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NHSCANCER                               NHS Improvement                                          StrokeDIAGNOSTICSHEARTLUN...
AuthorsSarah Gillham - National Improvement Lead,NHS Improvement - StrokeMichael Carpenter - Associate, NHSImprovement - S...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachContents       Endorsements ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach    Endorsements    The phys...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachSummary      This paper mode...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach    Introduction    A majori...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach                  In England...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach    The pathway for psycholo...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachRoutine screening of        ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     Level 2 psychological c...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachTable 1: Summary of assumpti...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     • There is a strong rel...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachThe need for Level 2 and 3  ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     Estimating demand for  ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachThe model combines the data ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     Combining demands and c...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachModelling the impact of a se...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach          Box 1: Calculating...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachAvoiding nights in hospital ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     This exercise has been ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachSummary of resultsTable 6: S...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     Discussion     This pap...
Psychological care after stroke: Economic modelling of a clinical psychology led team approachProvision of psychological c...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     References             ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach[22]   Williams LS, Kroenke ...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach     Appendix 1             ...
NHS                                                                                                NHS ImprovementCANCERDI...
Psychological care after stroke: Economic modelling of a clinical psychology led team approach
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Psychological care after stroke: Economic modelling of a clinical psychology led team approach

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

  1. 1. NHSCANCER NHS Improvement StrokeDIAGNOSTICSHEARTLUNGSTROKEPsychological care after stroke:Economic modelling of a clinicalpsychology led team approach
  2. 2. AuthorsSarah Gillham - National Improvement Lead,NHS Improvement - StrokeMichael Carpenter - Associate, NHSImprovement - StrokeDr Michael Leathley - Research FellowClinical Practice Research Unit, University ofCentral LancashireAcknowledgementsGrateful thanks to all who contributed to Dr Peter Knapp, Senior Lecturer, Departmentthe discussions about the assumptions and of Health Sciences and the Hull York Medicalevidence on which the model is based, and School, University of Yorkto those who reviewed and commented onthe finished paper. Dr Ian Kneebone, Consultant Clinical Psychologist and Visiting Reader, UniversityThe Stroke Improvement Programme of Surrey, Haslemere and District Communitypsychological care after stroke consensus Hospital and Associate, NHS Improvement -group StrokeDr Jane Barton, Consultant Clinical Professor Nadina Lincoln, Professor ofPsychologist, Michael Carlisle Centre, Nether Clinical Psychology, University ofEdge Hospital, Sheffield NottinghamDr Roger Beech, Reader in Health Services Jill Lockhart, National Improvement Lead,Research / Director, Keele University Hub, NHS Improvement - StrokeWest Midlands NIHR Research Design Service Dr Jessica Read, Clinical Psychologist,Dr Noelle Blake, Head of Neuropsychology, Lancashire Care NHS Foundation TrustCroydon Health Services NHS Trust Professor Tom Robinson, Stroke Consultant,Dr Bridget Carew, Clinical Psychologist, Royal University Hospitals of Leicester NHS TrustFree Hospital and Clinical Lead for SIPDr Helen Hosker, Central Manchester Clinical Dr Becky Simm, Principal ClinicalCommissioning Group, Lead for Urgent Care, Psychologist, Southport and Ormskirk NHSClinical Commissioning Lead for Stroke and Hospital TrustFalls, NHS Manchester Dr Kate Swinburn, Research and PolicyProfessor Allan House, Director, Leeds Manager, Connect - the communicationInstitute of Health Sciences disability network
  3. 3. Psychological care after stroke: Economic modelling of a clinical psychology led team approachContents 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
  4. 4. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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 Surrey4
  5. 5. Psychological care after stroke: Economic modelling of a clinical psychology led team approachSummary 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
  6. 6. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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
  7. 7. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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 aspsychologists part of their stroke rehabilitation. Clinical psychologists as essential members of the stroke team [3] have unique specialist knowledge and skills. Clinicalas essential psychologists can identify and manage stroke related problems with memory,members of understanding and reasoning; help patients and families adjust to the impact ofthe stroke team the stroke, and identify and manage problems with mood [9]. Evidence is availablehave unique to support the benefits to patients and families of access to clinical psychologyspecialist after stroke [9]; however, there is little evidence of the economic impact ofknowledge 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
  8. 8. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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
  9. 9. Psychological care after stroke: Economic modelling of a clinical psychology led team approachRoutine screening of Third screen is timed at about six Level 1 psychological carepsychological need months after stroke. At this stage Psychological care will be delivered atThe route to psychological care after much physical and social recovery has Level 1 by the multidisciplinary strokestroke is through appropriate stabilised and it is possible to get a team to any patient with problemsassessment. The term screening is picture of likely longer-term problems. identified at screening. For theused in this paper to describe a brief Notwithstanding these purposes of the model theassessment using a validated tool in recommendations it is acknowledged multidisciplinary stroke team membersconjunction with clinical judgement to that anxiety and depression can occur are considered to be at the top ofdecide if a person needs to be further at any time after stroke and it follows Agenda for Change (AfC) band 5. Thisassessed, monitored, or to gain access screening may be indicated at any first level of psychological care isto psychological care. In the model, time in actual clinical practice. Within anticipated to be carried out alongsidethe multidisciplinary team are the model, the multidisciplinary stroke current therapy or nursingassumed to carry out routine mood team (MDT), mainly physiotherapists, interventions. For the purposes of thescreens for all patients as occupational therapists, speech and model the amount of time the patientrecommended in national clinical language therapists, and qualified receives psychological care at Level 1guidance [3] [16]; the cost of screening nurses, carry out routine screening of is equivalent to six sessions of 20time and staff training by the clinical patients for problems with mood and minutes. Training and supervisionpsychologist to carry out screening is cognition (the latter is not addressed costs by a clinical psychologist forincluded 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 comprisesthe UK Stroke Forum Education and active listening, helping withTraining standards (www.ukfst.org). A range of validated mood (and adjustment, exploring and supportingScreening time points fit with the cognition) screening tools are the impact of the stroke, informationrecommended guidance for general available and are described giving, goal setting and identifyingreview 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 andin the report ‘Psychological care after access to psychological care, stroke services provided by the voluntarystroke’ [15]: teams should aim to adopt a holistic sector are effective ways to deliver approach to assessment of Level 1 support. These services haveFirst 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 ashospital discharge, if that is sooner. concerns expressed by family members, staff providing otherSecond screen is timed around the elements of care, or information fromsix week post discharge review or at GPs regarding pre-existing mentalabout three months after stroke, at health needs.which point most people will havebeen discharged from hospital andthe assessment will be able to judgeboth persistence of early-onsetproblems and emergence of newproblems after discharge. 9
  10. 10. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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 CP10
  11. 11. Psychological care after stroke: Economic modelling of a clinical psychology led team approachTable 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
  12. 12. Psychological care after stroke: Economic modelling of a clinical psychology led team approach • 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
  13. 13. Psychological care after stroke: Economic modelling of a clinical psychology led team approachThe need for Level 2 and 3 Figure 3 shows that by the end of 12 In reality, this process will not be aspsychological care is defined after months 51% of people will have had neat as this model implies. Forscreening or after a period of Level 1 no psychological care, but will have example, some lower level supportpsychological care. Level 2 care is been screened at one, three, and six may be triggered by concerns raisedprovided 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, somepsychology 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
  14. 14. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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 support14
  15. 15. Psychological care after stroke: Economic modelling of a clinical psychology led team approachThe model combines the data on Estimating costs average was taken from the cost ofstatus 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 tosection above, to make the following inform the model are summarised in the proportion of time spent by GPsestimates of the demand for Table 2. Basic salary costs were taken on those activities. A list ofpsychological services within the from Agenda for Change Pay Circular antidepressant medications thatmodel’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 anTable 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
  16. 16. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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 £68,96916
  17. 17. Psychological care after stroke: Economic modelling of a clinical psychology led team approachModelling the impact of a servicefor psychological care after strokeThis section focuses on the impacts Impact on the NHS In addition, an assumption wasthat such a psychological service for Significant investment has been made made, based on peer review and thepeople with stroke can have on both in recent years in community-based SIP national projects, that thethe demand for other local health mental health services as part of the approach described in the modeland social care services and on the Improving Access to Psychological would lead to less frequent use ofindividuals 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 whereMeasuring these impacts is difficult, were reviewed. There are little data there is considered to be an absencepartly because of a lack of empirical on the impact of psychological of alternatives.data, particularly with respect to services on resource use that are bothstroke-specific services. Additional specific to stroke and UK-based. Two In order to combine the figures withdifficulties arise because of the studies from the USA have shown those of the psychological carecomplex nature of emotional and that depression following stroke service provided by this model it ispsychological issues and the difficulty resulted in an increase in the length necessary to:in tracking the impact of specific of stay for subsequent hospitalelements of a multidisciplinary admissions, and more outpatient 1. Calculate the total time for whichservice. procedures [23] [27]. Because of the each person benefits from the population under study and the Level 1 or Level 2/3 support, whichThis 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 theimpacts. 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 andgeneral it uses broader research on based review, although not stroke- medication) are realised bythe impact of support for people with specific, which has quantified the providing Level 1 and Level 2/3low/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 oftested with clinical psychologists, and of outpatient procedures [28]. the realisation of benefits because itpeer reviewed by a range of health is unrealistic to assume that thesecare 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 1In the following three sections, to average annual reductions in support are likely to have relativelyimpacts are described on individuals, healthcare usage per person as mild mental health issues, so thisin terms of: the NHS; adult social care follows: intervention will release a lowerservices; and quality-adjusted life overall saving. Even for peopleyears (QALYs). Finally there is a • 1.59 GP consultations; receiving Level 2/3 support, thediscussion 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 whichwere not included in the analysis. 17
  18. 18. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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 £63,08718
  19. 19. Psychological care after stroke: Economic modelling of a clinical psychology led team approachAvoiding nights in hospital beds and It has been estimated that around These assumptions could then beGP consultations may not realise 12.5% of people who have had a combined with data on the averagedirect cash savings as the bed and stroke and survive to transfer home cost of residential care and theappointment will inevitably be filled require some home care [30] services. number of admissions to residentialby other patients. These care (taken from the SIA) to estimatecalculations demonstrate the The assumptions about the impact on the total value of this saving atsaving from reducing the cost of take up of these services from £14,060 over the first two years afterthe burden of stroke on health psychological support are: stroke. Potential savings from nursingcare 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 inServices year 1 and 2.5% less in year 2 Quality adjusted life yearsA 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 commissioningrelated to Local Authority funded 2/3 support need 10% less home health and social care services is toadult social care. However, there is a care in year 1 and 5% less in year 2 get the best possible outcomes forlack 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 serviceswere no research-based data to with data on the average cost of and hence inform commissioningsupport the model assumptions, home care packages to estimate the decisions. One tool that can help withthese assumptions have instead been total savings of £31,151 (£17,918 in this process is ‘quality adjusted lifetested through peer review. year 1 and £13,233 in year 2). years’ (QALYs) [32]. The QALY is used to quantify the benefits of a medicalOne such area is formal personal care There is also anecdotal evidence that intervention and takes into accountprovided at the stroke survivor’s own psychological support has an impact both quality and quantity of lifehome (assistance with activities such on the likelihood of someone moving generated by healthcare. The QALY isas washing and dressing). Untreated into residential care [31]. Because based on the amount of years of lifedepression has a negative impact on admission to a care home is generally that would be added by thefunction, independent of level of a one-off event, rather than on-going intervention. Each year in perfectphysical 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. Afor depression-related disorders, developed a model based on the monetary amount is used to estimateanxiety 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 isconfidence 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
  20. 20. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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
  21. 21. Psychological care after stroke: Economic modelling of a clinical psychology led team approachSummary of resultsTable 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% moreSensitivity analysis This sensitivity analysis found that,The model’s results were tested in a psychological care produces ansensitivity analysis with different overall cost saving after two years ifassumptions about the effectiveness social care savings are included. Ifand cost of psychological care (Table social care savings are not included6). 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 yearspragmatic approach to the sensitivity of the initial investment in all but theanalysis was adopted. Therefore, ‘10% less effective’ scenario (Figure 6).assumptions were made that theinterventions were either 10% more,or 10% less effective; which resulted Figure 6: NHS and adult social care savings in relation to costin concomitant impacts on the overallsavings generated i.e. 10% more or £140,00010% less. As more information aboutpsychological care after stroke £120,000becomes available it will be possible £100,000to make more informed decisionsabout which variables to include in a £80,000sensitivity analysis and the range of £60,000levels that they can realistically take.This would allow a more robust £40,000sensitivity 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
  22. 22. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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
  23. 23. Psychological care after stroke: Economic modelling of a clinical psychology led team approachProvision of psychological care after The assumption in this paper that The assumption about the impact ofstroke in England has been shown to psychotherapy is of benefit to stroke psychotherapy on costs was not asbe at best variable and at worst patients was not unreasonable. There strong because it had to be drawninadequate [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]) orraised awareness of the need for psychotherapy can prevent the was non-stroke data (e.g. [28]). Thisservices to improve. Inclusion of development of depression, though means that the model is not as robustnational measures of psychological little evidence of the benefit of as would be ideal, but because thecare in the national stroke audit, and psychotherapy on treating model has been developed on mixedtheir consideration for inclusion in the depression; two trials not included in levels of evidence, assumptions madeCommissioning Outcomes this latter review have shown a small are conservative. Whilst this model isFramework is welcomed as potential benefit of psychotherapy on treating considered by the authors to be ofdrivers for continued improvement depression [22] [24]. Of particular value, further research into thein 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 beenon 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 individualand their family who are at the heart of Academics and Further research into the economic benefits of psychologicalthese 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 apsychological support to manage the clinical psychologist-led service for psychological care based on astroke and its consequences. The review of current provision of psychological care.significant benefits of meeting this Stroke-specific psychological care is commissioned through theneed 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 thethis model was a lack of empirical impact of psychological care for people with stroke.evidence of the cost-effectiveness, oreven cost-utility of treating Providers Psychological care pathways are developed using a stepped approach.depression after stroke [34]. It wouldhave been better if this modelling Views of patients and families about the quality of psychologicalwork 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 theeffectiveness 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
  24. 24. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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, ONeil 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
  25. 25. Psychological care after stroke: Economic modelling of a clinical psychology led team approach[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
  26. 26. Psychological care after stroke: Economic modelling of a clinical psychology led team approach 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. 200826
  27. 27. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTLUNGSTROKENHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lungand stroke and demonstrates some of the most leading edge improvement work in Englandwhich supports improved patient experience and outcomes.Working closely with the Department of Health, trusts, clinical networks, other health sectorpartners, professional bodies and charities, over the past year it has tested, implemented,sustained and spread quantifiable improvements with over 250 sites across the country aswell as providing an improvement tool to over 2,000 GP practices.NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NBTelephone: 0116 222 5184 | Fax: 0116 222 5101www.improvement.nhs.uk Publication Ref: NHSIMP/Stroke0003 - November 2012 ©NHS Improvement 2012 | All Rights ReservedDelivering tomorrow’simprovement agendafor the NHS

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