Table 4.
Economic characteristics.
| Study | Currency | Cost Data (CG) | Cost Data (EG) | Trial Duration | Authors’ Economic Conclusion |
|---|---|---|---|---|---|
| Hesse et al., 2014 [18] | EUR | The experienced therapist in the control group treated 3825 patients per year; the total costs (salary, 10% overhead) of the individual arm therapy were EUR 38,500, i.e., one treatment cost EUR 10.00. Thus, the difference in actual costs for the employer was EUR 5.85 per session. | The net investment costs for the devices (EU list prices) plus a 25% overhead (for maintenance, energy, consumables) were EUR 48,000, to be deducted within four years resulting in an annual cost of EUR 12,000. The annual gross salary of the assistant therapist was EUR 25,000, and it was EUR 35,000 for the experienced therapist. The assistant therapist in the experimental group treated 8925 patients per year, thus the total costs (device, overhead, salary) of the robot-assisted group therapy were EUR 37,000, i.e., one treatment cost EUR 4.15. |
1 month | Robot-assisted group therapy (comprising Bi-ManuTrack®, RehaDigit®, Reha-Slide® and Reha-Slide duo®, all considered end-effector robot devices) + individual arm therapy were as effective as a double session of individual arm therapy in subacute stroke patients. Robot-assisted group therapy is probably more cost-efficient than individual arm therapy. The robot-assisted group therapy, supervised by an assistant therapist, cost less. |
| Bustamante et al., 2016 [19] | MXN | The salary of a rehabilitation specialized therapist in the Mexican public health institution was reported to be around MXN 235,344 (USD 19,612) per year. Traditional therapy, which consisted of the time-matched standard of care where patients received 2 h of therapy, was estimated to have a therapy cost of MXN 230.52 (USD 19.21) per session. |
The full cost of the robotic equipment (adding transportation and importation costs) was MXN 432,592.4, to be settled within 2 years with annual payments of MXN 216,296 (approximately USD 18,024 at that time). For the robotic therapy group, the therapy cost would be MXN 83.90 (USD 6.99) within the first 2 year and after this period of time, the net cost of the equipment will be liquidated and only the percentage reserved for maintenance will remain, reducing the estimated cost for robotic therapy to MXN 51.48 (USD 4.29) per session with a 2 h therapy session per patient. |
2 months |
Robot Gym (Theradrive system® + Ness for upper extremity® + Ness for lower extremity® + Motomed Viva 2® for upper extremities + Motomed Viva 2® for lower extremities + Captain’s Log Brain-trainer®; all the robots considered were end-effector robot devices) enhanced functionality in the upper-extremity tests similarly to patients in the control group. In the lower-extremity tests, the EG showed a greater improvement compared to those subjected to traditional therapy. Robot Gym could be a more cost- and labour-efficient option for countries with scarce clinical resources and funding. |
| McCabe et al., 2015 [20] | USD | Therapist cost was USD 98,000, which is the annual salary for an experienced therapist in Ohio where the study was conducted FES cost for a 4-channel tabletop and 2-channel portable system was USD 4000, with a 5-year equipment life Motor learning approach treatment: USD 4570 FES plus motor learning approach: USD 4604 |
Shoulder/elbow clinical level robot with 5-year life cost: USD 89,000; annual robot warranty and maintenance: USD 8000 Robotics plus motor learning approach: USD 5686 |
3 months | Severely impaired stroke survivors with persistent (>1 year) upper-extremity dysfunction can make clinically and statistically significant gains in coordination and functional task performance in response to treatment with InMotion2® Shoulder-Elbow Robot (end-effector robot device) plus a motor learning approach, FES plus motor learning approach, and motor learning approach alone in an intensive and long-duration intervention; no group differences were found. The motor learning approach alone protocol was less expensive than the robotics plus motor learning approach protocol (by USD 1116) and the FES plus motor learning approach protocol (by USD 34). Therefore, if a cost differential of approximately USD 1000 per patient is considered important, the FES plus motor learning approach protocol and/or the motor learning approach alone protocol would be preferable. |
| Wagner et al., 2011 [21] | USD | Cost per session of the intensive comparison therapy: USD 218 Average cost: USD 7382 |
Cost per session of the robot training: USD 140. Average cost: USD 5152 |
3 months | The average cost of delivering robot therapy (MIT-Manus®, considered as an end-effector robot device) and intensive comparison therapy was USD 5152 and USD 7382, respectively, and both were significantly more expensive than usual care alone (no additional intervention costs). The added cost of delivering robot or intensive comparison therapy was recuperated by lower healthcare use costs compared with those in the usual care group. The changes in quality of life were modest and not statistically different. Cost data were analysed at 36 weeks post-randomization. |
| Masiero et al., 2014 [22] | EUR | Hourly/year physiotherapist cost: EUR 18,773. | Hourly/year cost (robot + therapist; ratio 1 robot/therapist): EUR 25,119 Hourly/year cost during (robot + therapist; ratio 3 robots/therapist): EUR 12,604 |
1 month versus 1 month and 1 week | By comparing several NeReBot® (end-effector robot device) treatment protocols, comprising different combinations of robotic and non-robotic exercises, the authors showed that robotic technology can be a valuable and economically sustainable aid in the management of post-stroke patient rehabilitation. |
| Housley et al., 2016 [23] | USD | Projected outpatient therapy based on three 1 h weekly physical therapy sessions for 90 days: USD 3619.95. | Monthly costs of home-based robot-assisted therapy: USD 1268.07 | 3 months | Home-based, robotic therapy (Hand and Foot Mentor®, considered a hybrid robot device) reduced costs, while expanding access to a rehabilitation modality for people who would not otherwise have received care. The analysis revealed an average of USD 2352 (64.97%) in savings compared to clinic-based therapy per stroke survivor. Further, the inclusion of home-based telerehabilitation leads to a return of approximately USD 2.85 for therapy on every dollar spent by the health system. |
| Chan et al., 2022 [24] | HKD | Therapist salary: HKD 63,000 Total hourly cost (therapists): HKD 269.23 |
Total machine cost: HKD 1,759,200.00 Total hourly cost (robot): HKD 175.92 |
NR | ROBERT® (end-effector robot device) was better than physical therapy in performing repetitive exercises for lower limbs. The physiotherapist’s time can be saved when the robot is being used. The cost analysis result showed that employing ROBERT® is less costly than the equivalent performed by a physiotherapist. Its cost benefit was HKD 175.92/one eff. unit, whereas that of physical therapy is HKD 269.23/one eff. unit. Although the capital cost of the robotic system was high, its average hourly operating cost was just one-tenth of the cost for one specialty outpatient session in a hospital. |
| Fernández-García et al., 2021 [25] | GBP | Usual care: GBP 3785 EULT: GBP 4451 |
Robot-assisted training: GBP 5387 | 3 months | The cost-effectiveness analysis suggested that neither robot-assisted training with MIT-Manus robotic gym (InMotion®
commercial version, considered an end-effector robot device) nor EULT, as delivered in this trial, were likely to be cost-effective at any of the cost-per-QALY thresholds considered. At 6 months, on average, usual care was the least costly option (GBP 3785), followed by EULT (GBP 4451), with robot-assisted training being the most expensive (GBP 5387). The mean difference in total costs between the usual care and robot-assisted training groups (GBP 1601) was statistically significant (p < 0.001). The mean QALY was highest for the EULT group (0.23) but there was no evidence of a difference (p = 0.995) between the robot-assisted training (0.21) and usual care groups (0.21). 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 GBP 20 000 WTP threshold. Usual care was most likely to be cost-effective at all the WTP values considered in the analysis. |
| Rodgers et al., 2020 [26] | GBP | Usual care: GBP 3785 EULT: GBP 4451 |
Robot-assisted training: GBP 5387 | 3 months | The RATULS trial did not find evidence that a robot-assisted training programme using the MIT-Manus robotic gym (InMotion®
commercial version, considered an end-effector robot device), as implemented in this trial, improved upper limb function following a stroke when compared with an EULT programme based on goal-orientated repetitive functional task practice at the same frequency and duration, or with usual care. Neither robot-assisted training nor the EULT programme as provided in the RATULS trial (1:1 patient-to-therapist ratio) were cost-effective at the current UK WTP per QALY (GBP 20,000–30,000). |
| Pinto et al., 2023 [27] | USD | Conventional training cost: USD 1758 Litegait overground training system: USD 0.47/session for rehabilitation hospital purchasing department. Body weight-supported treadmill and harness system: USD 6.86/session Rehabilitation hospital-quality treadmill: USD 35,000 + annual maintenance contract (USD 8500) |
Robotic training cost: USD 3952 Overground exoskeleton device: USD 18.36/session Capital cost of robot (purchase price): USD 150,000 + annual maintenance contract (USD 10,000) Stationary robotic system: USD 38.95/session (USD 350,000 + annual maintenance contract (USD 15,000)) Track-based overground training and harness system: USD 7.52/session (USD 225,000 + annual maintenance contract (USD 7500)) |
NR | The most cost-effective locomotor training strategy for people with an SCI differed depending on injury completeness: conventional overground training was more effective and cost less than robotic therapy (type of robot/s used not reported) for people with an incomplete SCI. Overground robotic training was more effective and cost more than conventional training for people with a complete SCI. Costs were lower for conventional training (USD 1758) versus overground robotic training (USD 3952) and lower for those with an incomplete versus complete injury. The incremental cost utility ratio for overground robotic training for people with a complete spinal cord injury was USD 12,353/QALY. |
| Lloréns et al., 2015 [28] | USD | The overall expense for one participant belonging to the in-clinic programme was USD 1490.23 | The home-based programme required an estimated expenditure of USD 800 to acquire the hardware needed for the VR system | 2 months | VR-based telerehabilitation interventions can promote the reacquisition of locomotor skills associated with balance in the same way as in-clinic interventions, both complemented by a conventional therapy programme. The telerehabilitation intervention can involve savings (mainly derived from transportation services) compared with the in-clinic intervention. Both treatment modalities used a computer/laptop, Kinect® (semi- immersive virtual reality system) and Internet access. The cost of one hour of physical therapy was USD 21.85. The difference between the two interventions was USD 654.72 (in favour of the telerehabilitation intervention). Beyond human resources, the most influential factor was the travel expenses (USD 1308.11), which represented 87.77% of the total cost of the in-clinic intervention. |
| Islam et al., 2019 [29] | USD | The average monthly take-home salary of an experienced physiotherapist in Norway is approximately USD 3224. Hence, the average hourly wage is about USD 21.5 (USD 35.72, including the income tax and social security contribution costs for both the employee and the employer). | The price of one YouGrabber Basic system is equivalent to USD 7544 including VAT. | 1 month | The YouGrabber® system (now called Bi-Manu-Trainer®, is considered a semi-immersive virtual reality system) was used. In the VIRTUES trial, no cost savings in favour of VR were found. Additional upper-extremity VR training was equally as effective as additional conventional therapy in the subacute phase after stroke. |
| Adie et al., 2017 [30] | GBP | Arm exercises group cost: GBP 730 | Wii® group cost: GBP 1106 | 1 month and 2 weeks |
Wii® (non-immersive virtual reality system) was not superior to arm exercises in home-based rehabilitation for stroke survivors with arm weakness. Wii® was well tolerated but more expensive than arm exercises. |
| Thomas et al., 2017 [31] | GBP | Using an estimated cost of GBP 32 per hour for a hospital physiotherapist equates to a per participant cost of the intervention of GBP 384 for physiotherapy time. | The equipment cost (Nintendo Wii® console plus peripherals and software) was approximately GBP 300 per unit. The mean cost of delivering Mii-vitaliSe was GBP 684 per person. |
12 months and 6 months, for each group |
A Nintendo Wii® system, considered a non-immersive virtual reality system (Wii Fit Plus®, Wii Sports® and Wii Sports Resort® along with the Wii Balance Board (and non-slip cover), two Wii remote controls, two Nunchuk controls, battery and remote control chargers and spare rechargeable batteries), was used. The mean time per participant spent by the physiotherapists delivering Mii-vitaliSe was 12 hours with approximately half of this time involving face-to-face contact. |
| Farr et al., 2021 [32] | GBP | NR | The cost of a therapist’s time over the 12-week intervention was GBP 20.10 per child in the supported group (Nintendo Wii Fit®). This is based on an hourly rate for a band 5 physiotherapist (AfC specialist level) of GBP 37. The physiotherapists in this study, however, were band 7 (advanced/team leader) and 8 (principal/consultant). Costs at these higher levels would be around GBP 30 or GBP 40 per child, respectively. | 3 months | Therapeutic use of Nintendo Wii®, considered a non-immersive virtual reality system, with the Wii Balance Board ® and Wii Fit® in-home was inexpensive and acceptable in short periods of around six weeks. |
CG: control group; EG: experimental group; EU: European Union; EULT: enhanced upper limb therapy; FES: functional electrical stimulation; SCI: spinal cord injury; WTP: willingness to pay; VAT: Value-Added Tax; VR: virtual reality.