Cost study on spinal cord injury rehabilitation care in Sweden

Transcription

1 Cost study on spinal cord injury rehabilitation care in Sweden Version: Final Date: Quantify Research Authors Name: Anders Gustavsson Name: Linda Karlsson Title: Partner Title: Senior Researcher Phone Phone Name: Stefanie Luthman Title: Researcher Phone

2 Table of contents 1. Introduction Background Rationale Objectives Methods Questionnaire to clinics Development and distribution of questionnaire Responding clinics Primary rehabilitation Re-admissions Outpatient and day care visits Staff Facilities at the clinic Questionnaire to SCI-specialists Unit costs Model Results Base case analysis Care provision Staff resources and facilities Costs One-way sensitivity analysis Sensitivity analysis 1: Including total number of visits when determining number of full-time employees in decentralised care Sensitivity analysis 2: Assuming equal occupancy rates in decentralised and centralised care Sensitivity analysis 3: Assuming the SCI-experts underestimated the true staff-need with 10%, hence increasing the full-time employees needed by 10% in centralised care Multi-way sensitivity analysis Sensitivity analysis Sensitivity analysis Discussion Staffing costs

3 4.2 Acute care costs Facility costs Re-admissions and outpatient visits Care at home Other benefits Model limitations Conclusions References Appendix A: Questionnaire to clinics Appendix B: Questionnaire to SCI-specialists

4 Study Glossary Term Average DRG ESCIF KPP SCI SCIC Definition Arithmetic mean diagnosis-related-groups European Spinal Cord Injury Federation Cost per patient Spinal Cord Injury Spinal Cord Injury Centre Weighted average Average based on number of patients in primary rehabilitation 2012 or number of incident patients in

5 1. Introduction 1.1 Background Spinal cord injuries are damage or trauma to the spinal cord that results in a loss or impaired function causing reduced mobility or sensibility. Common causes of a spinal cord injury are falls, diving accidents, car accidents or disease [1]. While the incidence of spinal cord injury (SCI) is relatively low, the physical, medical, psychological, social and financial consequences of such injuries are highly complex and, potentially, devastating for the injured person and his/her family [2]. It is therefore important for these patients to receive the best care possible to make their re-integration back into society after injury as successful as possible. The rehabilitation care of SCI-patients today is decentralised to different hospitals around the country. These clinics do not only care for SCI-patients but also care for other patients in primary rehabilitation (e.g. patients with stroke and traumatic brain injuries). The Swedish Association for Survivors of Accident and Injury (RTP) [3] has for a long time worked for the establishment of centralised rehabilitation care for SCI-patients in Sweden. By centralizing the care for SCI-patients to 2-4 spinal cord injury centres (SCIC), these centres would specialize on SCI-care and possibly be able to provide better care for this specific patient group. Centralization also enable specialisation of staff, more focus on research and innovation, knowledge and information pooling, availability of role models during rehabilitation (so called peer-support) and economies of scale. A thorough description of centralised care, what it should include and potential benefits are presented in a report from the European Spinal Cord Injury Federation (ESCIF) [2]. ESCIF and its members also work to promote centralised care of SCI-patients [4] which today is available in other countries such as Denmark, Norway, Switzerland, the United States and Australia. 1.2 Rationale Although many experts seem to agree that centralization would lead to better care for SCI-patients, little or no evidence of the potential benefits are available. This may be explained by the low incidence of SCI and high variation in the injury, opportunities for rehabilitation and outcomes of the patients. These factors make any comparative study on alternative interventions within Sweden (e.g. decentralized or centralized care) very difficult. Comparisons across countries are also difficult to interpret because there are a range of differences in care structure and other circumstances which may all be potential causes of any differences in outcomes. In absence of feasible ways of showing that centralisation causes improved care for SCI patients, this study will focus on the potential changes in costs by centralization of SCI-care. By learning more about the costs of centralization, decision makers will have more information at hand when considering centralization. Estimations of costs will necessarily need to be estimated aided by assumptions because we don t know how an actual centralised organisation would turn out, what resources would be needed exactly and what potential effects the centralisation process would have on today s care providers. For this reason, an economic model was developed, combining available data and various assumptions to estimate care and resource needs as well as their costs. 4

6 1.3 Objectives The aim of this study was to compare the available resources and costs for today s decentralised care of SCI-patients with the resources and costs that are expected to be needed in a hypothetical scenario where the care of the same patients would be centralised to fewer sites. The study aims to answer the below listed questions: What are the available resources and costs for rehabilitation of SCI-patients in Sweden today? How would a hypothetical centralised care of SCI-patients in Sweden be organised regarding resources and costs? What differences in total costs are expected with centralised care? Is there a difference between costs for today s decentralised care and for a hypothetical centralised care? 2. Methods Two questionnaires were prepared to collect data on the current and potential care and resource use in today s decentralised scenario and a hypothetical centralised scenario, respectively (see appendices A and B). These data were analysed and the results are summarised below. Data on costs of units of resources were derived from price lists and other publicly available sources, and also summarised below. The responses from the questionnaire and the unit costs where then used as inputs in a model comparing rehabilitation care today (decentralised care) and a hypothetical SCIC scenario (centralised care). The model used is presented in section Questionnaire to clinics Development and distribution of questionnaire The questionnaire was developed by Quantify Research together with SCI-specialists [5-8] and an expert from Personskadeförbundet RTP [9] to capture all relevant resource use both related to all care at the clinic and to SCI-patients only. The questionnaire included questions regarding primary rehabilitation, re-admissions, outpatient visits, day care visits, staff and facilities at the clinic (see appendix A). Twenty-six clinics were identified and considered for inclusion. Three clinics were excluded (Mälarsjukhuset Eskilstuna, Skaraborgs sjukhus in Skövde and Södra Älvsborg Sjukhus in Borås) for the following reasons; one did not report any patients in primary rehabilitation, one sent in the questionnaire after all the analyses had been conducted and one referred all SCI-patients to other hospitals and did therefore not have any SCI-patients. Before distributing the questionnaire, the clinics were contacted by phone and asked to participate. The questionnaire was thereafter e- mailed to the clinics, and they were reminded both by and phone if not responding in time Responding clinics Of the remaining 23 clinics, 20 responded (response rate = 87%) and the responding clinics are listed below: Akademiska sjukhuset in Uppsala Blekingesjukhuset in Karlshamn Centralsjukhuset in Karlstad 5

7 Karolinska Universitetssjukhuset in Stockholm Länssjukhuset Centrallasarettet in Växjö Länssjukhuset in Halmstad Länssjukhuset Sunderby in Luleå Länssjuhuset Sundsvall/Härnösand Länssjukhuset Ryhov Norrlands Universitetssjukhus (NUS), Umeå RehabStation Stockholm Rehabiliteringsenheten, Sahlgrenska Universitetssjukhuset in Gothenburg Ryggmärgsskadeenheten, Sahlgrenska Universitetssjukhuset in Gothenburg Sandvikens sjukhus Skånes Universitetssjukhus in Höör Stockholms sjukhem Universitetssjukhuset in Linköping Universitetssjukhuset in Örebro Västmanlands sjukhus in Västerås Östersunds sjukhus Time constraints were the main reason for three clinics not participating (Falu lasarett, Uddevalla sjukhus and Västerviks sjukhus). In the following sub-sections preliminary variables received from the questionnaire are described and the majority of these were later used as input in the model described in section Primary rehabilitation The number of patients and length of stay in primary rehabilitation are presented in Table 1. In total 2,310 patients (18 responding clinics) were in primary rehabilitation during 2012 (including all patients at the clinic irrespective of whether a spinal cord injury was the cause of rehabilitation). We did not ask how many of these were hospitalised in 2012 (i.e. incident patients) but they can be estimated to 1,960 patients assuming that the average length of stay did not change over time. Table 1 Primary rehabilitation in today s decentralised care of SCI-patients Number of responding clinics Mean Sd Min Median Max Adjusted mean 1 Average number of patients in primary rehabilitation during 2012 per clinic All patients SCI-patients Average number of incident patients in 2012 per clinic 3 All patients SCI-patients Average number of days per hospitalisation in primary rehabilitation per patient All patients SCI-patients Adjusted mean across all responding clinics based on total number of SCI-patients and their average care time at each clinic. 2. Two clinics only reported results for their SCI-patients. 3. Estimated assuming that the average length of stay did not change over time. 6

8 Considering SCI-patients only; 20 clinics reported a total of 422 patients in primary rehabilitation during 2012 and the estimated number of incident patients in 2012 was 350. Transferring from one clinic to another during a patient s primary rehabilitation was not captured in the questionnaire. Based on the SCI-specialists knowledge regarding transfers it was assumed that the total adjusted number of incident SCI-patients in 2012 was about 270 (13.5 incident patients per clinic). To estimate the length of stay for patients in primary rehabilitation the questionnaire included a question regarding the average number of days per hospitalisation at the clinic. The weighted average across all clinics (based on number of SCI-patients in primary rehabilitation in 2012 and their average hospitalisation time in each clinic) was 61.7 days. The average total number of days in primary rehabilitation (including potential transfers) was estimated to 80 days. This was calculated by multiplying the weighted average number of days per hospitalisation per clinic (61.7) with the total number SCI-patients in all responding clinics (350) and dividing by the estimated number of unique incident patients (270) Re-admissions Table 2 Re-admissions in today s decentralised care of SCI-patients Number of responding clinics Mean Sd Min Median Max Adjusted mean Number of re-admissions per clinic All patients SCI-patients Average number of days per hospitalisation for re-admitted SCI-patients SCI-patients Adjusted mean across all responding clinics based on the number of incident SCI-patients 2012 in primary rehabilitation. 2. Eight clinics reporting at least one re-admission. 3. Adjusted mean across all responding clinics based on number of re-admissions and total hospitalisation time for these re-admissions at each clinic. Re-admissions during 2012 were also asked for in the questionnaire and the results are summarised in Table 2. A total of 235 re-admissions (12 responding clinics) were reported for all patients at the clinics with an average of 19.6 re-admissions per clinic. Considering SCI-patients, there were 133 readmissions (13 responding clinics) with an average of 10.2 re-admissions per clinic. Weighting the average number of re-admissions based on the clinic s size (number of incident SCI-patients in primary rehabilitation) resulted in a weighted average of 21.3 re-admissions for SCI-patients per clinic. The weighted average number of days per hospitalisation at the clinics for re-admitted patients was estimated to 13.5 days (based on the eight clinics reporting re-admitted SCI-patients). In addition, for the eight clinics, a ratio of re-admissions / primary rehabilitations in 2012 was calculated. No clear pattern between re-admissions and primary rehabilitation for SCI-patients was seen between larger/smaller clinics (see Figure 1). 7

9 Number of re-admitted SCI-patients / number of SCI-patients in primary rehabilitation Number of patients in primary rehabilitation 2012 Figure 1 Correlation between number of admissions and patients in primary rehabilitation Outpatient and day care visits Clinics were asked to report the total number of outpatient and day care visits (including for example physician visits for prescription of medical drugs, physiotherapist/occupational therapist training visits and nurse visits for care of pressure sores). Table 3 presents outpatient and day care visits separately and in total. The total row in Table 3 includes 6 clinics which were not able to separate outpatient/day care visits and/or to separate SCI-patients visits from the total number of visits. A problem with the above results was that several clinics with outpatient/day care visits had only reported physician visits excluding any other outpatient/day care visits. Therefore calculations were also performed by only including 7 clinics reporting the complete range of possible visits, raising the mean number of outpatient/day care visits from 566 to In addition, a weighted (based on number of incident SCI-patients in 2012) average ratio (0.7) was calculated as number of visits divided by number of primary rehabilitation days in 2012 for the reporting clinics which had at least one outpatient or day care visit. Table 3 Outpatient and day care visits for SCI-patients Number of responding clinics Mean Sd Min Median Max Ratio 1 Number of visits per clinic Outpatient visits Day care visits All visits All visits only including clinics reporting all possible visits Weighted average ratio of outpatient and day care visits divided by total number of hospitalisation days in primary rehabilitation for SCIpatients in 2012 at responding clinics. 2. Outpatient and/or day care visits. 8

10 2.1.6 Staff The clinics were asked for number of full-time employees for the below listed groups: Administrative assistant Counsellor Dietician Head of administration Nurse Nursing assistant Occupational therapist Psychologist Physician Physiotherapist Rehabilitation assistant Speech therapist Urotherapist Other, please state They were also asked to state, if possible, percentage of the employees time that was intended for SCI-patients. Seven clinics were able to report how much of their employees working time that was spent on SCI-patients (see Table 4 for number of full time employees working with SCI-patients). Table 4 Number of full-time employees working with SCI-patients Number of responding clinics Mean Sd Min Median Max Administrative assistant Counsellor Dietician Head of administration Nurse Nursing assistant Occupational therapist Psychologist Physician Physiotherapist Rehabilitation assistant Speech therapist Urotherapist To estimate how staff intensive the decentralised clinics were on average, two ratios (number of employees per 10,000 hospitalisation days) and (number of employees per 10,000 hospitalisation days and visits) were calculated for each clinic. Two out of the seven clinics (29%) did not have 9

11 complete information regarding number of outpatient and/or day care visits which resulted in that the estimated ratio including visits was based on fewer clinics compared with only considering hospitalisations. In addition, a weighted average of full-time employees per 10,000 hospitalisation days or per 10,000 hospitalisation days + visits were calculated for each occupation based on the ratios calculated for each clinic. The weighting was based on number of SCI-patients in primary rehabilitation The results are presented in Table 5 and Table 6. As can be seen, nurses and nursing assistants were the most resource intensive occupations. Table 5. Number of full time employees working with SCI-patients, per hospitalisation days (both including patients in primary rehabilitation and re-admitted patients) Number of responding clinics Mean Sd Min Median Max Weighted mean 1 Administrative assistant Counsellor Dietician Head of administration Nurse Nursing assistant Occupational therapist Psychologist Physician Physiotherapist Rehabilitation assistant Speech therapist Urotherapist Weighted mean across all responding clinics based on number of SCI-patients in primary rehabilitation

12 Table 6. Number of full time employees working with SCI-patients, per hospitalisation days and visits (both including patients in primary rehabilitation/re-admitted patients and outpatient/day care visits to the clinic) Number of responding clinics Mean Sd Min Median Max Weighted mean 1 Administrative assistant Counsellor Dietician Head of administration Nurse Nursing assistant Occupational therapist Psychologist Physician Physiotherapist Rehabilitation assistant Speech therapist Urotherapist Weighted mean across all responding clinics based on number of incident SCI-patients in primary rehabilitation Facilities at the clinic The clinics were asked how many inpatient beds they had in total and how many of these were intended for SCI-patients. In today s decentralised care no beds are reserved for SCI-patients, however these patients are a prioritised group when injured. The occupancy rate for each clinic was therefore calculated based on all patients and all available beds at the clinics. According to ESCIF [2] all rooms at a SCIC should be equipped with: Electric, height-adjustable beds Fully-adapted toilet and bathroom facilities Ceiling hoists/lifts and other appropriate aids. In addition the following facilities should be present: Access to patients mini bus Access to specialised driving tuition Day room Dental facilities Dining area Family accommodation Fitness room and sports hall Helicopter pad Internet café Isolation rooms en-suite 11

13 Kitchen facilities Library Meeting room/consultation room Offices and facilities for personnel and therapists employed Outdoor recreational and training facilities Restaurant (staff, patient, visitor) Seating and posture clinic Shop Swimming pool Training apartments Twin bedded rooms en-suite (for patients and carer/personal assistant) Vocational training facilities The share of clinics where all rooms were equipped with electric/height-adjustable beds, fully adapted bathroom facilities and ceiling hoists/lifts are presented in Figure 2, whereas the share of clinics which had access to the above described facilities are presented in Figure 3. Ceiling hoists/lifts and other appropriate aids. Fully-adapted toilet and bathroom facilities Electric, height-adjustable beds 0% 20% 40% 60% 80% 100% Share of the clinics where all rooms have the above described equipment Figure 2. Share of clinics where all rooms are equipped with ceiling hoists/lifts and other appropriate aids, fully-adapted toilet and bathroom facilities and electric height-adjustable beds 12

14 Share of clinics that had access to the below described facilities 100% 80% 60% 40% 20% 0% Figure 3. Share of the responding clinics which had access to facilities described by ESCIF 2.2 Questionnaire to SCI-specialists Four SCI-specialists (Håkon Ro, Skåne Universitetssjukhus, Per Ertzgaard, Linköpings Universitetssjukhus, Claes Hultling, Karolinska Universitetssjukhuset/ Spinalis Stockholm and Richard Levi, Umeå Universitetssjukhus) [5-8] were given a questionnaire (see appendix B) in which they were asked to visualise a SCIC in Sweden with the following characteristics: Primary rehabilitation: SCI-patients are referred to the centre from acute/emergency care once medically stable and all relevant decisions on surgical interventions have been made. One centre was assumed to care for approximately 70 incident SCI-patients per year (4 centres in total). Reintegration in the community resource: The centre is responsible for a patient s reintegration in society including contact with the patient s employer, 24-hour-phone service with physicians, physiotherapists in general practice and local caregivers, and for conducting home visits in the patient s community. Re-admissions: The centre is responsible for re-admissions of patients that have ended their rehabilitation at the centre. An estimated 30% of patients in primary rehabilitation are assumed to be re-admitted during their life-time. Life-long follow-up: The centre should follow-up on each patient that has ended his/her primary rehabilitation at the centre on a regular basis including home visits, specialised outpatient care if needed and contact with local care providers. Assuming the above, the SCI-specialists were asked questions regarding capacity for re-admissions, outpatient/day care visits, home-visits, how many inpatient beds and full-time employees that are needed for each centre in order to maintain the above described scenario. 13

15 Two SCI-specialists (Expert A) completed the questionnaire together and had pictured a SCIC following the above description and imagined how a future SCIC would be organised in their area of work (more rural area). Another SCI-specialist (Expert B), working at a SCI-specialist centre in a more urban area today had looked at how the care of their SCI-patients was managed in 2012 and from that imagined an increase in patients and resources needed by 35%. Hence, when estimating how many re-admissions the centre would have capacity for the SCI-expert first considered how many readmissions the centre had in 2012 and assumed a 35% increase to arrive at the number of readmissions in a centralised scenario. The same calculation was done when estimating number of hospital beds, number of visits (outpatient/day care/home visits) and staff resources needed. The results are presented in Table 7 and Table 8. Table 7. Estimated capacity (by SCI-specialists) for a SCIC assuming 70 incident SCI-patients/year, centre responsible for patient s re-integration in society, re-admissions and life-long follow-up of patients who have completed primary rehabilitation at the centre Expert A Expert B Number of re-admissions/year Number of outpatient/day care visits Number of home-visits Number of hospital beds Outpatient visits only (Day care visits could not be estimated). 2. Number based on assumption that half of the SCI-population can go to the SCIC for a visit and the other half needs a home-visit. Table 8. SCI-specialists estimated number of full-time employees at the SCIC Expert A Expert B Administrative assistant Counsellor 2 3 Dietician 1 1 Head of administration 3 2 Nurse * Nursing assistant * Occupational therapist 6 6 Psychologist 1 1 Physician Physiotherapist 7 6 Rehabilitation assistant 2 2 Speech therapist Urotherapist 1 2 * Could not be estimated 14

16 2.3 Unit costs Average salaries for different types of staff were collected from Statistics Sweden [10] and were adjusted (+48%) to include social security contributions paid by the employer [11]. Total yearly salaries are presented in Table 9. Table 9. Average yearly salaries for employees including social fees Salary (SEK) Administrative assistant 526,655 Counsellor 507,083 Dietician 512,421 Head of administration 652,091 Nurse 541,482 Nursing assistant 434,135 Occupational therapist 482,174 Psychologist 619,176 Physician 1,047,972 Physiotherapist 487,512 Rehabilitation assistant 462,602 Speech therapist 535,551 Urotherapist 541,482 The yearly cost for one inpatient bed excluding staff resources and inventories was estimated in discussion with Maria Karlberg at Skåne University hospital [12]. The Spinal Cord Injury clinic at Skåne University hospital rent their premises (including 12 hospital beds, meeting rooms, dining areas, and offices for physicians/nurses/nursing assistants) for a total of 1.3 million SEK yearly. In addition the unit has a training facility together with three other clinics for a total cost of 6 million SEK yearly which is divided equally between the clinics (1.5 million per clinic). The training facilities include for example training rooms for occupational therapists/physiotherapists, fitness room, pool, conference and separate training rooms. The above information resulted in a total cost of 233,333 SEK ( million SEK divided by 12) per inpatient bed excluding staff resources. The cost for SCI-patients time spent in acute care was calculated using the cost per patient (KPP)- database available from the Swedish Association of Local Authorities and Regions (SKL) [13]. The KPPdatabase covers around 70% of the care episodes in the Swedish inpatient care and is built on diagnosis-related-groups (DRG) which is an administrative method to group care-contacts. To track costs for SCI-patients in the acute phase, DRG-codes of 004 (surgeries on spinal cord and surrounding tissue) and 009 (sickness and injuries related to the spinal cord) was searched for in the KPPdatabase. These DRG-codes correspond to the following main diagnoses in the ICD-10 system: S140, S141, S142, S143, S240, S241, S243, S340, S341, S342 and S343. A total of 4,093 hospitalisation days corresponding to 135 care episodes were located for these codes with a total cost of 40.3 million SEK. This resulted in an average cost per care-episode of 299,000 SEK. 15

17 An average from regional pricelists from Uppsala läns landsting [14] and Södra regionsnämnden [15] was used when pricing primary care visits to a physician (SEK 1,541). The cost of a visit to physiotherapists, occupational therapists and nurses was not reported separately but assumed to be the same (SEK 530). 2.4 Model An economic model was developed combining the data discussed in this method section to estimate the care provision, resource use and costs for the decentralised and centralised scenario, respectively. The model was based on the questionnaires and accounted for primary rehabilitation, re-admitted patients and patients visiting the clinics/future SCIC for outpatient and day care visits. A lot of assumptions were needed to fill gaps in the collected questionnaires where the respondents could not give any answer. These assumptions have been detailed below. The model did not consider that patients may transfer from one clinic to another during their primary rehabilitation. The model captured resources (including staff) needed to care for the estimated number of SCI-patients. Apart from the information received from the questionnaires the model also accounted for acute care and long-term care in the community setting. The different parts of the model and its results are presented in detail in section Results The model was based on the questionnaires and built in order to capture (as far as possible) all relevant parts/costs of care for SCI-patients. The care provided in the twenty responding clinics in today s scenario was compared to a hypothetical centralised scenario with 4 SCICs. Four SCIC was estimated to be needed based on 270 incident SCI-patients per year. The model can be divided into three different parts: Care provision Resources Costs Much of the data inputs going into the model are uncertain. We therefore first present a base case analysis which is a best guess based on input received from the questionnaires and key assumptions. Thereafter, the model inputs are modified in a set of sensitivity analyses showing how the results may change using different assumptions where there is uncertainty. 3.1 Base case analysis The results from the base case analysis is presented in Table 10 and discussed below Care provision Based on section it was assumed that there were 270 incident SCI-patients in Sweden each year resulting in 13.5 incident patients per centre today and 67.5 patients per SCIC. In discussion with SCIexperts it was assumed that 7000 prevalent SCI-patients live in Sweden. Incident SCI-patients were assumed to stay in primary rehabilitation for 80 days on average in both the decentralised and centralised scenario. This resulted in a total of 21,592 hospitalisation days in primary rehabilitation in 16

18 both scenarios with 1,080 hospitalisation days per clinic (20 in total) today and 5,398 hospitalisation days per SCIC (4 in total). No clear correlation between re-admissions and primary rehabilitation for SCI-patients was seen comparing larger and smaller clinics (see Figure 1). Therefore, we used the average number of readmitted patients (10.2) rather than the weighted average (21.3) when estimating number of readmitted patients per year and clinic for decentralised care in the model. For centralised care, the SCI-experts estimations varied from 15 to 46 re-admissions per centre. Expert B s estimation of 46 readmissions per year and centre was used in the base case analysis after agreement from Expert A. The weighted average length of stay for re-admitted patients (13.5) retrieved from the questionnaire was used for both decentralised and centralised care when calculating number of hospitalisation days for each scenario. A total of 2,754 hospitalisation days for decentralised care (138 per clinic) and 2,484 hospitalisation days for centralised care (621 per SCIC) were estimated. Common reasons to why SCI-patients may need to see a physician, nurse, physiotherapist etcetera in an outpatient or day care setting are urinary tract infections (UTI), pressure sore assessment, prescriptions, nociceptive- neurogenic pain, autonomic dysreflexia, orthostatic hypotension, legal matters, fecal/urinary incontinence, life style associated disorders and neurological assessment. There are no data available on how often these visits occur in practice today but there is undoubtedly high variation across patients. When estimating the number of outpatient and day care visits per clinic in today s decentralised care the ratio (number of visits divided by number of hospitalisation days in primary rehabilitation 2012) described in section was multiplied with the total estimated number of hospitalisation days in primary rehabilitation per clinic (1,080). This resulted in a total of 15,468 visits (773 visits per clinic, 20 clinics). For the centralised scenario, the SCI-experts estimations regarding visits (including outpatient, day care and home visits) varied from ~1,200 to ~1,500 per SCIC. In the base case model it was assumed that each SCIC had 1,500 visits, resulting in a total of 6,000 visits. This resulted in a difference of ~9,500 visits between decentralised and centralised care. In a centralised scenario, it is anticipated that many of these visits will take place in primary care instead. Because many patients will have farther to travel to a SCIC, they are assumed to go to a local care provider with some of their needs. It is unknown how many primary care visits SCI-patients have on average during a year. In the model, we assume that SCI-patients on average see a general practitioner 2 times a year and a physiotherapist, nurse or occupational therapist 5 times a year in a primary care setting. It is furthermore assumed that 95% of the 9,500 fewer visits in centralised care would take place in primary care instead and that half of these additional primary care visits are to a physician and the other half to a physiotherapist, nurse or occupational therapist. A 5% decrease in total outpatient, day care, home and/or primary care visits is expected in a centralised scenario. Due to the longer transportation (in some cases) between acute care and primary rehabilitation, SCIpatients in a centralised scenario are assumed to stay longer (5%) in acute care compared with a decentralised setting. 17

19 Table 10. Estimated care of SCI-patients in decentralised and centralised care Care for SCI-patients Decentralised Centralised Number of incident patients Number of centres 20 4 Average number of incident patients per centre Number of prevalent patients 7,000 7,000 Primary rehabilitation Number of unique admissions in primary rehabilitation per centre Average number of days per hospitalisation in primary rehabilitation Total number of hospitalisation days in primary rehabilitation per centre 3 1,080 5,398 Long-term follow-up Total number of re-admissions per centre Average number of re-admissions per primary rehabilitation Average number of days per hospitalisation for re-admitted patients Total number of hospitalisation days for re-admitted patients per centre Total number of hospitalisation days per centre 8 1,217 6,019 Total number of outpatient and day care visits 9 per centre 773 1,500 Number of visits per hospitalisation days /20 vs. 270/4 2. Based on assumption on the share of patients transferring from one clinic to another and the weighted average hospitalisation time for a clinic *80 vs. 67.5*80 4. Average number of visits from the questionnaire to clinics vs. SCI-experts estimation of number of re-admitted patients to a SCIC. 5. Total number of re-admissions per centre divided by average number of incident patients per centre. 6. Weighted average of days per hospitalisation for re-admitted patients. Retrieved from the questionnaire to clinics and based on centres reporting at least one re-admitted SCI-patient *13.5 vs. 46*13.5, 8. Including both patients in primary rehabilitation and re-admitted patients 9. Outpatient and day care visits. Home visits are included in centralised care, but were not captured in the questionnaire to the clinics. 10. Total number of visits divided by total number of hospitalisation days per centre Staff resources and facilities In the base case scenario it was decided to use staff weighted ratios calculated using hospitalisation days only compared with including outpatient and day care visits as well (see section 2.1.2). This was decided due to the fact that estimations including more clinics could be utilised. However, including visits as well for the staff calculation was accounted for in sensitivity analyses. The weighted ratios for each occupation were multiplied with the estimated total number of hospitalisation days (1,217) per centre in order to estimate average number of staff for one decentralised centre. For the centralised scenario the SCI-experts estimated how staff-intensive a 18

20 SCIC would be, based on the description presented in section 2.2. In situations where the SCI-experts gave different estimates, an average number of staff was calculated with the following exceptions: Expert B s estimations for nurses and nursing assistants were used since Expert A had not estimated these. In addition, Expert A s answer for total number of physicians was used since their estimates had included time for research. Table 11. Number of full-time employees per centre and per 10,000 hospitalisation days in the base case model for decentralised and centralised care Full time employees per centre Full-time employees per 10,000 hospitalisation days Number of full-time employees Decentralised Centralised Decentralised Centralised Administrative assistant Counsellor Dietician Head of administration Nurse Nursing assistant Occupational therapist Psychologist Physician Physiotherapist Rehabilitation assistant Speech therapist Urotherapist Total number of full-time employees per centre Total number of full-time employees for all centres Total number of full-time employees per 10,000 hospitalisation days The results from the staff calculations are presented in Table 11. In both the decentralised and centralised scenario, nurses and nursing assistants were the most resource intensive occupations. Including all occupations, a total of 14.2 full-time positions per centre (284 in total) were estimated in decentralised care and 58.2 full-time positions per centre (233 in total) in centralised care. Hence, a 20% lower staff need was seen in a hypothetical centralised care compared to today s decentralised care. Possible explanations to this difference are discussed in section 4. The results of average occupancy rate and average number of hospital beds needed are shown in Table 12. The SCI-experts estimations of needed number of hospital beds per SCIC varied between 15 and 18. In the base case model it was assumed that an average of 17 hospital beds was needed at each SCIC. Together with the calculated total number of hospitalisation days for SCI-patients during 2012 (both in primary rehabilitation and for re-admitted patients) this resulted in a total occupancy 19

21 rate of 95%. For decentralised care, the total occupancy rate for all patients was calculated using the number of hospital beds and the estimated total number of patients in primary rehabilitation 2012 and re-admitted patients. Two clinics had not reported total number of patients and were therefore excluded from this calculation. For the clinics which were unable to report re-admissions these were estimated by using the weighted average ratio of total number of re-admissions/all patients in primary rehabilitation 2012 (0.4) for the clinics which reported both. This ratio was thereafter multiplied with the number of patients in primary rehabilitation 2012 to receive the estimated number of re-admitted patients per clinic. Thereafter the weighted average of hospitalisation days for all re-admitted patients (13.8) was multiplied with the estimated number of re-admitted patients to get total hospitalisation days. The estimates of number of hospital beds and total hospitalisation days in primary rehabilitation/re-admissions resulted in a weighted average occupancy rate of 87% with a total need of 4 hospital beds per clinic. Table 12. Occupancy rates for decentralised and centralised care Decentralised Centralised Assumed bed occupancy rate 87% 95% Number of hospital beds per centre 4 17 Total number of hospital beds for all centres Costs Table 13. Summary of the costs for decentralised and centralised care Per incident patient (SEK) Per centre (million SEK) The whole country (million SEK) Decentralised Centralised Decentralised Centralised Decentralised Centralised Acute/ emergency care 299, , Centre -Staff 558, , Facilities 66,485 58, Subtotal 624, , Care at home 148, , Total 1,072,320 1,029, Change with centralised care -43,

22 A summary of the costs for decentralised and centralised care is presented in Table 13. The cost for acute care was estimated to be 5% higher per patient in a centralised setting compared to a decentralised setting due to longer transportations to reach a SCIC. For the whole country this resulted in a cost difference of 4 million SEK. Costs for staff resources were estimated to be higher in decentralised care compared to centralised care. Per patient a cost difference of ~84,000 SEK was seen and cost-savings in a centralised scenario were estimated to a total of 23 million SEK. Costs for facilities were higher in a decentralised setting with a difference of 2 million SEK in the whole country compared with a centralised setting. Due to the increase in primary care visits in a centralised setting this cost was estimated to be higher in a centralised scenario compared to decentralised care (total cost difference: 9 million SEK). In summary, the total costs of care for SCI-patients would according to our base case model be lower (-12 million SEK) with centralised care compared with decentralised care. The cost savings can mostly be derived to the lower staff costs in a centralised scenario. 3.2 One-way sensitivity analysis We performed two types of sensitivity analyses; one-way and multi-way. In a one-way sensitivity analysis certain parameters are varied to see how this specific parameter would impact the results, whereas in a multi-way sensitivity analysis more than one parameter is changed at the same time. The following sections present the results from three one-way and two multi-way sensitivity analyses. Table 14. One-way sensitivity analyses. The results are presented for the whole country in million SEK. Base case analysis Sensitivity analysis 1 1 Sensitivity analysis 2 2 Sensitivity analysis 3 3 Decentralised Centralised Decentralised Decentralised Centralised Acute/emergency care Centre -Staff Facilities Subtotal Care at home Total ,7 Change with centralised care Including total number of visits when determining number of full-time employees in decentralised care. 2. Assuming the same occupancy rate in decentralised and centralised setting. 3. Assuming that the SCI-experts underestimated the true staff need with 10%. 21

23 The results from the one-way sensitivity analyses are presented in Table 14 together with the results from the base-case analysis in order to ease comparisons Sensitivity analysis 1: Including total number of visits when determining number of full-time employees in decentralised care Estimation of number of full-time employees could either be done by using a ratio based on hospitalisation days or by also including total number of visits (see section 2.1.2). In the base case analysis, estimation of full-time employees in decentralised care was estimated based on number of hospitalisation days but not visits (outpatient and day care) to the clinic. In this sensitivity analysis visits are included in the staff calculation and the estimations of total staff need are therefore based on 6 clinics since the remaining 2 did not report all possible visits in their answers. It is also assumed that one visit has the same resource need as one hospitalisation day. To estimate the total number of full-time employees based on both hospitalisations and visits, the weighted ratios for each occupation were multiplied with the estimated total number of hospitalisation days and visits (1,990) per decentralised centre. When considering visits in the staff calculation a higher number of full-time employees per centre were estimated in decentralised care compared with not including visits (a total of 16.7 vs fulltime employees per centre). This corresponds to a 17% increase in total decentralised care staff costs (from 151 to 177 million SEK) and even higher cost-savings compared with the base case analysis (38 million SEK vs. 12 million SEK) for centralised care vs. decentralised care Sensitivity analysis 2: Assuming equal occupancy rates in decentralised and centralised care The occupancy rate in the decentralised base case scenario was estimated based on the clinics occupancy rates for all patients cared for at the clinic. It is possible that the occupancy rate would have been higher if it would have been possible to only consider SCI-patients at the clinics. Assuming that both decentralised and centralised care had an occupancy rate of 95% (estimated in centralised care based on the SCI-experts input) resulted in similar hospital bed costs in a decentralised and centralised scenario. The difference in total cost between centralised and decentralised care decreased by 2 million SEK compared with the base case analysis (10 million in cost-savings for centralised care vs. decentralised care compared with 12 million in the base case analysis) Sensitivity analysis 3: Assuming the SCI-experts underestimated the true staff-need with 10%, hence increasing the full-time employees needed by 10% in centralised care In this scenario it was assumed that the SCI-experts underestimated the true staff-need for a SCIC by 10%. This is not unlikely since no SCIC exists today in Sweden and it is therefore difficult to foresee exactly how much staff resources that are needed. Assuming a 10% increase in staff resources resulted in a 5% increase in total cost for centralised care to 291 million SEK compared with 278 million SEK in the base case scenario. This resulted in a total difference in costs between decentralised and centralised care of 1 million SEK. Hence, with a 10% increase in estimated staff resources in centralised care, no cost-savings in a centralised setting could be seen compared with a decentralised setting. 22

24 3.3 Multi-way sensitivity analysis The results from the multi-way analyses are presented in Table 15. The two analyses describe what would happen with costs and how centralised and decentralised care would differ in two extreme scenarios. Table 15 Multi-way analyses for decentralised vs centralised SCI-patient care. The results are presented for the whole country in million SEK. Base case analysis Sensitivity analysis 4 4 Sensitivity analysis 5 5 Decentralised Centralised Decentralised Centralised Decentralised Centralised Acute/emergency care Centre -Staff Facilities Subtotal Care at home Total Change with centralised care Assumptions: Number of full-time employees per centre in a decentralised setting was based on number of hospitalisation days and visits per clinic. The SCI-experts had overestimated the true staff-need in a centralised scenario by 10%, hence a 10% decrease in staff resources compared with the base-case analysis was accounted for. The occupancy rate in decentralised care was assumed to be lower (75%) compared with the base case scenario (87%). 5. Assumptions: Number of full time employees per 10,000 hospitalisation days was the same in decentralised care as in centralised care. The occupancy rate in decentralised care was equal to the occupancy rate in centralised care. Centralised care is causing a higher increase in primary care at the patient s home community then was first expected, resulting in an increase with 20,000 visits compared with previously assumed 9,000. Patients stay even longer at acute care in a centralised scenario than was previously assumed (10% longer compared with previously 5% longer) Sensitivity analysis 4 In this analysis, compared with the base case analysis, it was assumed that: Number of full-time employees per centre in a decentralised setting was based on number of hospitalisation days and visits per clinic (described in Sensitivity analysis 1). The SCI-experts had overestimated the true staff-need in a centralised scenario by 10%, hence a 10% decrease in staff resources compared with the base-case analysis was accounted for in this sensitivity analysis. The occupancy rate in decentralised care was assumed to be lower (75%) compared with the base case scenario (87%). Based on the above assumptions, staff resources in decentralised care increased compared with the base case analysis; this is also described in Sensitivity analysis 1. Together with the 10% lower staff 23