the economics of stroke care in ontario -...

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