Estimated Life-Time Savings in the Cost of Ongoing Care Following Specialist Rehabilitation for Severe Traumatic Brain Injury in the United Kingdom.

OBJECTIVES: To evaluate cost-efficiency of rehabilitation following severe traumatic brain injury (TBI) and estimate the life-time savings in costs of care. SETTING/PARTICIPANTS: TBI patients (n = 3578/6043) admitted to all 75 specialist rehabilitation services in England 2010-2018. DESIGN: A multicenter cohort analysis of prospectively collated clinical data from the UK Rehabilitation Outcomes Collaborative national clinical database. MAIN MEASURES: Primary outcomes: (a) reduction in dependency (UK Functional Assessment Measure), (b) cost-efficiency, measured in time taken to offset rehabilitation costs by savings in costs of ongoing care estimated by the Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA), and (c) estimated life-time savings. RESULTS: The mean age was 49 years (74% males). Including patients who remained in persistent vegetative state on discharge, the mean episode cost of rehabilitation was £42 894 (95% CI: £41 512, £44 235), which was offset within 18.2 months by NPCNA-estimated savings in ongoing care costs. The mean period life expectancy adjusted for TBI severity was 21.6 years, giving mean net life-time savings in care costs of £679 776/patient (95% CI: £635 972, £722 786). CONCLUSIONS: Specialist rehabilitation proved highly cost-efficient for severely disabled patients with TBI, despite their reduced life-span, potentially generating over £4 billion savings in the cost of ongoing care for this 8-year national cohort.

Unmet need for specialised rehabilitation following neurosurgery: can we maximise the potential cost-benefits?

OBJECTIVE: To identify the needs for specialised rehabilitation provision in a cohort of neurosurgical patients; to determine if these were met, and to estimate the potential cost implications and cost-benefits of meeting any unmet rehabilitation needs. METHODS: A prospective study of in-patient admissions to a regional neurosurgical ward. Assessment of needs for specialised rehabilitation (Category A or B needs) was made with the Patient Categorisation Tool. The number of patients who were referred and admitted for specialised rehabilitation was calculated. Data from the unit's submission to the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database 2012-2015 were used to estimate the potential mean lifetime savings generated through reduction in the costs of on-going care in the community. RESULTS: Of 223 neurosurgical in-patients over 3 months, 156 (70%) had Category A or B needs. Out of the 105 patients who were eligible for admission to the local specialised rehabilitation service, only 20 (19%) were referred and just 11 (10%) were actually admitted. The mean transfer time was 70.2 (range 28-127) days, compared with the national standard of 42 days. In the 3-year sample, mean savings in the cost of on-going care were £568 per week. Assuming a 10-year reduction in life expectancy, the approximate net lifetime saving for post-neurosurgical patients was estimated as at least £600K per patient. We calculated that provision of additional bed capacity in the specialist rehabilitation unit could generate net savings of £3.6M/bed-year. CONCLUSION: This preliminary single-centre study identified a considerable gap in provision of specialised rehabilitation for neurosurgical patients, which must be addressed if patients are to fulfil their potential for recovery. A 5-fold increase in bed capacity would cost £9.3m/year, but could lead to potential net savings of £24m/year. Our findings now require confirmation on a wider scale through prospective multi-centre studies.

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

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.

Cost-efficiency of specialist inpatient rehabilitation for working-aged adults with complex neurological disabilities: a multicentre cohort analysis of a national clinical data set.

OBJECTIVES: To evaluate functional outcomes, care needs and cost-efficiency of specialist rehabilitation for a multicentre cohort of inpatients with complex neurological disability, comparing different diagnostic groups across 3 levels of dependency. DESIGN: A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2010-2015. SETTING: All 62 specialist (levels 1 and 2) rehabilitation services in England. PARTICIPANTS: Working-aged adults (16-65 years) with complex neurological disability. INCLUSION CRITERIA: all episodes with length of stay (LOS) 8-400 days and complete outcome measures recorded on admission and discharge. Total N=5739: acquired brain injury n=4182 (73%); spinal cord injury n=506 (9%); peripheral neurological conditions n=282 (5%); progressive conditions n=769 (13%). INTERVENTION: Specialist inpatient multidisciplinary rehabilitation. OUTCOME MEASURES: Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK Functional Independence Measure (FIM)+FAM). Cost-efficiency: (1) time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of ongoing care, (2) FIM efficiency (FIM gain/LOS days), (3) FIM+FAM efficiency (FIM+FAM gain/LOS days). Patients were analysed in 3 groups of dependency. RESULTS: Mean LOS 90.1 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in 'weekly care costs' was greatest in the high-dependency group at £760/week (95% CI 726 to 794)), compared with the medium-dependency (£408/week (95% CI 370 to 445)), and low-dependency (£130/week (95% CI 82 to 178)), groups. Despite longer LOS, time taken to offset the cost of rehabilitation was 14.2 (95% CI 9.9 to 18.8) months in the high-dependency group, compared with 22.3 (95% CI 16.9 to 29.2) months (medium dependency), and 27.7 (95% CI 15.9 to 39.7) months (low dependency). FIM efficiency appeared greatest in medium-dependency patients (0.54), compared with the low-dependency (0.37) and high-dependency (0.38) groups. Broadly similar patterns were seen across all 4 diagnostic groups. CONCLUSIONS: Specialist rehabilitation can be highly cost-efficient for all neurological conditions, producing substantial savings in ongoing care costs, especially in high-dependency patients.

A cost analysis of specialist inpatient neurorehabilitation services in the UK.

OBJECTIVE: To determine the range and variation in costs and service characteristics between different levels of specialist neurorehabilitation services in England, and to determine key predictors of service costs. DESIGN: A retrospective analysis of service costs, staffing and activity levels, with comparison across service types. SETTING: Specialist neurorehabilitation services (n = 17) from different areas of England, were divided into three types according to predefined criteria: adult level 1 (tertiary) (n = 8) and level 2a (supra-district) (n = 7) services; and children's services (n = 2). MAIN MEASURES: Annual service costs were collated using a standard costing template, and divided according to principal cost type (direct/indirect/overheads) and behaviour (variable/non-variable). For comparison between the level 1 and 2a services, costs and service characteristics were calculated per occupied bed. RESULTS: The percentage breakdown of costs was consistent across all three service types, with direct costs making up 83%, indirect 10%, and overheads 7% of total costs. The median variable component ranged from 75 to 76%. Staff pay made up 66% and accounted for 95% of the variance of the total costs in adult services. Level 1 services had higher total staffing costs, mainly reflecting higher therapy staff numbers (z = -2.0, P = 0.05). The median total costs/bed-day were: level 1 £530 (interquartile range (IQR) 435-574) (equivalent to US$860 or €650) and level 2a £402 (US$650 or €459) (IQR 326-451) (z = -2.5, P = 0.009). Children's services cost almost twice that (£1017-1177). CONCLUSIONS: Expected variations in cost are largely due to differences in staff costs. Total staff costs projected by 150% provided a reasonable estimate of total unit costs.