Psychological care after stroke: Economic modelling of a clinical psychology led team approach

NHS
CANCER
NHS Improvement
Stroke

DIAGNOSTICS

HEART

LUNG

STROKE

Psychological care after stroke:
Economic modelling of a clinical
psychology led team approach

Authors

Sarah Gillham - National Improvement Lead,
NHS Improvement - Stroke

Michael Carpenter - Associate, NHS
Improvement - Stroke

Dr Michael Leathley - Research Fellow
Clinical Practice Research Unit, University of
Central Lancashire

Acknowledgements

Grateful thanks to all who contributed to Dr Peter Knapp, Senior Lecturer, Department
the discussions about the assumptions and of Health Sciences and the Hull York Medical
evidence on which the model is based, and School, University of York
to those who reviewed and commented on
the finished paper. Dr Ian Kneebone, Consultant Clinical
Psychologist and Visiting Reader, University
The Stroke Improvement Programme of Surrey, Haslemere and District Community
psychological care after stroke consensus Hospital and Associate, NHS Improvement -
group Stroke

Dr Jane Barton, Consultant Clinical Professor Nadina Lincoln, Professor of
Psychologist, Michael Carlisle Centre, Nether Clinical Psychology, University of
Edge Hospital, Sheffield Nottingham

Dr Roger Beech, Reader in Health Services Jill Lockhart, National Improvement Lead,
Research / Director, Keele University Hub, NHS Improvement - Stroke
West Midlands NIHR Research Design Service
Dr Jessica Read, Clinical Psychologist,
Dr Noelle Blake, Head of Neuropsychology, Lancashire Care NHS Foundation Trust
Croydon Health Services NHS Trust
Professor Tom Robinson, Stroke Consultant,
Dr Bridget Carew, Clinical Psychologist, Royal University Hospitals of Leicester NHS Trust
Free Hospital and Clinical Lead for SIP

Dr Helen Hosker, Central Manchester Clinical Dr Becky Simm, Principal Clinical
Commissioning Group, Lead for Urgent Care, Psychologist, Southport and Ormskirk NHS
Clinical Commissioning Lead for Stroke and Hospital Trust
Falls, NHS Manchester
Dr Kate Swinburn, Research and Policy
Professor Allan House, Director, Leeds Manager, Connect - the communication
Institute of Health Sciences disability network

Psychological care after stroke: Economic modelling of a clinical psychology led team approach

Contents

Endorsements 4

Summary 5

Introduction 6

The pathway for psychological care after stroke 8

Modelling the impact of a service for 17
psychological care after stroke

Summary of results 21

Discussion 22

References 24

Appendix 1 26

3


Endorsements

The physical effects of stroke are plain for This document provides information that is
all to see and much has been done, and vital to the improvement of psychological
continues to be done, to improve services to outcomes after stroke. There are strong
meet these physical needs. The less easily seen arguments to support the provision of
psychological and social consequences, are psychological services to improve functional
equally or even more important to people with independence, mood, coping and quality of life
stroke and their families and carers, but are more after stroke from a clinical perspective. However,
easily overlooked. The significant benefits of the provision of such services in practice has been
meeting these less tangible needs are almost hampered by the lack of information on the costs
impossible to quantify. and savings for the NHS. Despite the lack of
randomised trials determining the cost-
As many as forty per cent of people experience effectiveness of psychological interventions after
each of cognitive loss, behavioural problems and stroke, having the information in this document
disorder of mood, with as many as thirty per cent will enable a far stronger case to be made for the
of people experiencing a severe depressive illness resources needed to deliver a quality service to
after stroke. Comprehensively and systematically stroke patients and their carers.
meeting these needs will bring benefits not only
to people with stroke and their carers, but will
also improve productivity and financial Professor Nadina Lincoln
sustainability of services. We thus need to Professor of Clinical Psychology, University of
continue to use all opportunities to develop Nottingham
services.

The case for psychological interventions after The psychological impacts of stroke have
stroke is already well made but the health been well defined, but to date little work
economic case – until this publication – has not has been available to identify the fiscal
been clear. Whilst the focus of this report is on consequences of these sequelae. For the first
the economic impact of psychological care, it is time, the authors of this paper have attempted
the individual and their family who are at the to garner all the relevant evidence to make the
heart of the services that will flow from it, and financial case for early and comprehensive
who may have a very real need for emotional and intervention. We know stroke survivors want and
psychological support to manage their stroke and are deserving of psychological treatments, now
its consequences. we can lobby the fund holders where they live,
with evidence of the potential cost savings
of service provision. Hooray!
Dr Damian Jenkinson
National Clinical Director Stroke (interim)
Dr Ian Kneebone
Consultant Clinical Psychologist, Surrey
Community Health and Visiting Reader,
University of Surrey

4


Summary

This paper models the costs and potential cost savings of delivering a
psychological support service for people with problems affecting their mood after
stroke. A stroke service where psychological care is led by a clinical psychologist
using a stepped approach has the potential to reduce the cost burden of stroke,
with savings to the NHS and adult social care recovered in around two years. This
modelling indicates that an investment of around £69,000 in psychological care
through a clinical psychologist-led service, with clinical psychology assistant
support and an appropriately trained multidisciplinary team, may deliver a benefit
of around £108,300 to the NHS and social care in around two years.

The outcomes of such a service for patients should also be positive and beyond
those expected in terms of the criteria set by the National Institute for Health and
Clinical Excellence (NICE) – yielding a five-fold benefit measured in terms of
‘Quality Adjusted Life Years’.

To deliver these benefits the stroke service needs to operate within the National
Stroke Strategy recommendations and evidence-based national guidance: that
patients are routinely screened for mood several times after their stroke; that
acute and community and social care services are well integrated, with access to
six week and six month reviews; and a stepped approach to psychological care is
used.

The model used is essentially designed for the purposes of estimating the
economic benefits of psychological care. The service described is of necessity a
simplified one, and whilst it is based on best available evidence and consensus, it
is not intended as a prescription for how psychological care should be delivered
or as a service specification. The model is intended as a way to estimate the
possible economic benefits of a service constructed in this way, and as a local
decision making tool for services to calculate the potential economic implications
of their psychological care provision. Where no clinical psychologist-led service
currently exists, there is the potential to realise the full economic benefits of the
model. Where a service currently exists, the model would have to be adapted to
reflect that service, and this will have an impact on both costs and benefits.

The model and help notes can be found at www.improvement.nhs.uk/stroke
on the psychological care pages.

5


Introduction

A majority of Services to manage physical health needs after stroke have been steadily
long-term improving since the publication of the National Stroke Strategy in 2007 [1]. This
increase in access to and availability of services has not been mirrored in the
stroke survivors
provision of mental health services after stroke and there is still less than one
with emotional clinical psychologist for every 100 stroke unit beds [2]. A majority of long-term
needs reported stroke survivors with emotional needs reported that they did not receive
that they did adequate help to deal with them [3]. This is despite the fact that many people
not receive who have had a stroke also experience a mental health problem. For example,
adequate help around a third are affected by depression at some point post stroke [4], almost a
quarter experience generalised anxiety disorder [5], with post-traumatic stress
to deal with disorder affecting between 10% and 30% of stroke patients [6] [7] [8]. A significant
them number of those affected by stroke, including family members, experience
problems in adapting to life after stroke, and can be considered to have an
‘adjustment disorder’ [9]. Abnormal mood after stroke has been shown to hamper
rehabilitation [9] and there is a significant impact of other emotional disorders,
such as anxiety [9], on recovery after stroke.

Despite this clearly identified and well known mental health need, access to
emotional and psychological assessment and support is demonstrably limited.
Half of the patients and carers questioned in the National Audit Office review of
stroke services [10] rated psychological care as poor or very poor. This stroke
survivor feedback was supported by the Care Quality Commission’s review of
post hospital stroke care in 2011 [11]. The review found that the provision of even
generic services to support people with depression and anxiety and other
psychological issues after stroke was inadequate in terms of availability; most
Primary Care Trusts (PCTs) were unable to provide comprehensive access to
psychological care.

It is known that mental health problems can exacerbate other problems
associated with long term health conditions: these include worse recovery from
the stroke [12], lower quality of life and reduced ability to manage their physical
conditions effectively [13]. Patients with both physical and mental ill health show
an increased use of health services for their physical problems, increasing the
costs associated with their care [13]. In the USA for example, people who have had
a stroke and who also have mental health problems, have annual health care
costs 40% higher than those without a mental health problem [13].

6


In England, the King’s Fund and Centre for Mental Health [13] have estimated that
between £8 and £13 billion of NHS spending is attributable to health needs of
people with long-term conditions who also have a mental health problem.
Integrating the management of psychological and mental health needs of people
with long-term conditions can reduce their use of hospital services, as well as
bringing other significant health effects. The King’s Fund suggests that the costs
of incorporating psychological or mental health management into rehabilitation
programmes for people with long term conditions and a co-morbid mental health
problem would more than likely be outweighed by the savings arising from
improved physical health and decreased service use.

Clinical People with stroke should have access to support with mental health needs as
psychologists part of their stroke rehabilitation. Clinical psychologists as essential members of
the stroke team [3] have unique specialist knowledge and skills. Clinical
as essential
psychologists can identify and manage stroke related problems with memory,
members of understanding and reasoning; help patients and families adjust to the impact of
the stroke team the stroke, and identify and manage problems with mood [9]. Evidence is available
have unique to support the benefits to patients and families of access to clinical psychology
specialist after stroke [9]; however, there is little evidence of the economic impact of
knowledge and psychological care in a clinical psychologist-led stroke service.
skills This paper aims to marshal available data and professional consensus about the
costs and benefits of a psychologist-led service for stroke to inform a model
that will quantify the impact of such a service. The paper describes the model
used to calculate the economic impact of a clinical psychologist-led service
for psychological care after stroke, and the results. A web-based
spreadsheet forms part of the model and is available with help notes at
www.improvement.nhs.uk/stroke. The spreadsheet can be used interactively
by adjusting the figures in the grey cells to reflect local circumstances and
test out different assumptions to calculate the local economic benefit of
a local service.

7


The pathway for psychological
care after stroke
The stepped care model (Figure 1) is Stepped care manages patients using The model used to calculate the
recommended by NICE [14] and is a hierarchical approach offering economic impact of psychological
endorsed in the recent Intercollegiate simpler interventions first, care after stroke follows the service
Stroke Working Party (ICSWP) progressing to more complex design described in the NHS
‘National Clinical Guideline for interventions if required. Patients can Improvement – Stroke publication,
Stroke’ (2012) [3]. access care according to their level of ‘Psychological care after stroke’ [15]. In
need at the time. Most stroke order to deliver best practice, it is
“Stroke services should patients will require the simplest expected that the service will have
interventions which can be provided access to a clinical psychologist or
adopt a ‘stepped care’ by the stroke team (Level 1 [Step 1]); neuropsychologist and that they are
approach to delivering fewer patients will need additional supported by a clinical assistant [9].
clinical psychology-supervised support
psychological care. The from the stroke team or clinical
stepped care model is psychology assistant (Level 2 [Step
intended to be dynamic; 2]); still fewer patients will require
more complex care requiring
a patient might, for specialist clinical (neuro) psychology
example, progress straight or psychiatric intervention (Level 3
[Step 3]).
from Step 1 to Step 3”
(ICSWP, 2012)

Figure 1: Stepped care model for psychological interventions after stroke.
Adapted from IAPT model with input from Professor Allan House and Dr Posy Knights

LEVEL 3: Severe and persistent disorders of mood and/or cognition that
are diagnosable and require specialised intervention, pharmacological
treatment and suicide risk assessment and have proved resistant to
treatment at levels 1 and 2. These would require the intervention of
clinical psychology (with specialist expertise in stroke) or
neuropsychology and/or psychiatry.
LEVEL 3
LEVEL 2: Mild/Moderate symptoms of impaired mood and
/or cognition that interfere with rehabilitation. These may be
addressed by non psychology stroke specialist staff,
supervised by clinical psychologists (with special expertise in
LEVEL 2 stroke) or neuropsychologists.

LEVEL 1: ‘Sub-threshold problems’ at a level
common to many or most people with stroke.
General difficulties coping and perceived
consequences for the person’s lifestyle and
LEVEL 1
identity. Mild and transitory symptoms of
mood and/or cognitive disorders such as a
fatalistic attitude to the outcome of
stroke, and which have little impact on
engagement in rehabilitation.
Support could be provided by
peers, and stroke specialist staff.

8


Routine screening of Third screen is timed at about six Level 1 psychological care
psychological need months after stroke. At this stage Psychological care will be delivered at
The route to psychological care after much physical and social recovery has Level 1 by the multidisciplinary stroke
stroke is through appropriate stabilised and it is possible to get a team to any patient with problems
assessment. The term screening is picture of likely longer-term problems. identified at screening. For the
used in this paper to describe a brief Notwithstanding these purposes of the model the
assessment using a validated tool in recommendations it is acknowledged multidisciplinary stroke team members
conjunction with clinical judgement to that anxiety and depression can occur are considered to be at the top of
decide if a person needs to be further at any time after stroke and it follows Agenda for Change (AfC) band 5. This
assessed, monitored, or to gain access screening may be indicated at any first level of psychological care is
to psychological care. In the model, time in actual clinical practice. Within anticipated to be carried out alongside
the multidisciplinary team are the model, the multidisciplinary stroke current therapy or nursing
assumed to carry out routine mood team (MDT), mainly physiotherapists, interventions. For the purposes of the
screens for all patients as occupational therapists, speech and model the amount of time the patient
recommended in national clinical language therapists, and qualified receives psychological care at Level 1
guidance [3] [16]; the cost of screening nurses, carry out routine screening of is equivalent to six sessions of 20
time and staff training by the clinical patients for problems with mood and minutes. Training and supervision
psychologist to carry out screening is cognition (the latter is not addressed costs by a clinical psychologist for
included in the model. MDT training within this paper because it is not the these staff are included in the model.
and competencies should align with focus of the model). Level 1 psychological care comprises
the UK Stroke Forum Education and active listening, helping with
Training standards (www.ukfst.org). A range of validated mood (and adjustment, exploring and supporting
Screening time points fit with the cognition) screening tools are the impact of the stroke, information
recommended guidance for general available and are described giving, goal setting and identifying
review of stroke patients [17] and are elsewhere [15] [17]. It should be noted psychological difficulties.
consistent with the recommendations that, while such tools should guide Befriending and peer support and
in the report ‘Psychological care after access to psychological care, stroke services provided by the voluntary
stroke’ [15]: teams should aim to adopt a holistic sector are effective ways to deliver
approach to assessment of Level 1 support. These services have
First screen is timed at about one psychological need: they should draw not been included in the modelling.
month after stroke or just before on other sources of evidence such as
hospital discharge, if that is sooner. concerns expressed by family
members, staff providing other
Second screen is timed around the elements of care, or information from
six week post discharge review or at GPs regarding pre-existing mental
about three months after stroke, at health needs.
which point most people will have
been discharged from hospital and
the assessment will be able to judge
both persistence of early-onset
problems and emergence of new
problems after discharge.

9


Level 2 psychological care Level 3 psychological care Model assumptions
Level 2 care may be provided by A proportion of patients with more When designing the economic
stroke team staff (AfC band 5) complex needs will require further model, certain assumptions and
additionally trained by the clinical psychological support at Level 3. simplifications were made to reduce
psychologist, or by a clinical Level 3 psychological care is delivered its complexity and account for lack of
psychology assistant (CPA) (AfC band in this model by a clinical psychologist available evidence (Table 1). All the
5) following assessment of the (mid AfC band 8a). Level 3 care will assumptions and simplifications have
patient by a clinical psychologist (see comprise more detailed assessment been tested and developed through
Figure 2a). Level 2 psychological care and use of a number of therapies, for discussion with clinical psychologists
may comprise brief psychological example cognitive behavioural and peer reviewed by a range of
interventions, advice and information, therapy (CBT), solution-focused health care professionals.
help with adjustment, goal setting therapy, or motivational interviewing.
and problem solving, motivational The model operates in the context of
interviewing or group work using The time allocated for a patient the National Stroke Strategy [1]
psychosocial education or relaxation requiring this level of psychological recommendations that key elements
groups. care is six sessions of 90 minutes of the stroke pathway are in place:
including time to prepare and write
Level 2 care may also be provided by up the sessions. • Transfer of care processes fully
Improving Access to Psychological involve the individual and their
Therapies (IAPT) services, which are Further referral to community mental family, and consider physical,
often based in primary care. Provision health services or psychiatry has not communicative, cognitive,
of these services is not separately been included in the scope of this psychological and financial
costed. model. circumstances;

Figure 2a: Structure of Level 2/3 support
No further support
The MDT decide how level 2 care
will be provided depending on
Level 2 support provided by MDT
screening outcomes and response
to level 1 psychological care

Level 2 support provided by CPA
Assessment by
clinical psychologist
Level 3 support provided by CP

10


Table 1: Summary of assumptions and justifications

ASSUMPTION JUSTIFICATION
A process is in place for review of psychological need at about National Stroke Strategy (2007) recommendations for general
one month or just prior to discharge if sooner, and at three assessment and review of stroke patients
and six months post-stroke

Screening for mood and cognition is carried out alongside ICSWP National Clinical Guideline for Stroke (2012)
current assessments by existing staff

Level 1 psychological care is provided by the multidisciplinary Based on the stepped care model and recommended by NICE
stroke team and in the ICSWP National Clinical Guideline for Stroke (2012)

The amount of time of Level 1 psychological care is provided Based on peer review
for each patient is equivalent to six sessions of 20 minutes.

Level 2 psychological care is provided by additionally trained Based on the stepped care model and recommended by NICE
stroke team staff or supervised clinical psychology assistants and in the ICSWP National Clinical Guideline for Stroke (2012)
following clinical psychology assessment

The amount of time of Level 2 psychological care is provided Based on peer review
for each patient is equivalent to six sessions of 90 minutes

Level 3 psychological care is provided wholly by a clinical Based on the stepped care model recommended by NICE and
psychologist in the ICSWP National Clinical Guideline for Stroke (2012)

The amount of time Level 3 psychological care is provided for Based on peer review
each patient is equivalent to six sessions of 90 minutes

11


• There is a strong relationship This paper should still be of use in of people are assessed as needing
between the stroke unit and areas where these elements are not Level 1 care at/around transfer home
community (including social care) fully established but, for costs to be or one month, and of these 67% are
teams, and agreements covering minimised and benefits fully realised assessed as needing further
the quality and timeliness of implementation of psychological care psychological care at the second
information transfer and maximum should be planned as part of wider screen. Figure 2b also shows show
waiting times for provision of implementation of these elements of the proportions of people who have
community services; the strategy. received services following the staged
• Reviews at six weeks and six screens.
months. Pathway of care
The overall pathway for psychological These figures are based on advice
These elements provide the care and the assumptions made from the national project sites
framework on which the economic about the proportion of people highlighted in the NHS Improvement
model for psychological care is built. assessed as needing psychological - Stroke report ‘Psychological care
care at each stage is shown in Figure after stroke’ [15], as well as further
2b. For example, it is assumed 33% consensus from peer review.

Figure 2b: The psychological care pathway

Level 2&3 support No third screen for people who
67% have had level 1 &2/3 support
Level 1 support
Level 2&3 support
33%
No intervention 73%
33%
No intervention
27%
ALL PATIENTS
Level 2&3 support
Level 1 support 67%
18%
No intervention
No intervention 33%
67%
Level 1 support
No intervention 7%
82%
No intervention
93%

Screening 1 Screening 2 Screening 3
(@2 weeks/1month) (@3months) (@6months)

12


The need for Level 2 and 3 Figure 3 shows that by the end of 12 In reality, this process will not be as
psychological care is defined after months 51% of people will have had neat as this model implies. For
screening or after a period of Level 1 no psychological care, but will have example, some lower level support
psychological care. Level 2 care is been screened at one, three, and six may be triggered by concerns raised
provided by additionally trained MDT months; 11% will have had Level 1 by the person who has had a stroke,
members or a supervised clinical care and 38% will have received or their family; alternatively, some
psychology assistant. Level 2 or 3 care. In the model, all people may be referred directly for
people receiving Level 2/3 care will Level 2/3 support. Hence the pathway
have had Level 1 care previously. set out above should be seen as a
description of a psychology service
for stroke, which can be used to
inform the model’s parameters and
not as a service specification.
Figure 3: Summary 100
of services received 90 Similarly, the percentages of people
by the end of each
80 assessed as needing services at
period
70 different stages will vary from these
60
assumptions. The accompanying
spreadsheet can be used to test
50
Percentage

different assumptions and recalculate
40
costs and benefits, as described in the
30 remaining chapters of this paper.
20

10

0
month 1 month 3 month 6 month 12

Level 3 (CP) 0.0% 0.0% 4.4% 7.7%

Level 2 (CPA) 0.0% 0.0% 8.9% 15.3%

Level 2 (MDT) 0.0% 0.0% 8.9% 15.3%

Level 1 supt only 0.0% 33.3% 23.1% 10.8%

% screened 100% 67% 66% 0%

13


Estimating demand for From this initial cohort of 500 stroke significantly since 1996 so
psychological care patients an estimation was made of adjustments to the data have been
The size of the population chosen in the proportion who would be alive made to reflect this. Adjustments for
this paper is 250,000. This figure was (and able to benefit from) the 30 day mortality, length of hospital
used because it is the size of the psychology service at different stages stay, readmission rate and
catchment population in the Stroke in the pathway (Figure 4). proportions of people in residential
Interface Audit (SIA) [18] on which The main source for these estimates care have been made in order to
some of the estimates in this paper is the SIA [18], which identified make them more representative of
are based. An assumed annual stroke patients admitted consecutively to current stroke care and outcomes.
incidence rate of 2/1000 makes the two hospitals in Liverpool from
model’s stroke population January to June 1996 and followed Detail of the adjustments made can
approximately 500 strokes per year them up in person at 3, 6 and 12 be found in both Appendix 1 of the
(first-ever and recurring). The model months post stroke, and then spreadsheet and Appendix 1 of this
assumes that all of these patients are annually via postal questionnaire until paper.
admitted to hospital. 5 years. Stroke care has developed

The model does not include
assumptions about (or dis-economies)
of scale and hence it is Figure 4: Overview of stroke survivors at
straightforward to scale these results different points post-stroke
to different population sizes and
incidence rates. 500
450
It is recognised that many people
400
with stroke will also have problems
with cognition [3], the management of 350
which by clinical psychology could 300
have potential economic benefit. 250
However, in order to keep this model
simple, it has not included an analysis 200
of the management of people with 150
cognitive problems in the service 100
described.
5
0
0 months 6 months 12 months 18 months 24 months

Alive Alive benefitting from Alive benefitting
level 1+2/3 support from level 1 support

14


The model combines the data on Estimating costs average was taken from the cost of
status and psychological care input, Direct NHS and adult social care costs consultations: surgery; clinic; phone;
described in the Pathway of care have been used. The costs used to home visits; prorated according to
section above, to make the following inform the model are summarised in the proportion of time spent by GPs
estimates of the demand for Table 2. Basic salary costs were taken on those activities. A list of
psychological services within the from Agenda for Change Pay Circular antidepressant medications that
model’s population: (24 March 2011) [19], pay bands from might be used for stroke patients
1 April 2010, and inflated to include was identified from the
• A total of 834 screens will take oncosts and overheads. MDT training literature [21] [22] [23] [24] and can be seen
place costs were taken from the SIP case in the spreadsheet (Table 2.1,
• 182 people will be offered Level 1 studies. The Unit Costs of Health [20] Appendix 2). The cost of each
support as part of their were used to inform costs of: medication was calculated, based on
rehabilitation inpatient bed nights (for hospital suggested dose [25] and pack price [26].
• Of these 56 will receive this service readmissions); outpatient procedures; These costs were then averaged to
alone, while 126 will also be GP contacts; care home packages provide an estimate of the average
offered additional psychological and residential care. The inpatient one year cost of antidepressant
care (100 at Level 2 and 26 bed nights were taken as non- medication.
Level 3). elective, short stay. For GP costs an

Table 2: Cost of resources used in the model

COST ITEM LEVEL DESCRIPTOR COST REFERENCE
MDT staff member Annual salary with oncosts £39,821 Pay Circular AfC-2-2011 (Annex B)
and overheads
AfC band 5 (point 23)

Clinical Psychology Assistant Annual salary with oncosts £39,821 Pay Circular AfC-2-2011 (Annex B)
and overheads
AfC band 5 (point 23)

Clinical Psychologist Annual salary with oncosts £62,961 Pay Circular AfC-2-2011 (Annex B)
and overheads
AfC band 8a (point 36)

Training for MDT member Per person £192 Data from SIP case studies [15]

Inpatient bed night Per night £549 PSSRU [20]

Outpatient procedures Average per procedure £147 PSSRU [20]

GP contact Average of surgery, clinic, £39 PSSRU [20]
telephone, and home visits

Care home package Per week £304 PSSRU [20]

Residential care Per week £983 PSSRU [20]

Antidepressants One year cost £52 Table 2.1, Appendix 2 (spreadsheet)

15


Combining demands and costs Table 3: Costs of service delivery in this
Based on the figures reported above pathway for the chosen population
and the other assumptions on the
cost of services the provision of SERVICE COST AVERAGE INPUT PER WEEK
psychological care for this population
can be costed (Table 3). The table also Screening & Level 1 support £23,201 16 screens
shows the average weekly workload, by MDT members 21 Level 1 sessions
to give a more practical description of 6 Level 2 sessions
the size of the service. The
Training for MDT members £1,471
accompanying spreadsheet enables
individual adjustment of any of these Clinical Psychology Assistant £16,438 6 Level 2 sessions (.41 FTE)
assumptions (including population
size, stroke incidence and people’s Clinical Psychologist £27,952 1.5 assessments (after Level 1
location at different stages of the support)
pathway) and recalculates this total 2.9 Level 3 support sessions
cost. 3 hours supervision (0.44 FTE)

Total £68,969

16


Modelling the impact of a service
for psychological care after stroke
This section focuses on the impacts Impact on the NHS In addition, an assumption was
that such a psychological service for Significant investment has been made made, based on peer review and the
people with stroke can have on both in recent years in community-based SIP national projects, that the
the demand for other local health mental health services as part of the approach described in the model
and social care services and on the Improving Access to Psychological would lead to less frequent use of
individuals who receive them. These Therapies (IAPT) programme. A antidepressant medication.
are considered over a period of two number of studies about the impact Anecdotally it appears that anti-
years. of emotional and psychological depressants may be regularly used as
support on health service activity a first line approach in services where
Measuring these impacts is difficult, were reviewed. There are little data there is considered to be an absence
partly because of a lack of empirical on the impact of psychological of alternatives.
data, particularly with respect to services on resource use that are both
stroke-specific services. Additional specific to stroke and UK-based. Two In order to combine the figures with
difficulties arise because of the studies from the USA have shown those of the psychological care
complex nature of emotional and that depression following stroke service provided by this model it is
psychological issues and the difficulty resulted in an increase in the length necessary to:
in tracking the impact of specific of stay for subsequent hospital
elements of a multidisciplinary admissions, and more outpatient 1. Calculate the total time for which
service. procedures [23] [27]. Because of the each person benefits from the
population under study and the Level 1 or Level 2/3 support, which
This section aims to gather together different health care system, it is they receive (Box 1)
the limited available data on these difficult to quantify these impacts in a 2. Estimate what proportion of the
impacts. Where possible it draws on UK population. However, such savings (GP, inpatient bed night,
stroke-specific information, but in impacts are consistent with a UK- outpatient procedures and
general it uses broader research on based review, although not stroke- medication) are realised by
the impact of support for people with specific, which has quantified the providing Level 1 and Level 2/3
low/moderate mental health needs. benefits of reducing depression on support.
Where such data are not available it resources such as GP consultations,
uses assumptions which have been nights spent in hospital, and numbers It is necessary to make estimates of
tested with clinical psychologists, and of outpatient procedures [28]. the realisation of benefits because it
peer reviewed by a range of health is unrealistic to assume that these
care professionals and analysts. Recovery from a common mental benefits will be fully realised. For
health problem was estimated to lead example, people receiving just Level 1
In the following three sections, to average annual reductions in support are likely to have relatively
impacts are described on individuals, healthcare usage per person as mild mental health issues, so this
in terms of: the NHS; adult social care follows: intervention will release a lower
services; and quality-adjusted life overall saving. Even for people
years (QALYs). Finally there is a • 1.59 GP consultations; receiving Level 2/3 support, the
discussion about the areas where • 0.73 inpatient bed nights. recovery rate will be less than 100%.
emotional and psychological support • 0.36 outpatient procedures.
is likely to have an impact, but which
were not included in the analysis.

17


Box 1: Calculating the total time over which people who receive psychological support benefit
Benefits from the service are calculated by estimating how long each person benefits from each intervention
they receive.

For example, Figure 5 below shows the timescales over which a person who receives Level 1 support after the
first screening and then Level 2/3 support after the third screening benefits from these services:

Figure 5: Pathway of care for an individual receiving psychological support
Months

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ... 22 23 24

Screen 1 Screen 2 Screen 3

Level 1 support Level 2&3 support

Benefitting from level 1 support Benefitting from level 2/3 support

Hence this individual will benefit for 5 months from the Level 1 support, and then benefit for a further 16
months from Level 2/3 support (in the 24 months following stroke).

The costing model can be used to total the “time for which each person benefits from psychological care”
across the subset of the cohort of 500 who receive either Level 1 or Level 2/3 support. In total, based on the
assumptions outlined in the previous section.

• The total benefit from Level 1 support is 1068 “person months”
• The total benefit from Level 2/3 support is 2328 “person months”

The accompanying spreadsheet costs • Level 2/3 support is assumed to on demand and cost to calculate the
the benefits of these services deliver 80% of the estimated cost estimated savings for emotional and
separately for each of the two years savings in the first year after stroke psychological support across four
following stroke. In line with this, it and 50% of these savings in the areas of health service spending (GP,
assumes that the impact of services second year. inpatient bed night, outpatient
lessens over this time and includes a procedures and medication)
factor to discount benefits in year These data can then be combined discussed above (Table 4).
two. As limited data are available on with data from the previous section
the longer term impacts of these
services this paper focuses on impacts Table 4: Savings to NHS from provision of
up to 24 months after stroke. In psychological care over two years
particular:
From Level 1 From Level 2 & 3 TOTAL
• Level 1 support is assumed to
deliver 60% of the estimated cost GP consultations £2,453 £6,020 £8,473
savings in the first year after stroke
and 40% of these savings in the Inpatient bed nights £7,789 £19,118 £26,907
second year Outpatient procedures £5,927 £14,546 £20,473

Anti-depressants £2,094 £5,140 £7,234

Total £18,263 £44,824 £63,087

18


Avoiding nights in hospital beds and It has been estimated that around These assumptions could then be
GP consultations may not realise 12.5% of people who have had a combined with data on the average
direct cash savings as the bed and stroke and survive to transfer home cost of residential care and the
appointment will inevitably be filled require some home care [30] services. number of admissions to residential
by other patients. These care (taken from the SIA) to estimate
calculations demonstrate the The assumptions about the impact on the total value of this saving at
saving from reducing the cost of take up of these services from £14,060 over the first two years after
the burden of stroke on health psychological support are: stroke. Potential savings from nursing
care resources. home care were not included in the
• That people who have had Level 1 model.
Impact on Adult Social Care support need 5% less home care in
Services year 1 and 2.5% less in year 2 Quality adjusted life years
A similar analysis to that presented following stroke (QALYs)
above is also possible for some costs • That people who have had Level The main driver for commissioning
related to Local Authority funded 2/3 support need 10% less home health and social care services is to
adult social care. However, there is a care in year 1 and 5% less in year 2 get the best possible outcomes for
lack of quantitative research in this following stroke. the population at large. However,
area and hence this part of the outcomes can be difficult to measure,
analysis is exploratory. Where there These assumptions can be combined making it difficult to compare services
were no research-based data to with data on the average cost of and hence inform commissioning
support the model assumptions, home care packages to estimate the decisions. One tool that can help with
these assumptions have instead been total savings of £31,151 (£17,918 in this process is ‘quality adjusted life
tested through peer review. year 1 and £13,233 in year 2). years’ (QALYs) [32]. The QALY is used
to quantify the benefits of a medical
One such area is formal personal care There is also anecdotal evidence that intervention and takes into account
provided at the stroke survivor’s own psychological support has an impact both quality and quantity of life
home (assistance with activities such on the likelihood of someone moving generated by healthcare. The QALY is
as washing and dressing). Untreated into residential care [31]. Because based on the amount of years of life
depression has a negative impact on admission to a care home is generally that would be added by the
function, independent of level of a one-off event, rather than on-going intervention. Each year in perfect
physical disability [12]. Psychological activity, it cannot be modelled in the health is assigned the value of 100%
care has been shown to be effective savings discussed above. Instead we down to a value of 0% for death. A
for depression-related disorders, developed a model based on the monetary amount is used to estimate
anxiety and behavioural problems assumptions that psychological the value of the extra life year. The
[29] and can improve people’s mood, support could delay the need for impact of a particular intervention is
confidence and ability to cope. admission to residential care for a quantified by estimating how much it
small proportion (20%) of people – improved people’s quality of life on
by four weeks for people who had this scale and then multiplying by the
had Level 1 support and 12 weeks for value of the “extra life year”.
people who were provided with Level
2/3 support.

19


This exercise has been carried out for Table 5: Estimated proportions benefitting
treatment for moderate depression or and QALY benefit for psychological care
anxiety and the resulting value was
£6,600 [28]. To calculate the total
% of maximum benefits Value of benefits
QALY benefit of the stroke-specific
delivered
psychological care service an
estimation was made of how much Year 1 Year 2
of this total benefit is realised by each
Level 1 care 25% 12% £102,535
intervention. The QALY benefit
calculated is £462,807. The Level 2/3 care 50% 25% £360,272
assumptions and results of the QALY
calculations are show in Table 5. TOTAL £462,807

Other impacts
There are a number of additional
benefits likely from these services
which could not be included in the
analysis. These include:

• Benefits from the screening process • Savings related to people returning
alone for people who are not to work, these are indirect costs,
referred for Level 1 support (e.g. which have not been measured in
some people may be signposted this model. However 25% of
after the initial screening for people with stroke are of working
informal support via local stroke age; calculation of the impact of
groups). psychological care on return to
• Avoidance of ‘crisis management’ work could yield some potential
of people with stroke and economic benefits.
psychological issues who feel • Benefits to the carers of people
unsupported or uninformed and with stroke who have psychological
who attend emergency needs: addressing a patient’s
departments or access community psychological need may reduce the
mental health crisis teams when carers utilisation of health and
unable to cope. This could be a social care resources; carers may
significant benefit, but is difficult to also have a greater opportunity to
quantify using current evidence. return to work.

20


Summary of results

Table 6: Sensitivity analysis

Estimated Savings

1 Year Year 1 and 2

Base case 10% less 10% more Base case 10% less 10% more
effective effective effective effective

NHS £33,410 £30,069 £36,751 £63,087 £56,778 £69,396
Costs
Social Care £29,101 £26,191 £32,011 £45,211 £40,690 £45,211 £62,075 10% less

TOTAL

QALY Benefits
£62,510

£266,764
£56,259 £68,761

£240,087 £293,440
£108,298

£462,807
£97,468 £114,607

£416,526 £509,088
{ £68,972

£75,869
Base case

10% more

Sensitivity analysis This sensitivity analysis found that,
The model’s results were tested in a psychological care produces an
sensitivity analysis with different overall cost saving after two years if
assumptions about the effectiveness social care savings are included. If
and cost of psychological care (Table social care savings are not included
6). Due to a lack of empirical data then psychological care is (just about)
around measures of effectiveness, a cost neutral for the NHS in two years
pragmatic approach to the sensitivity of the initial investment in all but the
analysis was adopted. Therefore, ‘10% less effective’ scenario (Figure 6).
assumptions were made that the
interventions were either 10% more,
or 10% less effective; which resulted
Figure 6: NHS and adult social care savings in relation to cost
in concomitant impacts on the overall
savings generated i.e. 10% more or £140,000
10% less. As more information about
psychological care after stroke £120,000
becomes available it will be possible £100,000
to make more informed decisions
about which variables to include in a £80,000
sensitivity analysis and the range of £60,000
levels that they can realistically take.
This would allow a more robust £40,000
sensitivity analysis of the model.
£20,000

£0
Base case 10% less 10% more Base case 10% less 10% more
effective effective effective effective
Savings year 1 Savings year 1 & 2

Social care NHS Cost Cost -10% Cost +10%

21


Discussion

This paper has modelled the costs Potential cost benefits to the health There were substantial additional
and potential cost savings of economy were estimated as well as treatment costs in year one of more
delivering a psychological care service suggested quality of life benefits to than £4.5 million, however in year
for people with problems affecting individuals in having their mental two, £450,000 savings to health and
their mood after stroke. It has health needs assessed regularly and social care were made due to lower
estimated the potential cost savings met by a stroke team who are aware costs associated with depression and
of a clinical psychologist-led service of psychological issues and are able benefits from reduced productivity
that funds clinical psychology and to manage them appropriately. The losses. A Hillingdon study
clinical psychology assistant posts to modelling indicates that an demonstrated savings of £837 per
support the development of good investment of £68,972 to deliver a person with depression and Chronic
psychological care after stroke. stroke-specific psychological care Obstructive Pulmonary Disease
service in the first year after stroke to (COPD) who attended the
The modelling has from necessity a stroke population of 500 people breathlessness clinic in the six months
been based on a number of may be virtually realised by the NHS after treatment. This is around four
assumptions about a service in order over a two year period with the times the upfront cost. A Liverpool
to define the economic benefits. benefit being £63,087. If economic study of 433 people with angina who
Where possible the assumptions have benefits to both the NHS and adult attended a cognitive behavioural
been based on best practice or social care are considered then a chronic disease management
evidence for psychological care after more significant benefit of £39,326 programme demonstrated reductions
stroke, or on evidence for people may be realised in the second year. in healthcare usage of approximately
with long term conditions. Where this £2,000 per person in the year after
has not been possible clinical opinion In terms of outcomes, the total treatment, ‘well in excess of the cost
has underpinned the assumption. The benefit of this service measured in of psychological intervention.’
context of the service described is terms of quality adjusted life years are
one led by a clinical psychologist who significant and well beyond those There is further work to be done to
trains and supports a multidisciplinary expected in terms of the criteria set define the economic impact of
team to provide Level 1 and some by NICE. The total QALY value for psychological care specifically for
Level 2 psychological care and has people receiving Level 1 and 2/3 care stroke. In particular there was little
clinical psychology assistant support. is £462,807. available evidence to define the
The service is compliant with the extent of crisis management of
National Stroke Strategy Studies exploring the benefits of psychological need of this group by
recommendations that patients are psychological services in other mental health services and
reviewed at six weeks and six months conditions have aimed to estimate emergency departments and primary
and that there is good integration the wider benefits to services and care. There is evidence to show that
between acute and community society and large substantial functional recovery is impeded by
services and social care. additional amounts have been depression [12], but the economic
identified [33]. Six months of implications of this are not yet well
collaborative care of people with type defined in terms of impact on length
2 diabetes and depression resulted in of hospital stay, continued
an additional 115 depression-free involvement with rehabilitation
days per individual. services and additional support
needs, although this evidence is
available for other long term
conditions.

22


Provision of psychological care after The assumption in this paper that The assumption about the impact of
stroke in England has been shown to psychotherapy is of benefit to stroke psychotherapy on costs was not as
be at best variable and at worst patients was not unreasonable. There strong because it had to be drawn
inadequate [10] [2]. The national focus is evidence from two Cochrane from either the stroke literature,
of attention on psychological care has reviews [35] [36] to suggest that which was not trial-based (e.g. [23]) or
raised awareness of the need for psychotherapy can prevent the was non-stroke data (e.g. [28]). This
services to improve. Inclusion of development of depression, though means that the model is not as robust
national measures of psychological little evidence of the benefit of as would be ideal, but because the
care in the national stroke audit, and psychotherapy on treating model has been developed on mixed
their consideration for inclusion in the depression; two trials not included in levels of evidence, assumptions made
Commissioning Outcomes this latter review have shown a small are conservative. Whilst this model is
Framework is welcomed as potential benefit of psychotherapy on treating considered by the authors to be of
drivers for continued improvement depression [22] [24]. Of particular value, further research into the
in services. promise however is the potential of benefit of psychotherapy after stroke
patients to be assisted by in a multi-centre trial is
psychological treatments modified to recommended. Such trials will need
A proportion of stroke services
suit those with stroke [17]. Empirical to consider the type of psychotherapy
have made improvements in their
support has established stroke delivered, the timing of the therapy
services based on reconfiguration
patients with low mood and aphasia (aligning it to current guidance) a
of stroke pathways and by linking
benefitted from behaviour therapy range of outcome measures (mood,
with adjacent services and the
modified for their communication function and resources) and recording
voluntary sector; however, the
disability [37]. of outcomes up to one year, if not
significant shortfall in stroke
longer.
specific clinical psychologists will
only be addressed through the
provision of these posts where Recommendations
they currently do not exist.
NHS Commissioning National data about the provision of psychological care is regularly
Board published and is publically available.
Whilst the focus of this paper has been
on the economic impact of Royal College of Specific audits of community and long term stroke services include
Physicians examination of psychological, cognitive and emotional care.
psychological care, it is the individual
and their family who are at the heart of Academics and Further research into the economic benefits of psychological
these services, and who may have a researchers therapy after stroke is undertaken in a multi-centre study.
very real need for emotional and
Commissioners The model is used to establish the local economic benefits of a
psychological support to manage the clinical psychologist-led service for psychological care based on a
stroke and its consequences. The review of current provision of psychological care.
significant benefits of meeting this
Stroke-specific psychological care is commissioned through the
need are almost impossible to quantify. engagement of adult social care, acute and community stroke
services, voluntary sector and mental health services.
One of the difficulties in developing Data and information are used to monitor access to and the
this model was a lack of empirical impact of psychological care for people with stroke.
evidence of the cost-effectiveness, or
even cost-utility of treating Providers Psychological care pathways are developed using a stepped
approach.
depression after stroke [34]. It would
have been better if this modelling Views of patients and families about the quality of psychological
work could have been informed by a care they received in the stroke service are elicited to support
development of these services.
large multi-centre trial exploring the
effectiveness and cost-effectiveness Consistent and routine mood and cognition screening is carried
(or utility) of psychotherapy delivered out in line with national evidence based guidance.
early after stroke.

23


References

[1] Department of Health, “National Stroke Strategy,”
Department of Health, London, 2007.
[2] Intercollegiate Stroke Working Party, “National Sentinel Stroke Clinical Audit 2010:
Round 7. Public report for England, Wales and Northern Ireland,” Royal College of
Physicians, London, 2011.
[3] Intercollegiate Stroke Working Party, “National Clinical Guidelines for Stroke,”
Royal College of Physicians, London, 2012.
[4] Hackett et al, “Frequency of depression after stroke; a systematic review of
observational studies,” Stroke, vol. 36, p. 1330, 2005.
[5] Campbell-Burton CA, Murray J, Holmes J et al, “Frequency of anxiety after stroke:
A systematic review and meta-analysis of observational studies,”
DOI:10.1111/j.1747-4949.2012.00906.2012.
[6] Sembi S, Tarrier N, O'Neil P et al, “Does post-traumatic stress disorder occur after
stroke: A preliminary study,” International Journal of Geriatric Psychiatry, vol. 13,
pp. 315-322, 1998.
[7] Bruggimann L, Annon, J M, Staub F et al, “Chronic posttraumatic stress symptoms
after nonsevere stroke,” Neurology, vol. 66, pp. 513-16, 2006.
[8] Field E L, Norman P, Barton J. et al, “Cross-sectional and prospective associations
between cognitive appraisals and posttraumatic stress disorder symptoms following
stroke,” Behaviour Research and Therapy, vol. 46, pp. 62-70, 2008.
[9] British Psychological Society, “Psychological services for stroke survivors and their
families - Briefing paper 19,” 2010.
[10] National Audit Office, “Progress in improving stroke care,”
Department of Health, London , 2010.
[11] Care Quality Commission, “A review of services for people who have had a stroke
and their carers,” Care Quality Commission, London, 2011.
[12] West, R., Hill, K., Hewison, J., Knapp, P. House, A., “Psychological disorders after
stroke are an important influence on functional outcomes; a prospective cohort
study,” Stroke, vol. 41, pp. 1723-1727, 2010.
[13] The Kings Fund and Centre for Mental Health, “Long term conditions and mental
health - the cost of comorbidities.,” London, 2012.
[14] National Institute for Health and Clinical Excellence, “Depression in adults with a
chronic physical health problem . Clinical guideline 91,” 2009.
[15] NHS Improvement, “Psychological care after stroke; Improving services for people
with mood and cognitive disorders,” NHS Improvement, 2011.
[16] National Institute for Health and Clinical Excellence,
“Stroke Quality Standard,” 2012.
[17] Lincoln, N.B. Kneebone, I.I. Macniven, J.A.B. and Morris, R., Psychological
management of stroke, Chichester: Wiley, 2012.
[18] Watkins et al, “Stroke Interface Audit: pre/post discharge audit of stroke services
and care in Liverpool and Sefton: Delivery timeliness and targeting. 36 month
report,” March 2002.
[19] Department of Health, “Agenda for Change Pay Circular,”
Department of Health, 2011.
[20] Personal Social Services Research Unit (PSSRU), “Unit Costs of Health and Social
Care 2011,” 2011. [Online]. Available: http://www.pssru.ac.uk/project-pages/unit-
costs/2011/index.php. [Accessed 7th August 2012].
[21] Turner-Stokes L, Hassan N, “Depression after stroke: A review of the evidence base
to inform the development of an integrated care pathway. Part 2: Treatment
alternatives,” Clinical Rehabilitation, vol. 16, pp. 248-60, 2001.

24


[22] Williams LS, Kroenke K, Bakas T et al, “Care management of post stroke
depression: A randomised controlled trial,” Stroke, vol. 38, pp. 998-1003, 2007.
[23] Jia, H., Damush, T.M., Qin, H. et al, “The impact of poststroke depression on
healthcare use by veterans with acute stroke,” Stroke, vol. 37,
pp. 27996-2801, 2006.
[24] Mitchell PH, Veith RC, Becker KJ et al, “Brief psychological behavioural with
antidepressant reduces poststroke depression significantly more than usual care
with antidepressant: living well with stroke: randomised controlled trial.,” Stroke,
vol. 40, pp. 3073-8, 2009.
[25] WHO Collaborating Centre for Drug Statistics Methodology, [Online]. Available:
http://www.whocc.no [Accessed 24th May 2012].
[26] BNF online, [Online]. Available: http://www.bnf.org/bnf/index.htm.
[Accessed 24th May 2012].
[27] Ghose, S.S.. Williams, L.S., Swindle, R.W.,, “Depression and other mental health
diagnoses after stroke increases inpatient and outpatient medical utilisation three
years poststroke,” Medical Care, vol. 43, pp. 1259-1264, 2005.
[28] Department of Health, “Impact assessment of the expansion of talking therapies
services as set out in the Mental Health Strategy,” Department of Health, 2011.
[29] Kneebone, I. I., Lincoln, N.B, “Psychological Problems after Stroke and Their
Management: State of Knowledge,” Neuroscience and Medicine, vol. 3,
pp. 83-89, 2012.
[30] Saka O, McGuire A, Wolfe C. , “Cost of stroke in the United Kingdom,” Age and
Ageing, vol. 38, pp. 27-32, 2009.
[31] NHS Improvement, “Care Homes,” [Online]. Available:
http://www.improvement.nhs.uk/stroke/Carehomes/tabid/201/Default.aspx.
[Accessed 30th August 2012].
[32] National Institute for Health and Clinical Excellence, “Measuring effectiveness and
cost effectiveness: the QALY,” 20th April 2010. [Online]. Available:
http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcost
effectivenesstheqaly.jsp. [Accessed 8th August 2012].
[33] NHS Confederation and Mental Health Network, “Investing in emotional and
psychological wellbeing in people with long term conditions,” 2012.
[34] R. Marsh, “Evidence Adoption Centre NHS East of England- Reviews in progress,”
The cost and cost-effectiveness of psychological therapies for post stroke
management: a rapid evidence assessment, 2012. [Online]. Available:
http://www.eac.cpft.nhs.uk/reviewsinprogress.aspx.
[Accessed 10th September 2012].
[35] Hackett ML, Anderson CS, House A et al, “Interventions for preventing depression after
stroke,” Cochrane Database of Systematic Reviews, no. 3, 2008a.
[36] Hackett ML, Anderson CS, House A, et al, “Interventions for treating depression after
stroke,” Cochrane Database of Systematic reviews, no. 4, 2008b.
[37] Thomas SA, Walker MF, Macniven JA, Haworth H, Lincoln N,, “Communication and Low
Mood (CALM): a randomized controlled trial of behavioural therapy for stroke patients
with aphasia.,” Clinical Rehabilitation, In Press.

25


Appendix 1

Adjustments made to the Stroke Interface Audit data
Stroke care has taken considerable strides forward since 1996 and so adjustments have been
made to the data in order to make it more representative of modern stroke care and
outcomes.

In the original cohort the level of mortality was high compared with other cohorts and more
modern data; for example, the 30-day mortality in the cohort was 34%, which is much higher
than the 17% cited in the National Sentinel Audit (2011)1. The mortality data was reviewed
from a series of studies2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and increased the number alive at the different time
points by a factor of 18%. Similarly, the length of hospital stay for the index stroke is much
longer [mean 35.3 days] than the mean 19.5 days cited in the National Sentinel Audit (2011)1.
Consequently we reduced the length of stay data by 40%.

The proportion of readmissions during each month up to 12 months was available from the
cohort, but there were limited data on readmissions beyond 12 months. Consequently, an
estimate was made of the likely proportion of readmissions per month, for months 13 through
24, based on the data up to 12-months (readmissions per month were on average 6.3% of
the patients alive in the community) and data reported elsewhere2. Using these figures it was
estimated that for each of months 13 through 24, the number of readmissions is equivalent to
approximately 5.0% of the number of patients alive. Data on the exact time of entry to
residential care was not known – residence was recorded using point estimates at the time of
assessments (i.e. 3, 6, 12 and 24 months) and so a rounded estimate has been used, based on
the known proportion at the time of assessment. For each of months 13 through 24 we have
estimated that 25% of patients in the community were in residential care.

1
Intercollegiate Stroke Working Party, “National Sentinel Stroke Clinical Audit 2010: Round 7. Public report for England,
Wales and Northern Ireland,” Royal College of Physicians, London, 2011.
2
Bravata Dm, Shih-Yieh H, Meehan TP, et al, “Readmission and death after hopitalisation for acute ischaemic stroke:
5 year follow up in the Medicare population,” Stroke, vol. 38, pp. 1899-904, 2007.
3
Brønnum-Hansen H, Davidsen M, Thorvaldsen P, “Long term survival and causes of death
4
Dennis MS, Burn JP, Sandercock PA et al, “Long term survivalafter first-ever stroke: the Oxfordshire community stroke
project,” Stroke, vol. 24, pp. 976-800, 1993.
5
Eriksson SE, Olsson JE, Broadhurst RJ et al, “Five year survival after first-ever stroke and related prognostic factorsin the
Perth community stroke study,” Stroke, vol. 34, pp. 1842-6, 2000.
6
Hardie K, Hankey GJ, Jamrozik K, et al, “Ten-year survival after first ever stroke in the Perth community stroke study,”
Stroke, vol. 34, pp. 1842-6, 2003.
7
Turaj W, Slowik A, Dziedzic T et al, “Increased plasma fibrinogen predicts one year mortality in patients with acute
ischaemic stroke,” Journal of Neurological Sciences, vol. 246, pp. 13-19, 2005.
8
Stavem, K, Rønning OM, “Survival of unselected stroke patients in a stroke unit compared with conventional care,”
QJ Med, vol. 95, pp. 143-152, 2002
9
Wang y, Lim LL-Y, Heller RF et al, “A prediction model of 1-year mortality for acute ischaemic stroke patients,”
Arch phys Med Rehab, vol. 84, pp. 1006-11, 2003.
10
Hankey GJ, Jamrozik K, Broadhurst RJ, et al, Five-year survival after first-ever stroke and related prognostic factors in
the Perth community stroke study. Stroke;31: 2080-6. 2000
11
Eriksson SE, Olsson JE. Survival and recurrent strokes in patients with different subtypes of stroke: a fourteen-year
follow-up. Cerebrovascular Diseases;12:171-80. 2001
12
Saposnik G, Hill MD, O’Donnell M, Fang J, Hachinski V, Kapral MK. Variables associated with 7-day, 30-day,
and 1-year fatality after ischemic stroke. Stroke;39:2318–2324. 2008

26

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CANCER

DIAGNOSTICS

HEART

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STROKE

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