Stroke Health Economics Project A new NHS resource for data on the health and social care costs of stroke Dr Benjamin Bray

The vision Make use of the richness of data available on stroke care in the NHS Base cost estimates on individual patient characteristics – getting deeper insights than simple averages Interactive tools to explore the costs and benefits of implementing interventions with a strong evidence base: early supported discharge and thrombolysis Creating synergies by integrating cost data into routine SSNAP outputs

SSNAP Ischaemic stroke Primary ICH ≈ 80,000 per year Whole pathway care quality: from admission, up to 6 months after stroke Data, analysis, visualisations every 3 months designed for: Teams CCGs Clinical networks Stroke survivors National level reports All acute admitting hospitals in England Organisational audits of acute and post acute care services

Building a new health economic engine into SSNAP Ischaemic stroke Primary ICH ≈ 80,000 per year Whole pathway care quality: from admission, up to 6 months after stroke Data, analysis, visualisations every 3 months designed for: Teams CCGs Clinical networks Stroke survivors National level reports All acute admitting hospitals in England Whole pathway level health and social care costs of stroke Organisational audits of acute and post acute care services

What does the model produce? Patient level estimates in categories of: Age Sex Stroke type Stroke severity (80 different combinations) Outcomes: NHS and social care costs Total length of inpatient stay QALYs Interactive tools to model cost/benefit of: Early supported discharge Thrombolysis Age Sex Stroke type Stroke severity NHS costs – 1 year NHS costs – 5 year Social care costs – 1 year Social care costs – 5 year 80 Female ICH Severe £XXXXX e.g. ∑ Add up to produce estimates for any cohort of patients

Headline results ≈80 000 people are admitted to hospital with stroke each The total costs attributable to stroke in people with a acute stroke per year : NHS Social Care NHS & Social Care 1 year £1.03 billion £633 million £1.66 billion 5 year £1.40 billion £2.05 billion £3.45 billion NHS: Hospital admission, rehabilitation, GP attendances, prescribing Social Care: Care home admission, packages of care (Note issues of “who pays” for care)

Previous cost estimates have been averages £23,000 over 10 years

...but the new model allows us to understand costs in a much more detailed way Each dot represents a single patient with stroke (n=80000)

...and can be used for new analyses such as identifying the costs of potentially avoidable stroke The blue dots are patients with AF

Data sources SSNAP was the major data resource April 2013 - March 2015 Patients were stratified to sub-groups South London Stroke Registry (SLSR) was used for longer term data including survival and resource use Cost data was obtained from standard NHS sources NHS reference costs Personal Social Services Research Unit Quality of life weights: EQ-5D scores were mapped from Modified Rankin Scale (mRS) using an equation from Whynes et al 2013 Whynes, D.K., et al., Testing for differential item functioning within the EQ-5D. Medical Decision Making, 2012: p. 0272989X12465016.

Patient pathway Acute stroke care Rehabilitation Longer term care Ambulance Brain scan Acute stroke unit Thrombolysis Rehabilitation Inpatient rehabilitation Early supported discharge Community rehabilitation Longer term care GP Home help Care home Other support (e.g. meals on wheels) Recurrence

NHS and social care costs Results – Current cost Average costs per patient: Mean NHS costs Mean social care cost NHS and social care costs Mean QALY 1-year £13,459 £8,716 £22,175 0.48 5-year £17,931 £27,301 £45,233 1.63 Explain QALY

Results – Current costs Costs increase with age Costs of haemorrhage patients are higher than ischaemic patients

Summary of results Mean NHS cost per stroke patient £13,500 in first year £18,000 over 5 years. NHS cost savings over 5 years £4,100 per extra patient thrombolysed £1,600 per extra patient discharged to ESD Better health related outcomes over 5 years 0.26 QALYs per extra patient thrombolysed 0.14 QALYs per extra patient discharged to ESD The results will be used to provide bespoke estimates to SSNAP users

How might the data be useful? Making the case for investing in prevention (AF etc) Readily available figures (from a source you can reference) to put into business cases for improvement and service development Keeping stroke on the agenda of policy makers and commissioners Helping to model financial case for improving access to thrombolysis and ESD

Summary One of the first national quality programmes in the world to integrate patient level cost data alongside data on healthcare quality We can now estimate health & social care costs from stroke for any geography in England A new resource for QI, commissioning, transformation and prevention Potentially could be expanded to other high cost, high burden health conditions

NHS England: Project funder Acknowledgements NHS England: Project funder SSNAP: Data and analytics National Guideline Centre: Health economics South London Stroke Register: Data Xiangming Xu National Guideline Centre David Wonderling National Guideline Centre Rachel Otago SSNAP Emma Vestesson SSNAP Lizz Paley SSNAP Alex Hoffman SSNAP Anita Desikan South London Stroke Register Charles Wolfe South London Stroke Register Anthony Rudd NHS England & Guy’s and St Thomas Foundation Trust