Cost analysis of the treatment of severe spinal spasticity with a continuous intrathecal baclofen infusion system

Objective: The purpose of our study was to analyse and evaluate the costs o f continuous intrathecal baclofen administration as a modality in the treat ment of severe spasticity in the Netherlands. Design: A cost analysis was conducted as part of a prospective, multicentre , multidisciplinary, randomised and placebo-controlled clinical trial. The study covered the period from December 1991 to September 1995. The data on medical consumption and costs were collected over a 3-year period from diff erent sources: administrative databases of health insurance companies, hosp ital registries and a patient survey. These data were structured by means o f a flowchart analysis of the medical decision-making by specialists and ge neral practitioners (GPs). They included data on in- and outpatient care, h ome care and care in nursing homes. The cost analysis was conducted using data from 18 patients included in the trial and from 15 so-called 'match' patients. The latter group are patient s with comparable diseases leading to spasticity and living in comparable c ircumstances. Next to absolute costs (direct and indirect) of care and trea tment for the 2 groups of patients, cost differences between the 2 groups w ere considered (differential cost analysis). Setting: Per patient cost data, collected prospectively for 2 years during the phase of clinical evaluation, and retrospectively 1 year before implant ation. The data were collected on patients from in- and outpatient care, ho me care and care in nursing home settings. Patients and participants: The trial patients (8 men) had a mean age of 46 years; 11 patients had multiple sclerosis and 7 patients had spinal cord in juries. The match patients (7 men) had a mean age of 48 years; 9 patients h ad multiple sclerosis and 6 patients had spinal cord injuries. Interventions: Trial patients were treated with a subcutaneously implanted programmable continuous infusion pump (SynchroMed, Medtronic), filled with baclofen (a muscle relaxant) to treat patients with chronic disabling spast icity who did not respond to a maximum dose of oral baclofen, dantrolene an d tizanidine. Main outcome measures and results: an analysis of hospital stay between bot h groups showed a significant difference during the implantation year. The average number of hospital days per patient in that year in the treated gro up was 31.5 days and in the match group was 18.7 days. Significant cost dif ferences between both groups in the year that started with pump implantatio n and the following year can be attributed mostly to the costs of implantat ion of the pump and related hospitalisation days. The total costs of patien t selection, testing, implanting the pump and follow-up amounted to $US28 4 73 for the first year. Savings must be taken into consideration as well. Th e savings of direct costs were due to withdrawal of oral medication (estima ted annual total of between $US1950 and $US2800 per patient). Indirect savi ngs on employment and nursing home costs, amounted annually to $US1047 and $US5814, respectively. Scenarios make it possible to consider policy consequences. The case of 'ex tending' the indications for this treatment to a larger population has been calculated and visualised. Conclusions: The costs of the therapy (continuous intrathecal infusion of b aclofen) can be attributed mostly to implantation of the pump and related h ospitalisation days. Savings originated from withdrawal of oral medication, job preservation and avoidance or delay of admission to a nursing home.