Marina Richardson, M.Sc. Deb Willems, BSc.PT David Ure, OT Robert Teasell, MD FRCPC

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1 Assessing the Impact of Southwestern Ontario s Community Stroke Rehabilitation Teams: An Economic Analysis Presenters: Laura Allen, M.Sc. (cand.) Matthew Meyer, Ph.D (cand.) Marina Richardson, M.Sc. Deb Willems, BSc.PT David Ure, OT Robert Teasell, MD FRCPC 2013 Stroke Collaborative October 28, 2013

2 Outline 1. In-home rehabilitation 2. The CSRT s 3. Description of Study 1. Objective 2. Data Collection Methods 3. Results 4. Long term projection of study results

3 Home-based Rehabilitation Majority of studies focus on in home care compared with outpatient rehabilitation In home rehabilitation has demonstrated: Greater client satisfaction Reduced caregiver strain Lower hospital readmission rates Increased functional independence and ADLs Greater opportunity to set relevant and achievable rehabilitation goals Provides the opportunity to immediately transfer skills learned in one s own living environment

4 Home-based Rehabilitation in Ontario In-home rehabilitation services are lacking In 2011, CCAC rehab patients: Waited 20.4 days for first visit Received 5.7 total visits from PT, OT, SLP on average

5 Outline 1. In-home rehabilitation 2. The CSRT s 3. Description of Study 1. Objective 2. Data Collection Methods 3. Primary results 4. Long term projection results

6 The Community Stroke Rehabilitation Teams Established in 2009 LHIN Funded Designed to offer rehabilitation in the community for stroke survivors with on-going rehabilitation needs Teams consist of Registered Nurses Physiotherapists Occupational Therapists Speech Language Pathologists Social Workers Therapeutic Recreation Specialists Rehabilitation Therapists

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8 Provide direct patient care in the most appropriate setting (home and community) Secondary prevention System navigation Community re-integration Provide caregiver support

9 CSRT Eligibility Criteria Adult stroke survivors with rehabilitation needs Client needs are best met by specialized stroke rehabilitation services in the community Willing and motivated to participate in the program Cognitively and physically able to participate in therapies Achievable rehabilitation goals

10 CSRT Services Interdisciplinary collaboration in setting and achieving patient goals Mean # of visits: Service Mean(SD) Physiotherapist 8.2(7.3) Occupational Therapist 6.7(5.7) Speech Language Pathologist 6.3(6.3) Registered Nurse 5.4(3.4) Social Worker 4.3(3.5) Therapeutic Recreation Specialist 6.2(5.1) Rehabilitation Therapist 13.3(11.8) Total 33.6(26.3)

11 Outline 1. In-home rehabilitation 2. The CSRT s 3. Description of Study 1. Objective 2. Data Collection Methods 3. Primary results 4. Long term projection results

12 Objectives Primary: Perform a prospective economic evaluation of 12- month outcomes and costs comparing clients of the CSRT to similar patients unable to access communitybased outpatient rehabilitation programs Secondary: To model the long-term health economic impact of CSRT care compared to no rehabilitation

13 Hypotheses CSRT participants will demonstrate greater functional improvements and report greater Quality of Life compared to similar controls Consolidated, organized CSRT services and system navigation will lead to fewer healthcare resources consumed compared to similar controls

14 Methods Study Timeline Recruitment/ Baseline CSRT Recruitment/ 6-Month Follow Baseline Up Recruitment/ 12-Month Follow Baseline Up Demographics Health Quality of Life Health Quality of Life Costs Health Quality of Life Costs

15 Measures Used Baseline Questionnaire Age, date of stroke, comorbidities, place of residence Stroke Impact Scale Physical function, activities of daily (ADL/IADL), communication, emotion, memory, and social participation EQ-5D Five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) Health and Social Services Utilization Survey Health services accessed Health related out of pocket expenses

16 Methods CSRT Participants: Consecutive CSRT clients were approached for consent to participate in the study Controls Recruited from hospitals elsewhere in Ontario Individuals discharge from hospital with no access to further rehabilitation services Inpatient acute and rehabilitation units Individuals who met eligibility criteria for CSRT services

17 Methods Names and telephone numbers passed on to research team Telephone Interviews Completed: Baseline Study explained further Verbal consent to participate Baseline questionnaire and outcomes measures Follow up 6 months following baseline 12 months following baseline

18 Results Recruited CSRT = 212 Controls = 15 Baseline Assessment Completed CSRT = 164 Controls = 10 6 Month Follow Up Completed CSRT = 108 Controls = 4 12 Month Follow Up Completed CSRT = 37 Control = 0

19 Results Demographics n= 164 Age - years (SD) 66.7 (12.8) Number of Males (%) 95 (57.9%) Place of Residence (%) House/Apartment 148 (90.2%) Nursing Home 2 (1.2%) Retirement Home 3 (1.8%) Seniors Apartment 6 (3.7%) Relatives House 3 (1.8%) Lives with family member or other support person 142 (86.6%) Family or other support available on a daily basis 126 (76.8%)

20 Results Stroke Event and History Able to stand up and walk around on own after stroke 82 (50%) (%) Days Since Stroke (Median, IQR) 62 (66) Recurrent Event (%) Stroke 27 (16.5%) TIA 4 (2.4%) Stroke Risk Factors Diagnosed with Diabetes 50 (30.5%) Diagnosed with High Blood Pressure 116 (70.7%) Diagnosed with Heart Disease 37 (22.6%) Diagnosed with High Cholesterol 82 (50%)

21 Results EQ-5D-5L Mean (SD) EQ-5D-5L Index Value EQ-5D-5L VAS Baseline (n=164) (0.17) (17.83) 6 Month Follow up (n=108) (0.21) (21.82) 12 Month Follow up (n=37) (0.19) (24.39) Repeated Measures ANOVA F=2.205; P=0.125 F=1.898; P=0.166 SIS Mean (SD) SIS2 (Memory/Thinking) SIS3 (Emotions) SIS4 (Communication) SIS8 (Participation) SIS1,5,6,7 (Physical) (22.69) (17.58) (20.41) (22.85) (21.18) (25.40) (16.65) (21.31) (26.70) (23.52) (29.40) (20.71) (18.99) (26.16) (23.35) F=0.645; P=0.531 F=0.743; P=0.483 F=1.691; P=0.199 F=9.527; P<0.001 F=1.186; P=0.318

22 Results EQ-5D-5L Mean (SD) EQ-5D-5L Index Value EQ-5D-5L VAS Baseline (n=164) (0.17) (17.83) 6 Month Follow up (n=108) (0.21) (21.82) 12 Month Follow up (n=37) (0.19) (24.39) Repeated Measures ANOVA F=2.205; P=0.125 F=1.898; P=0.166 SIS Mean (SD) SIS2 (Memory/Thinking) (22.69) SIS3 (Emotions) (17.58) SIS (Communication) (20.41) SIS8 (Participation) SIS8 (Participation) (22.85) SIS1,5,6,7 (Physical) (21.18) (25.40) (16.65) (21.31) (26.70) (23.52) (29.40) (20.71) (18.99) (26.16) (23.35) F=0.645; P=0.531 F=0.743; P=0.483 F=1.691; P=0.199 F=9.527; P<0.001 F=1.186; P=0.318

23 Results Mean Cost Per Client* (SD) 0-6 Month Follow up Mean Cost Per Client* (SD) 6 12 Month Follow up CSRT Related Costs ( ) (490.08) All Other Costs** ( ) ( ) Average Total Cost Per Client: ( ) ( ) *Based on complete cases (N).**All other costs: Primary and specialty care, all other health service providers, hospital admissions, day surgeries, LTC, retirement home, shelter, outpatient laboratory tests, special treatments, supplies, household help, babysitting, total travel costs, total parking costs

24 Discussion Recruitment difficulty precluded control comparison Data on CSRT patients provides excellent data for economic model Patients demonstrated maintenance of function and QoL up to 12 months post admission Significant improvements in Participation domain of the SIS

25 Outline 1. In-home rehabilitation 2. The CSRT s 3. Description of Study 1. Objective 2. Data Collection Methods 3. Primary results 4. Long term projection results

26 CSRT Clients vs. Literature Based Controls - Economic model allowing for long term projection of costs and benefits - Projected for 35 years - CSRT client data from primary study - Control data taken from literature based estimates

27 Health States Independent: able to live completely independently, in their own home, while being independent in their activities of daily living Dependent: able to live in their own home, but requires assistance for activities of daily living either from a family/ friend caregiver or from home care services (i.e. Community Care Access Centres) LTC: an individual resides in a long term care or assisted living facility and is no longer capable of residing in their own home Dead

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29 CSRT Stroke No Further Therapy

30 Utility Values CSRT: - EQ-5D No Further Therapy: - Derived from the literature

31 Quality Adjusted Life Year (QALY): Standardized measurement Takes into account both the quantity and the quality (utility) of life A year of perfect health is scaled to be 'worth' 1 A year of less than perfect health 'worth' less than 1 Death is commonly indicated by 0

32 Costing Information CSRT: - Health and Social Services Utilization Survey - Direct health care costs only - # of visits from CSRT administrative data No Further Therapy: - BURST study - Medication, rehabilitation, and indirect costs removed - Canadian based study (2012): cost of ischemic stroke Mittmann N, Seung SJ, Hill MD et al. Impact of disability status on ischemic stroke costs in Canada in the first year.

33 $ Utility: 0.85 CSRT $ Utility: 0.62 Stroke $ Utility: 0.71 No Further Therapy $11, Utility: 0.32

34 ICE Ratio More Costly X? Less Effective More Effective? Less Costly

35 Long term model - Results CSRT: $232,533 per 11 QALYs gained No Further Therapy: $104,121 per 6 QALYs gained ICER = $25,692/ 1 QALY

36 Willingness to Pay New health interventions often represent added cost Willingness to Pay represents our judgment about what is acceptable Willingness to Pay thresholds of $50,000 are commonly used (ie. we will pay $50,000 to provide 1 additional QALY)

37 Long term model - Results 76.99% of simulations are considered cost effective in favour of CSRT

38 Long term model - Results WTP value of greater than $26,000 would result in superiority of the CSRT program

39 Discussion Initial cost of the program may be offset by reduced health care usage in the long term Did not consider out of pocket expenses CSRT Clients have a better QoL leading to higher QALYs Estimates for CSRT were kept conservative

40 Conclusions Incremental Cost Effectiveness Ratio (ICER) = $25,692/1 QALY Cost effective in >75% of simulations CSRT cost effective after WTP threshold of $26,000

41 Future Directions Additional Impacts of CSRT program: Early Supported Discharge Reduced Alternative Level of Care days Provide feedback to CSRTs

42 Thank you The Community Stroke Rehabilitation Teams Karen Heys David Ure Deborah Willems Rachel Mays Ontario Stroke Network

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