Economic analyses in stroke rehabilitation are made challenging by a number of factors. There is still much debate surrounding which patients should and should not receive rehabilitation, what type of rehabilitation is best, and how much rehabilitation is appropriate. Perhaps the only indisputable fact regarding stroke rehabilitation is that it costs money. Yet, research suggests that an efficient post-acute stroke rehabilitation system may actually help to relieve the financial burden of other healthcare sectors including acute and long-term care4,15.
In Ontario’s current rehabilitation system, emerging evidence suggests that limited funding may be negatively influencing our ability to provide care. As previously mentioned, Ontario-based research suggests that 37% of stroke patients discharged from an acute facility are good candidates for inpatient rehabilitation, yet our sample drawn from the 2008/09 Ontario Stroke Audit suggests that only 33% were actually admitted. The results of the model application in phase 2 appear to confirm the impact of limited accessibility to rehabilitation. Without exception, patients whose characteristics suggest that they may have been candidates for inpatient
rehabilitation were identified in every LHIN. Using the probability of admission to inpatient rehabilitation greater than 70% as an estimate of rehabilitation candidacy, estimates suggest that 2-4% of patients not admitted to inpatient rehabilitation across the province may have been reasonable candidates. At the provincial level, this suggests that between 200 and 400
candidates for inpatient rehabilitation are unable to access these services each year.
Limited budgets are a problem in many Canadian healthcare sectors. Based on the best available evidence, it seems fair to assume that Ontario’s stroke rehabilitation system is also under-resourced. The purpose of this phase of the study was to use patient characteristics to infer where investments should be made to Ontario’s stroke rehabilitation system and to identify regions that are most likely to benefit from increased investment.
Methods
Evidence from previous research and estimates derived from the count statistic in this report suggest that inpatient rehabilitation resources are insufficient to meet the annual demand of stroke patients across the province. In order to assess the gap between actual and necessary rehabilitation resources, the count statistic was used to estimate the number of stroke patients in each LHIN who could be identified as good rehabilitation candidates, but were not admitted to inpatient rehabilitation. An individual probability of rehabilitation admission greater than 0.7 was used to identify good rehabilitation candidates in our sample and this proportion was used to estimate the total number of such patients in each LHIN in 2008/09. The LHIN-specific number of patients was then multiplied by an inflation adjusted estimate of the average cost of inpatient rehabilitation in Ontario to generate an estimate of the minimum investment that should be made in stroke rehabilitation in each LHIN.
Identifying Regions Most in Need of Future Investment
Rank statistics across each of the resource variables were used to identify LHINs that need further evaluation of resource availability. The bottom five LHINs in average rank for each of inpatient, outpatient and CCAC rehabilitation services were identified as regions in which further evaluation of rehabilitation resources is necessary.
Results
Estimating the Cost of Meeting Unmet Need
The estimated proportion and total number of patients whose probability of admission to
inpatient rehabilitation was greater than 0.7 among those not admitted to inpatient rehabilitation was calculated for each LHIN (table 21). Estimates for the necessary increase in annual investment by region was calculated by multiplying the estimated unmet need by the average per diem cost of inpatient rehabilitation16 ($645, inflation adjusted to 201117) times the mean active length of stay in inpatient rehabilitation from 2009/107 (34.5 days).
Table 21. Estimates of necessary investment in post-stroke inpatient rehabilitation by LHIN based on unmet need in 2008/09 LHIN Proportion >0.7 probability of admission Patients not admitted to inpatient rehabilitation (2009/10) Estimated Unmet Need Necessary Increase in Annual Investment 1 Erie St. Clair 0.031 596 18 $405,179 2 South West 0.042 837 35 $770,927 3 Waterloo Wellington 0.035 456 16 $350,003
4 Hamilton Niagara Haldimand Brant 0.041 1227 50 $1,103,233
5 Central West 0.036 402 14 $317,371 6 Mississauga Halton 0.033 650 21 $470,399 7 Toronto Central 0.044 1199 53 $1,156,939 8 Central 0.026 801 21 $456,714 9 Central East 0.019 877 17 $365,420 10 South East 0.032 384 12 $269,476 11 Champlain 0.033 711 23 $514,544
12 North Simcoe Muskoka 0.043 368 16 $347,020
13 North East 0.026 666 17 $379,740
14 North West 0.042 253 11 $233,028
Total Estimate 9427 326 $7,139,991
Identifying Regions Most in Need of Future Investment
The five worst ranking LHINs for rehabilitation resource availability for stroke patients were identified for each of inpatient, outpatient and CCAC rehabilitation. Results are presented in table 22.
Table 22. LHINs in greatest need of investment in post-stroke inpatient, outpatient and CCAC rehabilitation
Inpatient Outpatient CCAC
Central Central North West
North West Central East Toronto Central
North Simcoe Muskoka South West Champlain
Central East Mississauga Halton South East
Waterloo Wellington Erie St. Clair Central East
Discussion
A formal economic assessment of rehabilitation resources in Ontario is made difficult by limited information. However, there is more than sufficient information to begin to develop a data-
driven approach to resource assessment, and one that with only slight modification of current data collection strategies could become a routine part of resource assessment.
The methods developed in this study appear to confirm previous research suggesting that post- stroke inpatient rehabilitation is under resourced in Ontario. Using the count statistic, patients with a probability of admission to rehabilitation greater than 70% but were not admitted were identified in every region. While there are often explanations for this other than resource availability, previous Ontario research suggests that a lack of bed availability is the number one reason for patients not being able to access care4. Also, there were a number of patients whose probability of admission was between 50-70% who were also not admitted. Therefore, we felt that an economic assessment based only on patients whose probability was greater than 70% would provide conservative estimates of necessary investment.
In every region, some increased investment in inpatient rehabilitation resources appears
warranted. Based on our estimates, this investment should reflect the size and current capacity of each region. Therefore, our recommended investments range from just over $200,000 to nearly $1,200,000 million dollars per region. While these estimates amount to a significant investment, there is evidence to suggest that the post-acute rehabilitation of many of these patients may actually save the system money by reducing ALC bed days in acute facilities or the number of admissions to long-term care facilities4,15. Future research should further explore the potential impact of increased investment.
Survey respondents continually noted that outpatient and CCAC rehabilitation services were lacking across the province and needed more resources. While limited information hindered our ability to perform any true economic assessments in these areas, the methods applied to
inpatient rehabilitation could easily be extrapolated if more information became available. In lieu of this economic assessment, we felt it was important to identify the regions that appeared to be lagging behind in terms of the availability of inpatient, outpatient and CCAC rehabilitation
services. This was done to alert policy makers to regions where future investments are needed and may have the greatest impact.
Key Findings
access inpatient rehabilitation in 2009/10
A minimum investment of $7,139,991 is recommended to help improve accessibility Investments in each LHIN are recommended and range from approximately $233,000 to
$1,150,000
The Central, North West, North Simcoe Muskoka, Central East and Waterloo Wellington LHINs appear to have the greatest need of investment in inpatient rehabilitation
The Central, Central East, South West, Mississauga Halton, and Erie St. Clair LHINs appear to have the greatest need for investment in outpatient rehabilitation
The North West, Toronto Central, Champlain, South East and Central East LHINs appear to have the greatest need for investment in CCAC rehabilitation services