Key reference: https://onlinelibrary.wiley.com/doi/10.1111/aor.14922
Extended continuity of at-home care with smartphone based close-loop ENS device
How big is the gap?
Over 8 million people report a history of stroke in the US1, with 795,000 new patients each year2. Effective neurological rehabilitation has been shown to benefit from therapy even after a year, in the late-chronic stage3. The healthcare system is not designed for long-lasting, intensive care, and is currently unable to give the best recovery to patients, mainly due to:
Lack of continuity. Fewer than 10% access the rehabilitation they need after hospitalization, and access is related to socio-economic disparity. 4 5
Cost-prohibitive. Most insurances don’t cover the full year of 1-on-1 therapy. Total lifetime costs can be over $140,0486 per patient, but most of it is concentrated on the first 90 days7.
On average, $59,900 is spent per patient per year8. But that is only when we do not take into consideration patients who stopped receiving therapy.
The total spent annually in the US is $103.5 billion8, a third being direct costs, which equates to $43171 spent on direct costs for stroke population per patient annually when considering all the post-stroke population in the US.
Is it enough?
Post-stroke patients usually have pre existing or developed comorbidities9 and have increased risk of falls10, thrombosis11 and secondary stroke events12. All of these can produce rehospitalization, worsen prognosis and overall decrease in quality of life. At the same time most of them can be reasonably prevented with continued therapy that provides optimal cardio-metabolic exercises13. There is also evidence that functionality can be increased even past the traditional 3-6 months “critical window”3, suggesting there could be a substantial benefit of continuing rehabilitation long term, specially when using high intensity home based FES devices in the late chronic phase 14 15.
Cost of “ideal rehabilitation” using traditional methods:
It is proposed that to maintain optimal cardio-metabolic metrics and incentivize functional gains in patients long-term, a high intensity program is maintained with the target of 6 days a week of training, utilizing the best equipment for functional recovery.
The cost of high intensity training as described, that includes dosage of PT and OT exercises daily (1-hour each), is $118,000 per patient per year (considering the national average therapy cost). If provided in a traditional setting to each stroke patient today, this would require a $1 trillion a year national budget.
This high cost has meant the continuity of care is cut short for 90% of the stroke population4. A 10X improvement in efficiency of therapy delivery is required.
Cost of high intensity rehabilitation programs can go upwards of $10,000/mo.
Is there room for improvement?
Out of the direct costs, a significant amount comes from preventable hospitalization. Three of the main cost drivers are stroke recurrence, thrombosis and increased fall risk.
Previous systematic reviews show “telerehabilitation seems to be as clinical and cost-effective as traditional rehabilitation, even if, generally, telerehabilitation is less costly”, with one previous study showing significant difference in incremental cost-effectiveness ratio per QALY ($−21,666.41/QALY)16.
Treated under ideal conditions, estimated reduction in the 3 main cost drivers (recurrence, thrombosis and fall risk) amounts to $11B/year 2, 8, 11, 12, 13, 18, 19, 20.
These potential savings could leave space to implement new technologies and alternative solutions, especially taking into consideration that they are direct cost savings, before the consideration of indirect costs and social benefit.
Potential real world implementation
Although existing HPCS and CPT codes offer limited availability, new technology allows for efficient use of these codes to increase overall therapy amount.
Following the therapeutic dosage utilized in protocols within our previous research, the amount of therapy sessions can be increased progressively until at least 6-hours per week. This takes into account the sum of both the 1-on-1 and self-guided remote sessions. At first, half of the sessions are 1-on-1 and then transition to mostly self-guided.
Picture with how this looks like (graph, useful for other docs) – timeline of intervention and timeline of reimbursement
When compared with the cost of a traditional intervention:
Traditional equivalent freelancer PT (6-hours a week)
$3,000 a month ($125/hour)
Traditional equivalent Outpatient Facility (6-hours a week)
Up to $10,000/mo (high-end rehabilitation hospitals and clinics)
As discussed above, this amount of therapy is currently not feasible for the wider population using the traditional model due to costs. It becomes a necessity to further validate alternatives that potentially increase the efficiency and ultimately the quality of care.
One of the aims of this grant will provide evidence required to determine effectiveness and incremental cost reduction, based on these new complementary technologies.