Abstract
Background: Robotic exoskeletons have shown promise in gait rehabilitation for stroke and spinal cord injury (SCI) patients. However, there is a need to evaluate their cost-effectiveness compared to conventional physiotherapy. We evaluated patients undergoing robot-assisted gait rehabilitation using the EksoGT exoskeleton in a pilot program with Alexandra Hospital, Saint Luke's Hospital, Jurong Community Hospital, Stroke Support Station, and NTUCHealth Day Care and Rehab Center. The study also integrated co-design approaches, engaging patients, caregivers, and relevant stakeholders to ensure the initiative's effectiveness.
Method: A decision-analytic model was employed to estimate costs and outcomes over a 5-year period from healthcare system’s perspective. The study involved patients in acute, sub-acute, and chronic disease phases depending on duration with impaired mobility (Acute < 1 month, Subacute 1 to 9 months, and Chronic > 9 month). The quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER) for each group were calculated. The ICERs represent the additional cost per QALY gained. The QALYs were calculated based on utilities gained in terms of EQ-5D-5L value sets for Singapore. The ICERs were compared with the willingness-to-pay threshold, equivalent to one GDP/capita, as per the World Health Organization recommendation for Singapore. The discount rate was assumed at 3% based on Agency for Care Effectiveness Singapore guidelines.
Results: The cost-effectiveness analysis revealed favorable ICERs for stroke and SCI patients in the acute and sub-acute stage, with ICER/QALY gained values of SG$16,671 and SG$22,708 for the acute stage and SG$24,650 and SG$57,653 for the sub-acute stage under the base-case scenario. These findings, coupled with a willingness-to-pay threshold of SG$100,000, indicate that integrating EksoGT exoskeletons into rehabilitation programs is cost-effective for stroke and SCI patients at the acute or sub-acute stage. Training with EksoGT exoskeletons leads to higher QALY gains and improved patient-perceived health and overall quality of life in the acute and sub-acute stages. However, for patients in the chronic stage, the patients with conventional physiotherapy exhibited higher QALY gains, resulting in unfavorable ICERs (Stroke SG$ 1,211,866; SCI SG$440,388).
Discussion: Although robotic exoskeletons involve higher upfront costs, they demonstrate potential cost-effectiveness due to their ability to enhance functional abilities which could reduce long-term healthcare expenses related to assistive devices and caregiver support and increase productivity. Integrating exoskeleton technology into rehabilitation programs offered several integrated care benefits in the context of healthcare system, such as enhanced functional recovery, improved patient engagement and adherence, potential for earlier mobilization, improved patient outcomes, reduced therapist fatigue and manpower shortages, and financial attractiveness for certain conditions.
Conclusion: Integrating robotic exoskeletons into gait rehabilitation programs for stroke and SCI patients was cost-effective for acute and sub-acute patients. This has potential to revolutionize stroke and SCI rehabilitation practices and benefit a broader audience. Future research should involve investigation into the factors influencing the cost-effectiveness of robotic exoskeletons in chronic condition patients. Additionally, future research should also explore long-term outcomes, patient satisfaction, and broader societal implications to inform policy decisions.