A New Rehabilitation Approach Could Improve Recovery for 54% of Stroke Survivors and Save State up to €7m

The research, led by the Economic and Research Institute of Ireland (ESRI) and the Royal College of Surgeons in Ireland (RCSI), found that 54% of stroke survivors– more than 3,000 people a year – could benefit from early supported discharge programmes that would reduce hospital bed days by 24,000, resulting in annual net savings of from €2 to €7 million. Early Supported Discharge is an intensive approach to rehabilitation in the community used internationally but not generally available in Ireland.

According to the new report titled Towards Earlier Discharge, Better Outcomes, Lower Cost: Stroke Rehabilitation in Ireland, implementing Early Supported Discharge would require a substantial increase in the resourcing of community therapists (physiotherapists, occupational therapists, and speech and language therapists), community nurses and other community care above current levels in Ireland. However, savings from the reduced cost of acute bed days could fund this increase in resourcing. The research found that there is currently poor resourcing of and wide regional variation in community and inpatient rehabilitation for stroke survivors in Ireland.

Dr Maev-Ann Wren, lead author of the report and senior research officer at the ESRI, said:

“The analysis in this report supports a move to international best practice in stroke rehabilitation in Ireland, with the potential for better outcomes for patients from better care in the community. This could be achieved at a net saving in national health expenditure by freeing up acute hospital beds.

“Translating acute care savings into community care resourcing requires shifting the balance from over-reliance on hospitals to greater delivery of care in the community. Allocation of resources to community care should prioritise those areas which are relatively under-resourced.”

The study, which was commissioned by the Irish Heart Foundation (IHF) and funded by the IHF and the Health Service Executive (HSE), had four main objectives: to describe current rehabilitation for stroke patients in Ireland; to analyse best practice pathways of stroke rehabilitation; to compare costs, outcomes and cost-effectiveness implications of actual and best practice pathways of rehabilitation in Ireland; and to recommend how best to deliver stroke rehabilitation after the inpatient phase depending on age, severity of disability and type of stroke.  The report’s authors include researchers from the ESRI, NUIG, RCSI and King’s College London. The report’s steering group included clinicians engaged in stroke care.

Mr Barry Dempsey, Chief Executive of the IHF said:

“Acute stroke services in Ireland have been transformed in the last three years, resulting in a 13% reduction in relative mortality and a 28% fall in the numbers being discharged to nursing homes[1]. That means more people than ever are returning home after stroke, but community services to maximise their recovery have remained as bad as ever, with appalling quality of life consequences for discharged stroke patients.

“Stroke survivors currently face chronic service deficits[2] - one in three have no access to physiotherapy and half can’t get any speech and language therapy or occupational therapy. Just 11% have access to psychological services despite the often severe mental health impact of stroke and 36% pay privately for rehabilitation.

“The IHF believes this new research removes the cost barrier to better community services for stroke survivors and provides the evidence base for the development of a national rehabilitation infrastructure that will benefit Ireland’s 50,000 stroke survivors and many others with neurological conditions.”

The report also found significant regional variation in stroke rehabilitation services, such as physiotherapy and speech and language therapy, length of hospital stay, availability of nursing home places, community rehabilitation staffing and the intensity of therapy delivered in different locations. The report found that there are more referrals to nursing homes where more are located, whilst the average length of hospital stay for patients discharged to nursing homes ranges from 79 days in the HSE Dublin North-East Region to 24 days in the HSE West Region.

A survey of hospital stroke lead clinicians conducted by the researchers found that severe stroke patients may experience long waits for nursing home care and for specialist inpatient rehabilitation. Mr Dempsey added:

“This research proves again that it is far more expensive to provide bad stroke services than services that maximise good outcomes. Despite Ireland’s economic collapse health policymakers have had the courage to find extra funds to increase the lifesaving capacity of acute stroke services. Now they must act again to develop the community rehabilitation infrastructure that will improve the quality of life of thousands of stroke survivors and save the State money into the bargain.”

The authors of the report are:

Dr Maev-Ann Wren (ESRI), Dr Paddy Gillespie (NUIG), Dr Samantha Smith (ESRI), Ms Karen Kearns (ESRI), Ms Siobhan Crichton (KCL), Professor David Parkins (KCL), Professor Anne Hickey (RCSI), Dr Frances Horgan (RCSI), and Professor Miriam Wiley (ESRI).

Media queries to: press@esri.ie

Key Findings

This study’s key findings are:

1.        There is an international consensus that:

i.       stroke survivors with mild or moderate disability are in general suited to Early Supported Discharge (ESD);

ii.       ESD is an intensive approach to rehabilitation in the community, which can improve disability outcomes, reduce the likelihood of long-term institutional care and reduce acute hospital length of stay;

iii.       the needs of survivors with more severe disability are better met by specialised inpatient rehabilitation;

2.        There is currently poor resourcing of and wide regional variation in community and inpatient rehabilitation for stroke survivors in Ireland.

3.        There is considerable regional and hospital variation in stroke survivors’ length of stay in acute hospitals, which appears to reflect differing regional pathways of care and differing resourcing of care in alternative settings.

4.        There are long waits for nursing home care and specialist inpatient rehabilitation for patients with severe stroke conditions. 5.        On base case assumptions, implementing ESD in Ireland for stroke survivors with mild to moderate disability:

i.       could save nationally approximately €12 million from reduced hospital length of stay;

ii.       could free up over 24,000 hospital bed days, the equivalent of 67 hospital beds annually;

iii.       could cost nationally between €5 million and €10 million to resource the community therapy and other community services necessary, depending on the model of ESD adopted;

iv.       would require a substantial increase in the resourcing of community therapists and other community care from current levels in Ireland, even in areas where community rehabilitation is better-resourced;

v.       taking account of these costs and savings could result in a net saving nationally of between €2 million and €7 million   in first-year care after stroke, depending on the model of ESD;

vi.       could deliver a mean additional Quality-Adjusted Life Year (QALY) for a mean additional cost of €4,734 over ten           years, which compares favourably to standard UK benchmarks for cost-effective healthcare interventions.

6.        Sensitivity analysis, undertaken to test the robustness of the analysis, shows:

i.     that this first-year cost saving generally holds, provided ESD delivers an expected mean eight-day reduction in hospital  length of stay at Irish average stroke bed-day costs;

ii.    In one scenario, a marginal first-year cost of ESD implementation arises, when high unit costs are applied to the most      generously-resourced ESD model. Even in this scenario, the marginal cost of implementing ESD is one-third of the cost          of an inpatient day;

iii.     the level of cost-effectiveness (cost per QALY gained) is sensitive to assumptions about the improvement in disability     levels consequent on ESD and the costing methodology applied.

The report’s recommendations, developed from the findings of the report and in discussion with the steering group, are:

Recommendations for patients with mild to moderate disability after stroke

•  Early Supported Discharge should be the preferred rehabilitation option in Ireland for patients with mild to moderate disability after stroke;
• Savings from reduced acute bed days achieved by ESD should be applied to resourcing community care staff: physiotherapists, occupational therapists, speech and language therapists, community nurses, social workers, home helps, psychologists and counsellors;
•  Further research is required to assess the feasibility of ESD in rural areas of dispersed population. If implementation of ESD is not found to be feasible in some such areas, inpatient or centre-based rehabilitation programmes should be maintained or developed and resourced.

Recommendations for patients with severe disability after stroke

• Capacity and staffing should be expanded for specialist inpatient rehabilitation for patients with severe stroke;
•  Numbers of nursing home places suitable for support and care for stroke patients with significant disability should be increased, particularly in areas where there is evidence of long delays in discharge from hospital due to difficulties in accessing nursing home care;
• Patients with severe stroke, who could potentially be discharged home following rehabilitation, should be identified early and offered specialised inpatient rehabilitation;
• The rehabilitation needs of survivors of a severe or moderate stroke should be reassessed weekly for the first month, and then at intervals as indicated by their health status;
• Given the relatively limited research on best practice in rehabilitation for patients with severe stroke, a randomised controlled trial (RCT) should be conducted in Ireland to assess the relative costs and outcomes of systematically providing specialised inpatient rehabilitation for severe stroke as compared to usual care;
• Such an RCT should measure functional outcomes and include the costs of long-term care, whether delivered at home or in an institutional setting and by formal or informal carers.

General recommendations for stroke rehabilitation in Ireland

• Services should be provided to stroke survivors on a needs basis, without regard to age or region and with standardised delivery of care, meeting international and national best practice guidelines;
• Any stroke survivor with declining physical activity, ability to undertake everyday tasks or mobility at six months or later after stroke should be assessed for appropriate targeted rehabilitation;
• Evidence from this and other studies of deficits in the availability of psychological services for stroke survivors in the acute setting, in the community and in nursing homes, combined with evidence of considerable emotional distress in stroke survivors, indicates a clear need for the development of psychological and counselling services;
•  Any stroke survivor with declining cognitive function or mood at six months or later after stroke should be assessed for appropriate targeted rehabilitation;
• A national stroke register should be resourced to sustain the systematic recording of treatment, outcomes (including measures of disability) and care in hospital, the community and long-term care settings of patients with stroke.

[1] HSE’s National Stroke Programme [2] National Survey of Stroke Survivors, RCSI, IHF 2014