Table 4Health economic evidence profile: Robot-assisted arm training versus usual care

StudyApplicabilityLimitationsOther commentsIncremental costIncremental effectsCost effectivenessUncertainty

Fernandez-Garcia 202131

(UK)

Directly applicableMinor limitations(a)
  • Within-trial analysis of RATULS RCT88 (n=768)
  • Cost-utility analysis (QALYs)
  • Population: adults with moderate or severe upper limb functional limitation as a result of first-ever stroke that had occurred between 1 week and 5 years before randomisation
  • Comparators:
    1. Usual care (45 minutes with a physiotherapist or occupational therapist, 5 days a week)
    2. More intensive – robot-assisted training (45 minutes per day, 3 times per week) plus usual care
    3. More intensive – enhanced upper limb therapy (EULT) (45 minutes with a physiotherapist, 3 times per week) plus usual care.
  • Time horizon: 6 months

2-1: £1601(b)

3-1: £741(b)

3-2: Saves −£936(b)

2-1: 0.00 QALYs

3-1: 0.01 QALYs

3-2: 0.02 QALYs

2-1: More intensive rehabilitation (robot arm training) was dominated by usual care.

3-1 (More intensive (EULT) vs usual care): £74,100 per QALY gained

3-2: EULT dominated Robot (lower costs and higher QALYs)

Probability cost effective (£20K threshold):

  • usual care 81%
  • more intensive (robot) 0%
  • more intensive (EULT) 19%
Sensitivity analyses around missing data and robot costs did not change conclusions.

Extrapolation of data to 12-month time horizon made more intensive rehabilitation (EULT) cost effective compared to usual care (£6,095; probability cost effective 55%). More intensive (robot) remained dominated by usual care.

Remy-Neris 202149Partially applicable(c)Potentially serious limitations(d)
  • Within-trial analysis of an RCT (n=215) included in the clinical review (same paper) with no modelled extrapolation.
  • Cost-utility analysis (QALYs)
  • Population: Adults, 3 weeks to 3 months post-stroke, with an FMA score of 10 to 40 points.
  • Comparators:
    1)

    Control group (n=108) was provided with usual rehabilitation for 1 hour, 5 days per week plus an additional daily hour of self-rehabilitation consisting of basic stretching and active exercises for 4 weeks.

    2)

    Exo group (n=107) was provided with usual rehabilitation for 1 hour, 5 days per week plus an additional daily hour of self-rehabilitation consisting of gravity-supported, games-based training using an exoskeleton (Armeo®Spring) for 4 weeks

  • Follow-up: 12 months
2−1: Saves £99(e)2−1(f): 0.01 QALYsResults suggested that the Exo group intervention dominates usual care (lower costs and higher QALYs), however total costs and QALY gains were not statistically significant between groups.

Probability of cost effective (£20K/£30K threshold): NR

Results were robust to probabilistic sensitivity analysis, where uncertainty on the ICER was described using 1000 bootstrap replications on the cost-effectiveness plane.

Abbreviations: 95% CI= 95% confidence interval; EQ-5D-3L= EuroQol 5 dimensions 3 levels (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death); FIM= functional independence measure (scale 0-18, higher values are better); FMA UE= Fugl-Meyer Assessment Upper Extremity (scale 0-66, higher scores are better); ICER= incremental cost-effectiveness ratio; NA= not applicable; NR= not reported; QALYs= quality-adjusted life years; RCT= randomised controlled trial; SIS hand function= stroke Impact Scale - hand function domain (scale 0-100, higher values are better).

(a)

Within-trial analysis based on RATULS RCT and so only reflects this study and not the wider evidence base identified in the clinical review.

(b)

2018 UK pounds. Cost components incorporated: intervention costs, follow-up costs, primary care, therapy and community-based, services, secondary care, residential and nursing home care, social services, medication costs. Unit costs were taken from 2017/18 NHS reference costs and 2017 PSSRU unit costs (which were inflated to 2018 prices using the Bank of England inflator7)

(c)

French healthcare system may not reflect current UK NHS context. EQ-5D-3L French tariff was used to estimate QALYs but NICE reference case specifies that the UK tariff is preferred.

(d)

Within-trial analysis based on a single-blinded RCT, therefore results only reflect this study and not the wider evidence base identified in the clinical review. References for unit costs were not reported which limits interpretation of results for UK context. Probability that intervention was cost-effective at £20K threshold was not reported.

(e)

2018 euros (€) converted to UK pounds purchasing power parities.81 References for unit costs were not reported but 2018 was assumed based on the study completion date. No significant between-group differences were reported for total costs (p=0.99). Cost components incorporated: Armeo®Spring exoskeleton (device cost, 5-year linear depreciation, maintenance, and physical therapist for patient training). Resource use estimates included inpatient rehabilitation days, outpatient physiotherapy, GP and specialist consultations and transportation costs.

(f)

Mean difference taken from Figure 4 of guideline clinical review. There were no significant between-group differences in changes for any of the reported outcomes at any time point (p>0.05).

From: Evidence reviews for robot-assisted arm training

Cover of Evidence reviews for robot-assisted arm training
Evidence reviews for robot-assisted arm training: Stroke rehabilitation in adults (update): Evidence review M.
NICE Guideline, No. 236.
Copyright © NICE 2023.

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