Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis

Abstract

Objectives: To evaluate functional outcomes, care needs and cost-efficiency of hyperacute (HA) rehabilitation for a cohort of in-patients with complex neurological disability and unstable medical/surgical conditions.

Design: A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2012-2015.

Setting: Two HA specialist rehabilitation services in England, providing different service models for HA rehabilitation.

Participants: All patients admitted to each of the units with an admission rehabilitation complexity M score of ≥3 (N=190; mean age 46 (SD16) years; males:females 63:37%). Diagnoses were acquired brain injury (n=166; 87%), spinal cord injury (n=9; 5%), peripheral neurological conditions (n=9; 5%) and other (n=6; 3%).

Intervention: Specialist in-patient multidisciplinary rehabilitation combined with management and stabilisation of intercurrent medical and surgical problems.

Outcome measures: Rehabilitation complexity and medical acuity: Rehabilitation Complexity Scale-version 13. Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK FIM+FAM).

Primary outcomes: (1) reduction in dependency and (2) cost-efficiency, measured as the time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of on-going care in the community.

Results: The mean length of stay was 103 (SD66) days. Some differences were observed between the two units, which were in keeping with the different service models. However, both units showed a significant reduction in dependency and acuity between admission and discharge on all measures (Wilcoxon: p<0.001). For the 180 (95%) patients with complete NPCNA data, the mean episode cost was £77 119 (bootstrapped 95% CI £70 614 to £83 894) and the mean reduction in 'weekly care costs' was £462/week (95% CI 349 to 582). The mean time to offset the cost of rehabilitation was 27.6 months (95% CI 13.2 to 43.8).

Conclusions: Despite its relatively high initial cost, specialist HA rehabilitation can be highly cost-efficient, producing substantial savings in on-going care costs, and relieving pressure in the acute care services.

Keywords: Cost-efficiency; Functional gain; Outcome measurement.

Figure 1

The rehabilitation pathway following major illness or injury. Following major injury or illness, the majority of patients will progress satisfactorily along the pathway to recovery with the support of the local non-specialist (Level 3) services. However, a small number will have more complex needs requiring rehabilitation in specialist (Level 1 or 2) units.

Figure 2

RCSE-M scores and serial allocation between HA and Level 1a beds. The figure illustrates the serial RCS-M sores recorded for a single patient over the course of his stay on the London unit. Of his total length of stay (256 days), 165 days were allocated to the Level1a bed-day activity and 91 days to the HA activity in four discrete periods, without having to relocate the patient or interrupt his rehabilitation programme.

Figure 3

Flow chart of the data extraction process. The figure summarises the data extraction process for the main data set and subset included in the analysis.

Figure 4

Composite FAM-Splats for the two units: median scores at admission and discharge. The radar chart (or ‘FAM splat’) provides a graphic representation of the disability profile from the FIM+FAM data. The 30-scale items are arranged as spokes of a wheel. Scoring levels from 1 (total dependence) to 7 (total independence) run from the centre outwards. Thus, a perfect score would be demonstrated as a large circle. These composite radar charts illustrate the median scores on admission and discharge for the two units. The yellow-shaded portion represents the median scores on admission for each item. The blue-shaded area represents the change in median score from admission to discharge. Clear differences in the pattern of disability can be seen between the two centres.