Rehabilitation after critical illness. Costing report. Implementing NICE guidance

Transcription

1 Rehabilitation after critical illness Costing report Implementing NICE guidance March 2009 NICE clinical guideline 83 1 of 28

2 This costing report accompanies the clinical guideline: Rehabilitation after critical illness (available online at Issue date: March 2009 This guidance is written in the following context This report represents the view of the Institute, which was arrived at after careful consideration of the available data and through consulting healthcare professionals. It should be read in conjunction with the NICE guideline. The report and templates are implementation tools and focus on those areas that were considered to have significant impact on resource utilisation. The cost and activity assessments in the reports are estimates based on a number of assumptions. They provide an indication of the likely impact of the principal recommendations and are not absolute figures. Assumptions used in the report are based on assessment of the national average. Local practice may be different from this, and the template can be amended to reflect local practice to estimate local impact. National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA National Institute for Health and Clinical Excellence, March All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute. 2 of 28

3 Contents Executive summary... 4 Supporting implementation... 4 Significant resource-impact recommendations... 4 Total cost impact... 5 Benefits and savings... 5 Local costing template Introduction Supporting implementation What is the aim of this report? Estimated number of general adult critical care patients Models of care Costing methodology Process Scope of the cost-impact analysis General assumptions made Basis of unit costs Cost of significant resource-impact recommendations Delivery of self-directed, supported and continuous rehabilitation services Benefits and savings Sensitivity analysis Methodology Impact of sensitivity analysis on costs Impact of guidance for commissioners Conclusion Total national cost for England Next steps Appendix A. Approach to costing guidelines Appendix B. Results of sensitivity analysis of 28

4 Executive summary This costing report looks at the resource impact of implementing the NICE guideline Rehabilitation after critical illness in England. The costing method adopted is outlined in appendix A; it uses the most accurate data available, was produced in conjunction with key clinicians, and reviewed by clinical and financial professionals. Supporting implementation The NICE clinical guideline on rehabilitation after critical illness is supported by a range of implementation tools available on our website and detailed in the main body of this report. Significant resource-impact recommendations As the guideline is a short clinical guideline, this report looks at the recommendations as a system to improve timeliness, accessibility and delivery of services where a gap has been identified. This is in line with the guideline s key principles of care, which recommend that, to ensure continuity of care, healthcare professional(s) with the appropriate competencies should coordinate the patient s rehabilitation care pathway, short-term and medium-term rehabilitation goals should be regularly reviewed and updated, and information should be communicated between hospitals and other relevant services and to patients. The recommendations considered to have the greatest resource impact, and therefore require the most additional resources to implement, apply across all the recommendations as they involve increasing rehabilitation staff capacity for: clinical psychological services during hospital stay and in the community setting physiotherapy services during critical care where early mobilisation can be achieved, and after discharge from hospital 4 of 28

5 other services such as speech and language therapy, occupational therapy and dietetics. Total cost impact The annual changes in revenue costs arising from fully implementing the guideline are summarised in the table below. Estimated recurrent costs/savings Elements of recommendations that will have a resource impact ( 000s) Additional costs - multidisciplinary rehabilitation teams (recommendations ) 28,656 Potential savings as a result of early intervention and multidisciplinary follow-up services 15,139 Outreach rehabilitation services and community rehabilitation are not covered by Payment by results. Benefits and savings Implementing the clinical guideline may bring the following benefits (potential national savings identified below relate to resources released as a result of optimising the use of NHS resources). Some of these may not be cash releasing savings, but allow the opportunity to free up resources that can be redirected elsewhere. Patients spending less time on critical care and general wards because of early intervention for mobilisation treatment (estimated to save 15 million annually). Savings in ongoing care by reducing dependence on services and nursing care, and preventing disability. Patients and their relatives/carers may be able to return to work earlier because of a reduced dependence on relatives/carers and social care. The potential for reduced patient morbidity as a result of early rehabilitation. 5 of 28

6 The potential for a discount on contributions to the NHS Litigation Authority schemes (including the Clinical Negligence Scheme for Trusts) because compliance with NICE guidance is one of the criteria indicating good risk reduction strategies. Local costing template The costing template produced to support this guideline enables organisations in England, Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that additional costs of approximately 56,500 could be incurred for a population of 100,000. This comprises assessment and rehabilitation costs estimated at 56,500, which may be offset by savings made as a result of reduced critical care stay and reduced general ward stay totalling 29,800. These savings do not include savings in ongoing care, which we have not been able to quantify. There may also be non-recurrent costs associated with changing the care pathway. 6 of 28

7 1 Introduction 1.1 Supporting implementation The NICE clinical guideline on rehabilitation after critical illness is supported by the following implementation tools available on our website costing tools a national costing report; this document a local costing template; a simple spreadsheet that can be used to estimate the local cost of implementation. a slide set; key messages for local discussion audit support A practical guide to implementation, How to put NICE guidance into practice: a guide to implementation for organisations, is also available to download from the NICE website. It includes advice on establishing organisational level implementation processes as well as detailed steps for people working to implement different types of guidance on the ground. 1.2 What is the aim of this report? This report provides estimates of the national cost impact arising from implementation of guidance on rehabilitation after critical illness in England. These estimates are based on assumptions made about current practice and predictions of how current practice might change following implementation This report aims to help organisations plan for the financial implications of implementing NICE guidance This report does not reproduce the NICE guideline on rehabilitation after critical illness and should be read in conjunction with it (see 7 of 28

8 1.2.4 The costing template that accompanies this report is designed to help those assessing the resource impact at a local level in England, Wales or Northern Ireland. NICE clinical guidelines are developmental standards in the Department of Health s document Standards for better health. The costing template may help inform local action plans demonstrating how implementation of the guideline will be achieved. 1.3 Estimated number of general adult critical care patients The short clinical guideline estimates that approximately 110,000 people (estimated from the UK Intensive Care National Audit and Research Centre [ICNARC] Case Mix Programme [CMP] Summary Statistics ) spend time in critical care units in England and Wales each year, the majority surviving to be discharged home. 1.4 Models of care The guideline covers adult patients requiring rehabilitation after a period of critical illness. Current rehabilitation strategies tend to focus on physical function (mobility) and are limited to inpatient settings There is some evidence to suggest that individualised rehabilitation programmes, including structured, self-directed rehabilitation strategies after critical illness can aid physical recovery and help people cope with the physical and psychological effects associated with critical illness The guideline aims to provide trusts with care pathways that are patient focused, allow optimum timing for assessment and intervention to treat physical and non-physical dysfunction, and that deliver coordinated, continuous services during the patient s hospital-based care and up to 3 months after the patient is discharged from hospital. 8 of 28

9 2 Costing methodology 2.1 Process We use a structured approach for costing clinical guidelines (see appendix A) Little reliable data has been systematically collected about the rehabilitation of adult patients in general critical illness. Only one randomised controlled trial on the clinical effectiveness of rehabilitation strategies/programmes for UK general adult critical care was found, and this has been analysed in the short clinical guideline (appendix 4). This has led to problems in building a comprehensive bottom-up model for costing (a costing methodology where the unit cost of individual elements and number of units are estimated and added together to provide a total cost). To overcome this limitation, we had to make assumptions in the costing model. We developed these assumptions and tested them for reasonableness with members of the Guideline Development Group (GDG) and key clinical practitioners in the NHS. 2.2 Scope of the cost-impact analysis The guideline offers best practice advice on the care of adults in general critical care for whom no alternative rehabilitation pathway currently exists The need for physical rehabilitation during hospital stay is well established and has been adopted by many trusts into current practice. This is not the case in the UK for dedicated psychological services. Services helping patients cope with cognitive deficits are even scarcer - C Jones (2008). There is also currently unmet demand for early rehabilitation for patients in general adult critical care who may benefit from early mobilisation treatments, an example is the Allied Healthcare professional audit of unmet need in critical care stage 2 report (2006) relating to Lancashire and 9 of 28

10 South Cumbria. A list of the NHS trusts covered in the audit can be found in appendix D of this report. The trusts covered include teaching hospitals and a district general hospital. This is a local audit which has been referred to in the absence of national results. Therefore a local view needs to be taken when considering these findings. Upon discharge from hospital there are very few joined-up programmes for general adult critical care patients in need of further physiotherapy, counselling and other rehabilitation services. The demand for these services is currently managed within primary care and patient referral is often a lengthy process made longer by waiting times to access services The guideline aims to allow trusts to establish a mechanism for streamlining access to services across secondary care and provides for earlier and continued assessment and treatment of patients for both physical and non-physical conditions before discharge from critical care (recommendations 1.1.1, and 1.1.3). The guideline recommends further physical and non-physical assessments during ward-based care and up to 2 3 months following discharge (recommendations , and ). A key principle of care from the guideline is that patients are fully involved and informed about their care through self-directed rehabilitation programmes that are delivered and supported by the rehabilitation teams that were involved in their care from the outset. To achieve this, recommendations 1.1.1, and recommend a multidisciplinary, joined-up approach with direct access to follow-up services The guideline does not cover: adults receiving palliative care clinical subgroups of patients whose specialist rehabilitation needs are already routinely assessed and delivered as part of their care pathway (for example, patients who received critical 10 of 28

11 care as part of an elective pathway and who did not develop an unanticipated, critical illness, and in areas where published guidelines already exist such as, myocardial infarction and stroke). These groups are outside the scope of the guideline and have not been included in the costing work Because this is a short clinical guideline that focuses on a specific area, the costing work has looked at the guideline as a whole. This has identified that the costs can be applied across the whole of the guidance, and therefore all the recommendations have been considered in the costing work We have limited the consideration of costs and savings to direct costs to the NHS that will arise from implementation. We have not included consequences for the individual, the private sector or the not-for-profit sector. Where applicable, any realisable cost savings arising from a change in practice have been offset against the cost of implementing the change. 2.3 General assumptions made The model is based on annual incidence and population estimates (see table 1 below). Table 1 Annual incidence and population estimates for patients accessing general critical care services Estimated admissions to level 2 and 3 critical Adult population in England care each year 39,557, , Basis of unit costs The way the NHS is funded has undergone reform with the introduction of Payment by results, based on a national tariff. The 11 of 28

12 national tariff will be applied to all activity for which Healthcare Resource Groups (HRGs) or other appropriate case-mix measures are available For critical care, there is currently a range of indicative tariff categories that are not compulsory. A weighted average cost based on the number of occupied bed days taken from each category has been used. This has produced a figure of 1,159 per day. This relates to general critical care and excludes cardiac, burns and neurological care. After applying inflation and uplifting for the national average market forces factor, the inflated 2009/10 cost per day is estimated to be 1,390 which has been used to estimate potential savings Using these prices ensures that the costs in the report are the cost to the primary care trust (PCT) of commissioning predicted changes in activity at the tariff price, but may not represent the actual cost to individual trusts of delivering the activity The salary costs used to estimate the cost impact of additional capacity for multidisciplinary teams are based on the Department of Health s Agenda for Change pay scales from April 2008, using the midpoint in the pay band. 3 Cost of significant resource-impact recommendations 3.1 Delivery of self-directed, supported and continuous rehabilitation services Background According to expert opinion, when patients are discharged from hospital following a level 2 (ICU) or level 3 (high dependency unit) critical care stay, they often experience difficulty trying to live in 12 of 28

13 their own environment. Even where relevant services exist, care may be delivered in a piecemeal manner and there is often a lack of documentation to follow patients into primary care. Demand for rehabilitation of these patients is currently managed in primary care once they have left hospital. Referral can be a lengthy process from GP to specialist services either in secondary care (outpatients) or clinics within primary care. This is based on discussion with experts. Assumptions made After gaining expert opinion, the costing model assumes initial ward-based checks are carried out to assess physical and non-physical morbidity by the medical staff in critical care units and on the wards. The patient is referred for clinical reassessment only if these checks identify that the patient is at risk of specific physical and non-physical morbidity The estimated percentage of patients referred for detailed comprehensive assessment (70%) is based on the total population group of 110,000 and therefore includes patients with more complex needs, who are also covered in the guideline. This estimate is assumed after implementation of the guideline and is based on expert opinion. The remaining 30% takes into account that not all patients need further physical therapy, psychotherapy or other therapies, and that a proportion may not survive their critical illness The estimated 85% of patients who are then referred for comprehensive follow-up therapies after clinical reassessment is based on expert opinion and takes into account that not all patients who have clinical reassessment will need follow-up therapies. This produces an estimated 65,450 patients for England (the proportion is taken after the adjustment made to the 110,000 population group in above). 13 of 28

14 3.1.5 The assumptions about the percentage of patients in need of further clinical assessment and follow-up therapies are based on published data by Jones 2008 relating to the incidence of psychological problems, and expert opinion in the absence of published information on physiotherapy and other therapies. The proportions in table 2 relate to the estimated number of patients referred for comprehensive follow up therapies of 65,450 (included in above). These estimates are shown in table 2. Table 2 Estimated additional patients by type of therapy Patients in need of rehabilitation following Description clinical assessment (%) a Patient numbers Psychological therapies 28 18,326 Physiotherapy in the community 50 32,725 Other therapies 15 9,818 a Flexibility has been given in the costing tools to amend these figures The purchase of self directed and supported tailored rehabilitation manuals for patients with more complex needs assumes that 15% of patients will have complex needs. This is based on expert opinion in the absence of published information. Although costs are not estimated to be significant nationally, flexibility has been given in the costing template for local estimates. A unit cost of 100 for copyright payments has been quoted based on expert experience. This can be used where hospitals commission care programmes externally to specialist consultants or academic organisations. We have not been able to estimate what other national costs may be for this type of care, however flexibility has been provided in the costing template to allow for other costs. Cost summary The significant costs identified are driven by: 14 of 28

15 the unmet capacity in critical care for patients who can undergo and benefit from early mobilisation treatments while in critical care the number of patients who have been assessed during ward checks as being in need of follow-up services during hospital stay patients in need of continuing support after discharge from hospital The relevant significant costs were found to be the employee resources needed to bridge the current unmet demand in services. This is to be achieved in a multidisciplinary and continuous manner to ensure effectiveness (recommendation and ) The number of full-time staff needed to support additional patients in need of rehabilitation services was calculated using the results of the Allied Healthcare Professional Audit of unmet need in critical care report for Lancashire and South Cumbria. A list of the trusts included in the audit can be found in appendix d of this report. The results were used to identify the capacity needed to support early mobilisation physiotherapy for patients in general critical care. It is recognised that the results may not be representative of all regions; flexibility has been given in the costing template to reflect local circumstances Staffing calculations for clinical psychologists, community physiotherapists and other therapists is based on discussion with GDG members on unmet demand in service including average contact time needed with patients for assessments and therapies, and elements of the Personal Social Services Research Unit (PSSRU) 2008 publication. The table below shows how the ratio of patients to full-time equivalent (FTE) staff was calculated. 15 of 28

16 Table 3 Capacity calculations for staffing of multidisciplinary teams Role Average hours per year Patient contact (% time) Average time per patient (hours) Estimated patients per full-time post/fte to critical care beds Physiotherapist (critical care) One FTE to every four critical care beds Clinical psychologist Physiotherapist (community) Other therapists The full-time salary costs for each role were based on midpoint values taken from the Department of Health s Agenda for Change The Agenda for Change grades for each role were informed by the PSSRU 2008 report. Flexibility is given in the costing tool to amend figures as relevant to local circumstances Table 4 shows the estimated numbers of patients and the type of medical staff needed to support the capacity for multidisciplinary teams The number of critical care physiotherapists is based on the number of critical care beds and reflects the ratio of one FTE to every four beds identified in Table 3 of this report. 16 of 28

17 Table 4 Estimated cost of capacity by activity and patient numbers Annual salary ( ) Change Numbers of patients/general critical care beds Cost ( 000s) Total fulltime posts needed to deliver services Physiotherapists critical care early intervention 34, , Clinical psychologists hospital and follow-up services 40,842 18,326 7, Physiotherapists community follow-up services 34,119 32,725 9, Other therapists 34,119 9,818 1, Total 28, The predicted costs in table 4 of the medical staff needed to deliver services are calculated from the estimates in tables 3 and 4 as follows: Numbers of patients (table 4) Estimated patients per full-time post (table 3) annual salary (table 4) Other considerations The proportion of patients who can undergo early procedures while in critical care is limited by the presence of oral and tracheal tubes that allow the patient to breath, as well as by analgesics and sedatives, which limit the assessments and treatments that can be carried out P Skirrow et al (2001) There may be other costs relating to the self-directed rehabilitation manuals depending on the conditions of the copyright licence referred to in above, including staff training on how to deliver the manuals, and their printing and distribution. There may also be costs of translation into different languages where needed. 17 of 28

18 More robust processes in place as a result of implementation of this guideline could result in a possible increase in GP visits. This is because follow-up services such as psychology services may be accessed wholly in the community. There may also be problems not previously identified that may arise with the patient as a result of more robust rehabilitation pathways, and this may also lead to an increase in GP visits. The costs of this are not considered to be significant nationally, and may be offset by a reduction in GP visits where different pathways exist such as hospital rehabilitation units, or specialist community units. Flexibility has been provided in the template under other costs for local estimates to be made There are some patients that may have been accessing services at a later date; therefore existing services may be redirected earlier as a result of implementation thereby improving the way resources are used. 3.2 Benefits and savings Background It could be anticipated that the patient benefits of improved mortality, increased functional capacity and improved quality of life could result in health service savings. Not all the savings may be cash releasing, but they may allow for the redirection of resources to deal with other increasing demands. Table 5 below shows the relevant savings that may arise by implementing this guideline. Assumptions made An estimated 22% of patients can undergo early mobilisation treatment, of these it is assumed 20% may leave critical care earlier The estimated 22% of patients who can undergo early mobilisation physiotherapy during critical care stay is based on the findings of the Lancashire and South Cumbria critical care network audit 18 of 28

19 (2006). This percentage has been used to ascertain patient numbers who can undergo this treatment, and then applied to the unmet need identified in the audit report It is estimated that 20% of patients will stay in level 2 or level 3 critical care for a shorter time if the guideline is implemented, and the same proportion will stay on the general ward for a shorter time. This percentage is based on expert opinion and takes into account that not all patients who can receive early mobilisation treatment may benefit from it, or that they may not be discharged earlier from critical care or general ward care because of other factors The savings in general ward length of stay are with reference to the results of a trial of 330 patients carried out by Morris PE et al (2008) on early intensive care unit mobility therapy in the treatment of acute respiratory failure. The study compared 165 patients with acute respiratory failure who were treated with a physical therapy mobility protocol to 165 who received usual care. Outcomes were assessed in patients who survived to hospital discharge. There were no reported adverse events during mobility activities. The findings showed that the mean duration of hospital stay was shorter with early physical therapy (by 3.3 days) compared with usual care It is acknowledged that this is a US trial and the data is not reflective of all people admitted to general critical care. The results have therefore been adjusted to an average of 2 days after gaining expert opinion. The number of days has been applied to the average tariff cost per bed day relating to lobar atypical or viral pneumonia (HRG codes DZ11 A, B and C). These codes have been used with reference information on critical care admissions by Harrison DA et al (2004) which indicate that pneumonia is one of the most common reasons for admission to critical care. This gives an average cost per bed day of 174 when uplifted by the national 19 of 28

20 market forces factor, and produces potential savings of 1.7 million annually when applied to the estimated total reduction in days of 4,840 annually for patients in England The potential for savings as a result of patients spending less time in level 2 critical care because of timely initiation of rehabilitation is supported by data presented by McWilliams D (2006) and by expert opinion. This suggests early mobilisation such as getting the patient to sit on the edge of the bed or turning the patient at frequent intervals (where it is possible and will benefit the patient), can reduce level 2 critical care stay by up to 5 days for long-stay critical care (more than 4 weeks) and 1 day for short-stay critical care (up to 1 week). An average reduction of 2 days has been used based on data produced by ICNARC on length of stay in general critical care units during 2006 and The weighted average tariff cost per day for level 2 and level 3 critical care is 1,159 based on the number of occupied bed days for each category of general critical care and applied to the respective cost per bed day in the National Schedule of Reference Costs 2006/07. This has been inflated to prices using a 3.5% annual increment, and uplifted using the national average market forces factor for to provide a current estimated cost of 1,390 per day. This produces potential savings of 13.4 million when applied to the estimated total reduction in days of 4,840 annually for patients in England. 20 of 28

21 Table 5 Potential savings arising from implementation Description Estimated annual savings ( 000s) Reduced length of stay on general wards as a result of early mobilisation 1,684 Reduced length of critical care stay as a result of early mobilisation 13,455 Total 15,139 4 Sensitivity analysis 4.1 Methodology There are a number of assumptions in the model for which no empirical evidence exists. Because of the limited data, the model developed is based mainly on discussions of typical values and predictions of how things might change as a result of implementing the guideline and is therefore subject to a degree of uncertainty As part of discussions with practitioners, we discussed possible minimum and maximum values of variables, and calculated their impact on costs across this range. It should be acknowledged that estimates have come from small unpublished studies and expert opinion; therefore we have used broader parameters for minimum and maximum values in the sensitivity analysis Wherever possible we have used the national tariff plus market forces factor to determine cost. We used the variation of costs for the 25th and 75th percentiles from reference costs compared with the reference cost national average as a guide to inform the maximum and minimum range of costs It is not possible to arrive at an overall range for total cost because the minimum or maximum of individual lines would not occur simultaneously. We undertook one-way simple sensitivity analysis, 21 of 28

22 altering each variable independently to identify those that have greatest impact on the calculated total cost Appendix B contains a table detailing all variables modified and the key conclusions drawn are discussed below. 4.2 Impact of sensitivity analysis on costs Estimated percentage of patients needing reassessment following ward-based checks The estimated percentage of patients needing reassessment following ward-based checks drives the potential number of patients in need of rehabilitation follow-up services, which in turn drives the capacity needed to deliver services. Because of the type of costs involved, that is, professional medical staff, small variations in numbers can result in significant cost variations. When the baseline percentage of 70% is varied to a minimum value of 50% and a maximum value of 80% this produces a cost variation of million. Estimated percentage of patients needing rehabilitation follow-up services after ward-based checks The estimated baseline percentage of patients needing rehabilitation follow-up services as a result of clinical reassessment is 85%. This is based on expert opinion. When this is varied to a minimum value of 70% and a maximum value of 90% this produces a cost variation of million. Potential savings reduced length of critical care stay The baseline value for the percentage of patients with reduced critical care stay following early mobilisation is estimated at 20%. When this is varied to a minimum value of 5% and a maximum value of 30% this produces a variation in savings of 19 million. This also takes into account patient numbers and the daily cost of critical care. 22 of 28

23 4.2.4 The potential savings from reduced length of critical care stay is driven by the percentage of patients who can undergo early mobilisation treatments, and the proportion of those patients who leave critical care earlier than the target length of stay for their condition. The baseline proportion of patients who can undergo early mobilisation exercises during critical care stay is 22%. When this is varied to a minimum of 15% and a maximum of 30% this produces a variation in savings of 10.3 million. This takes into account patient numbers and the cost per day of ICUs. 5 Impact of guidance for commissioners The current tariff is indicative for critical care which includes rehabilitation, but PCTs may commission on different terms. Follow-up rehabilitation services in the community are outside the scope of payment by results. Programme budgeting Depending on the underlying reason for critical care admission, this activity may fall across a number of programme budgeting categories. 6 Conclusion 6.1 Total national cost for England Using the significant resource-impact recommendations shown in table 1 and assumptions specified in section 3 we have estimated the annual cost impact of fully implementing the guideline in England to be 13.5 million. Table 8 below shows the breakdown of cost of each significant resource-impact recommendation. 23 of 28

24 Table 6 Estimated annual cost impact of implementing the guideline in England Elements of recommendations that will have a resource impact Estimated costs/savings ( 000s) Additional costs - multidisciplinary rehabilitation teams (recommendations ) 28,656 Potential savings as a result of early intervention and multidisciplinary follow-up services 15, We applied reality tests against existing data wherever possible, but this was limited by the availability of detailed data. We consider this assessment to be reasonable, given the limited detailed data regarding diagnosis and treatment paths and the time available. However, the costs presented are estimates and should not be taken as the full cost of implementing the guideline In order to realise the potential savings, the full range of coordination of care and capacity needed for early and multidisciplinary interventions would need to be implemented fully, and within a short time period, to ensure services achieve the streamlined referral process and continuity of services recommended in the guideline. 6.2 Next steps The local costing template produced to support this guideline enables organisations such as PCTs or health boards in Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that a population of 100,000 could expect to incur costs of 56,506. Use this template to calculate the cost of implementing this guidance in your area. 24 of 28

25 Appendix A. Approach to costing guidelines Guideline at first consultation stage Identify significant recommendations and population cohorts affected through analysing the clinical pathway Identify key cost drivers gather information required and research cost behaviour Develop costing model incorporating sensitivity analysis Draft national cost- impact report Determine links between national cost and local implementation Internal peer review by qualified accountant within NICE Develop local cost template Circulate report and template to cost -impact panel and GDG for comments Update based on feedback and any changes following consultations Cost -impact review meeting Final sign off by NICE Prepare for publication in conjunction with guideline 25 of 28

26 Appendix B. Results of sensitivity analysis Costing template for rehabilitation after critical illness Sensitivity analysis Assessment of sensitivity costs to a range of variables Parameter varied Baseline value Minimum value Maximum value Baseline costs ( 000s) Minimum costs ( 000s) Maximum costs ( 000s) Change ( 000s) Vary all parameters including incidence, unit costs and activity assumptions Estimated proportion of patients for reassessment following wardbased checks 70% 50% 80% 28,656 23,289 31,340 8,051 Estimated proportion of whom in need of rehabilitation follow-up services 85% 70% 90% 28,656 25,341 29,762 4,421 Estimated proportion patients in need of psychiatric assessment/therapies 28% 20% 35% 28,656 26,518 30,528 4,010 Estimated proportion of patients in need of additional physiotherapy in the community 50% 40% 60% 28,656 26,764 30,549 3,785 Estimated proportion of patients needing other therapies such as occupational therapy, speech therapy 15% 10% 20% 28,656 28,043 29,270 1,227 Potential savings Estimated proportion of patients with reduced ICU stay 20% 5% 30% -15,139-3,785-22,709-18,924 Estimated proportion of patients who can undergo mobilisation excercises during critical care stay (impact on ICU savings) 22% 15% 30% -15,139-10,322-20,645-10, of 28

27 Appendix C. References 1. Allied healthcare professional audit of unmet need in critical care stage 2006 for Lancashire and South Cumbria Critical Care Network 2. Curtis L, (2008) Units Costs of Health and Social Care. Personal Social Services Research Unit, University of Kent 3. Harrison DA, Brady AR, Rowan K (2004) Case mix, outcome and length of stay for admission to adult, general critical care units in England, Wales and Northern Ireland. Critical Care 2004, 9:S1-S13. Available from Graham BJM (2002) Cost analysis of The Heart Manual. Edinburgh: Information Services Division 6. Jones C (2008) ICU follow-up can we predict the problems? Journal of the Intensive Care Society 9: Available from journal.ics.ac.uk/pdf/ pdf 7. Lewin B, Robertson IH, Cay EL, et al. (1992) Effects of self-help postmyocardial infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992; 339: McWilliams D (2006) Rehabilitation within critical care. Presentation at Manchester Royal Infirmary. Available from 9. Morris PE et al (2008) Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical care medicine 2008: 36 (8) Available from ng=f1000,f1000m,isrctn 10. National Institute for Health and Clinical Excellence (2009) Rehabilitation after critical illness (scope). NICE clinical guideline 83. Available from P Skirrow et al (2001) Intensive care easing the trauma. The Psychologist volume 14 no UK Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme (CMP) Summary Statistics ( ). Available from 27 of 28

28 Appendix D NHS trusts covered in the Lancashire and South Cumbria audit of unmet need in critical care Blackpool, Fylde and Wyre Hospitals NHS Trust East Lancashire Hospitals NHS Trust Lancashire Teaching Hospitals NHS Foundation Trust North Cumbria Acute Hospitals NHS Trust Wyre Primary Care Trust Morecambe Bay PCT Preston PCT Units that took part in the audit were: Blackpool and Victoria Hospital Blackburn Royal Infirmary Burnley General Hospital Chorley and Sounth Ribble DGH Royal Preston Hospital Furness General Hospital Lancaster Royal Infirmary West Cumberland Hospital 28 of 28