Economic evaluation: readiness in practice settings Mirek Skrypak, Prevention Programme Manager, UCLPartners June 5th 2014

Outline 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. Summer 2007- The Genesis Stroke Rehab Multi-agency Steering Group - Site Visits, Literature Reviews and discussing joined up pathway Winter 2007 – The National Stroke Strategy Early 2008 – Funding opportunity and backs of envelopes Summer 2008 - The specification and testing the market 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: Speech and Language Therapy Occupational Therapy Physiotherapy Social Work Rehabilitation Assistant Nursing Dietetics Psychology Stroke Navigator 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 end of week 1: 385min 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 Goal Attainment (GAS) 91% of person focused goals set have been achieved by stroke survivors Performance COPM Satisfaction COPM Activities of Daily Living (N eADL) 92% of clients improved their score (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): Barthel MRS COPM GAS NeADL EQ5D Stroke Navigation and Coordination 60% of population (week 6, 6 month follow up, annually):

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

ESD Evaluation – Required data 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 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

Mirek Skrypak Prevention Programme Manager Mirek.Skrypak@uclpartners.com 020 3108 2317