King Abdul Aziz University

Comments

Transcription

King Abdul Aziz University
Financial Implications of Discharge Plan in Armed
Forces Rehabilitation Center, Taif, KSA
1
Financial Implications of Discharge Plan in Armed
Forces Rehabilitation Center, Taif, KSA
Abstract
Objectives: To identify expenditure of patients who completed their rehabilitation
program for the two groups of patients (discharged compared with non-discharged as
well as to evaluate and develop discharge plan manuals, criteria and (PPGs) in the
rehabilitation facilities.
Material and Methods: Retrospective case-control record reviewing of discharged
patients was applied in Armed Forces Rehabilitation Center, Taif, KSA, 2011. Records
of patients who completed treatment plan and rehabilitation program over a period of 12
months for the year 2010 were categorized into two groups for the purpose of the study;
Disabled patients who not discharged after completing their rehabilitation program
(considered as cases), Disabled patients who discharged after completing their
rehabilitation program (they need only outpatient follow up and considered as controls).
A convenient random sample of 40 records was chosen from each group. A standardized
form for data collection was utilized. The expenditure for health care of one year for
each sample was calculated.
Results: The age of control patients ranged between 11 and 89 years with a mean of
42.83±21.8 while the age of cases ranged between 7 and 84 years with a mean of
43.1±17.9. Males represent 75% of control group of patients compared to all cases. Most
of discharged patients (72.5%) cost less than 30,000 USD/year while the great majority
of in-patients (97.5%) cost more than 60,000 USD/year. The mean annual cost of inpatients was much higher than that of discharged patients (78799.6±14588.5versus
15467.4±9784.3). This difference was strongly significant (P<0.001).
Conclusions: The cost for patients discharged after completing their rehabilitation
program was much less than that for patients, who stayed in the hospital after
completing their program, The research efforts could be conducted to the betterment of
science and society as well as to contribute to the development of new and better
services and support for persons with disabilities and their families, and recommend
implementing of an effective discharge plan in the convenient time to improve the Cost
containment, an efficient psychological program is required to overcome patient’s
problems and to adapt to everyday life, a community-based educational program should
be provided to increase awareness of the community to deal with disabled people,
improving post-discharge care , health education programs to minimize the burden of
road traffic accidents as a major cause of traumatic disability.
2
Financial Implications of Discharge Plan in Armed
Forces Rehabilitation Center, Taif, KSA
INTRODUCTION
The KSA has focused on person with disability since initiation of its social and
economic development plans four decades ago, with the government providing modern
and appropriate welfare means for person with disabilities to help them adapt to society,
the environment, and life by taking into consideration their intellectual, psychological,
physical and livelihood features. 1
Chronic disabling conditions are an emerging challenge facing developing and
industrialized nations.2 Despite the growing awareness of the public, the health and
education professionals about the economic, psychological and medical impact of
disability, limited research has been carried out to determine the economic impact of
prolonged hospital stay of disabled patients in KSA.3 Pattern of disability among Saudi
patients in Taif region as well as determinants of long hospital stay at Armed Forces
Rehabilitation center has been previously reported.4
There are a number of difficulties associated with conducting research on
disability-related issues in KSA, perhaps the most important obstacle is the complete
lack of appropriate epidemiological research on the general population where most
disability researches done in KSA were on disabled children.
1, 5, 6
Moreover, the
appropriateness of the official disability statistics for determining the amount and cost of
3
care needed by disabled persons is a controversial issue and therefore needs to be more
emphasized and ascertained.7
Many disabled people require a continuous healthcare system, home help and
other supportive services, which make healthcare services programs very costly. The
management of disabilities requires substantial medical, educational, social, and
rehabilitative care.2,
8, 9
The cost of preventive efforts is substantially lower and thus
cost-effectiveness favors the prevention approach.10
The first three months following trauma or injury causing disability are seen the
most critical period when greatest recovery is thought to occur.11 Patients admitted to the
Rehabilitation hospital are expected to stay maximally for 6 months following the
Scottish Intercollegiate Guidelines, 1998,12 then should be discharged. However, in the
study carried by Al-Shehri, et al, 2008,4 9.8% of the patients admitted during the period
of the study stayed for more than 6 months, among them there were 5.5% stayed for
more than one year. According to their findings, male, single, less than 45 years old and
with paralytic-type of disability were more likely to stay at the hospital for longer
periods.
Several studies have compared inpatient care to home care costs for a specific
group of patients. An analysis of studies that investigated the use of home care as a costeffective substitute for acute care services found a statistically significant relationship
between home health use and reduced use of inpatient hospital care.13 Home care is a
cost-effective service for individuals recuperating from a hospital stay and for those
who, because of a functional or cognitive disability, are unable to take care of
themselves. However, it should be noted that cost-effectiveness is not the only rationale
4
for home care. Home care reinforces and supplements care provided by family members
and friends and maintains the recipient’s dignity and independence, qualities that can be
lost even in the best institutions. Home care also allows patients to take an active role in
their care.14
The present study, therefore, was conducted to identify the financial impact of
long hospital stay by comparing costs of non-discharged patients who completed their
rehabilitation program with discharged patients who need only outpatient follow up.
Methodology
This is a retrospective case-control record reviewing of discharged patients. The
study was applied in Armed Forces Rehabilitation Center, Taif, KSA, 2011. This facility
was established in 1980 consisting of (100) beds and is located in the city of Taif. The
Rehabilitation Center offers restorative and rehabilitative care to adults and children.
The center provides physiotherapy, hydrotherapy, occupational therapy, speech therapy,
social services, psychology, orthotics and prosthetics. Disabling conditions which are
treated in the center include in-patients are mostly of RTA’s such as brain and spinal
cord injuries and post surgical. Patients with multiple traumas, neurological condition,
musculo-skeletal disease, CVA’s and pediatric patients such as cerebral palsy are also
rehabilitated here. In addition, post-surgical orthopedic such as total knee replacement,
amputees are also admitted for rehabilitation programs. The mixture of chronic and
active patients has made it necessary to have broad competence among medical and
paramedical staff.
5
To study the secondary data through the medical records of disabled patients
who completed treatment plan and rehabilitation program over a period of 12 months for
the year 2010, patients` records were categorized into two groups for the purpose of the
study Group 1: Disabled patients who not discharged after completing their
rehabilitation program (considered as cases), Group 2: Disabled patients who discharged
after completing their rehabilitation program (they need only outpatient follow up and
considered as controls). A convenient sample of 40 records was chosen from each group,
the number and cost of days spent Rehabilitation center and treatment costs were
compared on an annual basis. A standardized form for data collection was prepared and
data from records were collected to find out the expenditure of health care for one year
for each group. the following items were collected: Number of bed days for patient with
cost, number of bed days for patient who admitted to the ICU with cost, cost of
therapeutic services (physical, occupational, speech and orthotics and prosthetics) for
patient, procedure and cost of radiology for the patient, test and cost for laboratory
works of the patient, prescription no. and cost of
medications used for patient,
equipments provided for patient with cost, supplies dispensed and cost for patient
provided by central supplies and services department (CSSD) and the grand total cost of
the patient for the year. The expenditure of health care for one year for each group was
calculated as follows: Cost of patients beds days, cost of bed days for patients who
admitted to intensive care unit (ICU), cost of therapeutic services, cost of radiology
services, cost of Laboratory Tests, cost of medication administered to patients, cost of
equipment required for handicapped patients as well as cost of central supplies and
services.
6
Statistical Analysis
The data were verified by hand then coded and entered to a personal computer.
SPSS software statistical program version 16 was used for data entry and analysis.
Significance was determined at p value < 0.05. Continuous variables were presented as
means & standard deviation. Categorical variables were presented as frequencies &
percentages. Studemt1 t-test was used for comparison of the means of continuous
variables while Chi-square test was applied to test for the association between
categorical variables.
Results
The Study included 40 disabled patients, who discharged after completing their
rehabilitation program (controls) and 40 disabled patients who not discharged after
completing their rehabilitation program (Cases). As shown in table 1, the age of control
patients ranged between 11 and 85 years with a mean of 43.5±21.1 while the age of
cases ranged between 7 and 84 years with a mean of 43.1±17.9. However, as obvious
from figure 1, this difference was not statistically significant, p>0.05. Males represent
75% of control group of patients compared to all cases. This difference was statistically
significant, p>0.001 as shown in table 1. Exactly half of discharged patients were
married (50%) compared to 37.5% of in-patients with no statistically significant
difference (P>0.05).
As shown in table (2), diagnosis of the two groups are exactly the same, 30
patients (50%) were diagnosed with quadriplegia, 8 patients (20%) with Paraplegia and
2 patients (5%) with hemiplegia. Regarding etiology, in most of discharged patients (70%), it
7
was non-traumatic while in inpatient group, in the majority of them (92.5%), it was
traumatic. This difference was statistically significant. P<0.001.
Table (3) shows that most of discharged patients (72.5%) cost less than 100,000
SR/year while the great majority of in-patients (97.5%) cost more than 200,000 SR/year.
As obvious from table (3) and figure (2), the mean annual cost of in-patients was much
higher than that of discharged patients (295498.7±54707.2 versus 78590.6±36055.9).
This difference was strongly significant (P<0.001).
From table (4), it is obvious that within each group of patients separately
(discharged and in-patient groups), there was no statistically significant difference
between traumatic and non-traumatic patients regarding their annual costs. While
overall, traumatic patients cost higher than non-traumatic patients regardless patient`s
category (discharged or in-patient).The costs were 231399.7±105368.7SR versus
103710.4±78461.1SR for traumatic and non-traumatic patients respectively, P<0.001.
Table (5) shows that patients diagnosed with quadriplegia cost higher than other
patients (mean annual cost was 250726.9 SR), followed by those diagnosed with
paraplegia (mean annual cost was 205222.2 SR), hemiplegia (mean annual cost was
128508.6.2 SR) and finally patients diagnosed with other lesions such as lower limb
amputation, disturbed or loss of consciousness, abnormal urination or defecation (mean
annual cost was 74278.4 SR). This difference was statistically significant (p>0.001).
Discussion
There are a number of difficulties associated with conducting research on
disability-related issues in Saudi Arabia. Some of these difficulties are associated with
8
the characteristics of the Saudi society such as the fact that some families feel ashamed
about having a person with a disability and as a result, tend to avoid participation in such
research.15 Saudi society’s view of people with disabilities is based on a simple notion of
disability, and comprises helplessness, continuing dependence, being homebound, low
quality of life and lack of productivity.15
Disability is one of the most important social and economical medical issues in
the community. In contrast to the developed countries, sufficient records on the current
issues of disability such as the number of disabled and handicapped, and their sociodemographic properties are unfortunately unavailable due to the lack of appropriate
studies in the specified area.
Estimates of disability prevalence and its pattern in Saudi Arabia are very
lacking. However, there are number of centers of excellence in Saudi Arabia which
provide various services and care for disabled people.16 However, Rehabilitation center
is the only rehabilitation center that belongs to the Armed Medical services. It provides
services to military people and their families, so all patients included in this study were
Saudi.
Reducing patient length of stay is a high priority for health service providers and
is considered to be an indicator of efficiency.
17, 18
The implications of a reduction in
length of stay are potentially significant for the individual, the health service and for the
community. A reduction in length of stay means the individual can return to their
community sooner, that individuals may not have to wait so long for a bed, that the
health service can treat more patients, and that there are cost savings for the community.
However, from the perspective of the health system, if reducing length of stay is
9
achieved at the expense of quality of care, this will reduce efficiency and could increase
pressures and costs to other health services. Despite this concern, there is some
evidence, at least in acute hospitals, that reducing length of stay has not been achieved at
the expense of quality of care.19
In the current study, the cost of care that was provided to patients who attended
the Rehabilitation center during the period of study, whether discharged after completing
rehabilitation program or stayed in the hospital after completing the rehabilitation
programs, was estimated. It was found that the mean annual cost of in-patients was
much higher and significant than that of discharged patients (295498.7±54707.2 versus
78590.6±36055.9). Al Shehri, 2008
4
reported that each patient admitted to the
Rehabilitation hospital throughout the year 2007 costs about 680 Saudi Riyals (SAR)
days and on average 122,400 SAR for 6 months. Estimated cost of patients who stayed
for more than 6 months in that study was 82,548,600. All costs are paid by the Saudi
Government. That study also documented that the cost of providing home care to those
patients, who completed their rehabilitation program was estimated. Although this
estimate was not accurate because data were not complete, rough estimation came with
2000 SAR per month which was equal to 12,000 SAR for 6 months, which was much
less when compared to hospital care. Based on the average length of stay in
rehabilitation in the public system in Australia of 26.7 days, 20 reductions of length of
stay observed in pilot project of about 3 days if confirmed in the proposed trial have the
potential to save more than $40, and would allow more than 2,200 extra patients to
receive rehabilitation each year across Australia. Their economic evaluation analysis
will allow a rigorous evaluation of the potential benefits of providing additional
10
rehabilitation and include health care costs other than length of stay and take into
account functional outcomes and quality of life after discharge.
Effective discharge management will be considered when both individual and
staff are satisfied knowing that adequate plans have been made for discharge, with the
outcome of the individual’s discharge taking place without unforeseen difficulties, and
the process is considered in the context of ensuring equity and the efficient use of
resources.21 The rehabilitation center, we have a discharge planning. However, it needs
to be effectively implemented in order to avoid unnecessary long patient stay after
completing the rehabilitation program.
The study has several limitations that are discussed in the following sections.
Since the analytic sample is not a random sample of individuals with disabilities in
Rehabilitation centre, the external validity is limited. In other words, we cannot
generalize our findings to the population of people with disabilities. However, we can
expect similar results from eligible applicants to the Rehabilitation Program. Due to
selection bias we cannot determine if the Taif Rehabilitation services caused the
differences that were observed. To completely eliminate selection bias we would need to
create an experiment where individuals were randomly assigned to discharge after
completing rehabilitation program or not.
Conclusively, there are great opportunities in Saudi Arabia to develop new
details of information about disabilities, particularly their nature, incidence, and
financial impact of long hospital stay. The cost for patients discharged after completing
their rehabilitation program was much less than that for patients, who stayed in the
hospital after completing their program The research efforts could be conducted to the
11
betterment of science and society as well as to contribute to the development of new and
better services and support for persons with disabilities and their families. Short-term
experience of home care service in the Rehabilitation center is promising and its
expansion to include more people in different regions of Saudi Arabia, as well as the
implementation of health education programs for the public, would help in providing
quality care and minimizing the burden of road traffic accidents as a major cause of
traumatic disability in Saudi Arabia. An efficient program for psychological support and
counseling should be implemented to help those patients to overcome their problems and
to adapt to everyday life. A community-based educational program should be provided
to increase awareness of the community to deal with disabled people. Discharge plane
should be written in the individual’s file and effectively implemented. This will lead to
decreasing the number of hospital readmissions and ER visits as well as improving of
the Cost containment.
Acknowledgment:
The authors would like to thank Prof. Moataz Abdel-Fattah, for his valuable
advices throughout preparation of this manuscript.
References
1. The Economic Bureau, Kingdom of Saudi Arabia, Profile of Welfare and
Disability in Kingdom of Saudi Arabia, 2006.
2. El-Hazmi MAF. Early recognition and intervention for prevention of disability
and its complications. Eastern Med Health J 1997; 3(1):154 – 161.
3. El-HazmiMAF, Al-Swailem AA, Al-MosaNA, Al-Jarallah AA. Prevalence of
mental retardation among children in Saudi Arabia. Eastern Med Health J 2003;
9:1/2 Jan.
12
4. Al-Shehri AA, Farahat FM, Hassan MH, Abdel-Fattah MM. Pattern of disability
among patients attending Taif Rehabilitation Center, Saudi Arabia. Disability &
Rehabilitation. 2008; 30:11, 884 – 890.
5. Abdul-Wahab S. The effect of ageing on muscle strength and functional ability of
healthy Saudi Arabian males. Ann Saudi Med 1999; 19(3):211 – 215.
6. Pobutsky AM, Hirokawa R, Reyes-Salvail F. Estimates ofdisability among ethnic
groups in Hawaii. Californian J HealthPromotion 2003; 1(Spec Issue: Hawaii):65
– 82.
RetrievedMarch22,2002from:http://www.emro.who.int/Rd/AnnualReports/1994/
94%20RD's%20Rep.-Diag.,%20Therap.,%20Rehab.%20Tech.-Disability%20
Prev.htm
7. Driller E, Pritzbuer EV, Pfaff H. Care required by disabled persons: Are official
severe disability statistics good enough for requirement analyses?
Gesundheitswesen 2004; 66(5):319 –325.
8. Gill TM, Kurland B. Prognostic effect of prior disability episodes among
nondisabled community-living older persons. Am J Epidemiol 2003;
158(11):1090 – 1096.
9. Gill TM, Kurland B. The burden and patterns of ADL disability among
community-living older persons. J Gerontol A BiolSci Med Sci 2003; 58:70–75.
10. Al-Shehri AA, Abdel-Fattah MM. Disability among clients attending Taif
Rehabilitation Center, Saudi Arabia. Asia Pacific Disability Rehabilitation
Journal 2008; 19(2): 50-62
11. Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in
adults. Lancet Neurology 2008;7 (8): 728–41
12. Scottish Intercollegiate Guidelines Network. Management of patients with
stroke, IV: Rehabilitation, prevention and management of complications and
discharge planning. Edinburgh; 1998.
13. Pigott HE, Trott T. Translating Research into Practice: The Implementation of an
In-home Crisis Intervention Triage and Treatment Service in the Private Sector.
American Journal of Health Quality 1993; 3: 138-144.
14. Fuhrman MP. Home care for the elderly. Nutr Clin Pract. 2009 AprMay;24(2):196-205.
15. Al-Gain SI, Al-Abdulwahab SS. Issues and obstacles in disability research in
Saudi Arabia. Asia Pacific Disability Rehabilitation Journal 2002; 13(1):45–49.
16. Al-Essa M, Ozand P, AlGain S. Awareness of inborn errors of metabolism
among parents in Saudi Arabia. Annals of Saudi Medicine 1997; 17(5).
17. Borghans I, Heijink R, Kool T, Lagoe RJ, Westert GP: Benchmarking and
reducing length of stay in Dutch hospitals. BMC Health Serv Res 2008; 8:220229.
18. Clarke A, Rosen R, Length of stay: How short should hospital care be? Eur J
Public Health 2001, 11(2):166-170.
19. Scott I, Vaughan L, Bell D. Effectiveness of acute medical units in hospitals: a
systematic review. Int J Qual Health Care (2009); 21 (6): 397-407
20. Taylor NF, Brusco NK, Watts JJ, Shields N, Casey Peiris C, Sullivan N, et al. A
study protocol of a randomised controlled trial incorporating a health economic
analysis to investigate if additional allied health services for rehabilitation reduce
13
length of stay without compromising patient outcomes. BMC Health Services
Research 2010; 10:308-314
21. Homeless Coalition of Hillsborough County. Recommendations for Collier
County Discharge Planning Policy, 2007.
14
Table 1: Socio-demographic characteristics of disabled
participated in the study, Rehabilitation center, Taif, 2010.
Demographic
Discharged
In-patients
characteristics
(n=40)
(n=40)
No. (%)
No. (%)
<40
21 (52.5)
16 (40.0)
40-60
8 (20.0)
18 (45.0)
>60
11 (27.5)
6 (15.0)
Range
11-89
7-84
Mean±SD
42.8±21.8
43.1±17.9
Male
30 (75.0)
40 (100.0)
Female
10 (25.0)
0 (0.0)
Single
20 (50.0)
25 (62.5)
Married/widow
20 (50.0)
15 (37.5)
P-value
Age in years
0.951
Gender
0.001
Marital status
15
0.218
patients
Figure (1): Comparison of age between cases (in-patients) and controls (discharged
patients), Rehabilitation center, Taif, 2010.
16
Table 2: Medical characteristics of disabled patients participated in the study,
Rehabilitation center, Taif, 2010.
Demographic
Discharged
In-patients
characteristics
(n=40)
(n=40)
No. (%)
No. (%)
Quadriplegia
30 (75.0)
30 (75.0)
Paraplegia
8 (20.0)
8 (20.0)
Hemiplegia
2(5.0)
2(5.0)
Traumatic
35 (87.5)
37 (92.5)
Non-traumatic
5(12.5)
3 (7.5)
P-value
Diagnosis
Etiology
17
<0.001
Table 3: Comparison of Annual Cost between Discharged Patients and Inpatients,
Rehabilitation Center, Taif, 2010.
Costs
Discharged
(n=40)
No. (%)
In-patients
(n=40)
No. (%)
<100,000
100,000-200,000
200,001-300.000
>300,000
33 (82.5)
7 (17.5)
0 (0.0)
0 (0.0)
0 (0.0)
1 (2.5)
20 (50.0)
19 (47.5)
Range
Mean±SD
6749-138,423
58002.8±36691.1
193,690-440,771
295498.7±54707.2
P-value
Cost in Saudi
Riyals
18
<0. 001
Figure (2): Comparison between annual cost of discharged and in-patients,
rehabilitation center, Taif, 2010.
19
Table 4: Comparison of Annual Cost between Discharged Patients and Inpatients
According To Etiology, Rehabilitation Center, Taif, 2010.
Demographic
characteristics
Traumatic
Nontraumatic
Saudi Riyals
Saudi Riyals
P-value
Discharged
patients
Mean±SD
58199.1±37325.90
56628.6±35786.7
0.341
294544.4±54485.7
307267.7±68557.3
0.691
231399.7±105368.7
103710.4±78461.1
<0.001
Inpatients
Mean±SD
Total
Mean±SD
20
Table 5: Comparison Of Annual Cost Of Disabled Patients According
To Diagnosis In Rehabilitation Center, Taif, 2010.
Demographic
characteristics
Annual cost
Mean±SD
Quadriplegia (n=36)
250726.9±98660.6
Paraplegia (n=15)
205222.2±126197.1
Hemiplegia (n=13)
128508.6±101677.4
Others* (n=16
74278.4±38073.0
P-value
<0.001
*LL amputation, disturbed or loss of consciousness, abnormal urination or defecation,
abnormal speech and long-term staying in bed.
21
Appendix
Cost Per Services for the Year Of 2010
Services
Inpatients
Discharged Patients
Patient Days
7,300,000
1,036,041
Physician Visits
163,750
44,774
Physical Therapy
1,104,448
268,831
613,582
134,415
Speech Therapy
409,055
100.811
Orthotics / Prosthetics
368,149
82,216
Radiology
245,433
67,207
Laboratory
327,244
89,611
Pharmacy
429,395
117,582
Equipments
654,488
268,831
204,402
33,635
11,819,946
2,274,248
Occupational
Therapy
Central Supplies &
Services
Grand Total
22

Similar documents