WASHINGTON, DC—This time last year, a group of VA-funded researchers at MIT announced that they had developed a robot-assisted therapy for stroke patients that greatly improved patient outcome without significantly raising costs. In chronic stroke survivors, robot-assisted therapy led to modest improvements in upper-body motor functioning and in quality of life.
The expectation voiced by the researchers was that this would be the next generation of stroke rehabilitation, and that use of robots would eventually become widespread. However, new data analysis shows that the benefits of the robot were statistically small, and its cost-effectiveness is in question.
Stroke survivors are a common sight in the VA system. Approximately 6,000 veterans are hospitalized annually in VA facilities for stroke. Some 40% of stroke survivors have moderate functional impairments, and an additional 15% to 30% have severe impairments. The rehab robot, which resembles a robotic gym with a flat-screen monitor connected to a joystick-like device, was designed to help patients build strength and dexterity in their arms.
“One of the things that robots do nicely is that they work on direction, speed, and control. And they work on a movement many more times than a therapist can do it,” said Todd Wagner, PhD, a health economist at the Palo Alto VA, as he explained his research to a roomful of researchers at the annual VA Health Services R&D conference. “It really focuses on what the patient needs to improve.”
The robot also gives quantifiable feedback on quality and performance but doesn’t really take the place of a human therapist. “The downside is that it doesn’t chat with you. It doesn’t get you coffee,” Wagner said. “When you talk to veterans about how they see the robot, you realize that there is a real benefit to having a person there.”
And while a therapist is still needed to oversee therapy with the robot, that therapist often must split his or her time with a number of patients. “But it means that these robots could lead to efficiencies,” Wagner said. “You can put multiple patients on the same robot at one time. The therapist just needs to spend 15 minutes with the patients getting them set up.”
The Cost of Innovation
The initial cost of each robot is significant—$230,750—and it has an estimated five-year lifespan. There is also a $15,000 maintenance contract for years two through five plus an average $20 cost per patient session to run the machine, and $120 for therapist time, although the latter can be split among multiple patients.
Wagner looked at study data comparing the robot system to a high-intensity form of traditional therapy which mirrored the kind of intensity of treatment patients were getting with the robot. He and his colleagues estimated the intervention costs and tracked participants’ VA health care use and costs using national VA databases for 36 weeks. They also collected self-reported non-VA utilization, use of caregiver support, and quality of life. Then the researchers analyzed the cost data using multivariate regression models while controlling for site, presence of a prior stroke, and VA costs in the year prior to randomization.
The average cost of the 12-week therapy session was approximately $9,500 and $8,000 for the robot and in- tensive comparison therapy, respectively. However, this difference was offset by health care intervention costs. When intervention and health care costs were combined, the average cost of the robot group was $22,171 while the intensive comparison therapy groups and usual care groups were $20,368 and $19,098, respectively.
“Robot therapy was not more expensive, but the changes in quality of life were small and not statistically significant,” Wagner said.
“All we can really say is that there’s considerable uncertainty about this new technology and whether or not it’s cost effective,” Wagner admitted. “We have not yet identified the cost-effectiveness benchmark.”