Economic evaluation of robot-assisted training versus an enhanced upper limb therapy programme or usual care for patients with moderate or severe upper limb functional limitation due to stroke: results from the RATULS randomised controlled trial

Abstract

ObjectiveTo determine whether robot-assisted training is cost-effective compared with an enhanced upper limb therapy (EULT) programme or usual care.DesignEconomic evaluation within a randomised controlled trial.SettingFour National Health Service (NHS) centres in the UK: Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Northwick Park Hospital, London Northwest Healthcare NHS Trust; Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde; and North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust.Participants770 participants aged 18 years or older with moderate or severe upper limb functional limitation from first-ever stroke.InterventionsParticipants randomised to one of three programmes provided over a 12-week period: robot-assisted training plus usual care; the EULT programme plus usual care or usual care.Main economic outcome measuresMean healthcare resource use; costs to the NHS and personal social services in 2018 pounds; utility scores based on EQ-5D-5L responses and quality-adjusted life years (QALYs). Cost-effectiveness reported as incremental cost per QALY and cost-effectiveness acceptability curves.ResultsAt 6 months, on average usual care was the least costly option (£3785) followed by EULT (£4451) with robot-assisted training being the most costly (£5387). The mean difference in total costs between the usual care and robot-assisted training groups (£1601) was statistically significant (p<0.001). Mean QALYs were highest for the EULT group (0.23) but no evidence of a difference (p=0.995) was observed between the robot-assisted training (0.21) and usual care groups (0.21). The incremental cost per QALY at 6 months for participants randomised to EULT compared with usual care was £74 100. Cost-effectiveness acceptability curves showed that robot-assisted training was unlikely to be cost-effective and that EULT had a 19% chance of being cost-effective at the £20 000 willingness to pay (WTP) threshold. Usual care was most likely to be cost-effective at all the WTP values considered in the analysis.ConclusionsThe cost-effectiveness analysis suggested that neither robot-assisted training nor EULT, as delivered in this trial, were likely to be cost-effective at any of the cost per QALY thresholds considered.Trial registration numberISRCTN69371850.

Economic Cost of Rehabilitation with Robotic and Virtual Reality Systems in People with Neurological Disorders: A Systematic Review

“…A total of 23 records were assessed for eligibility, with 8 being excluded for different reasons (conference papers and studied diseases other than neurological disorders). Finally, 15 studies [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ] were included in the systematic review and were appraised for quality ( Figure 1 ).…”

“…A total of 15 studies with 1634 patients were included in this review (1108 individuals who experienced a stroke and 99 with a spinal cord injury for robotic studies; 367 people who experienced a stroke, 30 with multiple sclerosis and 30 with cerebral palsy for virtual reality studies). Ten papers were focused on robotics [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ] and five on virtual reality [ 28 , 29 , 30 , 31 , 32 ] ( Figure 2 ). The studies showed a greater predominance of men than women.…”

“…Regarding the papers focused on robotics, nine records recruited people who experienced a stroke [ 18 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ] and one record recruited people with an SCI [ 19 ]. Six studies employed robots for upper-limb rehabilitation [ 18 , 20 , 21 , 22 , 25 , 26 ], two for lower-limb rehabilitation [ 24 , 27 ], and two for upper- and lower-limb rehabilitation [ 19 , 23 ]. Two papers [ 18 , 19 ] used a combination of robots for their aims.…”

“…Two papers [ 18 , 19 ] used a combination of robots for their aims. The robotic device most frequently used for the upper limb was InMotion ® (Bionik Co., Watertown, MA, USA) [ 20 , 21 , 25 , 26 ], followed by (with an equal number) NeReBot ® (University of Padua, Padua, Italy) [ 22 ], the Theradrive system ® (University of Pennsylvania, PA, USA) [ 19 ] and a combination of Motomed Viva 2 ® (MOTOmed ©, Betzenweiler, Alemania), Bi-ManuTrack ® (Reha-Stim Inc., Berlin, Germany), RehaDigit ® (HASOMED, Magdeburg, Germany), Reha-Slide ® and Reha-Slide duo ® (Reha-Stim Medtec Inc., New York, NY, USA) [ 18 ], and Hand Mentor ® (Motus Nova Inc, Atlanta, GA, USA) [ 23 ]. For lower-limb rehabilitation, Foot Mentor ® (Motus Nova Inc., Atlanta, GA, USA) [ 23 ], Robert ® (Life Science Robotics Inc, Aalborg, Dinamarca) [ 24 ], Motomed Viva 2 ® for lower extremities [ 19 ] and an undeclared robot in [ 27 ] were used in equal numbers.…”

Retrospective Robot-Measured Upper Limb Kinematic Data From Stroke Patients Are Novel Biomarkers

“…This outcome has been subsequently confirmed by Mehrholz et al who reviewed the literature on the efficacy of upper limb Robot-assisted Therapy (ulRT) in improving activities of daily living, arm function, and arm muscle strength (6). The efficacy (7)(8)(9)(10)(11), acceptability (12), safety (13), and cost-effectiveness (14) of ulRT in stroke patients are well-established in literature.…”