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226 Musculoskeletal & Neurological Rehabilitation KCE reports 57 Rommers 237 found an incidence of LEA in the Netherlands of 19/100.000. He also states that about half of the patients are fitted with a prosthesis 66 . Based on other literature data as described in chapter 2 and on data of the RIZIV/INAMI we estimate the incidence in Belgium somewhat lower. (RIZIV/INAMI data: number of AK amputations in 1995: 653, in 1998: 614; BK amputations in 1995: 448, in 1998: 489; number of evaluation prostheses for BK provided in 2005 and 2006: 272 and 303; number of evaluation prostheses for AK provided in 2005 and 2006: 213 and 282). Combining these data, the number of LEA for Belgium is estimated at 1200/year. About 50% of the patients are fitted with a prosthesis, almost as much for AK as for BK. This means 300 patients for subgroup 1 as well as for subgroup 2, when patients deserving a prosthesis are taken into account for post-acute multidisciplinary rehabilitation, and patients without prosthesis are assumed to follow monodisciplinary treatment. The estimated incidence of SCI in Belgium based on literature (chapter 2) is between 1 and 3/100000. This seems to be confirmed by a newsletter of ISCoS (International Spinal Cord Society) in December 2006. A European survey was performed, using a questionnaire that was sent to experts in 21 European countries. The results showed a mean incidence of SCI of 1,75/100000. So we estimate the number of new cases in Belgium at 200/year, 100 paraplegics and 100 tetraplegics. For MS the number of new cases in Belgium yearly is estimated at 400. The prevalence in Belgium, which in this case is relevant as it concerns a progressive disorder, is estimated at 10 000 (see chapter 2). Based on Belgian expert opinion, it is assumed that +15% of the patients need continuous ambulatory rehabilitation, which means 1500 patients. Based on information of the FOD/SPF Volksgezondheid, Santé Publique (Technical Cell), it was estimated that each year 10% of the MS patients need hospitalization. These numvers are in line with the Flemish study published in 1998 by Carton et al 240 . Concerning stroke we estimate the number of new patients at 19 000/year (see chapter 2). According to the gold fist rule of Fortune and Wenn 238 , approximately 1/3 dies, 1/3 recovers and 1/3 presents with permanent disability. Of these patients only half is younger than 75 years and even less are younger than 70 years. Part of these patients goes directly to a nursing home and part of them can be treated in a geriatric ward. So it is assumed that only about 15% of all stroke patients need post-acute rehabilitation services, which brings us to 2860 patients yearly. This assumption was confirmed by the real data of a Belgian expert centre (Stroke Unit discharge). Especially for ambulatory rehabilitation, the percentages of patients needing multidisciplinary rehabilitation are highly uncertain. To account for this uncertainty, a beta distribution was applied to each of these percentages. This is the accepted distribution for uncertain proportions. The upper and lower limits are essentially arbitrary, as there are no data in literature or from centres that can provide a clue to the ranges. The lower limit was therefore arbitrarily set at a rehabilitation need of 50% of the point estimate and the upper limit at 130% of the point estimate. The point estimate itself was defined as the mean of the beta distribution. During the Monte Carlo simulation of the costs, revenues and expenditures for Belgium as a whole, values are chosen at random from these distributions. This eventually leads to total cost, revenue and expenditure estimates with a probabilistic distribution. 95% confidence intervals were constructed around the point estimates based on the Monte Carlo simulations. The analyses were performed in @risk version 4.5.5. Because these five pathologies obviously do not cover the entire population in need of multidisciplinary rehabilitation, it was assumed in the extrapolation that these five pathologies cover about 75% of the total hospitalization costs and 60% of the total ambulatory care costs for multidisciplinary rehabilitation. This is consistent with the figures in chapter 2 for hospital rehabilitation and with the reported case-mix of two non-university rehabilitation centres in Belgium. To account for the uncertainty associated with this 60%, a beta distribution was applied to this variable, with an arbitrary lower limit of 30% and an arbitrary upper limit of 78%. The mean of the distribution was set at 60%.
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 227 10.3 RESULTS 10.3.1 Costs Figure 10.6 summarises for each pathology group the number of rehabilitation days (in case of hospitalization), of rehabilitation sessions (in case of ambulatory rehabilitation) and the number of weeks treatment is needed according to the experts’ protocol. Using theoretical hourly wage cost of medical input and of the various paramedical inputs combined with total number of hours medical and paramedical input (accounting for the different wage levels and their respective fractions of participation to a session), theoretical cost of medical staff, costs of paramedical staff and total staff costs were calculated. These numbers represent the actual personnel costs that would be incurred by a rehabilitation centre following the rehabilitation path as proposed by the expert meeting. It should be stressed that these calculated staff costs only include the cost for rehabilitation activities specified by the protocols. For hospitalised patients, hotel services, nursing activities etc. are not included in these protocols and hence not included in the total costs reported in the following tables. The total costs of rehabilitation activities for the various pathologies (i.e. the cost to treat one patient according to the specified path), including personnel and overhead costs, are presented in Figure 10.7. Figure 10.6: Staff costs of rehabilitation protocols of five selected pathologies (Euro) According to expert protocol Days (hosp) or sessions (amb) Weeks Cost medical staff Calculated staff costs Cost Total staff paramedical staff costs THR polypathology 25 3.57 198 718 916 THR fragile 7 1.00 56 201 257 LEA BK 28 4.00 444 1 630 2 075 LEA AK, Hospitalization 70 10.00 1 111 5 095 6 206 LEA AK, ambulatory 20 10.00 370 1 853 2 223 SCI (paraplegia), Hospitalization 175 25.00 3 702 16 166 19 868 SCI (paraplegia), ambulatory 60 20.00 740 2 713 3 454 SCI (tetraplegia), Hospitalization 273 39.00 5 776 24 911 30 687 SCI (tetraplegia), ambulatory 78 26.00 1 203 3 484 4 687 MS, Hospitalization 28 4.00 592 2 555 3 147 MS ambulatory 104 52.00 1 925 4 646 6 571 Stroke, Hospitalization 112 16.00 2 370 7 075 9 445 Stroke, ambulatory 120 60.00 2 221 5 360 7 581 In addition sensitivity analyses with a different number of sessions (deviations of +25% and -25% of the reference path proposed by the expert meeting) and different wage levels (+10% and -10% of the reference wage level) were performed. Details on these sensitivity analyses are reported in the Appendix to chapter 10.
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