psychological care after stroke: economic modelling of a clinical psychology led team approach

Stroke

NHSNHS Improvement

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Psychological care after stroke:Economic modelling of a clinicalpsychology led team approach

Authors

Sarah Gillham - National Improvement Lead,NHS Improvement - Stroke

Michael Carpenter - Associate, NHSImprovement - Stroke

Dr Michael Leathley - Research FellowClinical Practice Research Unit, University ofCentral Lancashire

Acknowledgements

Grateful thanks to all who contributed to the discussions about the assumptions andevidence on which the model is based, andto those who reviewed and commented onthe finished paper.

The Stroke Improvement Programmepsychological care after stroke consensusgroup

Dr Jane Barton, Consultant ClinicalPsychologist, Michael Carlisle Centre, NetherEdge Hospital, Sheffield

Dr Roger Beech, Reader in Health ServicesResearch / Director, Keele University Hub,West Midlands NIHR Research Design Service

Dr Noelle Blake, Head of Neuropsychology,Croydon Health Services NHS Trust

Dr Bridget Carew, Clinical Psychologist, RoyalFree Hospital

Dr Helen Hosker, Central Manchester ClinicalCommissioning Group, Lead for Urgent Care,Clinical Commissioning Lead for Stroke andFalls, NHS Manchester

Professor Allan House, Director, LeedsInstitute of Health Sciences

Dr Peter Knapp, Senior Lecturer, Departmentof Health Sciences and the Hull York MedicalSchool, University of York

Dr Ian Kneebone, Consultant ClinicalPsychologist and Visiting Reader, Universityof Surrey, Haslemere and District CommunityHospital and Associate, NHS Improvement -Stroke

Professor Nadina Lincoln, Professor ofClinical Psychology, University ofNottingham

Jill Lockhart, National Improvement Lead,NHS Improvement - Stroke

Dr Jessica Read, Clinical Psychologist,Lancashire Care NHS Foundation Trust

Professor Tom Robinson, Stroke Consultant,University Hospitals of Leicester NHS Trustand Clinical Lead for SIP

Dr Becky Simm, Principal ClinicalPsychologist, Southport and Ormskirk NHSHospital Trust

Dr Kate Swinburn, Research and PolicyManager, Connect - the communicationdisability network

Endorsements

Summary

Introduction

The pathway for psychological care after stroke

Modelling the impact of a service for psychological care after stroke

Summary of results

Discussion

References

Appendix 1

Contents

Psychological care after stroke: Economic modelling of a clinical psychology led team approach

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Endorsements

The physical effects of stroke are plain for all to see and much has been done, andcontinues to be done, to improve services tomeet these physical needs. The less easily seenpsychological and social consequences, areequally or even more important to people withstroke and their families and carers, but are moreeasily overlooked. The significant benefits ofmeeting these less tangible needs are almostimpossible to quantify.

As many as forty per cent of people experienceeach of cognitive loss, behavioural problems anddisorder of mood, with as many as thirty per centof people experiencing a severe depressive illnessafter stroke. Comprehensively and systematicallymeeting these needs will bring benefits not onlyto people with stroke and their carers, but willalso improve productivity and financialsustainability of services. We thus need tocontinue to use all opportunities to developservices.

The case for psychological interventions afterstroke is already well made but the healtheconomic case – until this publication – has notbeen clear. Whilst the focus of this report is onthe economic impact of psychological care, it isthe individual and their family who are at theheart of the services that will flow from it, andwho may have a very real need for emotional andpsychological support to manage their stroke andits consequences.

Dr Damian JenkinsonNational Clinical Director Stroke (interim)


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This document provides information that isvital to the improvement of psychologicaloutcomes after stroke. There are strongarguments to support the provision ofpsychological services to improve functionalindependence, mood, coping and quality of lifeafter stroke from a clinical perspective. However,the provision of such services in practice has beenhampered by the lack of information on the costsand savings for the NHS. Despite the lack ofrandomised trials determining the cost-effectiveness of psychological interventions afterstroke, having the information in this documentwill enable a far stronger case to be made for theresources needed to deliver a quality service tostroke patients and their carers.

Professor Nadina LincolnProfessor of Clinical Psychology, University ofNottingham

The psychological impacts of stroke havebeen well defined, but to date little workhas been available to identify the fiscalconsequences of these sequelae. For the firsttime, the authors of this paper have attemptedto garner all the relevant evidence to make thefinancial case for early and comprehensiveintervention. We know stroke survivors want andare deserving of psychological treatments, nowwe can lobby the fund holders where they live,with evidence of the potential cost savings of service provision. Hooray!

Dr Ian KneeboneConsultant Clinical Psychologist, SurreyCommunity Health and Visiting Reader, University of Surrey


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Summary

This paper models the costs and potential cost savings of delivering apsychological support service for people with problems affecting their mood afterstroke. A stroke service where psychological care is led by a clinical psychologistusing a stepped approach has the potential to reduce the cost burden of stroke,with savings to the NHS and adult social care recovered in around two years. Thismodelling indicates that an investment of around £69,000 in psychological carethrough a clinical psychologist-led service, with clinical psychology assistantsupport and an appropriately trained multidisciplinary team, may deliver a benefitof around £108,300 to the NHS and social care in around two years.

The outcomes of such a service for patients should also be positive and beyondthose expected in terms of the criteria set by the National Institute for Health andClinical Excellence (NICE) – yielding a five-fold benefit measured in terms of‘Quality Adjusted Life Years’.

To deliver these benefits the stroke service needs to operate within the NationalStroke Strategy recommendations and evidence-based national guidance: thatpatients are routinely screened for mood several times after their stroke; thatacute and community and social care services are well integrated, with access tosix week and six month reviews; and a stepped approach to psychological care isused.

The model used is essentially designed for the purposes of estimating theeconomic benefits of psychological care. The service described is of necessity asimplified one, and whilst it is based on best available evidence and consensus, itis not intended as a prescription for how psychological care should be deliveredor as a service specification. The model is intended as a way to estimate thepossible economic benefits of a service constructed in this way, and as a localdecision making tool for services to calculate the potential economic implicationsof their psychological care provision. Where no clinical psychologist-led servicecurrently exists, there is the potential to realise the full economic benefits of themodel. Where a service currently exists, the model would have to be adapted toreflect that service, and this will have an impact on both costs and benefits.

The model and help notes can be found at www.improvement.nhs.uk/strokeon the psychological care pages.


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Introduction

Services to manage physical health needs after stroke have been steadilyimproving since the publication of the National Stroke Strategy in 2007 [1]. Thisincrease in access to and availability of services has not been mirrored in theprovision of mental health services after stroke and there is still less than oneclinical psychologist for every 100 stroke unit beds [2]. A majority of long-termstroke survivors with emotional needs reported that they did not receiveadequate help to deal with them [3]. This is despite the fact that many peoplewho have had a stroke also experience a mental health problem. For example,around a third are affected by depression at some point post stroke [4], almost aquarter experience generalised anxiety disorder [5], with post-traumatic stressdisorder affecting between 10% and 30% of stroke patients [6] [7] [8]. A significantnumber of those affected by stroke, including family members, experienceproblems in adapting to life after stroke, and can be considered to have an‘adjustment disorder’ [9]. Abnormal mood after stroke has been shown to hamperrehabilitation [9] and there is a significant impact of other emotional disorders,such as anxiety [9], on recovery after stroke.

Despite this clearly identified and well known mental health need, access toemotional and psychological assessment and support is demonstrably limited.Half of the patients and carers questioned in the National Audit Office review ofstroke services [10] rated psychological care as poor or very poor. This strokesurvivor feedback was supported by the Care Quality Commission’s review ofpost hospital stroke care in 2011 [11]. The review found that the provision of evengeneric services to support people with depression and anxiety and otherpsychological issues after stroke was inadequate in terms of availability; mostPrimary Care Trusts (PCTs) were unable to provide comprehensive access topsychological care.

It is known that mental health problems can exacerbate other problemsassociated with long term health conditions: these include worse recovery fromthe stroke [12], lower quality of life and reduced ability to manage their physicalconditions effectively [13]. Patients with both physical and mental ill health showan increased use of health services for their physical problems, increasing thecosts associated with their care [13]. In the USA for example, people who have hada stroke and who also have mental health problems, have annual health carecosts 40% higher than those without a mental health problem [13].

A majority oflong-termstroke survivorswith emotionalneeds reportedthat they didnot receiveadequate helpto deal withthem


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In England, the King’s Fund and Centre for Mental Health [13] have estimated thatbetween £8 and £13 billion of NHS spending is attributable to health needs ofpeople with long-term conditions who also have a mental health problem.Integrating the management of psychological and mental health needs of peoplewith long-term conditions can reduce their use of hospital services, as well asbringing other significant health effects. The King’s Fund suggests that the costsof incorporating psychological or mental health management into rehabilitationprogrammes for people with long term conditions and a co-morbid mental healthproblem would more than likely be outweighed by the savings arising fromimproved physical health and decreased service use.

People with stroke should have access to support with mental health needs aspart of their stroke rehabilitation. Clinical psychologists as essential members ofthe stroke team [3] have unique specialist knowledge and skills. Clinicalpsychologists can identify and manage stroke related problems with memory,understanding and reasoning; help patients and families adjust to the impact ofthe stroke, and identify and manage problems with mood [9]. Evidence is availableto support the benefits to patients and families of access to clinical psychologyafter stroke [9]; however, there is little evidence of the economic impact ofpsychological care in a clinical psychologist-led stroke service.

This paper aims to marshal available data and professional consensus about thecosts and benefits of a psychologist-led service for stroke to inform a model that will quantify the impact of such a service. The paper describes the model used to calculate the economic impact of a clinical psychologist-led service for psychological care after stroke, and the results. A web-based spreadsheet forms part of the model and is available with help notes atwww.improvement.nhs.uk/stroke. The spreadsheet can be used interactively by adjusting the figures in the grey cells to reflect local circumstances and test out different assumptions to calculate the local economic benefit of a local service.

Clinicalpsychologists as essentialmembers of the stroke teamhave uniquespecialistknowledge andskills


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Stepped care manages patients usinga hierarchical approach offeringsimpler interventions first,progressing to more complexinterventions if required. Patients canaccess care according to their level ofneed at the time. Most strokepatients will require the simplestinterventions which can be providedby the stroke team (Level 1 [Step 1]);fewer patients will need additionalclinical psychology-supervised supportfrom the stroke team or clinicalpsychology assistant (Level 2 [Step2]); still fewer patients will requiremore complex care requiringspecialist clinical (neuro) psychologyor psychiatric intervention (Level 3[Step 3]).

The model used to calculate theeconomic impact of psychologicalcare after stroke follows the servicedesign described in the NHSImprovement – Stroke publication,‘Psychological care after stroke’ [15]. Inorder to deliver best practice, it isexpected that the service will haveaccess to a clinical psychologist orneuropsychologist and that they aresupported by a clinical assistant [9].

The stepped care model (Figure 1) isrecommended by NICE [14] and isendorsed in the recent IntercollegiateStroke Working Party (ICSWP)‘National Clinical Guideline forStroke’ (2012) [3].

“Stroke services shouldadopt a ‘stepped care’approach to deliveringpsychological care. Thestepped care model isintended to be dynamic; a patient might, forexample, progress straightfrom Step 1 to Step 3”

(ICSWP, 2012)

The pathway for psychologicalcare after stroke

Figure 1: Stepped care model for psychological interventions after stroke. Adapted from IAPT model with input from Professor Allan House and Dr Posy Knights

LEVEL 3: Severe and persistent disorders of mood and/or cognition thatare diagnosable and require specialised intervention, pharmacological

treatment and suicide risk assessment and have proved resistant totreatment at levels 1 and 2. These would require the intervention of

clinical psychology (with specialist expertise in stroke) orneuropsychology and/or psychiatry.

LEVEL 2: Mild/Moderate symptoms of impaired mood and/or cognition that interfere with rehabilitation. These may be

addressed by non psychology stroke specialist staff,supervised by clinical psychologists (with special expertise in

stroke) or neuropsychologists.

LEVEL 1: ‘Sub-threshold problems’ at a levelcommon to many or most people with stroke.

General difficulties coping and perceivedconsequences for the person’s lifestyle and

identity. Mild and transitory symptoms ofmood and/or cognitive disorders such as a

fatalistic attitude to the outcome ofstroke, and which have little impact on

engagement in rehabilitation.Support could be provided by

peers, and stroke specialist staff.

LEVEL 3

LEVEL 2

LEVEL 1


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Routine screening of psychological needThe route to psychological care afterstroke is through appropriateassessment. The term screening isused in this paper to describe a briefassessment using a validated tool inconjunction with clinical judgement todecide if a person needs to be furtherassessed, monitored, or to gain accessto psychological care. In the model,the multidisciplinary team areassumed to carry out routine moodscreens for all patients asrecommended in national clinicalguidance [3] [16]; the cost of screeningtime and staff training by the clinicalpsychologist to carry out screening isincluded in the model. MDT trainingand competencies should align withthe UK Stroke Forum Education andTraining standards (www.ukfst.org).Screening time points fit with therecommended guidance for generalreview of stroke patients [17] and areconsistent with the recommendationsin the report ‘Psychological care afterstroke’ [15]:

First screen is timed at about onemonth after stroke or just beforehospital discharge, if that is sooner.

Second screen is timed around thesix week post discharge review or atabout three months after stroke, atwhich point most people will havebeen discharged from hospital andthe assessment will be able to judgeboth persistence of early-onsetproblems and emergence of newproblems after discharge.

Third screen is timed at about sixmonths after stroke. At this stagemuch physical and social recovery hasstabilised and it is possible to get apicture of likely longer-term problems.Notwithstanding theserecommendations it is acknowledgedthat anxiety and depression can occurat any time after stroke and it followsscreening may be indicated at anytime in actual clinical practice. Withinthe model, the multidisciplinary stroketeam (MDT), mainly physiotherapists,occupational therapists, speech andlanguage therapists, and qualifiednurses, carry out routine screening ofpatients for problems with mood andcognition (the latter is not addressedwithin this paper because it is not thefocus of the model).

A range of validated mood (andcognition) screening tools areavailable and are described elsewhere [15] [17]. It should be notedthat, while such tools should guideaccess to psychological care, stroketeams should aim to adopt a holisticapproach to assessment ofpsychological need: they should drawon other sources of evidence such asconcerns expressed by familymembers, staff providing otherelements of care, or information fromGPs regarding pre-existing mentalhealth needs.

Level 1 psychological carePsychological care will be delivered atLevel 1 by the multidisciplinary stroketeam to any patient with problemsidentified at screening. For thepurposes of the model themultidisciplinary stroke team membersare considered to be at the top ofAgenda for Change (AfC) band 5. Thisfirst level of psychological care isanticipated to be carried out alongsidecurrent therapy or nursinginterventions. For the purposes of themodel the amount of time the patientreceives psychological care at Level 1is equivalent to six sessions of 20minutes. Training and supervisioncosts by a clinical psychologist forthese staff are included in the model.Level 1 psychological care comprisesactive listening, helping withadjustment, exploring and supportingthe impact of the stroke, informationgiving, goal setting and identifyingpsychological difficulties. Befriending and peer support andservices provided by the voluntarysector are effective ways to deliverLevel 1 support. These services havenot been included in the modelling.


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Level 2 psychological careLevel 2 care may be provided bystroke team staff (AfC band 5)additionally trained by the clinicalpsychologist, or by a clinicalpsychology assistant (CPA) (AfC band5) following assessment of thepatient by a clinical psychologist (seeFigure 2a). Level 2 psychological caremay comprise brief psychologicalinterventions, advice and information,help with adjustment, goal settingand problem solving, motivationalinterviewing or group work usingpsychosocial education or relaxationgroups.

Level 2 care may also be provided byImproving Access to PsychologicalTherapies (IAPT) services, which areoften based in primary care. Provisionof these services is not separatelycosted.

Level 3 psychological careA proportion of patients with morecomplex needs will require furtherpsychological support at Level 3.Level 3 psychological care is deliveredin this model by a clinical psychologist(mid AfC band 8a). Level 3 care willcomprise more detailed assessmentand use of a number of therapies, forexample cognitive behaviouraltherapy (CBT), solution-focusedtherapy, or motivational interviewing.

The time allocated for a patientrequiring this level of psychologicalcare is six sessions of 90 minutesincluding time to prepare and writeup the sessions.

Further referral to community mentalhealth services or psychiatry has notbeen included in the scope of thismodel.

Model assumptionsWhen designing the economicmodel, certain assumptions andsimplifications were made to reduceits complexity and account for lack ofavailable evidence (Table 1). All theassumptions and simplifications havebeen tested and developed throughdiscussion with clinical psychologistsand peer reviewed by a range ofhealth care professionals.

The model operates in the context ofthe National Stroke Strategy [1]

recommendations that key elementsof the stroke pathway are in place:

• Transfer of care processes fully involve the individual and their family, and consider physical, communicative, cognitive, psychological and financial circumstances;

Figure 2a: Structure of Level 2/3 support

Assessment byclinical psychologist

No further support

Level 2 support provided by MDT

Level 2 support provided by CPA

Level 3 support provided by CP

The MDT decide how level 2 carewill be provided depending on

screening outcomes and responseto level 1 psychological care


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A process is in place for review of psychological need at aboutone month or just prior to discharge if sooner, and at threeand six months post-stroke

Screening for mood and cognition is carried out alongsidecurrent assessments by existing staff

Level 1 psychological care is provided by the multidisciplinarystroke team

The amount of time of Level 1 psychological care is providedfor each patient is equivalent to six sessions of 20 minutes.

Level 2 psychological care is provided by additionally trainedstroke team staff or supervised clinical psychology assistantsfollowing clinical psychology assessment

The amount of time of Level 2 psychological care is providedfor each patient is equivalent to six sessions of 90 minutes

Level 3 psychological care is provided wholly by a clinicalpsychologist

The amount of time Level 3 psychological care is provided foreach patient is equivalent to six sessions of 90 minutes

National Stroke Strategy (2007) recommendations for generalassessment and review of stroke patients

ICSWP National Clinical Guideline for Stroke (2012)

Based on the stepped care model and recommended by NICEand in the ICSWP National Clinical Guideline for Stroke (2012)

Based on peer review

Based on the stepped care model and recommended by NICEand in the ICSWP National Clinical Guideline for Stroke (2012)


Based on the stepped care model recommended by NICE andin the ICSWP National Clinical Guideline for Stroke (2012)


ASSUMPTION JUSTIFICATION

Table 1: Summary of assumptions and justifications


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• There is a strong relationship between the stroke unit and community (including social care) teams, and agreements covering the quality and timeliness of information transfer and maximum waiting times for provision of community services;

• Reviews at six weeks and six months.

These elements provide theframework on which the economicmodel for psychological care is built.

This paper should still be of use inareas where these elements are notfully established but, for costs to beminimised and benefits fully realisedimplementation of psychological careshould be planned as part of widerimplementation of these elements ofthe strategy.

Pathway of careThe overall pathway for psychologicalcare and the assumptions madeabout the proportion of peopleassessed as needing psychologicalcare at each stage is shown in Figure2b. For example, it is assumed 33%

of people are assessed as needingLevel 1 care at/around transfer homeor one month, and of these 67% areassessed as needing furtherpsychological care at the secondscreen. Figure 2b also shows showthe proportions of people who havereceived services following the stagedscreens.

These figures are based on advicefrom the national project siteshighlighted in the NHS Improvement- Stroke report ‘Psychological careafter stroke’ [15], as well as furtherconsensus from peer review.

Figure 2b: The psychological care pathway

Level 1 support33%

No intervention67%

Level 1 support18%

No intervention82%

No intervention33%

Level 2&3 support No third screen for people whohave had level 1 &2/3 support67%

Level 2&3 support73%

No intervention27%

Level 2&3 support67%

No intervention33%

Level 1 support7%

No intervention93%

ALL PATIENTS

Screening 1(@2 weeks/1month)

Screening 2(@3months)

Screening 3(@6months)


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The need for Level 2 and 3psychological care is defined afterscreening or after a period of Level 1psychological care. Level 2 care isprovided by additionally trained MDTmembers or a supervised clinicalpsychology assistant.

Figure 3 shows that by the end of 12months 51% of people will have hadno psychological care, but will havebeen screened at one, three, and sixmonths; 11% will have had Level 1care and 38% will have receivedLevel 2 or 3 care. In the model, allpeople receiving Level 2/3 care willhave had Level 1 care previously.

Figure 3: Summaryof services receivedby the end of eachperiod

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

month 1 month 3 month 6 month 12

Level 3 (CP)

Level 2 (CPA)

Level 2 (MDT)

Level 1 supt only

% screened

0.0%

0.0%

0.0%

0.0%

100%

0.0%

0.0%

0.0%

33.3%

67%

4.4%

8.9%

8.9%

23.1%

66%

7.7%

15.3%

15.3%

10.8%

0%

In reality, this process will not be asneat as this model implies. Forexample, some lower level supportmay be triggered by concerns raisedby the person who has had a stroke,or their family; alternatively, somepeople may be referred directly forLevel 2/3 support. Hence the pathwayset out above should be seen as adescription of a psychology servicefor stroke, which can be used toinform the model’s parameters andnot as a service specification.

Similarly, the percentages of peopleassessed as needing services atdifferent stages will vary from theseassumptions. The accompanyingspreadsheet can be used to testdifferent assumptions and recalculatecosts and benefits, as described in theremaining chapters of this paper.


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Estimating demand forpsychological careThe size of the population chosen inthis paper is 250,000. This figure wasused because it is the size of thecatchment population in the StrokeInterface Audit (SIA) [18] on whichsome of the estimates in this paperare based. An assumed annual strokeincidence rate of 2/1000 makes themodel’s stroke populationapproximately 500 strokes per year(first-ever and recurring). The modelassumes that all of these patients are admitted to hospital.

The model does not includeassumptions about (or dis-economies)of scale and hence it isstraightforward to scale these resultsto different population sizes andincidence rates.

It is recognised that many peoplewith stroke will also have problemswith cognition [3], the management ofwhich by clinical psychology couldhave potential economic benefit.However, in order to keep this modelsimple, it has not included an analysisof the management of people withcognitive problems in the servicedescribed.

From this initial cohort of 500 strokepatients an estimation was made ofthe proportion who would be alive(and able to benefit from) thepsychology service at different stagesin the pathway (Figure 4). The main source for these estimatesis the SIA [18], which identifiedpatients admitted consecutively totwo hospitals in Liverpool fromJanuary to June 1996 and followedthem up in person at 3, 6 and 12months post stroke, and thenannually via postal questionnaire until5 years. Stroke care has developed

significantly since 1996 soadjustments to the data have beenmade to reflect this. Adjustments for30 day mortality, length of hospitalstay, readmission rate andproportions of people in residentialcare have been made in order tomake them more representative ofcurrent stroke care and outcomes.

Detail of the adjustments made canbe found in both Appendix 1 of thespreadsheet and Appendix 1 of thispaper.

Figure 4: Overview of stroke survivors atdifferent points post-stroke

500

450

400

350

300

250

200

150

100

5

00 months 6 months 12 months 18 months 24 months

Alive Alive benefitting from level 1+2/3 support

Alive benefittingfrom level 1 support


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The model combines the data onstatus and psychological care input,described in the Pathway of caresection above, to make the followingestimates of the demand forpsychological services within themodel’s population:

• A total of 834 screens will take place

• 182 people will be offered Level 1 support as part of their rehabilitation

• Of these 56 will receive this service alone, while 126 will also be offered additional psychological care (100 at Level 2 and 26 Level 3).

Estimating costsDirect NHS and adult social care costshave been used. The costs used toinform the model are summarised inTable 2. Basic salary costs were takenfrom Agenda for Change Pay Circular(24 March 2011) [19], pay bands from1 April 2010, and inflated to includeoncosts and overheads. MDT trainingcosts were taken from the SIP casestudies. The Unit Costs of Health [20]

were used to inform costs of:inpatient bed nights (for hospitalreadmissions); outpatient procedures;GP contacts; care home packagesand residential care. The inpatientbed nights were taken as non-elective, short stay. For GP costs an

average was taken from the cost ofconsultations: surgery; clinic; phone;home visits; prorated according tothe proportion of time spent by GPson those activities. A list ofantidepressant medications thatmight be used for stroke patients was identified from the literature [21] [22] [23] [24] and can be seenin the spreadsheet (Table 2.1,Appendix 2). The cost of eachmedication was calculated, based onsuggested dose [25] and pack price [26].These costs were then averaged toprovide an estimate of the averageone year cost of antidepressantmedication.

MDT staff member

Clinical Psychology Assistant

Clinical Psychologist

Training for MDT member

Inpatient bed night

Outpatient procedures

GP contact

Care home package

Residential care

Antidepressants

Annual salary with oncosts and overheadsAfC band 5 (point 23)

Annual salary with oncosts and overheadsAfC band 5 (point 23)

Annual salary with oncosts and overheadsAfC band 8a (point 36)

Per person

Per night

Average per procedure

Average of surgery, clinic, telephone, and home visits

Per week

Per week

One year cost

COST ITEM LEVEL DESCRIPTOR

Table 2: Cost of resources used in the model

£39,821

£39,821

£62,961

£192

£549

£147

£39

£304

£983

£52

COST

Pay Circular AfC-2-2011 (Annex B)



Data from SIP case studies [15]

PSSRU [20]

PSSRU [20]

PSSRU [20]

PSSRU [20]

PSSRU [20]

Table 2.1, Appendix 2 (spreadsheet)

REFERENCE


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Combining demands and costsBased on the figures reported aboveand the other assumptions on thecost of services the provision ofpsychological care for this populationcan be costed (Table 3). The table alsoshows the average weekly workload,to give a more practical description ofthe size of the service. Theaccompanying spreadsheet enablesindividual adjustment of any of theseassumptions (including populationsize, stroke incidence and people’slocation at different stages of thepathway) and recalculates this totalcost.

Screening & Level 1 supportby MDT members

Training for MDT members

Clinical Psychology Assistant

Clinical Psychologist

Total

£23,201

£1,471

£16,438

£27,952

£68,969

SERVICE COST

Table 3: Costs of service delivery in thispathway for the chosen population

16 screens21 Level 1 sessions6 Level 2 sessions

6 Level 2 sessions (.41 FTE)

1.5 assessments (after Level 1support)2.9 Level 3 support sessions3 hours supervision (0.44 FTE)

AVERAGE INPUT PER WEEK


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Impact on the NHSSignificant investment has been madein recent years in community-basedmental health services as part of theImproving Access to PsychologicalTherapies (IAPT) programme. Anumber of studies about the impactof emotional and psychologicalsupport on health service activitywere reviewed. There are little dataon the impact of psychologicalservices on resource use that are bothspecific to stroke and UK-based. Twostudies from the USA have shownthat depression following strokeresulted in an increase in the lengthof stay for subsequent hospitaladmissions, and more outpatientprocedures [23] [27]. Because of thepopulation under study and thedifferent health care system, it isdifficult to quantify these impacts in aUK population. However, suchimpacts are consistent with a UK-based review, although not stroke-specific, which has quantified thebenefits of reducing depression onresources such as GP consultations,nights spent in hospital, and numbersof outpatient procedures [28].

Recovery from a common mentalhealth problem was estimated to leadto average annual reductions inhealthcare usage per person asfollows:

• 1.59 GP consultations;• 0.73 inpatient bed nights.• 0.36 outpatient procedures.

In addition, an assumption wasmade, based on peer review and theSIP national projects, that theapproach described in the modelwould lead to less frequent use ofantidepressant medication.Anecdotally it appears that anti-depressants may be regularly used asa first line approach in services wherethere is considered to be an absenceof alternatives.

In order to combine the figures withthose of the psychological careservice provided by this model it isnecessary to:

1. Calculate the total time for which each person benefits from the Level 1 or Level 2/3 support, whichthey receive (Box 1)

2. Estimate what proportion of the savings (GP, inpatient bed night, outpatient procedures and medication) are realised by providing Level 1 and Level 2/3 support.

It is necessary to make estimates ofthe realisation of benefits because itis unrealistic to assume that thesebenefits will be fully realised. Forexample, people receiving just Level 1support are likely to have relativelymild mental health issues, so thisintervention will release a loweroverall saving. Even for peoplereceiving Level 2/3 support, therecovery rate will be less than 100%.

This section focuses on the impactsthat such a psychological service forpeople with stroke can have on boththe demand for other local healthand social care services and on theindividuals who receive them. Theseare considered over a period of twoyears.

Measuring these impacts is difficult,partly because of a lack of empiricaldata, particularly with respect tostroke-specific services. Additionaldifficulties arise because of thecomplex nature of emotional andpsychological issues and the difficultyin tracking the impact of specificelements of a multidisciplinaryservice.

This section aims to gather togetherthe limited available data on theseimpacts. Where possible it draws onstroke-specific information, but ingeneral it uses broader research onthe impact of support for people withlow/moderate mental health needs.Where such data are not available ituses assumptions which have beentested with clinical psychologists, andpeer reviewed by a range of healthcare professionals and analysts.

In the following three sections,impacts are described on individuals,in terms of: the NHS; adult social careservices; and quality-adjusted lifeyears (QALYs). Finally there is adiscussion about the areas whereemotional and psychological supportis likely to have an impact, but whichwere not included in the analysis.

Modelling the impact of a servicefor psychological care after stroke


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Box 1: Calculating the total time over which people who receive psychological support benefit

Benefits from the service are calculated by estimating how long each person benefits from each interventionthey receive.

For example, Figure 5 below shows the timescales over which a person who receives Level 1 support after thefirst screening and then Level 2/3 support after the third screening benefits from these services:

Hence this individual will benefit for 5 months from the Level 1 support, and then benefit for a further 16months from Level 2/3 support (in the 24 months following stroke).

The costing model can be used to total the “time for which each person benefits from psychological care”across the subset of the cohort of 500 who receive either Level 1 or Level 2/3 support. In total, based on theassumptions outlined in the previous section.

• The total benefit from Level 1 support is 1068 “person months”• The total benefit from Level 2/3 support is 2328 “person months”

The accompanying spreadsheet coststhe benefits of these servicesseparately for each of the two yearsfollowing stroke. In line with this, itassumes that the impact of serviceslessens over this time and includes afactor to discount benefits in yeartwo. As limited data are available onthe longer term impacts of theseservices this paper focuses on impactsup to 24 months after stroke. Inparticular:

• Level 1 support is assumed to deliver 60% of the estimated cost savings in the first year after stroke and 40% of these savings in the second year

• Level 2/3 support is assumed to deliver 80% of the estimated cost savings in the first year after stroke and 50% of these savings in the second year.

These data can then be combinedwith data from the previous section

on demand and cost to calculate theestimated savings for emotional andpsychological support across fourareas of health service spending (GP,inpatient bed night, outpatientprocedures and medication)discussed above (Table 4).

GP consultations

Inpatient bed nights

Outpatient procedures

Anti-depressants

Total

£2,453

£7,789

£5,927

£2,094

£18,263

From Level 1

Table 4: Savings to NHS from provision ofpsychological care over two years

£6,020

£19,118

£14,546

£5,140

£44,824

From Level 2 & 3

£8,473

£26,907

£20,473

£7,234

£63,087

TOTAL

Figure 5: Pathway of care for an individual receiving psychological support

Benefitting from level 2/3 support

10 2 3 4 5 6 7 8 9 10

Months

11 12 13 14 15 ... 22 23 24

Screen 1 Screen 2 Screen 3

Level 1 support Level 2&3 support

Benefitting from level 1 support


19

It has been estimated that around12.5% of people who have had astroke and survive to transfer homerequire some home care [30] services.

The assumptions about the impact ontake up of these services frompsychological support are:

• That people who have had Level 1 support need 5% less home care inyear 1 and 2.5% less in year 2 following stroke

• That people who have had Level 2/3 support need 10% less home care in year 1 and 5% less in year 2following stroke.

These assumptions can be combinedwith data on the average cost ofhome care packages to estimate thetotal savings of £31,151 (£17,918 inyear 1 and £13,233 in year 2).

There is also anecdotal evidence thatpsychological support has an impacton the likelihood of someone movinginto residential care [31]. Becauseadmission to a care home is generallya one-off event, rather than on-goingactivity, it cannot be modelled in thesavings discussed above. Instead wedeveloped a model based on theassumptions that psychologicalsupport could delay the need foradmission to residential care for asmall proportion (20%) of people –by four weeks for people who hadhad Level 1 support and 12 weeks forpeople who were provided with Level2/3 support.

These assumptions could then becombined with data on the averagecost of residential care and thenumber of admissions to residentialcare (taken from the SIA) to estimatethe total value of this saving at£14,060 over the first two years afterstroke. Potential savings from nursinghome care were not included in themodel.

Quality adjusted life years(QALYs)The main driver for commissioninghealth and social care services is toget the best possible outcomes forthe population at large. However,outcomes can be difficult to measure,making it difficult to compare servicesand hence inform commissioningdecisions. One tool that can help withthis process is ‘quality adjusted lifeyears’ (QALYs) [32]. The QALY is usedto quantify the benefits of a medicalintervention and takes into accountboth quality and quantity of lifegenerated by healthcare. The QALY isbased on the amount of years of lifethat would be added by theintervention. Each year in perfecthealth is assigned the value of 100%down to a value of 0% for death. Amonetary amount is used to estimatethe value of the extra life year. Theimpact of a particular intervention isquantified by estimating how much itimproved people’s quality of life onthis scale and then multiplying by thevalue of the “extra life year”.

Avoiding nights in hospital beds andGP consultations may not realisedirect cash savings as the bed andappointment will inevitably be filledby other patients. Thesecalculations demonstrate thesaving from reducing the cost ofthe burden of stroke on healthcare resources.

Impact on Adult Social CareServicesA similar analysis to that presentedabove is also possible for some costsrelated to Local Authority fundedadult social care. However, there is alack of quantitative research in thisarea and hence this part of theanalysis is exploratory. Where therewere no research-based data tosupport the model assumptions,these assumptions have instead beentested through peer review.

One such area is formal personal careprovided at the stroke survivor’s ownhome (assistance with activities suchas washing and dressing). Untreateddepression has a negative impact onfunction, independent of level ofphysical disability [12]. Psychologicalcare has been shown to be effectivefor depression-related disorders,anxiety and behavioural problems[29] and can improve people’s mood,confidence and ability to cope.


20

• Savings related to people returning to work, these are indirect costs, which have not been measured in this model. However 25% of people with stroke are of working age; calculation of the impact of psychological care on return to work could yield some potential economic benefits.

• Benefits to the carers of people with stroke who have psychologicalneeds: addressing a patient’s psychological need may reduce the carers utilisation of health and social care resources; carers may also have a greater opportunity to return to work.

This exercise has been carried out fortreatment for moderate depression oranxiety and the resulting value was£6,600 [28]. To calculate the totalQALY benefit of the stroke-specificpsychological care service anestimation was made of how muchof this total benefit is realised by eachintervention. The QALY benefitcalculated is £462,807. Theassumptions and results of the QALYcalculations are show in Table 5.

Other impactsThere are a number of additionalbenefits likely from these serviceswhich could not be included in theanalysis. These include:

• Benefits from the screening processalone for people who are not referred for Level 1 support (e.g. some people may be signposted after the initial screening for informal support via local stroke groups).

• Avoidance of ‘crisis management’ of people with stroke and psychological issues who feel unsupported or uninformed and who attend emergency departments or access community mental health crisis teams when unable to cope. This could be a significant benefit, but is difficult toquantify using current evidence.

Level 1 care

Level 2/3 care

TOTAL

25%

50%

Year 1

Table 5: Estimated proportions benefittingand QALY benefit for psychological care

12%

25%

Year 2

£102,535

£360,272

£462,807

Value of benefits% of maximum benefitsdelivered


21

This sensitivity analysis found that,psychological care produces anoverall cost saving after two years ifsocial care savings are included. Ifsocial care savings are not includedthen psychological care is (just about)cost neutral for the NHS in two yearsof the initial investment in all but the‘10% less effective’ scenario (Figure 6).

Sensitivity analysisThe model’s results were tested in asensitivity analysis with differentassumptions about the effectivenessand cost of psychological care (Table6). Due to a lack of empirical dataaround measures of effectiveness, apragmatic approach to the sensitivityanalysis was adopted. Therefore,assumptions were made that theinterventions were either 10% more,or 10% less effective; which resultedin concomitant impacts on the overallsavings generated i.e. 10% more or10% less. As more information aboutpsychological care after strokebecomes available it will be possibleto make more informed decisionsabout which variables to include in asensitivity analysis and the range oflevels that they can realistically take.This would allow a more robustsensitivity analysis of the model.

Summary of results

NHS

Social Care

TOTAL

QALY Benefits

Base case

£33,410

£29,101

£62,510

£266,764

1 Year

Table 6: Sensitivity analysis

10% lesseffective

£30,069

£26,191

£56,259

£240,087

10% moreeffective

£36,751

£32,011

£68,761

£293,440

Base case

£63,087

£45,211

£108,298

£462,807

Year 1 and 2

10% lesseffective

£56,778

£40,690

£97,468

£416,526

10% moreeffective

£69,396

£45,211

£114,607

£509,088

Estimated Savings

£62,075

£68,972

£75,869

10% less

Base case

10% more

Costs

{

Figure 6: NHS and adult social care savings in relation to cost

£140,000

£120,000

£100,000

£80,000

£60,000

£40,000

£20,000

£0Base case 10% less

effective10% moreeffective

Savings year 1

Base case 10% lesseffective

10% moreeffective

Savings year 1 & 2

Social care NHS Cost Cost -10% Cost +10%


22

Potential cost benefits to the healtheconomy were estimated as well assuggested quality of life benefits toindividuals in having their mentalhealth needs assessed regularly andmet by a stroke team who are awareof psychological issues and are ableto manage them appropriately. Themodelling indicates that aninvestment of £68,972 to deliver astroke-specific psychological careservice in the first year after stroke toa stroke population of 500 peoplemay be virtually realised by the NHSover a two year period with thebenefit being £63,087. If economicbenefits to both the NHS and adultsocial care are considered then amore significant benefit of £39,326may be realised in the second year.

In terms of outcomes, the totalbenefit of this service measured interms of quality adjusted life years aresignificant and well beyond thoseexpected in terms of the criteria setby NICE. The total QALY value forpeople receiving Level 1 and 2/3 careis £462,807.

Studies exploring the benefits ofpsychological services in otherconditions have aimed to estimatethe wider benefits to services andsociety and large substantialadditional amounts have beenidentified [33]. Six months ofcollaborative care of people with type2 diabetes and depression resulted inan additional 115 depression-freedays per individual.

There were substantial additionaltreatment costs in year one of morethan £4.5 million, however in yeartwo, £450,000 savings to health andsocial care were made due to lowercosts associated with depression andbenefits from reduced productivitylosses. A Hillingdon studydemonstrated savings of £837 perperson with depression and ChronicObstructive Pulmonary Disease(COPD) who attended thebreathlessness clinic in the six monthsafter treatment. This is around fourtimes the upfront cost. A Liverpoolstudy of 433 people with angina whoattended a cognitive behaviouralchronic disease managementprogramme demonstrated reductionsin healthcare usage of approximately£2,000 per person in the year aftertreatment, ‘well in excess of the costof psychological intervention.’

There is further work to be done todefine the economic impact ofpsychological care specifically forstroke. In particular there was littleavailable evidence to define theextent of crisis management ofpsychological need of this group bymental health services andemergency departments and primarycare. There is evidence to show thatfunctional recovery is impeded bydepression [12], but the economicimplications of this are not yet welldefined in terms of impact on lengthof hospital stay, continuedinvolvement with rehabilitationservices and additional supportneeds, although this evidence isavailable for other long termconditions.

This paper has modelled the costsand potential cost savings ofdelivering a psychological care servicefor people with problems affectingtheir mood after stroke. It hasestimated the potential cost savingsof a clinical psychologist-led servicethat funds clinical psychology andclinical psychology assistant posts tosupport the development of goodpsychological care after stroke.

The modelling has from necessitybeen based on a number ofassumptions about a service in orderto define the economic benefits.Where possible the assumptions havebeen based on best practice orevidence for psychological care afterstroke, or on evidence for peoplewith long term conditions. Where thishas not been possible clinical opinionhas underpinned the assumption. Thecontext of the service described isone led by a clinical psychologist whotrains and supports a multidisciplinaryteam to provide Level 1 and someLevel 2 psychological care and hasclinical psychology assistant support.The service is compliant with theNational Stroke Strategyrecommendations that patients arereviewed at six weeks and six monthsand that there is good integrationbetween acute and communityservices and social care.

Discussion


23

The assumption in this paper thatpsychotherapy is of benefit to strokepatients was not unreasonable. Thereis evidence from two Cochranereviews [35] [36] to suggest thatpsychotherapy can prevent thedevelopment of depression, thoughlittle evidence of the benefit ofpsychotherapy on treatingdepression; two trials not included inthis latter review have shown a smallbenefit of psychotherapy on treatingdepression [22] [24]. Of particularpromise however is the potential ofpatients to be assisted bypsychological treatments modified tosuit those with stroke [17]. Empiricalsupport has established strokepatients with low mood and aphasiabenefitted from behaviour therapymodified for their communicationdisability [37].

The assumption about the impact ofpsychotherapy on costs was not asstrong because it had to be drawnfrom either the stroke literature,which was not trial-based (e.g. [23]) orwas non-stroke data (e.g. [28]). Thismeans that the model is not as robustas would be ideal, but because themodel has been developed on mixedlevels of evidence, assumptions madeare conservative. Whilst this model isconsidered by the authors to be ofvalue, further research into thebenefit of psychotherapy after strokein a multi-centre trial isrecommended. Such trials will needto consider the type of psychotherapydelivered, the timing of the therapy(aligning it to current guidance) arange of outcome measures (mood,function and resources) and recordingof outcomes up to one year, if notlonger.

Provision of psychological care afterstroke in England has been shown tobe at best variable and at worstinadequate [10] [2]. The national focusof attention on psychological care hasraised awareness of the need forservices to improve. Inclusion ofnational measures of psychologicalcare in the national stroke audit, andtheir consideration for inclusion in theCommissioning OutcomesFramework is welcomed as potentialdrivers for continued improvement in services.

Whilst the focus of this paper has beenon the economic impact ofpsychological care, it is the individualand their family who are at the heart ofthese services, and who may have avery real need for emotional andpsychological support to manage thestroke and its consequences. Thesignificant benefits of meeting thisneed are almost impossible to quantify.

One of the difficulties in developingthis model was a lack of empiricalevidence of the cost-effectiveness, oreven cost-utility of treatingdepression after stroke [34]. It wouldhave been better if this modellingwork could have been informed by alarge multi-centre trial exploring theeffectiveness and cost-effectiveness(or utility) of psychotherapy deliveredearly after stroke.

NHS CommissioningBoard

Royal College ofPhysicians

Academics andresearchers

Commissioners

Providers

Recommendations

National data about the provision of psychological care is regularlypublished and is publically available.

Specific audits of community and long term stroke services includeexamination of psychological, cognitive and emotional care.

Further research into the economic benefits of psychologicaltherapy after stroke is undertaken in a multi-centre study.

The model is used to establish the local economic benefits of aclinical psychologist-led service for psychological care based on areview of current provision of psychological care.

Stroke-specific psychological care is commissioned through theengagement of adult social care, acute and community strokeservices, voluntary sector and mental health services.

Data and information are used to monitor access to and theimpact of psychological care for people with stroke.

Psychological care pathways are developed using a steppedapproach.

Views of patients and families about the quality of psychologicalcare they received in the stroke service are elicited to supportdevelopment of these services.

Consistent and routine mood and cognition screening is carriedout in line with national evidence based guidance.

A proportion of stroke serviceshave made improvements in theirservices based on reconfigurationof stroke pathways and by linkingwith adjacent services and thevoluntary sector; however, thesignificant shortfall in strokespecific clinical psychologists willonly be addressed through theprovision of these posts wherethey currently do not exist.


24

[1] Department of Health, “National Stroke Strategy,” Department of Health, London, 2007.

[2] Intercollegiate Stroke Working Party, “National Sentinel Stroke Clinical Audit 2010: Round 7. Public report for England, Wales and Northern Ireland,” Royal College of Physicians, London, 2011.

[3] Intercollegiate Stroke Working Party, “National Clinical Guidelines for Stroke,” Royal College of Physicians, London, 2012.

[4] Hackett et al, “Frequency of depression after stroke; a systematic review of observational studies,” Stroke, vol. 36, p. 1330, 2005.

[5] Campbell-Burton CA, Murray J, Holmes J et al, “Frequency of anxiety after stroke: A systematic review and meta-analysis of observational studies,” DOI:10.1111/j.1747-4949.2012.00906.2012.

[6] Sembi S, Tarrier N, O'Neil P et al, “Does post-traumatic stress disorder occur after stroke: A preliminary study,” International Journal of Geriatric Psychiatry, vol. 13, pp. 315-322, 1998.

[7] Bruggimann L, Annon, J M, Staub F et al, “Chronic posttraumatic stress symptoms after nonsevere stroke,” Neurology, vol. 66, pp. 513-16, 2006.

[8] Field E L, Norman P, Barton J. et al, “Cross-sectional and prospective associations between cognitive appraisals and posttraumatic stress disorder symptoms following stroke,” Behaviour Research and Therapy, vol. 46, pp. 62-70, 2008.

[9] British Psychological Society, “Psychological services for stroke survivors and their families - Briefing paper 19,” 2010.

[10] National Audit Office, “Progress in improving stroke care,” Department of Health, London , 2010.

[11] Care Quality Commission, “A review of services for people who have had a stroke and their carers,” Care Quality Commission, London, 2011.

[12] West, R., Hill, K., Hewison, J., Knapp, P. House, A., “Psychological disorders after stroke are an important influence on functional outcomes; a prospective cohort study,” Stroke, vol. 41, pp. 1723-1727, 2010.

[13] The Kings Fund and Centre for Mental Health, “Long term conditions and mental health - the cost of comorbidities.,” London, 2012.

[14] National Institute for Health and Clinical Excellence, “Depression in adults with a chronic physical health problem . Clinical guideline 91,” 2009.

[15] NHS Improvement, “Psychological care after stroke; Improving services for people with mood and cognitive disorders,” NHS Improvement, 2011.

[16] National Institute for Health and Clinical Excellence, “Stroke Quality Standard,” 2012.

[17] Lincoln, N.B. Kneebone, I.I. Macniven, J.A.B. and Morris, R., Psychological management of stroke, Chichester: Wiley, 2012.

[18] Watkins et al, “Stroke Interface Audit: pre/post discharge audit of stroke services and care in Liverpool and Sefton: Delivery timeliness and targeting. 36 month report,” March 2002.

[19] Department of Health, “Agenda for Change Pay Circular,” Department of Health, 2011.

[20] Personal Social Services Research Unit (PSSRU), “Unit Costs of Health and Social Care 2011,” 2011. [Online]. Available: http://www.pssru.ac.uk/project-pages/unit-costs/2011/index.php. [Accessed 7th August 2012].

[21] Turner-Stokes L, Hassan N, “Depression after stroke: A review of the evidence base to inform the development of an integrated care pathway. Part 2: Treatment alternatives,” Clinical Rehabilitation, vol. 16, pp. 248-60, 2001.

References


25

[22] Williams LS, Kroenke K, Bakas T et al, “Care management of post stroke depression: A randomised controlled trial,” Stroke, vol. 38, pp. 998-1003, 2007.

[23] Jia, H., Damush, T.M., Qin, H. et al, “The impact of poststroke depression on healthcare use by veterans with acute stroke,” Stroke, vol. 37, pp. 27996-2801, 2006.

[24] Mitchell PH, Veith RC, Becker KJ et al, “Brief psychological behavioural with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomised controlled trial.,” Stroke, vol. 40, pp. 3073-8, 2009.

[25] WHO Collaborating Centre for Drug Statistics Methodology, [Online]. Available: http://www.whocc.no [Accessed 24th May 2012].

[26] BNF online, [Online]. Available: http://www.bnf.org/bnf/index.htm. [Accessed 24th May 2012].

[27] Ghose, S.S.. Williams, L.S., Swindle, R.W.,, “Depression and other mental health diagnoses after stroke increases inpatient and outpatient medical utilisation three years poststroke,” Medical Care, vol. 43, pp. 1259-1264, 2005.

[28] Department of Health, “Impact assessment of the expansion of talking therapies services as set out in the Mental Health Strategy,” Department of Health, 2011.

[29] Kneebone, I. I., Lincoln, N.B, “Psychological Problems after Stroke and Their Management: State of Knowledge,” Neuroscience and Medicine, vol. 3, pp. 83-89, 2012.

[30] Saka O, McGuire A, Wolfe C. , “Cost of stroke in the United Kingdom,” Age and Ageing, vol. 38, pp. 27-32, 2009.

[31] NHS Improvement, “Care Homes,” [Online]. Available: http://www.improvement.nhs.uk/stroke/Carehomes/tabid/201/Default.aspx. [Accessed 30th August 2012].

[32] National Institute for Health and Clinical Excellence, “Measuring effectiveness and cost effectiveness: the QALY,” 20th April 2010. [Online]. Available: http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp. [Accessed 8th August 2012].

[33] NHS Confederation and Mental Health Network, “Investing in emotional and psychological wellbeing in people with long term conditions,” 2012.

[34] R. Marsh, “Evidence Adoption Centre NHS East of England- Reviews in progress,” The cost and cost-effectiveness of psychological therapies for post stroke management: a rapid evidence assessment, 2012. [Online]. Available: http://www.eac.cpft.nhs.uk/reviewsinprogress.aspx. [Accessed 10th September 2012].

[35] Hackett ML, Anderson CS, House A et al, “Interventions for preventing depression after stroke,” Cochrane Database of Systematic Reviews, no. 3, 2008a.

[36] Hackett ML, Anderson CS, House A, et al, “Interventions for treating depression after stroke,” Cochrane Database of Systematic reviews, no. 4, 2008b.

[37] Thomas SA, Walker MF, Macniven JA, Haworth H, Lincoln N,, “Communication and LowMood (CALM): a randomized controlled trial of behavioural therapy for stroke patients with aphasia.,” Clinical Rehabilitation, In Press.


26

Adjustments made to the Stroke Interface Audit dataStroke care has taken considerable strides forward since 1996 and so adjustments have beenmade to the data in order to make it more representative of modern stroke care andoutcomes.

In the original cohort the level of mortality was high compared with other cohorts and moremodern data; for example, the 30-day mortality in the cohort was 34%, which is much higherthan the 17% cited in the National Sentinel Audit (2011)1. The mortality data was reviewedfrom a series of studies2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and increased the number alive at the different timepoints by a factor of 18%. Similarly, the length of hospital stay for the index stroke is muchlonger [mean 35.3 days] than the mean 19.5 days cited in the National Sentinel Audit (2011)1.Consequently we reduced the length of stay data by 40%.

The proportion of readmissions during each month up to 12 months was available from thecohort, but there were limited data on readmissions beyond 12 months. Consequently, anestimate was made of the likely proportion of readmissions per month, for months 13 through24, based on the data up to 12-months (readmissions per month were on average 6.3% ofthe patients alive in the community) and data reported elsewhere2. Using these figures it wasestimated that for each of months 13 through 24, the number of readmissions is equivalent toapproximately 5.0% of the number of patients alive. Data on the exact time of entry toresidential care was not known – residence was recorded using point estimates at the time ofassessments (i.e. 3, 6, 12 and 24 months) and so a rounded estimate has been used, based onthe known proportion at the time of assessment. For each of months 13 through 24 we haveestimated that 25% of patients in the community were in residential care.

Appendix 1

1 Intercollegiate Stroke Working Party, “National Sentinel Stroke Clinical Audit 2010: Round 7. Public report for England,Wales and Northern Ireland,” Royal College of Physicians, London, 2011.

2 Bravata Dm, Shih-Yieh H, Meehan TP, et al, “Readmission and death after hopitalisation for acute ischaemic stroke:5 year follow up in the Medicare population,” Stroke, vol. 38, pp. 1899-904, 2007.

3 Brønnum-Hansen H, Davidsen M, Thorvaldsen P, “Long term survival and causes of death 4 Dennis MS, Burn JP, Sandercock PA et al, “Long term survivalafter first-ever stroke: the Oxfordshire community stroke

project,” Stroke, vol. 24, pp. 976-800, 1993. 5 Eriksson SE, Olsson JE, Broadhurst RJ et al, “Five year survival after first-ever stroke and related prognostic factorsin the

Perth community stroke study,” Stroke, vol. 34, pp. 1842-6, 2000. 6 Hardie K, Hankey GJ, Jamrozik K, et al, “Ten-year survival after first ever stroke in the Perth community stroke study,”

Stroke, vol. 34, pp. 1842-6, 2003. 7 Turaj W, Slowik A, Dziedzic T et al, “Increased plasma fibrinogen predicts one year mortality in patients with acute

ischaemic stroke,” Journal of Neurological Sciences, vol. 246, pp. 13-19, 2005. 8 Stavem, K, Rønning OM, “Survival of unselected stroke patients in a stroke unit compared with conventional care,”

QJ Med, vol. 95, pp. 143-152, 20029 Wang y, Lim LL-Y, Heller RF et al, “A prediction model of 1-year mortality for acute ischaemic stroke patients,”

Arch phys Med Rehab, vol. 84, pp. 1006-11, 2003.10Hankey GJ, Jamrozik K, Broadhurst RJ, et al, Five-year survival after first-ever stroke and related prognostic factors in

the Perth community stroke study. Stroke;31: 2080-6. 200011Eriksson SE, Olsson JE. Survival and recurrent strokes in patients with different subtypes of stroke: a fourteen-year

follow-up. Cerebrovascular Diseases;12:171-80. 200112Saposnik G, Hill MD, O’Donnell M, Fang J, Hachinski V, Kapral MK. Variables associated with 7-day, 30-day,

and 1-year fatality after ischemic stroke. Stroke;39:2318–2324. 2008

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