Cost study on spinal cord injury

rehabilitation care in Sweden

Version: Final

Date: 2014-05-12

Quantify Research Authors

Name: Anders Gustavsson Name: Linda Karlsson Title: Partner Title: Senior Researcher Phone +46 70 715 7863 Phone +46 70 982 3725 E-mail: anders.gustavsson@quantifyresearch.com E-mail: linda.karlsson@quantifyresearch.com Name: Stefanie Luthman Title: Researcher Phone +46 76 834 2262 E-mail: stefanie.luthman@quantifyresearch.com

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Table of contents

1. Introduction ............................................................................................................... 4

1.1 Background .............................................................................................................................. 4

1.2 Rationale .................................................................................................................................. 4

1.3 Objectives ................................................................................................................................ 5

2. Methods .................................................................................................................... 5

2.1 Questionnaire to clinics ........................................................................................................... 5

2.1.1 Development and distribution of questionnaire ............................................................. 5

2.1.2 Responding clinics ........................................................................................................... 5

2.1.3 Primary rehabilitation...................................................................................................... 6

2.1.4 Re-admissions .................................................................................................................. 7

2.1.5 Outpatient and day care visits ......................................................................................... 8

2.1.6 Staff ................................................................................................................................. 9

2.1.7 Facilities at the clinic ..................................................................................................... 11

2.2 Questionnaire to SCI-specialists ............................................................................................ 13

2.3 Unit costs ............................................................................................................................... 15

2.4 Model .................................................................................................................................... 16

3. Results ..................................................................................................................... 16

3.1 Base case analysis .................................................................................................................. 16

3.1.1 Care provision ................................................................................................................ 16

3.1.2 Staff resources and facilities .......................................................................................... 18

3.1.3 Costs .............................................................................................................................. 20

3.2 One-way sensitivity analysis .................................................................................................. 21

3.2.1 Sensitivity analysis 1: Including total number of visits when determining number of

full-time employees in decentralised care .................................................................................... 22

3.2.2 Sensitivity analysis 2: Assuming equal occupancy rates in decentralised and centralised

care 22

3.2.3 Sensitivity analysis 3: Assuming the SCI-experts underestimated the true staff-need

with 10%, hence increasing the full-time employees needed by 10% in centralised care ........... 22

3.3 Multi-way sensitivity analysis ................................................................................................ 23

3.3.1 Sensitivity analysis 4 ...................................................................................................... 23

3.3.2 Sensitivity analysis 5 ...................................................................................................... 24

4. Discussion ................................................................................................................ 25

4.1 Staffing costs ......................................................................................................................... 25

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4.2 Acute care costs .................................................................................................................... 25

4.3 Facility costs .......................................................................................................................... 26

4.4 Re-admissions and outpatient visits ...................................................................................... 26

4.5 Care at home ......................................................................................................................... 26

4.6 Other benefits ....................................................................................................................... 27

4.7 Model limitations .................................................................................................................. 27

4.8 Conclusions ............................................................................................................................ 28

5. References ............................................................................................................... 29

6. Appendix A: Questionnaire to clinics ........................................................................ 30

7. Appendix B: Questionnaire to SCI-specialists ............................................................ 38

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Study Glossary

Term Definition

Average Arithmetic mean

DRG diagnosis-related-groups

ESCIF European Spinal Cord Injury Federation

KPP Cost per patient

SCI Spinal Cord Injury

SCIC Spinal Cord Injury Centre

Weighted average Average based on number of patients in primary

rehabilitation 2012 or number of incident patients in 2012

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1. Introduction

1.1 Background

Spinal cord injuries are damage or trauma to the spinal cord that results in a loss or impaired

function causing reduced mobility or sensibility. Common causes of a spinal cord injury are falls,

diving accidents, car accidents or disease [1]. While the incidence of spinal cord injury (SCI) is

relatively low, the physical, medical, psychological, social and financial consequences of such injuries

are highly complex and, potentially, devastating for the injured person and his/her family [2]. It is

therefore important for these patients to receive the best care possible to make their re-integration

back into society after injury as successful as possible.

The rehabilitation care of SCI-patients today is decentralised to 20-30 different hospitals around the

country. These clinics do not only care for SCI-patients but also care for other patients in primary

rehabilitation (e.g. patients with stroke and traumatic brain injuries). The Swedish Association for

Survivors of Accident and Injury (RTP) [3] has for a long time worked for the establishment of

centralised rehabilitation care for SCI-patients in Sweden. By centralizing the care for SCI-patients to

2-4 spinal cord injury centres (SCIC), these centres would specialize on SCI-care and possibly be able

to provide better care for this specific patient group. Centralization also enable specialisation of staff,

more focus on research and innovation, knowledge and information pooling, availability of role

models during rehabilitation (so called peer-support) and economies of scale. A thorough description

of centralised care, what it should include and potential benefits are presented in a report from the

European Spinal Cord Injury Federation (ESCIF) [2]. ESCIF and its members also work to promote

centralised care of SCI-patients [4] which today is available in other countries such as Denmark,

Norway, Switzerland, the United States and Australia.

1.2 Rationale

Although many experts seem to agree that centralization would lead to better care for SCI-patients,

little or no evidence of the potential benefits are available. This may be explained by the low

incidence of SCI and high variation in the injury, opportunities for rehabilitation and outcomes of the

patients. These factors make any comparative study on alternative interventions within Sweden (e.g.

decentralized or centralized care) very difficult. Comparisons across countries are also difficult to

interpret because there are a range of differences in care structure and other circumstances which

may all be potential causes of any differences in outcomes.

In absence of feasible ways of showing that centralisation causes improved care for SCI patients, this

study will focus on the potential changes in costs by centralization of SCI-care. By learning more

about the costs of centralization, decision makers will have more information at hand when

considering centralization. Estimations of costs will necessarily need to be estimated aided by

assumptions because we don’t know how an actual centralised organisation would turn out, what

resources would be needed exactly and what potential effects the centralisation process would have

on today’s care providers. For this reason, an economic model was developed, combining available

data and various assumptions to estimate care and resource needs as well as their costs.

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1.3 Objectives

The aim of this study was to compare the available resources and costs for today’s decentralised care

of SCI-patients with the resources and costs that are expected to be needed in a hypothetical

scenario where the care of the same patients would be centralised to fewer sites. The study aims to

answer the below listed questions:

What are the available resources and costs for rehabilitation of SCI-patients in Sweden today?

How would a hypothetical centralised care of SCI-patients in Sweden be organised regarding

resources and costs?

What differences in total costs are expected with centralised care?

Is there a difference between costs for today’s decentralised care and for a hypothetical

centralised care?

2. Methods

Two questionnaires were prepared to collect data on the current and potential care and resource use

in today’s decentralised scenario and a hypothetical centralised scenario, respectively (see

appendices A and B). These data were analysed and the results are summarised below. Data on costs

of units of resources were derived from price lists and other publicly available sources, and also

summarised below. The responses from the questionnaire and the unit costs where then used as

inputs in a model comparing rehabilitation care today (decentralised care) and a hypothetical SCIC

scenario (centralised care). The model used is presented in section 2.4.

2.1 Questionnaire to clinics

2.1.1 Development and distribution of questionnaire

The questionnaire was developed by Quantify Research together with SCI-specialists [5-8] and an

expert from Personskadeförbundet RTP [9] to capture all relevant resource use both related to all

care at the clinic and to SCI-patients only. The questionnaire included questions regarding primary

rehabilitation, re-admissions, outpatient visits, day care visits, staff and facilities at the clinic (see

appendix A). Twenty-six clinics were identified and considered for inclusion. Three clinics were

excluded (Mälarsjukhuset Eskilstuna, Skaraborgs sjukhus in Skövde and Södra Älvsborg Sjukhus in

Borås) for the following reasons; one did not report any patients in primary rehabilitation, one sent

in the questionnaire after all the analyses had been conducted and one referred all SCI-patients to

other hospitals and did therefore not have any SCI-patients. Before distributing the questionnaire,

the clinics were contacted by phone and asked to participate. The questionnaire was thereafter e-

mailed to the clinics, and they were reminded both by e-mail and phone if not responding in time.

2.1.2 Responding clinics

Of the remaining 23 clinics, 20 responded (response rate = 87%) and the responding clinics are listed

below:

Akademiska sjukhuset in Uppsala

Blekingesjukhuset in Karlshamn

Centralsjukhuset in Karlstad

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Karolinska Universitetssjukhuset in Stockholm

Länssjukhuset Centrallasarettet in Växjö

Länssjukhuset in Halmstad

Länssjukhuset Sunderby in Luleå

Länssjuhuset Sundsvall/Härnösand

Länssjukhuset Ryhov

Norrlands Universitetssjukhus (NUS), Umeå

RehabStation Stockholm

Rehabiliteringsenheten, Sahlgrenska Universitetssjukhuset in Gothenburg

Ryggmärgsskadeenheten, Sahlgrenska Universitetssjukhuset in Gothenburg

Sandvikens sjukhus

Skånes Universitetssjukhus in Höör

Stockholms sjukhem

Universitetssjukhuset in Linköping

Universitetssjukhuset in Örebro

Västmanlands sjukhus in Västerås

Östersunds sjukhus

Time constraints were the main reason for three clinics not participating (Falu lasarett, Uddevalla

sjukhus and Västerviks sjukhus). In the following sub-sections preliminary variables received from the

questionnaire are described and the majority of these were later used as input in the model

described in section 2.4.

2.1.3 Primary rehabilitation

The number of patients and length of stay in primary rehabilitation are presented in Table 1. In total

2,310 patients (18 responding clinics) were in primary rehabilitation during 2012 (including all

patients at the clinic irrespective of whether a spinal cord injury was the cause of rehabilitation). We

did not ask how many of these were hospitalised in 2012 (i.e. incident patients) but they can be

estimated to 1,960 patients assuming that the average length of stay did not change over time.

Table 1 Primary rehabilitation in today’s decentralised care of SCI-patients

Number of

responding clinics

Mean Sd Min Median Max Adjusted mean

1

Average number of patients in primary rehabilitation during 2012 per clinic

All patients 182 128.3 108.1 35 86 471

SCI-patients 20 21.1 21.5 1 10 65

Average number of incident patients in 2012 per clinic3

All patients 182 108.9 93.6 30 72 391

SCI-patients 20 17.5 17.8 1 8 50

Average number of days per hospitalisation in primary rehabilitation per patient

All patients 18 39.1 14.9 14.2 37 64

SCI-patients 15 58.5 26.4 27.8 51 120.4 61.7

1. Adjusted mean across all responding clinics based on total number of SCI-patients and their average care time at each clinic. 2. Two clinics only reported results for their SCI-patients. 3. Estimated assuming that the average length of stay did not change over time.

7

Considering SCI-patients only; 20 clinics reported a total of 422 patients in primary rehabilitation

during 2012 and the estimated number of incident patients in 2012 was 350. Transferring from one

clinic to another during a patient’s primary rehabilitation was not captured in the questionnaire.

Based on the SCI-specialists knowledge regarding transfers it was assumed that the total adjusted

number of incident SCI-patients in 2012 was about 270 (13.5 incident patients per clinic).

To estimate the length of stay for patients in primary rehabilitation the questionnaire included a

question regarding the average number of days per hospitalisation at the clinic. The weighted

average across all clinics (based on number of SCI-patients in primary rehabilitation in 2012 and their

average hospitalisation time in each clinic) was 61.7 days. The average total number of days in

primary rehabilitation (including potential transfers) was estimated to 80 days. This was calculated by

multiplying the weighted average number of days per hospitalisation per clinic (61.7) with the total

number SCI-patients in all responding clinics (350) and dividing by the estimated number of unique

incident patients (270).

2.1.4 Re-admissions

Table 2 Re-admissions in today’s decentralised care of SCI-patients

Number of

responding clinics

Mean Sd Min Median Max Adjusted

mean

Number of re-admissions per clinic

All patients 12 19.6 28.2 0 5 76

SCI-patients 13 10.2 17.7 0 2 58 21.31

Average number of days per hospitalisation for re-admitted SCI-patients

SCI-patients 82 23.5 22.7 5 18 77 13.5

3

1. Adjusted mean across all responding clinics based on the number of incident SCI-patients 2012 in primary rehabilitation. 2. Eight clinics reporting at least one re-admission. 3. Adjusted mean across all responding clinics based on number of re-admissions and total hospitalisation time for these re-admissions at each clinic.

Re-admissions during 2012 were also asked for in the questionnaire and the results are summarised

in Table 2. A total of 235 re-admissions (12 responding clinics) were reported for all patients at the

clinics with an average of 19.6 re-admissions per clinic. Considering SCI-patients, there were 133 re-

admissions (13 responding clinics) with an average of 10.2 re-admissions per clinic. Weighting the

average number of re-admissions based on the clinic’s size (number of incident SCI-patients in

primary rehabilitation) resulted in a weighted average of 21.3 re-admissions for SCI-patients per

clinic. The weighted average number of days per hospitalisation at the clinics for re-admitted

patients was estimated to 13.5 days (based on the eight clinics reporting re-admitted SCI-patients). In

addition, for the eight clinics, a ratio of re-admissions / primary rehabilitations in 2012 was

calculated. No clear pattern between re-admissions and primary rehabilitation for SCI-patients was

seen between larger/smaller clinics (see Figure 1).

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Figure 1 Correlation between number of admissions and patients in primary rehabilitation.

2.1.5 Outpatient and day care visits

Clinics were asked to report the total number of outpatient and day care visits (including for example

physician visits for prescription of medical drugs, physiotherapist/occupational therapist training

visits and nurse visits for care of pressure sores). Table 3 presents outpatient and day care visits

separately and in total. The total row in Table 3 includes 6 clinics which were not able to separate

outpatient/day care visits and/or to separate SCI-patients’ visits from the total number of visits.

A problem with the above results was that several clinics with outpatient/day care visits had only

reported physician visits excluding any other outpatient/day care visits. Therefore calculations were

also performed by only including 7 clinics reporting the complete range of possible visits, raising the

mean number of outpatient/day care visits from 566 to 1316. In addition, a weighted (based on

number of incident SCI-patients in 2012) average ratio (0.7) was calculated as number of visits

divided by number of primary rehabilitation days in 2012 for the reporting clinics which had at least

one outpatient or day care visit.

Table 3 Outpatient and day care visits for SCI-patients

Number of

responding clinics

Mean Sd Min Median Max Ratio1

Number of visits per clinic

Outpatient visits 9 313.9 322.4 0 271 1004

Day care visits 5 140.4 209.1 5 65 510

All visits2 20 566.1 1532.4 0 81 6960

All visits only including

clinics reporting all possible

visits

7 1316.2 2520.0 0 361 6960 0.7

1. Weighted average ratio of outpatient and day care visits divided by total number of hospitalisation days in primary rehabilitation for SCI-patients in 2012 at responding clinics. 2. Outpatient and/or day care visits.

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2.1.6 Staff

The clinics were asked for number of full-time employees for the below listed groups:

Administrative assistant

Counsellor

Dietician

Head of administration

Nurse

Nursing assistant

Occupational therapist

Psychologist

Physician

Physiotherapist

Rehabilitation assistant

Speech therapist

Urotherapist

Other, please state

They were also asked to state, if possible, percentage of the employees’ time that was intended for

SCI-patients. Seven clinics were able to report how much of their employees’ working time that was

spent on SCI-patients (see Table 4 for number of full time employees working with SCI-patients).

Table 4 Number of full-time employees working with SCI-patients

Number of

responding clinics

Mean Sd Min Median Max

Administrative assistant 6 0.7 0.7 0 0.5 2

Counsellor 7 1.2 0.9 0.5 1 3.1

Dietician 3 0.1 0.1 0 0.1 0.1

Head of administration 6 1.0 1.0 0 0.8 3

Nurse 7 6.3 3.4 1.5 7 10

Nursing assistant 7 8.5 3.4 1.5 9 12.8

Occupational therapist 6 2.9 1.3 2 2.5 5.6

Psychologist 5 0.3 0.2 0 0.5 0.5

Physician 7 1.9 0.8 0.5 2 3

Physiotherapist 7 2.9 1.8 0.5 2.5 6.4

Rehabilitation assistant 4 1.0 0.7 0.5 0.8 2

Speech therapist 1 0 - 0 0 0

Urotherapist 3 0.2 0.2 0 0.3 0.4

To estimate how staff intensive the decentralised clinics were on average, two ratios (number of

employees per 10,000 hospitalisation days) and (number of employees per 10,000 hospitalisation

days and visits) were calculated for each clinic. Two out of the seven clinics (29%) did not have

10

complete information regarding number of outpatient and/or day care visits which resulted in that

the estimated ratio including visits was based on fewer clinics compared with only considering

hospitalisations. In addition, a weighted average of full-time employees per 10,000 hospitalisation

days or per 10,000 hospitalisation days + visits were calculated for each occupation based on the

ratios calculated for each clinic. The weighting was based on number of SCI-patients in primary

rehabilitation 2012. The results are presented in Table 5 and Table 6. As can be seen, nurses and

nursing assistants were the most resource intensive occupations.

Table 5. Number of full time employees working with SCI-patients, per 10 000 hospitalisation days

(both including patients in primary rehabilitation and re-admitted patients)

Number of

responding clinics

Mean Sd Min Median Max Weighted

mean1

Administrative assistant 5 2.7 2.6 0 2.0 6.6 3.2

Counsellor 7 8.8 11.0 1.0 4.8 32.8 5.2

Dietician 2 0.3 0.1 0.2 0.3 0.3 0.2

Head of administration 5 4.3 3.3 1.6 3.8 9.8 4.3

Nurse 7 38.1 30.0 10.8 38.9 98.3 27.1

Nursing assistant 7 46.0 26.3 20.5 38.9 98.3 36.8

Occupational therapist 6 11.2 5.5 4.1 9.5 18.2 10.5

Psychologist 5 1.5 1.2 0 1.6 3.1 1.7

Physician 7 11.8 9.6 4.1 9.7 32.8 8.3

Physiotherapist 7 15.1 8.3 4.1 12.7 29.5 12.4

Rehabilitation assistant 4 11.4 14.3 4.0 4.4 32.8 5.3

Speech therapist 1 0 - - - - -

Urotherapist 3 1.1 1.3 0 0.8 2.5 1.3

1. Weighted mean across all responding clinics based on number of SCI-patients in primary rehabilitation 2012.

11

Table 6. Number of full time employees working with SCI-patients, per 10 000 hospitalisation days

and visits (both including patients in primary rehabilitation/re-admitted patients and

outpatient/day care visits to the clinic)

Number of

responding clinics

Mean Sd Min Median Max Weighted

mean1

Administrative assistant 3 1.9 1.2 0.8 2.0 3.1 1.6

Counsellor 5 3.4 1.1 2.2 3.0 5.1 3.3

Dietician 1 0.3 - 0.3 0.3 0.3 0.3

Head of administration 4 2.6 0.9 1.3 3.0 3.1 2.5

Nurse 5 23.4 16.0 3.3 29.3 38.9 20.6

Nursing assistant 5 30.1 13.9 9.1 38.8 41.0 28.0

Occupational therapist 5 8.5 3.3 5.5 7.3 14.1 7.6

Psychologist 4 1.4 1.0 0.2 1.4 2.6 1.2

Physician 5 6.5 2.6 3.0 6.5 10.3 5.9

Physiotherapist 5 9.7 3.1 6.3 10.1 14.1 9.0

Rehabilitation assistant 2 3.3 0.8 2.7 3.3 3.8 3.0

Speech therapist 0 - - - - - -

Urotherapist 2 1.2 1.3 0.2 1.2 2.1 0.8

1. Weighted mean across all responding clinics based on number of incident SCI-patients in primary rehabilitation 2012.

2.1.7 Facilities at the clinic

The clinics were asked how many inpatient beds they had in total and how many of these were

intended for SCI-patients. In today’s decentralised care no beds are “reserved” for SCI-patients,

however these patients are a prioritised group when injured. The occupancy rate for each clinic was

therefore calculated based on all patients and all available beds at the clinics.

According to ESCIF [2] all rooms at a SCIC should be equipped with:

Electric, height-adjustable beds

Fully-adapted toilet and bathroom facilities

Ceiling hoists/lifts and other appropriate aids.

In addition the following facilities should be present:

Access to patients’ mini bus

Access to specialised driving tuition

Day room

Dental facilities

Dining area

Family accommodation

Fitness room and sports hall

Helicopter pad

Internet café

Isolation rooms en-suite

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Kitchen facilities

Library

Meeting room/consultation room

Offices and facilities for personnel and therapists employed

Outdoor recreational and training facilities

Restaurant (staff, patient, visitor)

Seating and posture clinic

Shop

Swimming pool

Training apartments

Twin bedded rooms en-suite (for patients and carer/personal assistant)

Vocational training facilities

The share of clinics where all rooms were equipped with electric/height-adjustable beds, fully

adapted bathroom facilities and ceiling hoists/lifts are presented in Figure 2, whereas the share of

clinics which had access to the above described facilities are presented in Figure 3.

Figure 2. Share of clinics where all rooms are equipped with ceiling hoists/lifts and other

appropriate aids, fully-adapted toilet and bathroom facilities and electric height-adjustable beds

0% 20% 40% 60% 80% 100%

Electric, height-adjustable beds

Fully-adapted toilet and bathroom facilities

Ceiling hoists/lifts and other appropriate aids.

Share of the clinics where all rooms have the above described equipment

13

Figure 3. Share of the responding clinics which had access to facilities described by ESCIF

2.2 Questionnaire to SCI-specialists

Four SCI-specialists (Håkon Ro, Skåne Universitetssjukhus, Per Ertzgaard, Linköpings

Universitetssjukhus, Claes Hultling, Karolinska Universitetssjukhuset/ Spinalis Stockholm and Richard

Levi, Umeå Universitetssjukhus) [5-8] were given a questionnaire (see appendix B) in which they

were asked to visualise a SCIC in Sweden with the following characteristics:

Primary rehabilitation: SCI-patients are referred to the centre from acute/emergency care once

medically stable and all relevant decisions on surgical interventions have been made. One centre

was assumed to care for approximately 70 incident SCI-patients per year (4 centres in total).

Reintegration in the community resource: The centre is responsible for a patient’s reintegration

in society including contact with the patient’s employer, 24-hour-phone service with physicians,

physiotherapists in general practice and local caregivers, and for conducting home visits in the

patient’s community.

Re-admissions: The centre is responsible for re-admissions of patients that have ended their

rehabilitation at the centre. An estimated 30% of patients in primary rehabilitation are assumed

to be re-admitted during their life-time.

Life-long follow-up: The centre should follow-up on each patient that has ended his/her primary

rehabilitation at the centre on a regular basis including home visits, specialised outpatient care if

needed and contact with local care providers.

Assuming the above, the SCI-specialists were asked questions regarding capacity for re-admissions,

outpatient/day care visits, home-visits, how many inpatient beds and full-time employees that are

needed for each centre in order to maintain the above described scenario.

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14

Two SCI-specialists (Expert A) completed the questionnaire together and had pictured a SCIC

following the above description and imagined how a future SCIC would be organised in their area of

work (more rural area). Another SCI-specialist (Expert B), working at a SCI-specialist centre in a more

urban area today had looked at how the care of their SCI-patients was managed in 2012 and from

that imagined an increase in patients and resources needed by 35%. Hence, when estimating how

many re-admissions the centre would have capacity for the SCI-expert first considered how many re-

admissions the centre had in 2012 and assumed a 35% increase to arrive at the number of re-

admissions in a centralised scenario. The same calculation was done when estimating number of

hospital beds, number of visits (outpatient/day care/home visits) and staff resources needed. The

results are presented in Table 7 and Table 8.

Table 7. Estimated capacity (by SCI-specialists) for a SCIC assuming 70 incident SCI-patients/year,

centre responsible for patient’s re-integration in society, re-admissions and life-long follow-up of

patients who have completed primary rehabilitation at the centre

Expert A Expert B

Number of re-admissions/year 15 46

Number of outpatient/day care visits 10001 1082

Number of home-visits 5002 128

Number of hospital beds 15 17-18

1. Outpatient visits only (Day care visits could not be estimated). 2. Number based on assumption that half of the SCI-population can go to the SCIC for a visit and the other half needs a home-visit.

Table 8. SCI-specialists estimated number of full-time employees at the SCIC

Expert A Expert B

Administrative assistant 2.5 2

Counsellor 2 3

Dietician 1 1

Head of administration 3 2

Nurse * 8.5-9

Nursing assistant * 13.3-17.3

Occupational therapist 6 6

Psychologist 1 1

Physician 6 3.5

Physiotherapist 7 6

Rehabilitation assistant 2 2

Speech therapist 0.2 1

Urotherapist 1 2

* Could not be estimated

15

2.3 Unit costs

Average salaries for different types of staff were collected from Statistics Sweden [10] and were

adjusted (+48%) to include social security contributions paid by the employer [11]. Total yearly

salaries are presented in Table 9.

Table 9. Average yearly salaries for employees including social fees

Salary (SEK)

Administrative assistant 526,655

Counsellor 507,083

Dietician 512,421

Head of administration 652,091

Nurse 541,482

Nursing assistant 434,135

Occupational therapist 482,174

Psychologist 619,176

Physician 1,047,972

Physiotherapist 487,512

Rehabilitation assistant 462,602

Speech therapist 535,551

Urotherapist 541,482

The yearly cost for one inpatient bed excluding staff resources and inventories was estimated in

discussion with Maria Karlberg at Skåne University hospital [12]. The Spinal Cord Injury clinic at Skåne

University hospital rent their premises (including 12 hospital beds, meeting rooms, dining areas, and

offices for physicians/nurses/nursing assistants) for a total of 1.3 million SEK yearly. In addition the

unit has a training facility together with three other clinics for a total cost of 6 million SEK yearly

which is divided equally between the clinics (1.5 million per clinic). The training facilities include for

example training rooms for occupational therapists/physiotherapists, fitness room, pool, conference

and separate training rooms. The above information resulted in a total cost of 233,333 SEK (1.5+1.3

million SEK divided by 12) per inpatient bed excluding staff resources.

The cost for SCI-patients’ time spent in acute care was calculated using the “cost per patient” (KPP)-

database available from the Swedish Association of Local Authorities and Regions (SKL) [13]. The KPP-

database covers around 70% of the care episodes in the Swedish inpatient care and is built on

“diagnosis-related-groups” (DRG) which is an administrative method to group care-contacts. To track

costs for SCI-patients in the acute phase, DRG-codes of 004 (surgeries on spinal cord and surrounding

tissue) and 009 (sickness and injuries related to the spinal cord) was searched for in the KPP-

database. These DRG-codes correspond to the following main diagnoses in the ICD-10 system: S140,

S141, S142, S143, S240, S241, S243, S340, S341, S342 and S343. A total of 4,093 hospitalisation days

corresponding to 135 care episodes were located for these codes with a total cost of 40.3 million

SEK. This resulted in an average cost per care-episode of 299,000 SEK.

16

An average from regional pricelists from Uppsala läns landsting [14] and Södra regionsnämnden [15]

was used when pricing primary care visits to a physician (SEK 1,541). The cost of a visit to

physiotherapists, occupational therapists and nurses was not reported separately but assumed to be

the same (SEK 530).

2.4 Model

An economic model was developed combining the data discussed in this method section to estimate

the care provision, resource use and costs for the decentralised and centralised scenario,

respectively. The model was based on the questionnaires and accounted for primary rehabilitation,

re-admitted patients and patients visiting the clinics/future SCIC for outpatient and day care visits. A

lot of assumptions were needed to fill gaps in the collected questionnaires where the respondents

could not give any answer. These assumptions have been detailed below. The model did not consider

that patients may transfer from one clinic to another during their primary rehabilitation. The model

captured resources (including staff) needed to care for the estimated number of SCI-patients. Apart

from the information received from the questionnaires the model also accounted for acute care and

long-term care in the community setting. The different parts of the model and its results are

presented in detail in section 3.

3. Results

The model was based on the questionnaires and built in order to capture (as far as possible) all

relevant parts/costs of care for SCI-patients. The care provided in the twenty responding clinics in

today’s scenario was compared to a hypothetical centralised scenario with 4 SCICs. Four SCIC was

estimated to be needed based on 270 incident SCI-patients per year. The model can be divided into

three different parts:

Care provision

Resources

Costs

Much of the data inputs going into the model are uncertain. We therefore first present a base case

analysis which is a “best guess” based on input received from the questionnaires and key

assumptions. Thereafter, the model inputs are modified in a set of sensitivity analyses showing how

the results may change using different assumptions where there is uncertainty.

3.1 Base case analysis

The results from the base case analysis is presented in Table 10 and discussed below.

3.1.1 Care provision

Based on section 2.1.2 it was assumed that there were 270 incident SCI-patients in Sweden each year

resulting in 13.5 incident patients per centre today and 67.5 patients per SCIC. In discussion with SCI-

experts it was assumed that 7000 prevalent SCI-patients live in Sweden. Incident SCI-patients were

assumed to stay in primary rehabilitation for 80 days on average in both the decentralised and

centralised scenario. This resulted in a total of 21,592 hospitalisation days in primary rehabilitation in

17

both scenarios with 1,080 hospitalisation days per clinic (20 in total) today and 5,398 hospitalisation

days per SCIC (4 in total).

No clear correlation between re-admissions and primary rehabilitation for SCI-patients was seen

comparing larger and smaller clinics (see Figure 1). Therefore, we used the average number of re-

admitted patients (10.2) rather than the weighted average (21.3) when estimating number of re-

admitted patients per year and clinic for decentralised care in the model. For centralised care, the

SCI-experts estimations varied from 15 to 46 re-admissions per centre. Expert B’s estimation of 46 re-

admissions per year and centre was used in the base case analysis after agreement from Expert A.

The weighted average length of stay for re-admitted patients (13.5) retrieved from the questionnaire

was used for both decentralised and centralised care when calculating number of hospitalisation

days for each scenario. A total of 2,754 hospitalisation days for decentralised care (138 per clinic) and

2,484 hospitalisation days for centralised care (621 per SCIC) were estimated.

Common reasons to why SCI-patients may need to see a physician, nurse, physiotherapist etcetera in

an outpatient or day care setting are urinary tract infections (UTI), pressure sore assessment,

prescriptions, nociceptive- neurogenic pain, autonomic dysreflexia, orthostatic hypotension, legal

matters, fecal/urinary incontinence, life style associated disorders and neurological assessment.

There are no data available on how often these visits occur in practice today but there is

undoubtedly high variation across patients. When estimating the number of outpatient and day care

visits per clinic in today’s decentralised care the ratio (number of visits divided by number of

hospitalisation days in primary rehabilitation 2012) described in section 2.1.2 was multiplied with the

total estimated number of hospitalisation days in primary rehabilitation per clinic (1,080). This

resulted in a total of 15,468 visits (773 visits per clinic, 20 clinics). For the centralised scenario, the

SCI-experts’ estimations regarding visits (including outpatient, day care and home visits) varied from

~1,200 to ~1,500 per SCIC. In the base case model it was assumed that each SCIC had 1,500 visits,

resulting in a total of 6,000 visits. This resulted in a difference of ~9,500 visits between decentralised

and centralised care. In a centralised scenario, it is anticipated that many of these visits will take

place in primary care instead. Because many patients will have farther to travel to a SCIC, they are

assumed to go to a local care provider with some of their needs. It is unknown how many primary

care visits SCI-patients have on average during a year. In the model, we assume that SCI-patients on

average see a general practitioner 2 times a year and a physiotherapist, nurse or occupational

therapist 5 times a year in a primary care setting. It is furthermore assumed that 95% of the 9,500

fewer visits in centralised care would take place in primary care instead and that half of these

additional primary care visits are to a physician and the other half to a physiotherapist, nurse or

occupational therapist. A 5% decrease in total outpatient, day care, home and/or primary care visits

is expected in a centralised scenario.

Due to the longer transportation (in some cases) between acute care and primary rehabilitation, SCI-

patients in a centralised scenario are assumed to stay longer (5%) in acute care compared with a

decentralised setting.

18

Table 10. Estimated care of SCI-patients in decentralised and centralised care

Care for SCI-patients Decentralised Centralised

Number of incident patients 270 270

Number of centres 20 4

Average number of incident patients per centre 13.5 67.5

Number of prevalent patients 7,000 7,000

Primary rehabilitation

Number of unique admissions in primary rehabilitation per centre1 13.5 67.5

Average number of days per hospitalisation in primary rehabilitation2 80 80

Total number of hospitalisation days in primary rehabilitation per centre3 1,080 5,398

Long-term follow-up

Total number of re-admissions per centre4 10.2 46.0

Average number of re-admissions per primary rehabilitation5 0.8 0.7

Average number of days per hospitalisation for re-admitted patients6 13.5 13.5

Total number of hospitalisation days for re-admitted patients per centre7 138 621

Total number of hospitalisation days per centre8 1,217 6,019

Total number of outpatient and day care visits9 per centre 773 1,500

Number of visits per hospitalisation days10

0.64 0.25

1. 270/20 vs. 270/4 2. Based on assumption on the share of patients transferring from one clinic to another and the weighted average hospitalisation time for a clinic. 3. 13.5*80 vs. 67.5*80 4. Average number of visits from the questionnaire to clinics vs. SCI-experts estimation of number of re-admitted patients to a SCIC. 5. Total number of re-admissions per centre divided by average number of incident patients per centre. 6. Weighted average of days per hospitalisation for re-admitted patients. Retrieved from the questionnaire to clinics and based on centres reporting at least one re-admitted SCI-patient. 7. 10.2*13.5 vs. 46*13.5, 8. Including both patients in primary rehabilitation and re-admitted patients 9. Outpatient and day care visits. Home visits are included in centralised care, but were not captured in the questionnaire to the clinics. 10. Total number of visits divided by total number of hospitalisation days per centre.

3.1.2 Staff resources and facilities

In the base case scenario it was decided to use staff weighted ratios calculated using hospitalisation

days only compared with including outpatient and day care visits as well (see section 2.1.2). This was

decided due to the fact that estimations including more clinics could be utilised. However, including

visits as well for the staff calculation was accounted for in sensitivity analyses.

The weighted ratios for each occupation were multiplied with the estimated total number of

hospitalisation days (1,217) per centre in order to estimate average number of staff for one

decentralised centre. For the centralised scenario the SCI-experts estimated how staff-intensive a

19

SCIC would be, based on the description presented in section 2.2. In situations where the SCI-experts

gave different estimates, an average number of staff was calculated with the following exceptions:

Expert B’s estimations for nurses and nursing assistants were used since Expert A had not estimated

these. In addition, Expert A’s answer for total number of physicians was used since their estimates

had included time for research.

Table 11. Number of full-time employees per centre and per 10,000 hospitalisation days in the

base case model for decentralised and centralised care

Full time employees per centre Full-time employees per 10,000

hospitalisation days

Number of full-time employees Decentralised Centralised Decentralised Centralised

Administrative assistant 0.4 2.3 3.2 3.7

Counsellor 0.6 2.5 5.2 4.2

Dietician 0.03 1.0 0.2 1.7

Head of administration 0.5 2.5 4.3 4.3

Nurse 3.3 9.0 27.1 15.0

Nursing assistant 4.5 17.3 36.8 28.7

Occupational therapist 1.3 6.0 10.5 10.0

Psychologist 0.2 1.0 1.7 1.7

Physician 1.0 6.0 8.3 10.0

Physiotherapist 1.5 6.5 12.4 10.8

Rehabilitation assistant 0.6 2.0 5.3 3.3

Speech therapist 0.0 0.6 0 1.0

Urotherapist 0.2 1.5 1.3 2.5

Total number of full-time employees per centre 14.2 58.2 - -

Total number of full-time employees for all

centres

284.0 232.8 - -

Total number of full-time employees per 10,000

hospitalisation days

- - 116.3 96.9

The results from the staff calculations are presented in Table 11. In both the decentralised and

centralised scenario, nurses and nursing assistants were the most resource intensive occupations.

Including all occupations, a total of 14.2 full-time positions per centre (284 in total) were estimated

in decentralised care and 58.2 full-time positions per centre (233 in total) in centralised care. Hence,

a 20% lower staff need was seen in a hypothetical centralised care compared to today’s

decentralised care. Possible explanations to this difference are discussed in section 4.

The results of average occupancy rate and average number of hospital beds needed are shown in

Table 12. The SCI-experts estimations of needed number of hospital beds per SCIC varied between 15

and 18. In the base case model it was assumed that an average of 17 hospital beds was needed at

each SCIC. Together with the calculated total number of hospitalisation days for SCI-patients during

2012 (both in primary rehabilitation and for re-admitted patients) this resulted in a total occupancy

20

rate of 95%. For decentralised care, the total occupancy rate for all patients was calculated using the

number of hospital beds and the estimated total number of patients in primary rehabilitation 2012

and re-admitted patients. Two clinics had not reported total number of patients and were therefore

excluded from this calculation. For the clinics which were unable to report re-admissions these were

estimated by using the weighted average ratio of total number of re-admissions/all patients in

primary rehabilitation 2012 (0.4) for the clinics which reported both. This ratio was thereafter

multiplied with the number of patients in primary rehabilitation 2012 to receive the estimated

number of re-admitted patients per clinic. Thereafter the weighted average of hospitalisation days

for all re-admitted patients (13.8) was multiplied with the estimated number of re-admitted patients

to get total hospitalisation days. The estimates of number of hospital beds and total hospitalisation

days in primary rehabilitation/re-admissions resulted in a weighted average occupancy rate of 87%

with a total need of 4 hospital beds per clinic.

Table 12. Occupancy rates for decentralised and centralised care

Decentralised Centralised

Assumed bed occupancy rate 87% 95%

Number of hospital beds per centre 4 17

Total number of hospital beds for all centres 76 68

3.1.3 Costs

Table 13. Summary of the costs for decentralised and centralised care

Per incident patient

(SEK)

Per centre

(million SEK)

The whole country

(million SEK)

Decentralised Centralised Decentralised Centralised Decentralised Centralised

Acute/

emergency care

299,000 313,950 4.0 21.2 80.7 84.8

Centre

-Staff 558,228 474,175 7.5 32.0 150.7 128.0

-Facilities 66,485 58,765 0.9 4.0 18.0 15.9

Subtotal 624,713 532,941 8.4 36.0 168.7 143.9

Care at home 148,607 182,197 2.0 12.3 40.1 49.2

Total 1,072,320 1,029,088 14.5 69.5 289.5 277.9

Change with

centralised care

-43,233 54 -12

21

A summary of the costs for decentralised and centralised care is presented in Table 13. The cost for

acute care was estimated to be 5% higher per patient in a centralised setting compared to a

decentralised setting due to longer transportations to reach a SCIC. For the whole country this

resulted in a cost difference of 4 million SEK. Costs for staff resources were estimated to be higher in

decentralised care compared to centralised care. Per patient a cost difference of ~84,000 SEK was

seen and cost-savings in a centralised scenario were estimated to a total of 23 million SEK. Costs for

facilities were higher in a decentralised setting with a difference of 2 million SEK in the whole country

compared with a centralised setting. Due to the increase in primary care visits in a centralised setting

this cost was estimated to be higher in a centralised scenario compared to decentralised care (total

cost difference: 9 million SEK). In summary, the total costs of care for SCI-patients would according to

our base case model be lower (-12 million SEK) with centralised care compared with decentralised

care. The cost savings can mostly be derived to the lower staff costs in a centralised scenario.

3.2 One-way sensitivity analysis

We performed two types of sensitivity analyses; one-way and multi-way. In a one-way sensitivity

analysis certain parameters are varied to see how this specific parameter would impact the results,

whereas in a multi-way sensitivity analysis more than one parameter is changed at the same time.

The following sections present the results from three one-way and two multi-way sensitivity

analyses.

Table 14. One-way sensitivity analyses. The results are presented for the whole country in million

SEK.

Base case analysis Sensitivity analysis 1

1

Sensitivity analysis 2

2

Sensitivity

analysis 33

Decentralised Centralised Decentralised Decentralised Centralised

Acute/emergency

care

80.7 84.8 80.7 80.7 84.8

Centre

-Staff 150.7 128.0 176.6 150.7 140.8

-Facilities 18.0 15.9 18.0 16.4 15.9

Subtotal 168.7 143.9 194.6 167.1 156.7

Care at home 40.1 49.2 40.1 40.1 49.2

Total 289.5 277.9 315.4 288.0 290,7

Change with

centralised care

-12 -38 -10 1

1. Including total number of visits when determining number of full-time employees in decentralised care. 2. Assuming the same occupancy rate in decentralised and centralised setting. 3. Assuming that the SCI-experts underestimated the true staff need with 10%.

22

The results from the one-way sensitivity analyses are presented in Table 14 together with the results

from the base-case analysis in order to ease comparisons.

3.2.1 Sensitivity analysis 1: Including total number of visits when determining number of full-time employees in decentralised care

Estimation of number of full-time employees could either be done by using a ratio based on

hospitalisation days or by also including total number of visits (see section 2.1.2). In the base case

analysis, estimation of full-time employees in decentralised care was estimated based on number of

hospitalisation days but not visits (outpatient and day care) to the clinic. In this sensitivity analysis

visits are included in the staff calculation and the estimations of total staff need are therefore based

on 6 clinics since the remaining 2 did not report all possible visits in their answers. It is also assumed

that one visit has the same resource need as one hospitalisation day. To estimate the total number of

full-time employees based on both hospitalisations and visits, the weighted ratios for each

occupation were multiplied with the estimated total number of hospitalisation days and visits (1,990)

per decentralised centre.

When considering visits in the staff calculation a higher number of full-time employees per centre

were estimated in decentralised care compared with not including visits (a total of 16.7 vs. 14.2 full-

time employees per centre). This corresponds to a 17% increase in total decentralised care staff costs

(from 151 to 177 million SEK) and even higher cost-savings compared with the base case analysis (38

million SEK vs. 12 million SEK) for centralised care vs. decentralised care.

3.2.2 Sensitivity analysis 2: Assuming equal occupancy rates in decentralised and centralised care

The occupancy rate in the decentralised base case scenario was estimated based on the clinics

occupancy rates for all patients cared for at the clinic. It is possible that the occupancy rate would

have been higher if it would have been possible to only consider SCI-patients at the clinics.

Assuming that both decentralised and centralised care had an occupancy rate of 95% (estimated in

centralised care based on the SCI-experts input) resulted in similar hospital bed costs in a

decentralised and centralised scenario. The difference in total cost between centralised and

decentralised care decreased by 2 million SEK compared with the base case analysis (10 million in

cost-savings for centralised care vs. decentralised care compared with 12 million in the base case

analysis).

3.2.3 Sensitivity analysis 3: Assuming the SCI-experts underestimated the true staff-need with 10%, hence increasing the full-time employees needed by 10% in centralised care

In this scenario it was assumed that the SCI-experts underestimated the true staff-need for a SCIC by

10%. This is not unlikely since no SCIC exists today in Sweden and it is therefore difficult to foresee

exactly how much staff resources that are needed.

Assuming a 10% increase in staff resources resulted in a 5% increase in total cost for centralised care

to 291 million SEK compared with 278 million SEK in the base case scenario. This resulted in a total

difference in costs between decentralised and centralised care of 1 million SEK. Hence, with a 10%

increase in estimated staff resources in centralised care, no cost-savings in a centralised setting could

be seen compared with a decentralised setting.

23

3.3 Multi-way sensitivity analysis

The results from the multi-way analyses are presented in Table 15. The two analyses describe what

would happen with costs and how centralised and decentralised care would differ in two extreme

scenarios.

Table 15 Multi-way analyses for decentralised vs centralised SCI-patient care. The results are

presented for the whole country in million SEK.

Base case analysis Sensitivity analysis 44 Sensitivity analysis 5

5

Decentralised Centralised Decentralised Centralised Decentralised Centralised

Acute/emergency

care

80.7 84.8 80.7 84.8 80.7 88.8

Centre

-Staff 150.7 128.0 176.6 115.2 126.6 128.0

-Facilities 18.0 15.9 20.8 15.9 16.4 15.9

Subtotal 168.7 143.9 197.4 131.1 142.9 143.9

Care at home 40.1 49.2 40.1 49.2 40.1 60.8

Total 289.5 277.9 318.2 265.1 263.8 293.5

Change with

centralised care

-12 -53 30

4. Assumptions: Number of full-time employees per centre in a decentralised setting was based on number of hospitalisation days and visits per clinic. The SCI-experts had overestimated the true staff-need in a centralised scenario by 10%, hence a 10% decrease in staff resources compared with the base-case analysis was accounted for. The occupancy rate in decentralised care was assumed to be lower (75%) compared with the base case scenario (87%). 5. Assumptions: Number of full time employees per 10,000 hospitalisation days was the same in decentralised care as in centralised care. The occupancy rate in decentralised care was equal to the occupancy rate in centralised care. Centralised care is causing a higher increase in primary care at the patient’s home community then was first expected, resulting in an increase with 20,000 visits compared with previously assumed 9,000. Patients stay even longer at acute care in a centralised scenario than was previously assumed (10% longer compared with previously 5% longer).

3.3.1 Sensitivity analysis 4

In this analysis, compared with the base case analysis, it was assumed that:

Number of full-time employees per centre in a decentralised setting was based on number of

hospitalisation days and visits per clinic (described in Sensitivity analysis 1).

The SCI-experts had overestimated the true staff-need in a centralised scenario by 10%, hence a

10% decrease in staff resources compared with the base-case analysis was accounted for in this

sensitivity analysis.

The occupancy rate in decentralised care was assumed to be lower (75%) compared with the

base case scenario (87%).

Based on the above assumptions, staff resources in decentralised care increased compared with the

base case analysis; this is also described in Sensitivity analysis 1. Together with the 10% lower staff

24

need in centralised care, this resulted in an increase of the cost difference considering staff resources

between centralised and decentralised care from 23 to 61 million SEK compared with the base case

analysis. A lower occupancy rate in decentralised care resulted in higher costs and a total difference

of almost 5 million SEK compared with centralised care. In the base case analysis this difference was

less than 2 million SEK. In summary, this described scenario resulted in cost savings with centralised

care of 53 million SEK compared with decentralised care.

3.3.2 Sensitivity analysis 5

In this analysis, compared with the base case analysis, it was assumed that:

Number of full time employees per 10,000 hospitalisation days was the same in decentralised

care as in centralised care.

The occupancy rate in decentralised care was equal to the occupancy rate in centralised care.

Centralised care was causing a higher increase in primary care at the patient’s home community

then was first expected, resulting in an increase to 20,000 visits compared with previously

assumed 9,000.

Patients stay even longer at acute care in a centralised scenario than was previously assumed

(10% longer compared with previously 5% longer).

Based on the above assumptions, total resources costs (hospital beds and staff) were approximately

the same in decentralised and centralised care (143 vs. 144 million SEK). In the base case analysis the

difference was almost 25 million SEK. An increase in primary care visits in the centralised scenario

resulted in an increase in costs compared with the decentralised setting (a 20 million SEK difference

compared with 9 million SEK in the base case analysis). In addition, since patients in centralised care

were assumed to stay even longer in emergency care the cost difference for acute care, between

centralised and decentralised care, increased with 100% (from 4 million SEK difference to 8). In

summary, this scenario shows that unlike the base case analysis, decentralised care is less costly and

the cost increase in a centralised setting would be approximately 30 million SEK.

25

4. Discussion

The aim of this study was to compare available resources and costs for today’s decentralised care of

SCI-patients with the resource needs and costs for a hypothetical scenario with centralised care. This

was done with use of an economic model combining data from a questionnaire to clinics caring for

SCI-patients today (see appendix A), another questionnaire to SCI-specialists asked to envision a

hypothetical spinal cord injury centre (see appendix B), unit cost data from publicly available sources

and a range of assumptions to fill data gaps. Many such assumptions had to be made because the

responding centres had difficulties in answering our questions. Generally, we assumed that the

responses we actually received were representative to all centres (adjusting for centre size where

applicable). A range of sensitivity analyses were performed to test different assumptions where the

available data was uncertain.

4.1 Staffing costs

Our base case analysis showed that the hypothetical centralised scenario that our experts were

asked to envision would result in lower costs in total, albeit based on several uncertain assumptions.

The decrease in costs was mainly driven by lower staffing levels and the costs of staffing accounted

for approximately half of the total costs. The staffing costs rely on several uncertain assumptions.

Firstly, only one in four of the responding centres were able to provide estimates on their current

staffing which indicates how difficult it is to estimate already available resources. Furthermore, this

implied that we had to make assumptions on the staffing of the other centres without knowing

whether the responses we received were representative of all centres. In the base case analysis we

assumed that the staffing per number of hospitalisation days would be the same across all centres on

average. This implies that, in the base case analysis, the model did not take varying staff levels due

differences in number of visits into account. In the sensitivity analysis, this assumption was changed

to include both number of hospitalisation days and number of outpatient and day care visits at each

centre. This resulted in higher costs for decentralised care and larger cost savings from centralised

care. Secondly, the staffing of centralised care was based on expert assumptions of the staffing needs

of the described SCIC. These are also uncertain because no such centre is available in Sweden today.

In the sensitivity analysis, we showed that the cost savings from centralised care would

approximately be offset by a 10% increase in the staffing of centralised care. Although our estimates

related to staffing are uncertain, it is reasonable to assume that a higher degree of specialisation may

lead to economies of scale and efficiency gains that would result in lower staffing needs.

4.2 Acute care costs

The acute care costs were assumed to increase in the centralised scenario because many patients

may need to move from the initial emergency ward (the closest to the accident) to another acute

care facility where an SCIC is situated. This cost may very well change more or less than with our

assumptions, which was exemplified in the sensitivity analysis. It was pointed out by the SCI-experts

[5-8] that the average estimated unit costs for acute care (299,000 SEK) for SCI-patients was low.

When only considering a specific University Hospital using the same DRG-codes and main diagnoses

in the ICD-10 system the cost was estimated to be ~50% higher [16] than what was seen utilizing all

information captured in the KPP-database. If the true cost of acute care is higher than what has been

26

assumed in our calculations it would imply a larger cost increase in acute care associated with

centralised care and smaller total cost difference between the two scenarios.

4.3 Facility costs

The expert assumptions on the number of beds needed, caused relatively high occupancy rates. This

may not be achievable if there is a large variation in the admission of new patients. However, a large

centre with many beds should be able to handle such variation more easily than a small centre which

speaks in favour of our assumptions. There may also be need for careful planning of non-acute

hospitalisations so that they admitted during times of vacancy. This should also be easier in a

centralised setting where the competence is available within the same facilities. The facility costs

were based on interviews with one centre and their internal charges (or rent) were attributed to a

cost per inpatient bed and assumed to be representative to the whole country. The facilities which

the calculations were based on are partly old and newer facilities would naturally have a higher

rental cost. The estimated facility costs did not account for costs for specific equipment such as

electric, height adjustable beds and ceiling hoists. This may have resulted in underestimations of the

true facility costs but if so to a similar extent to both the decentralised and centralised care scenario.

4.4 Re-admissions and outpatient visits

According to the expert assumptions, the total number of re-admissions and outpatient care visits

would decrease in a centralised care scenario. This was reflected in the model assumptions and had

impact on the centre staffing and facility costs. This may be due to the farther distance to the SCIC

for many patients, implying that they would not be admitted to the SCIC to the same extent that they

are to a local rehabilitation centre. It is also possible that centralisation would increase the quality of

care resulting in a lower need for re-admissions and outpatient visits.

SCI-patients are sometimes sent on so called rehabilitation sun trips to for example Vintersol, a

Swedish neurological rehabilitation centre located in Los Cristianos, Spain [17]. How many SCI-

patients that are sent each year on these trips varies between counties in Sweden. Two of our SCI-

specialists [5, 8] stated that they rarely refer patients on these trips. A representative from

Stockholm county council [18] informed that they in 2012 sent 12 SCI-patients on these trips to a

total cost of 895,000 SEK. If this would be representative for the whole country it would imply costs

in the range of 4 million SEK per year for Sweden. In a centralised scenario more patients may travel

to a SCIC for rehabilitation instead of out of the country, which would imply reductions in these costs

for rehabilitation trips.

4.5 Care at home

The centralised scenario implies that the SCIC takes a larger responsibility for both the re-integration

in the community (after the completion of the primary rehabilitation) and the long-term care for the

patient. The resources needed for this at the SCIC have been included in the estimates provided by

the SCI-experts. However, resources on the local level will also be needed both during re-integration

and long-term follow-up. In the model, it was assumed that the number of visits to some of these

local resources (e.g. general practitioner and physiotherapist) would increase, because patients

would have farther to travel to the closest rehabilitation centre. This increase resulted in higher costs

in the centralised scenario which were also further elaborated in the sensitivity analysis. It has been

27

argued that centralised care may in fact not increase primary care visits if ambulating teams and e-

health from the SCIC would enable managing SCI-patients in their homes. If so, this would result in

even larger cost-savings in a centralised scenario compared with the base-case analysis. On top of

this, local care providers are expected to spend more time and resources on communication with the

SCIC and function as a link between each patient and the SCIC, both during re-integration and long-

term care. The costs of these resources are difficult to estimate but are not expected to be significant

compared to the care that is already provided by the local care provider. In some cases, the support

from the SCIC can even result in lower costs for the local care provider, assuming that more

competence results in more efficient care provision and a reduced care need in the long run.

4.6 Other benefits

As noted in the introduction, centralised care is expected by many to lead to better care for patients

with spinal cord injury. For example, Swedish qualitative studies have shown that today’s care of SCI-

patients has been unclear to some SCI-patients and that the lack of customised rehabilitation

programmes with clear, measurable goals could affect the SCI-patient negatively [19, 20].

Centralisation is expected to induce higher specialisation with more competent staff which may

result in better outcomes for patients. This may very well lead to fewer complications in the long run,

e.g. by optimizing the rehabilitation process increasing the chance of the each patient learning how

to avoid pressure sores. Similarly, better peer-support may increase the self-confidence and

motivation of patients increasing the chance of them getting back into work. Avoiding complications

and improving chances to work would both increase the quality of life of patients and their families,

and reduce costs to society. The indirect societal costs from work absence can be estimated at about

507,000 SEK1 per year, assuming equal value to what the employer would pay for one year salary

including social security contributions [10, 11]. Increasing the ability to work would therefore have

major impact on the total costs from a societal perspective.

4.7 Model limitations

In addition to the uncertainty discussed under the previous headings the model has the following

limitations that are worth mentioning.

The model assumed 270 incident patients while the actual number is unknown. This may of course

change from year to year but is expected to affect the costs of the decentralised and centralised

scenarios in similar ways.

In both scenarios patients were assumed not to transfer between clinics during their primary

rehabilitation although we know they do in today’s decentralised scenario. However, because we

accounted for the total time during primary rehabilitation this should not have any implications for

the results.

Some costs that may change with centralised care were not considered in the model due to lack of

data. These include costs for transportation (both for patients, their families and centre staff during

home visits), and certain one-time costs that may be associated with the change of organisational

1 SEK 29,800*1.48*12, where 29,800=Average monthly salary for all sectors from Statistics Sweden and 1.48=

adjustment to include social security contributions paid by the employer

28

systems. It is likely that the centralisation process would induce higher costs at the start during a

process where the SCICs are established, the right facilities and competence are put in place. There

may also be significant costs for setting up referral processes and contracts and routines between

county councils enabling centralised care.

The model did not consider what would happen with the available resources at the decentralised

centres if patients would move to a SCIC. In many cases, these resources are expected to be used in

the care of others whereas they in some cases would be redundant.

4.8 Conclusions

Our analysis indicates that a centralised organisation of the care for patients with spinal cord injuries

would be cost saving compared to the decentralised organisation of today. However, these results

are highly sensitive to assumptions on care and resource needs as outlined in this report, and altering

the assumptions may result in centralised care being more costly. According to our interpretation,

our results imply that the expected benefits of centralisation in terms of improved quality of care

would at worst come at a modest increase in costs with a higher potential for cost savings overall.

29

5. References

1. Apparelyzed, Spinal Cord Injury Peer Support. Available from: http://www.apparelyzed.com/. 2. Whooley, C., et al., ESCIF report on Centralisation of the treatment, rehabilitation and life-

long care of persons with spinal cord injury May 2010: www.escif.org. 3. The Swedish Association for Survivors of Accident and Injury (RTP). Available from:

http://www.rtp.se/. 4. ESCIF, policy statement. Available from: http://www.escif.org/ESCIF,,policy_statement.htm. 5. Ertzgaard, P., Linköpings Univeristetssjukhus. 6. Hultling, C., Rehab Station Stockholm 7. Levi, R., Umeå Universitetssjukhus. 8. Ro, H., Skåne Universitetssjukhus. 9. Åhrén, G., Personskadeförbundet, RTP. 10. Statistics Sweden. Available from: http://www.scb.se/sv_/Hitta-

statistik/Statistikdatabasen/Variabelvaljare/?px_tableid=ssd_extern%3aLonYrkeRegion4&rxid=bf4f2657-05ee-47e7-a8b7-47e76e4ceba4.

11. Arbetsgivarverket. Available from: http://www.bth.se/for/ekonomi.nsf/bilagor/avgifter-och-skatter-2014_pdf/$file/avgifter-och-skatter-2014.pdf.

12. Karlberg, M., Skåne Universitetssjukhus. 13. Swedish Association of Local Authorities and Regions (SKL). Available from:

http://www.skl.se/vi_arbetar_med/statistik/kostnad-per-patient/databas. 14. Prislista utomlänspatienter i Primärvården Uppsala län 2013. Available from:

http://svnuppsalaorebro.se/document/prislistor/2013/Uppsala2013.pdf. 15. Södra regionvårdsnämnden, primärvård/allmänmedicin. Available from:

http://www.skane.se/Upload/Webbplatser/Sodra%20regionvardsnamnden/prislista/2012/77_primarvard_ovr_spec2012.pdf.

16. Persson, H., Universitetssjukhuset i Linköping. 17. Vintersol. Available from: http://www.vintersol.com/?page_id=32. 18. Jonsson, K., Stockholm County Council. 19. Nordgren, C., et al., Societal services after traumatic spinal cord injury in Sweden. J Rehabil

Med, 2003. 35(3): p. 121-6. 20. Sand, A., I. Karlberg, and M. Kreuter, Spinal cord injured persons' conceptions of hospital care,

rehabilitation, and a new life situation. Scand J Occup Ther, 2006. 13(3): p. 183-92.

30

6. Appendix A: Questionnaire to clinics

GENERELL INFORMATION OM AVDELNINGEN

Tel: E-post:

PATIENTER PÅ AVDELNINGEN

1 Vilka patientgrupper vårdas på avdelningen? Ja Nej

Ryggmärgsskada (ej medfödda skador)

Icke-trauma

Trauma

Medfödd ryggmärgsskada

Hjärnskador (t.ex. stroke)

Multipel Skleros

Andra neurologiska skador och sjukdomar (t.ex.

patienter med ryggmärgsbråck)

Andra skador och sjukdomar

Avdelning:

Klinik:

Sjukhus:

Kontaktperson för enkäten:

Kommentarer:

31

32

2 Primärrehabilitering år 2012 Samtliga patienter

inlagda på avdelningen

Patienter med

traumatiska

ryggmärgsskador

Patienter med

icke-traumatiska

ryggmärgsskador

Hur många patienter fick

primärrehabilitering i slutenvård

år 2012?

I genomsnitt, hur många dagar

vårdades varje patient?

3 Återinskrivningar år 2012

Samtliga patienter

återinskrivna på

avdelningen

Patienter med

traumatiska

ryggmärgsskador

Patienter med

icke-traumatiska

ryggmärgsskador

Hur många patienter återinskrevs

i slutenvård år 2012?

I genomsnitt, hur många dagar

vårdades varje patient?

Kommentarer:

Kommentarer:

33

4 Öppen- och dagvård år 2012

Samtliga patienter som

nyttjade denna typ av

vård på avdelningen

Patienter med

traumatiska

ryggmärgsskador

Patienter med

icke-traumatiska

ryggmärgsskador

Hur många öppenvårdsbesök

gjordes vid avdelningen år 2012?

Hur många dagvårdsbesök

gjordes vid avdelningen år 2012?

PERSONAL PÅ AVDELNINGEN

Kommentarer:

5 Vilka yrkesgrupper bedriver

vård på avdelningen? Antal heltidstjänster totalt

vid avdelningen

(t.ex. 2 eller 0,5)

Andel av deras arbetstid som

avser vård av

ryggmärgsskadade patienter

(ej medfödda skador)

(t.ex. 50% eller 75%)

Arbetsterapeut

Dietist

Kurator

Läkare

Logoped

Psykolog

Rehabassistent

Sjukgymnast

Sjuksköterska

Undersköterska

Uroterapeut

34

Annan (vänligen ange)

35

6

Vilka yrkesgrupper arbetar på

administrativ nivå på

avdelningen?

Antal heltidstjänster totalt

vid avdelningen

(t.ex. 2 eller 0,5)

Andel av deras arbetstid som

avser ryggmärgsskadade

patienter (ej medfödda

skador)

(t.ex. 50% eller 75%)

Administrativ chef

Administrativ assistent

Annan (vänligen ange)

Kommentarer:

Kommentarer:

36

ÖVRIGA RESURSER PÅ AVDELNINGEN

7 Hur många vårdplatser finns på avdelningen

och hur är de fördelade?

Antal

Totalt

Antal i

enkelrum

Antal i

dubbelrum

Antal i

större

rum

Vårdplatser totalt

Vårdplatser avsedda för ryggmärgsskadade (ej

medfödda skador)

8 Är rummen på avdelningen utrustade med

följande utrustning?

Ja

alla rum

Ja

några rum

Hur många

vårdplatser? Nej

Elektriska, höj-och sänkbara sängar

Fullt anpassad toalett och badrum

Taklyftar / hissar

Kommentarer:

Kommentarer:

37

9 Finns det följande resurser och tjänster på eller i anslutning

till avdelningen? Ja Nej

Bibliotek

Butik

Dagrum

Ergonomiska träningsmöjligheter

Gym

Helikopterplatta

Internetmöjligheter

Isoleringsrum

Köksmöjligheter (t.ex. handikappanpassat kök)

Matplats

Möjligheter till arbetsrehabilitering

Mötesrum

Pool

Restaurang

Rum med övernattningsmöjligheter för anhöriga

Specialiserad förarutbildning (för handikappanpassade fordon)

Tandvårdsmöjligheter

Träningslägenheter

Tvåbäddsrum för patienter och vårdgivare / personlig assistent

Utomhusträningsmöjligheter

Stort tack för din medverkan!

Kommentarer:

38

7. Appendix B: Questionnaire to SCI-specialists

Vänligen föreställ dig ett specialiserat ryggmärgsskadecentre som har resurser att klara följande

Primärrehabilitering

Patienter remitteras till centret när de är resporatoriskt och cirkulatoriskt stabila samt alla kirurgiska

ställningstaganden är gjorda. Sammantaget fyra centre i Sverige ska ansvara för

primärrehabiliteringen av samtliga personer som drabbas av traumatiska (~120 per år) och akut icke-

traumatiska (~150 per år) ryggmärgsskador. Detta innebär ca. 30 traumatiska och knappt 40 akuta

icke-traumatiska ryggmärgsskador per centre och år. Genomsnittlig vårdtid i Skåne var 58 dagar år

2012.

Återintegrering i samhället

I slutet av primärrehabiliteringsfasen ansvarar varje centre också för sina patienters återintegrering i

samhället. Detta innefattar följande:

i. kontakt med samhällsfunktioner och arbetsplats på hemorten

ii. konstant tillgång till jourtelefon för vårdpersonal på hemorten

iii. videokonferenser mellan centre och vårdpersonal/patient på hemorten

iv. ambulerande team vid centret som kan göra hembesök (vanligen två personer, t.ex.

arbetsterapeut och sjukgymnast/kurator)

Återinläggningar

Varje centre ska ansvara för återinläggningar av personer som avslutat sin primärrehabilitering vid

centret (ca. 30%). Genomsnittlig vårdtid i Skåne 2012 var 22 dagar år 2012.

Långtidsuppföljning

Varje centre ska ansvara för den långsiktiga uppföljningen av sina patienter. Detta innefattar

följande:

i. konstant tillgång till jourtelefon för vårdpersonal på hemorten

ii. videokonferenser mellan centre och vårdpersonal/patient på hemorten (ca. 1 gång per år)

iii. ambulerande team vid centret som kan göra hembesök (ca. 1 gång vartannat år)

iv. uppföljning på ryggmärgsskadeenheten med inkluderad reha (ca. 1 gång vartredje år i ca 3-4

veckor med boende på patienthotell)

v. specialiserad öppen- och dagvård av personer med ryggmärgsskador efter behov

39

Vänligen, föreställ dig ett sådant centre och besvara följande frågor

1

Antag att centret skulle ta hand

om ca. 70 personer med nya

ryggmärgsskador per år, deras

primärrehabilitering,

återintegrering i samhället samt

långtidsuppföljning.

Antal Kommentarer

Hur många återinläggningar per år

skulle detta centre ha kapacitet för?

Hur många öppenvårdsbesök per år

skulle detta centre ha kapacitet för?

Hur många dagvårdsbesök per år

skulle detta centre ha kapacitet för?

Hur många hembesök per år skulle

detta centre ha kapacitet för?

Hur många slutenvårdplatser skulle

centret ha?

Kommentarer:______________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

40

2

Hur många heltidsanställda per

yrkeskategori behövs för varje

typ av vård vid centret?

Primär-

rehabilitering

Åter-

integrering i

samhället

Åter-

inläggningar

Långtids-

uppföljning Kommentarer

Arbetsterapeut

Dietist

Kurator

Läkare

Logoped

Psykolog

Rehabassistent

Sjukgymnast

Sjuksköterska

Undersköterska

Uroterapeut

Annan (vänligen ange)

Confidential

0

3 Hur många heltidsanställda per yrkeskategori behövs för

administration vid centret?

Administrativ chef

Administrativ assistant

Annan (vänligen ange)

Kommentarer:______________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________