Inpatient Rehabilitation
Recommendation:
• Patients currently admitted to CCC for “slow-stream” rehabilitation should instead be transferred to a higher-intensity inpatient rehabilitation bed
Inpatient Rehabilitation
N N
Discharged
Home
Mean
LOS in
CCC
(days)
Expected LOS
in Inpatient
Rehabilitation
(days)
Expected
Reduction
in LOS
(days)
1227 355 84.4 50.7 11,964
Inpatient Rehabilitation Cost Impact-Improved Efficiency - CCC
Total Potential Impact:
• ~30,000 CCC bed days
• ~18,000 additional inpatient rehabilitation bed days needed
~$6M healthcare dollars
Inpatient Rehabilitation
3-hours of therapy/day - calculating therapist shortage:
• Results from a 2009 survey of Ontario inpatient rehabilitation units for PT,OT, and SLP staffing was assumed to represent current staffing levels
• Rehabilitation facilities were assumed to operate at 100% occupancy
• The current staff:bed ratio was then compared to the proposed staffing ratios noted previously (1:6 PT/OT, 1:12 SLP) to estimate current staff shortages
Inpatient Rehabilitation
Weekend Therapy Staff Calculation:
• Assume full staff complement required on weekends (PT, OT, SLP, assistants)
• Calculate full best-practice weekday staffing complement (PT,OT,SLP/assistants) for stroke patients
• Multiply best-practice weekday staffing compliment by 28.5% (2/7) to estimate staffing needed on weekends
• Multiply weekend staffing estimate by mean annual salary (+ $1.55/hour premium for weekend and 25% benefits)
Inpatient Rehabilitation
Vacation and Sick-time Coverage:
• Assume 6 weeks vacation/sick-time per staff (PT, OT, SLP, assistants)
• Calculate full best-practice weekday/weekend staffing complement (PT,OT,SLP/assistants) for stroke patients
• Multiply best-practice weekday staffing compliment by 11.5% (6/52) to estimate staffing needed
Inpatient Rehabilitation
Discipline Additional Therapy Needs (FTE)
Estimated Cost
per FTE
Estimated Annual
Cost
Physiotherapy Weekday 11.1 $104,057 $1,155,033
Weekend 15.6 $107,835 $1,682,226
Occupational
Therapy
Weekday 18 $104,057 $1,873,026
Weekend 15.6 $107,835 $1,682,226
Speech
Language
Pathology
Weekday 14 $110,004 $1,540,056
Weekend 7.8
$113,782 $887,500
PT Assistant Weekday 5.5 $52,080 $286,440
Weekend 7.8 $55,858 $435,692
OT Assistant Weekday 8.9 $52,080 $463,512
Weekend 7.8 $55,858 $435,692
CDA Weekday 6.9 $53,688 $370,447
Weekend 3.9 $57,466 $224,117
Total $11,035,967
Inpatient Rehabilitation Cost Impact
Total Potential for Impact on Inpatient Rehabilitation Sector:
~30,000 CCC bed days (82 beds) eliminated annually
~1071 additional inpatient rehabilitation bed days required (2.9 beds)
A net savings of ~$5M annually
The Impact of Rehabilitation
on CCC and LTC
admissions, mortality and
costs 2-years post stroke
Methods:
• 2004/05 and 2008/09 OSA and NRS data used to
identify Rehab and Non-rehab patients
• Patients assigned a propensity score
• Patients matched 1-to-1 based on propensity
score and modified Rankin Score
• Death, CCC & LTC admissions, and costs tracked
up to 2 years post stroke
The Impact of Rehabilitation
on CCC and LTC
admissions, mortality and
costs 2-years post stroke
Summary – Rehab vs. No-Rehab
Mild stroke - CCC, LTC/Mortality, Cost
Mod. Stroke - CCC/LTC, Mortality, Cost
Sev. Stroke - CCC/LTC/Mortality, Cost*
Outpatient/ Community Rehabilitation
Recommendation:
III. Timely access to outpatient/community-based rehabilitation for appropriate patients
I. Early Supported Discharge (ESD) with engagement of CCAC
II. Mechanisms to support and sustain funding for outpatient and/or community based rehabilitation
III. 2-3 outpatient or CCAC visits/ week for 8-12 weeks
IV. Ambulatory rehabilitation provided as necessary
Outpatient/ Community Rehabilitation
Assumptions: • Based on the best available Canadian data, it was assumed
that 13% of patients discharged home from an acute hospital require OP/CCAC rehabilitation3,4
• 100% of patients discharged home from inpatient rehabilitation were assumed to require OP/CCAC rehab
• Due to a lack of data, it was assumed that 50% of patients currently discharged from inpatient rehabilitation receive adequate OP rehabilitation
• Many CCAC’s report only having sufficient resources to address safety issues and education, therefore, CCAC rehabilitation resources will not be considered sufficient to qualify as an Early Supported Discharge program
Outpatient/ Community Rehabilitation
Program Services Included Total cost
estimate
Outpatient rehabilitation
without SLP
PT & OT - 2.5 visits
each/week x 10 weeks $4716.50
Outpatient rehabilitation
with SLP
PT, OT & SLP - 2.5 visits
each/week x 10 weeks $7161.50
Community rehabilitation
without SLP
PT & OT - 2.5 visits
each/week x 10 weeks $6427.75
Community rehabilitation
with SLP
PT, OT & SLP - 2.5 visits
each/week x 10 weeks $9955.75 =~17 days
Outpatient/ Community Rehabilitation
What patients are appropriate for outpatient vs.
community rehabilitation?
Patient
Pop’n
(2010)
Total
Number
30 min from
OP
>30 min from
OP
Acute
Discharges 13,515 88% 12%
Outpatient/ Community Rehabilitation
Estimated Impact on Outpatient/ Community
Rehabilitation Sector:
• 751 outpatients (PT & OT only) x $4716.50 per patient = $3,542,092
• 751 outpatients (PT, OT, and SLP) x $7161.50 per patient = $5,378,287
• 102 community rehab patients (PT & OT only) x $6427.75 = $655,631
• 102 community rehab patients (PT, OT, and SLP) x $9955.75 = $1,015,487
=
$11M annual increase in spending
Moving to Stroke Rehabilitation Best Practices in Ontario: Preliminary Report
Acute Sector
• ~45,000 acute bed days eliminated
• ~$26 M made available
Inpatient Rehab
• ~1100 additional rehab bed days needed
• ~30,000 CCC bed days eliminated
• ~$5 M saved through greater efficiency
Outpatient/CCAC Rehab
• ~1700 additional patients need services annually
• ~$11 M in additional annual costs required
Preliminary Best-Practice Model Summary
Based on 100% attainment of the best-practice model for stroke rehabilitation in Ontario, the potential annual budgetary impact is:
$20 M
Overview
1. Provincial Economic Evaluation
• Where are the opportunities?
2. Practical Implementation
• How can efficiencies be achieved?
3. Future Evaluation
• Adding regional context
Practical Implementation
Strategies for Achieving Efficiencies:
Better Processes of Care
Timely Access to Care
Appropriate Intensity of Care
Stroke Expertise
Practical Implementation
Stroke Expertise – What is it?
Years of Experience?
Specialized Training?
Regular Patient Contact?
Foley, Meyer et al. (in press)5 – 80% of time in
stroke care
Practical Implementation
Stroke Expertise – The Role of Volume (literature)
Saposnik et al. (2007)6
Practical Implementation
Stroke Expertise – The Role of Volume (literature)
Hall et al. (2012)7
Compared Volumes and Mortality Based On:
Small = 15-120 annually
Medium = 132-190
High = 201-456
Small vs. High – Significant difference
Medium vs. High – No Difference
Practical Implementation
Stroke Expertise – The Role of Volume (practical)
Acute Stroke Units
N 100 150 200 250
Acute Beds 3.0 4.6 6.1 7.6
RN 2.8 4.3 5.7 7.1
RPN 1.4 2.1 2.8 3.6
PT 0.5 0.8 1.0 1.0
OT 0.5 0.8 1.0 1.0
SLP 0.3 0.4 0.5 0.6
PT/OT Assistants 0.0 0.0 0.0 0.3
CDA 0.0 0.0 0.0 0.0
SW 0.2 0.2 0.3 0.4
Dietician 0.2 0.4 0.5 0.6
Medical Staff 0.6 0.9 1.2 1.5
Practical Implementation
Stroke Expertise – The Role of Volume (practical)
Acute & Rehab Stroke Units
N 150 Acute only 150 Acute & Rehab
Acute Beds 4.6 4.6
Rehab Beds 0 5.5
RN 4.3 9.4
RPN 2.1 2.1
PT 0.8 1.1
OT 0.8 1.1
SLP 0.4 0.6
PT/OT Assistants 0.0 1.1
CDA 0.0 0.3
SW 0.2 0.2
Dietician 0.4 0.8
Medical Staff 0.9 2.0
Overview
1. Provincial Economic Evaluation
• Where are the opportunities?
2. Practical Implementation
• How can efficiencies be achieved?
3. Future Evaluation
• Adding regional context
Regional Evaluation
LHIN-level evaluations are under way that will include:
- Assessment of EMS utilization
- ED/ALC opportunities
- Local summary of acute and rehab (inpatient and
outpatient) flow
Regional Evaluation
Objectives:
1. Better understand local opportunities for
improved patient care and efficiency
2. Generate/facilitate regional discussion around
improved patient flow
3. Help facilities prepare for funding reform and to
develop strategies accordingly
Summary
Challenges Exist, but So Do Opportunities
Efficiencies Can Be Achieved Via Better
Care
Patients and Providers BOTH Stand to
Benefit
References
1. Ontario Case Costing Innitiative: Costing Analysis Tool. http://www occp
com/mainPage htm 2011.
2. Sutherland JM, Walker J. Challenges of rehabilitation case mix measurement in
Ontario hospitals. Health Policy 2008; 85:336-48.
3. Willems D. et al. Determining the need for rehabilitation services post stroke: Phase 1
report on the interrater reliability project. 2008
4. Mayo NE, Wood-Dauphinee S, Cote R, Gayton D, Carlton J, Buttery J, et al. There's
no place like home : an evaluation of early supported discharge for stroke. Stroke 2000
May;31(5):1016-23.
5. Foley N, Meyer M, Salter S, Bayley M, Hall R, Liu Y, Willems D, McClure A, Teasell R.
Inpatient stroke rehabilitation in Ontario: Are dedicated units better? International
Journal of Stroke 2012 Feb 15 [Epub ahead of print]
6. Saposnik G, Baibergenova A, O'Donnell M, Hill MD, Kapral MK, Hachinski V. Hospital
volume and stroke outcome: does it matter? Neurology 2007 September
11;69(11):1142-51.
7. Hall R, Fang J, Hodwitz K, Bayley M. Does the volume of stroke/TIA admissions relate
to clinical outcomes in the Ontario Stroke System? Abstract. 2012 International Stroke
Conference. New Orleans, LA
Acknowledgements/ Thanks
Thank you
The Impact of Rehabilitation
on CCC and LTC
admissions, mortality and
costs 2-years post stroke
Variable Rehab No-Rehab (p-value)
N=116 N=116
CCC Admission 10 (8.6%) <5* 0.005
LTC Admission 7 (6.0%) <5* 0.35
Death 14 (12.1%) 10 (8.6%) 0.39
Total Cost $51,821 $18,765 $33,056 <0.001
Cost/Survival Day $104 $41 $63 <0.0001
mRS 0-2
The Impact of Rehabilitation
on CCC and LTC
admissions, mortality and
costs 2-years post stroke
mRS 3
Variable Rehab No-Rehab (p-value)
N=263 N=263
CCC Admission 21 (8.0%) 17 (6.5%) 0.5
LTC Admission 29 (11.0%) 32 (12.2%) 0.68
Death 30 (11.4%) 61 (23.2%) <0.001
Total Cost $53,256 $30,862 $22,394 <0.001
Cost/Survival Day $103 $98 $5 <0.0001
The Impact of Rehabilitation
on CCC and LTC
admissions, mortality and
costs 2-years post stroke
mRS 4-5
Variable Rehab No-Rehab (p-value)
N=203 N=203
CCC Admission 35 (17.2%) 55 (27.1%) 0.02
LTC Admission 28 (13.8%) 49 (24.1%) 0.01
Death 44 (21.7%) 67 (33.0%) 0.01
Total Cost $68,514 $75,121 -$6607 0.24
Cost/Survival Day $179 $208 -$29 0.07
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