Cost-effectiveness analysis of combined cognitive and vocational rehabilitation in patients with mild-to-moderate TBI: results from a randomized controlled trial

Abstract

Background: Traumatic brain injury (TBI) represents a financial burden to the healthcare system, patients, their families and society. Rehabilitation interventions with the potential for reducing costs associated with TBI are demanded. This study evaluated the cost-effectiveness of a randomized, controlled, parallel group trial that compared the effectiveness of a combined cognitive and vocational intervention to treatment as usual (TAU) on vocational outcomes.

Methods: One-hundred sixteen participants with mild-to-moderate TBI were recruited from an outpatient clinic at Oslo University Hospital, Norway. They were randomized to a cognitive rehabilitation intervention (Compensatory Cognitive Training, CCT) and Supported Employment (SE) or TAU in a 1:1 ratio. Costs of CCT-SE and TAU, healthcare services, informal care and productivity loss were assessed 3, 6 and 12 months after study inclusion. Cost-effectiveness was evaluated from the difference in number of days until return to pre-injury work levels between CCT-SE and TAU and quality-adjusted life years (QALYs) derived from the EQ-5D-5L across 12 months follow-up. Cost-utility was expressed in incremental cost-effectiveness ratio (ICER).

Results: The mean total costs of healthcare services was € 3,281 in the CCT-SE group and € 2,300 in TAU, informal care was € 2,761 in CCT-SE and € 3,591 in TAU, and productivity loss was € 30,738 in CCT-SE and € 33,401 in TAU. Costs related to productivity loss accounted for 84% of the total costs. From a healthcare perspective, the ICER was € 56 per day earlier back to work in the CCT-SE group. Given a threshold of € 27,500 per QALY gained, adjusting for baseline difference in EQ-5D-5L index values revealed a net monetary benefit (NMB) of € -561 (0.009*27,500-979) from the healthcare perspective, indicating higher incremental costs for the CCT-SE group. From the societal perspective, the NMB was € 1,566 (0.009*27,500-(-1,319)), indicating that the CCT-SE intervention was a cost-effective alternative to TAU.

Conclusions: Costs associated with productivity loss accounted for the majority of costs in both groups and were lower in the CCT-SE group. The CCT-SE intervention was a cost-effective alternative to TAU when considering the societal perspective, but not from a healthcare perspective.

Trial registration: ClinicalTrails.gov NCT03092713 .

Keywords: Clinical trial; Health economics; Traumatic brain injury; Vocational rehabilitation.

Fig. 1

Scatterplot of 1000 bootstrapped iteration of health care costs and number of days earlier back to work as health outcome

Fig. 2

Scatterplots and CEACs of 1000 bootstrapped iteration of incremental health care costs. For each row there are different assumptions with regard to the estimation of health outcomes. In the upper row, we have estimated incremental QALY by adjusting for baseline EQ-5D-5L values. In the second row all EQ-5D-5L values for all observation points in the CCT-SE has been adjusted upwards with the difference in EQ-5D-5L between CCT-SE and TAU at baseline, while in the third row we have estimated the change in HRQoL value from baseline to 12 months

Fig. 3

Scatterplot of 1000 bootstrapped iteration of incremental societal costs and two different methods for estimation of QALYs. In the left plot incremental QALYs have been adjusted for the EQ-5D-5L measures at baseline, while in the right plot all values in the CCT-SE have been adjusted upwards with the difference in EQ-5D-5L between CCT-SE and TAU at baseline