Economic evaluation: readiness in practice settings
Mirek Skrypak, Prevention Programme Manager, UCLPartners
June 5th 2014
Outline
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THE PROBLEM
THE SOULTION
STAFFING
OUTCOMES
NHS IMPROVEMENT
QUALITY OF LIFE
OUTCOME MEASURES
LOS REDUCTION
NHS EVIDENCE QIPP
ESD ECONOMIC EVALUATION
ECONOMIC PATIENT SIMULATION
The problem
Length of stay on acute stroke units was on average 23 days and stroke specific
community service did not exist.
1.
Summer 2007- The Genesis
2.
Stroke Rehab Multi-agency Steering Group - Site Visits, Literature Reviews
and discussing joined up pathway
3.
Winter 2007 – The National Stroke Strategy
4.
Early 2008 – Funding opportunity and backs of envelopes
5.
Summer 2008 - The specification and testing the market
6.
Winter 2008 – Pilot with provider following tendering process
The Solution
ESD and Stroke Navigation Service Staffing
• Team consists of 9.2 full time equivalent staff including the following
professionals who specialise in stroke rehabilitation:
o Speech and Language Therapy
o Occupational Therapy
o Physiotherapy
o Social Work
o Rehabilitation Assistant
o Nursing
o Dietetics
o Psychology
o Stroke Navigator
o Team Coordinator
Stroke population and resource input
• Ischemic to haemorrhagic ratio 90:10
• Female to male ratio 47:53
• Average age 73 (range 36 – 107)
• Average therapy input 1511 minutes per patient
o end of week 1: 385min
o end of week 6: 179min
• Average occupational therapy input 597 minutes per patient
(NHS Improvement 2011)
Outcomes
• Over 40 % of all stroke survivors taken home via ESD
• On average discharging stroke survivors from Acute Stroke Units at day 10 post
stroke, Hyper Acute Stroke Unit at day 2 post stroke.
• Reduce overall packages of care by an average of 19 hours per week after ESD
• All discharges from HASU received holistic MDT review from stroke navigator
• Every stroke survivor offered review and on average uptake of reviews at 99%
(Dewan et al. 2014, Clark 2013, NHS Evidence 2012, Skrypak et al. 2012)
Outcomes
Modified Rankin Scale
100% of clients improved their score
Barthel
100% of clients improved their score
Goal Attainment
(GAS)
91% of person focused goals set have been achieved
by stroke survivors
Performance COPM
100% of clients improved their score
Satisfaction COPM
100% of clients improved their score
Activities of Daily Living 92% of clients improved their score
(N eADL)
(NHS Evidence 2012, Skrypak et al 2012)
NHS Improvement
• Met NICE Quality Standard 7 for Occupational Therapy: 6.4 point increase
• Not met Quality Standard 7 for Occupational Therapy: 3.4 point increase
• Meeting therapy standard results in better functional outcome (p = 0.001)
(NHS Improvement 2011)
A note about QoL
• People with higher levels of physical ability post stroke (ESD population)
perceive their quality of life to be lower: 48% using SAQOL-39 and 53% using
SIS (Ahmed et al. 2005, Skrypak 2011)
• Quality of life should not be used to evaluate effectiveness of stroke ESD
services (Skrypak 2011)
• Solely relying on conventional longitudinal change scores derived from generic
health-related quality of life questionnaires is less than ideal ie EQ5D (McPhail
et al. 2010)
• Clinically relevant measures and PROMS should help to illustrate a clearer
overall picture of change (McPhail et al. 2010)
Outcome Measures
• ESD 40% of population (pre and post ESD, 6 month follow up):
o Barthel
o MRS
o COPM
o GAS
o NeADL
o EQ5D
• Stroke Navigation and Coordination 60% of population (week 6, 6 month
follow up, annually):
o Barthel
o MRS
o EQ5D
LOS reduction
• Length of stay (LOS) of admissions for stroke examined to test for any
difference in LOS before early discharge team set up and during the period of
early discharge team intervention
• April 2005 and Dec 2008 – 847 admissions (available data pre-intervention
period)
• Jan 2009 – 246 admissions (available data during intervention period)
• Mann-Whitney U-test showed the difference in LOS between the two groups
to be significant (U=95457, p = 0.025)
(NHS Evidence 2012)
NHS Evidence
QIPP Case Study
Process
NHS Evidence QIPP Case Study
(NHS Evidence 2012)
ESD Evaluation – Required data
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Patient demographics
Type of stroke
Length of stay in each part of the system eg. HASU, ASU, ESD, community rehab beds etc
Outcome measures Barthel / Modified Rankin (MRS) at as many points along the pathway as
possible
Results of cognitive and physical assessments through the pathway
Eligibility criteria of each service and how patient characteristics match against this
Any decision making tools used by clinicians to determine onward referral
Numbers of beds in each service area of the pathway
Staff structure in each area
The ESD team structure in terms of therapy staff and care component
Monthly number of referrals
Length of stay in service
Number of professional contacts, length of sessions
Pre and post intervention Barthel and MRS scores
6 month Barthel and MRS scores
Goal Attainment utilising validated process ie GAS
Quality of life perception – EQ5D
Proposed Patient Simulation Evaluation
The development of a patient level simulation would give the ability to virtually change a particular
variable and see the potential impact based on the model.
Proposed Outcomes
• To create a patient level model that could inform commissioning decisions in terms of service
delivery
• To cost the pathway in monetary and quality terms
Data required
• Patient demographics
• Type of stroke
• Length of stay in each part of the system eg. HASU, ASU, ESD, community rehab beds etc
• EQ5D/ Barthel / Modified Rankin at as many points along the pathway as possible
• Results of cognitive and physical assessments through the pathway
• Eligibility criteria of each service and how patient characteristics match against this
• Any decision making tools used by clinicians to determine onward referral
• Numbers of beds in each team/service
• Staff structure in each team/service
References
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Ahmed, S., Mayo, N., Corbiere, M., Wood-Dauphinee, S., Hanley, J., Cohen, R., 2005. Change in
Quality of Life of People with Stroke over Time: True Change or Response Shift? Quality of Life
Research 14(3), 611-627
Clark, D., 2013. The role of multidisciplinary team care in stroke rehabilitation. Prog Neurol
Psychiatry. 17, 5–8
Dewan, B., Skrypak, M., Moore, J., Wainscote, R., 2014. A service evaluation into the feasibility of
a community based consultant and stroke navigator review of health and social care needs in
stroke survivors at six weeks following hospital discharge. Clinical Medicine. 14(2), 134-140
McPhail, S., Comans, T., Haines, T., 2010. Evidence of disagreement between patient-perceived
change and conventional longitudinal evaluation of change in health-related quality of life among
older adults. Clinical Rehabilitation 24: 1036–1044
NHS Evidence QIPP Case Study: Management of patients with stroke: REDS (REACH Early
Discharge Scheme). Oct 2012
NHS Improvement. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation. Dec
2011
Skrypak, M., 2011. Quality of life measures and their use in stroke services: insight into
appropriate use and careful selection. International Journal of Stroke. Vol 6 (Suppl. 2), 1–65
Skrypak, M., Basu-Doyle, M., Barron, S., 2012. Support for early stroke discharge. Health Service
Journal. 122(6288), 24-25
For more information please contact:
Mirek Skrypak
Prevention Programme Manager
Mirek.Skrypak@uclpartners.com
020 3108 2317
www.uclpartners.com
@uclpartners