Cost analysis of home telerehabilitation for speech treatment in people with Parkinson’s disease

Abstract

Introduction

Geographical barriers and impaired physical mobility among people with Parkinson’s disease (PD) hinder their timely access to speech pathology services. We compared the costs of delivering a speech treatment via in-person consultation versus telerehabilitation.

Methods

We used data from a non-inferiority randomised controlled trial delivering the Lee Silverman Voice Treatment (LSVT LOUD®), where patients with dysarthria associated with PD were assigned to either the urban in-person group (N = 16) or the urban online group (N = 15), supplemented with a non-randomised group (regional online; N = 21). We compared costs over a one-month treatment period from a health-system perspective and a patient perspective.

Results

The mean treatment costs of both urban online ($1076) and regional ($1206) treatments tended to be slightly higher than urban in-person ($1020) from a health-system perspective. From a patient perspective, the mean treatment cost was $831 in the urban in-person group, $247 in the urban online group and $200 in the regional group.

Discussion

LSVT LOUD® may be delivered via telerehabilitation at a slightly higher cost than in-person delivery from a health-system perspective, but it is cost saving from a patient perspective. Telerehabilitation is an economically beneficial alternative for the delivery of the LSVT LOUD® programme in PD patients with speech disorders.

Keywords

Telerehabilitation telemedicine Parkinson’s disease cost speech pathology

Introduction

Parkinson’s disease (PD) is the second most prevalent neurological disorder in Australia.¹ The primary speech disorder, hypokinetic dysarthria, is common in PD and causes a progressive loss of communication in patients, limiting their social interactions and activities of daily living.^2–6 Behavioural therapy is the gold standard of care for this speech disorder in PD patients, and the Lee Silverman Voice Treatment (LSVT LOUD®) is the most efficacious treatment available.⁷ Despite the compelling evidence for its benefits, the utilisation of LSVT LOUD® remains suboptimal. A recent survey in Australia found that only one third of speech-language pathologists (SLPs) offered LSVT LOUD® to their patients.⁸ Further, patients received SLP services at much later disease stages than is ideal and when communication abilities were already being moderately to severely affected.⁸ The reasons for poor utilisation of LSVT LOUD® are multifaceted. However, the intensive treatment schedule (one hour per day, four days per week, for four weeks) and distance/travel difficulties are two of the most frequently cited barriers.⁷,⁹,¹⁰

To deal with some of these barriers and to improve the utilisation of LSVT LOUD® among PD patients, alternative models of care such as home-based telerehabilitation have been proposed and tested. Telerehabilitation is a platform for delivering rehabilitation services at a distance and could help to negate utilisation issues by allowing the delivery of care directly into the patient’s home.¹¹ Evidence indicates that telerehabilitation can be successfully implemented in routine care. For example, a systematic review of 61 studies found that 71% of the telerehabilitation services were successful in patients with physical disabilities.¹² For speech disorders, the use of telerehabilitation has been found to be non-inferior to in-person rehabilitation programmes.¹³

Home-based telerehabilitation may alleviate the distance barrier, deliver patient-centred care, enhance compliance and provide an opportunity for real-time supervision.¹¹ However, the economic consequences of implementing and offering home-based telerehabilitation remain unknown. Moreover, the costs of delivering telehealth interventions have substantially changed in the recent years due to technological advancement, affecting both patients (e.g. increased household internet access) and treatment providers (e.g. the move from hardware to software-based platforms). We recently reported that home-based telerehabilitation delivery of LSVT LOUD® was non-inferior to LSVT LOUD® delivered face-to-face in terms of speech (acoustic, perceptual) and quality-of-life outcomes.⁷ As a follow-up to this study, we undertook an economic evaluation of these interventions to guide the future acceptance of this new delivery model by policymakers. Consequently, the objective of this study was to assess the costs of delivering LSVT LOUD® via home-based telerehabilitation and the in-person delivery of the same programme in patients with PD.

Methods

Design

A trial-based cost analysis was conducted from an Australian health-system perspective and a patient perspective. We used data collected as part of single-blinded, randomised controlled non-inferiority trial conducted among three groups from a large urban centre and a regional area for patients with hypokinetic dysarthria associated with PD conducted in Queensland, Australia. In brief, one group (N = 16) from the urban centre was assigned to in-person delivery of the intervention (hereafter ‘in-person’), another group (N = 15) also from the same urban centre was assigned to online delivery of the intervention (hereafter ‘urban online’) and a third group (N = 21) from a regional area was assigned the same online delivery of the intervention (hereafter ‘regional’). The intervention was the LSVT LOUD® treatment. The treatment procedure involved two baseline assessments, 16 one-hour sessions of speech treatment and two post-treatment evaluations.

Following baseline assessments, each participant underwent the LSVT LOUD® programme delivered by a certified research SLP for one hour a day, four days a week, for one month. Each session consisted of three repetitive drill exercises and functional speech activities. Patients also received daily home practice activities. Patients in the online groups received LVST LOUD® at home via a telerehabilitation system video-linked with an SLP located at the research institution. Patients in group 1 received LSVT LOUD® in-person at the research institution. The online evaluation and treatment was conducted using eHAB v2.0, a mobile multimedia telerehabilitation system developed in the Centre for Research in Telerehabilitation at the University of Queensland. Further detail on the overall conduct of the trial and patient demographics has been published elsewhere.⁷ The trial received ethical approval from the University of Queensland, Australia (HREC 2009001863).

Data collection

Costing followed the standard approach used in economic evaluation, including identification of the resources used, measurement and valuation.¹⁴ The resource utilisation was collected during the intervention period by the research team for all three groups. We included the cost of the intervention’s technology (computers and software) and the professional services provided by the SLPs. Since the original study was conducted, there has been a technological shift in the telerehabilitation system from a physical and mobile system (eHAB™ v2.0) to a software-based platform (eHAB® software). Therefore, the cost of the software-based platform of the telerehabilitation system was only considered for this analysis. Detailed cost assumptions and resource utilisation are provided in Table 1. We excluded the cost of the Internet connection and broadband services, as approximately 90% of Australian households already have Internet access.¹⁵ The technology used in the in-person group consisted of a suitcase type of device, including a laptop (AU$600) and software (AU$500) to measure vocal parameters. The costs of the device and iPad (AU$719) used by patients in online groups were annuitised¹⁴ to obtain an equivalent monthly cost for the capital outlay based on an initial purchase price and a usable life of three years, with the annuity factor corresponding to an interest rate of 5%. For online groups, eHAB software (AU$107.60/patient for 16 hours) was costed. One clinician was assumed to treat five patients consecutively, as the new eHAB software requires less time per patient than the old eHAB v2.0 system.

Table 1.

Cost assumptions (per person per one-month programme).

Perspective	Resources	Urban in-person (N = 16)	Urban online (N = 15)	Regional online (N = 21)
Heath system	Device cost^a (amortised)	Software, laptop	eHAB license fee, laptop	eHAB license fee, Laptop
	Photocopy	5 pages×16	1 page×16	1 page×16
	Clinician labour cost	16 sessions	16 sessions	16 sessions
Patient	Device cost^a (amortised)	NA	iPad	iPad
	Lost income	Self-reported	Self-reported	Self-reported
	Average travel	438 km	NA	NA

^aDevice costs were amortised to month. Usable life was estimated as three years.

NA: not applicable.

Speech pathologists’ labour costs for providing 16 treatment sessions per patient were based on: treatment time (60 minutes/session), data management (20 minutes/session) and preparation time (10 minutes/session). For online groups, we used the actual duration for the online sessions observed in the RCT to account for occasional connection dropouts/re-establishing connections, as expected in the real world. We used an average salary of AU$58.50 per hour based on the wage rates of Queensland State Department of Health¹⁶ and added salary on-costs of 28% to reflect the actual value of the clinicians’ time to the business. The same personnel rates were applied to both in-person and online groups. No travel costs were considered, as eHAB software can be simply delivered to a patient’s personal computer by downloading it directly from the website. For the in-person group, the cost of car travel was calculated as distance multiplied by AU$0.66/km, using cents-per-kilometre methods to claim business deductions as per the Australian Tax Office guidelines.¹⁷ In the base case, patient time was valued based on self-reported forgone wage, and unpaid time was estimated as leisure time foregone. Discounting of costs was not necessary, as costs were calculated for one month (programme duration). All costs were reported in 2020 US dollar values using the Cochrane recommended web-based tool that enable the conversion of costs across currencies (using purchasing power parities conversion rates) and years (using the gross domestic product deflator index values). The purchasing power parity for AU$1 was US$0.70 in 2020.¹⁸

Data analysis

We performed descriptive statistics due to the small sample size, and we reported group means, standard deviations (SD) and 95% confidence intervals for the means between in-person and online groups. All analyses were performed using Microsoft Excel.

Results

The characteristics of the participants are shown in Table 2. Of the 52 participants, 36 (69%) were male, with a mean age of 71 years (range 50–87 years). The mean time since diagnosis of PD was 4.8 years (range 0.5–22 years). Among the participants, the severity of dysarthria was mild (77%), moderate (19%) and severe (4%). As reported in the RCT publication, the baseline characteristics amongst the three groups were similar.⁷

Table 2.

Characteristics of the participants.

Variable	Urban in-person (N = 16)	Urban online (N = 15)	Regional online (N = 21)
Age (years), M (SD)	72 (10)	72 (8)	69 (9)
Male, n (%)	10 (63)	11 (73)	15 (71)
Mean time post diagnosis (years)	5	4	5
Dysarthria severity^a	1.3	1.3	1.2
SPL monologue (dB)	70	70	71

^a1 = mild; 2 = moderate; 3 = severe.

SD: standard deviation; SPL: sound pressure level.

The estimated mean costs per patient for a month programme for the three groups as incurred during the RCT are shown in Table 3. The mean treatment costs of both the urban online group ($1076) and the regional group ($1206) treatments tended to be slightly higher than urban in-person costs from a health-system perspective ($1020). The majority of the intervention cost accounted for clinician labour (90–95%) in all groups. The impact of location (urban vs. regional) on the costs of telerehabilitation was with regional online delivery incurring an extra $130 in total due to slightly longer online sessions in the regional group (M = 68 minutes) than in the urban group (M = 61 minutes).

Table 3.

Mean cost per patient for one-month programme.

Perspective	Cost component	Urban in-person (N = 16)		Urban online (N = 15)		Regional online (N = 21)
Perspective	Cost component	M	SD	M	SD	M	SD
Heath system	Device cost,^a amortised ($)	25	0	97	0	97	0
	Photocopy ($)	12	0	2	0	2	0
	Clinicians’ labour ($)	983	0	977	71	1107	167
	Total	1020	0	1076	71	1206	167
Patient	iPad cost,^a amortised ($)	–	–	17	0	17	0
	Lost income	531	467	247	99	200	0
	Travel cost^b	300	103	0	0	0	0
	Total	831	570	247	99	200	0

^aCosts reported in 2020 US dollar values.

^bPatient time cost reflects self-reported forgone wage calculated as the mean national hourly wage rate (A$32.81). The mean distance to the research centre in the city = 13.7 km (urban) and 95 km (regional).

We also assessed the economic benefits to patients in accessing telerehabilitation. From a patient’s perspective, the mean treatment cost was $831 in the urban in-person group, $247 in the urban online group and $200 in the regional online group. The cost differences were due to the absence of patients travelling in the online option and lower income loss. The mean total distance to travel to the research centre was 438 km for 16 visits which was reduced to zero in the online groups.

We also conducted a one-way sensitivity analysis. If all patients were assumed to be unemployed or retired and assigned costs for lost leisure time instead of wages, there was no difference for the regional group. However, the total cost reduced by $216 in the urban in-person group and by $44 in the urban online group. When regional patients were assumed to have to travel to the research centre instead of the nearest public hospital, telerehabilitation would alleviate the burden of distance travelled by 5.4 times, increasing the total cost saved of $107 (SD = $6) per visit and $1718 (SD = $91) per programme.

Discussion

This paper assessed whether different modes of service delivery (online vs. in-person) and participant location (urban vs. regional) impact costs to the health system and patients. We found that LSVT LOUD® may be delivered from home online at a slightly higher cost from the health-system perspective but at a lower cost from a patient perspective. This is potentially achievable without significantly impacting the clinical outcomes (acoustic, perceptual) and quality of life, as shown previously.⁷ The telerehabilitation programme was found to be cost saving for patients, consistent with the previous findings.¹⁹ The impact of location (urban vs. regional) on costs was small, assuring that telerehabilitation can be delivered to either location at a similar cost even if the in-person session was at nearby public hospitals rather than the research centre. Patients living in more remote areas were likely to derive more cost benefits, as they were required to travel for longer than our regional sample. Further, online telerehabilitation would allow non-remote patients to prioritise the work and social responsibilities which often compete with in-person sessions. This would ultimately improve access to SLP professional services that are in short-supply, especially in regional and remote areas.²⁰

The LSVT LOUD® programme is used worldwide, and patients’ out-of-pocket expenses may vary widely, depending on the reimbursement system. Moreover, unit costs and costing methods vary among jurisdictions, making it harder to compare cost estimates across studies.²¹ It is for this reason that we presented detailed cost assumptions and a cost breakdown for local adaptations to inform funding decisions in the jurisdiction of interest.

We also recognise some limitations. First, the non-inferiority effect was assessed immediately after the intervention in the RCT. It is not known whether or how frequently a follow-up booster is needed to sustain the intervention effect for each modality, and this could involve additional intervention costs over the long term. Similarly, our results were based on outcomes at the one-month period,⁷ which did not capture long-term effects and costs. Second, we used a cost-minimisation analysis, as telerehabilitation was shown to be non-inferior to in-person delivery.⁷ There is a view, however, that we should nevertheless aim to estimate cost-effectiveness and quantify uncertainty unless a study has been ‘specifically designed to show the equivalence of treatments’.²² By combining data on effectiveness and cost, we may have been better able to characterise the uncertainty around the estimates. Third, our results should be taken with caution due to our small sample size and the use of assumed values where no empirical data were available.

For some, an in-person modality is not an option due to the travelling logistics, while others may decline treatment as they ‘would rather do other things’ or would not consider speech treatment until their condition worsens ‘to the point where you couldn’t hear me’.²³ The observation is relatable, as 77% of our study population had mild dysarthria. We believe that our results will provide insight into barriers to early intervention from a patient perspective and inform providers’ investment decisions in a climate that increasingly seeks comparative assessments of SLP services,²⁴,²⁵ including the LSVT LOUD® programme. Future research should consider not only programme effectiveness or costs, but also patient preferences for programme delivery (e.g. home-based, waiting time, ability to see the same practitioner each time), as these would affect service uptake as well as patient adherence to treatment.

In conclusion, telerehabilitation has been shown to be a solution to the physical mobility and distance-related barriers involved in the delivery of speech therapy for people with PD. This study suggests that LSVT LOUD® may be delivered via telerehabilitation at a slightly higher cost than in-person delivery from a health-system perspective but at a lower cost from a patient perspective. These findings support the use of telerehabilitation as an alternative for the delivery of the LSVT LOUD® programme for disordered speech in PD.

Footnotes

Acknowledgements

We thank the people with Parkinson’s disease and their families for their participation in this research.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This research was supported by National Health and Medical Research Council Project Grant number 631514.

ORCID iDs

Trevor G Russell

Paul Scuffham

References

Parkinson’s Australia, Inc. Living with Parkinson’s disease. An updated economic analysis 2014, www.parkinsons-qld.org.au (2015, accessed 20 February 2020).

Klawans

HL.

Individual manifestations of Parkinson’s disease after ten or more years of levodopa. Mov Disord 1986; 1: 187–192.

Miller

Noble

Jones

, et al. Life with communication changes in Parkinson’s disease. Age Ageing 2006; 35: 235–239.

Mutch

Strudwick

Roy

, et al. Parkinson's disease: disability, review, and management. BMJ 1986; 293: 675–677.

Ramig

Sapir

Countryman

, et al. Intensive voice treatment (LSVT®) for patients with Parkinson’s disease: a 2 year follow up. J Neurol Neursurg Psychiatry 2001; 71: 493–498.

Ramig

Sapir

Fox

, et al. Changes in vocal loudness following intensive voice treatment (LSVT) in individuals with Parkinson’s disease: a comparison with untreated patients and normal age-matched controls. Mov Disord 2001; 16: 79–83.

Theodoros

Hill

Russell

TG.

Clinical and quality of life outcomes of speech treatment for Parkinson’s disease delivered to the home via telerehabilitation: a noninferiority randomized controlled trial. Am J Speech Lang Pathol 2016; 25: 214–232.

Swales

Theodoros

Hill

, et al. Communication service provision and access for people with Parkinson’s disease in Australia: a national survey of speech-language pathologists. Int J Speech Lang Pathol 2019; 21: 572–583.

Vickrey

KL.

Clinician survey of the Lee Silverman Voice Treatment for voice and speech disorders resulting from Parkinson’s disease, http://libres.uncg.edu/ir/uncg/f/L_Vickery_Clinician_2015.pdf (2015, accessed 31 March 2020).

10.

Theodoros

Aldridge

Hill

, et al. Technology-enabled management of communication and swallowing disorders in Parkinson’s disease: a systematic scoping review. Int J Lang Commun Disord 2019; 54: 170–188.

11.

Winters

JM.

A telehomecare model for optimizing rehabilitation outcomes. Telemed J E Health 2004; 10: 200–212.

12.

Hailey

Roine

Ohinmaa

, et al. Evidence of benefit from telerehabilitation in routine care: a systematic review. J Telemed Telecare 2011; 17: 281–287.

13.

Keck

Doarn

Telehealth technology applications in speech-language pathology. Telemed J E Health 2014; 20: 653.

14.

Drummond

Sculpher

Claxton

, et al. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press, 2015.

15.

Australian Bureau of Statistics. Household Use of Information Technology, Australia, 2016–17, https://www.abs.gov.au/ausstats/abs@.nsf/mf/8146.0 (accessed 15 February 2020).

16.

Queensland State Department of Health. Wage rates, https://www.health.qld.gov.au/hrpolicies/wage_rates/health-practitioners (2015, accessed 20 May 2020).

17.

Australian Taxation Office. Claiming motor vehicle expenses as a sole trader: cents per kilometre method, https://www.ato.gov.au/Business/Income-and-deductions-for-business/Deductions/Motor-vehicle-expenses/Claiming-motor-vehicle-expenses-as-a-sole-trader/Cents-per-kilometre-method/ (accessed 10 April 2020).

18.

Campbell and Cochrane Economics Methods Group and the Evidence for Policy and Practice Information and Coordinating Centre. CCEMG – EPPI-Centre Cost Converter v.1.6, http://eppi.ioe.ac.uk/costconversion/default.aspx (accessed 21 May 2020).

19.

Wade

Karnon

Elshaug

, et al. A systematic review of economic analyses of telehealth services using real time video communication. BMC Health Serv Res 2010; 10: 233.

20.

Commonwealth of Australia. Prevalence of different types of speech, language and communication disorders and speech pathology services in Australia. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Speech_Pathology, (2014, accessed 20 December 2019).

21.

Maru

Byrnes

Carrington

, et al. Economic implications of cardiovascular disease management programs: moving beyond one-off experiments. Expert Rev Pharmacoecon Outcomes Res 2015; 15: 657–666.

22.

Briggs

O’Brien

BJ.

The death of cost-minimization analysis?

Health Econ 2001; 10: 179–184.

23.

Yorkston

Baylor

Britton

Speech versus speaking: the experiences of people with Parkinson’s disease and implications for Intervention. Am J Speech Lang Pathol 2017; 26: 561–568.

24.

Sackley

Smith

Rick

, et al. Lee Silverman Voice Treatment versus standard speech and language therapy versus control in Parkinson’s disease: a pilot randomised controlled trial (PD COMM pilot). Pilot Feasibility Stud 2018; 4: 30.

25.

Sackley

Smith

Rick

, et al. Lee Silverman Voice Treatment versus standard NHS speech and language therapy versus control in Parkinson’s disease (PD COMM pilot): study protocol for a randomized controlled trial. Trials 2014; 15: 213.