Technical Report - Comparison of Cost Outcome Methods (Version 1.0)

Stephen Sprigle, PhD, PT & Frances Harris, PhD

Executive Summary

Cost has been identified as one of the key factors necessary to outcomes research in assistive technology (AT) (DeRuyter, 1995; Fuhrer, 2001; Smith, 1996). The field scan on cost includes first, a review of the literature on economic evaluations within the health care field in general and specifically in assistive technology, and second, a cost identification feasibility study.

Rationale for field scan

The results of this field scan are first, to develop research tools that enable clinicians to carry out outcomes research within the context of their service provision; second, to enable researchers to develop systematic methodologies and strategies for outcomes research; and third, to demonstrate the effectiveness and value of assistive technologies and services to policy makers.

A variety of compelling arguments may be made for recognizing and understanding economic evaluations in AT. The pragmatic issue of funding is one reason (Smith, Benge, & Hall, 2000). Articles by Holme, Guthrie, Kanny, and Johnson (1997) and Cowan and Turner-Smith (1999) identify the scarcity of funding for electronic aids to daily living (EADL). Mendelsohn (1997) discusses the relationship between public policy, technology, funding, and disability and its deleterious effect on the successful provision of AT to the disabled community.

Description of Scope of Scan

The first problem associated with economic evaluations and understanding costs is the seemingly daunting task of acquiring knowledge of the basic economic techniques to perform them. There is also a paucity of measurement tools and rigorous methodological strategies in the field. In addition, as Jutai, Ladak, Schuller, Naumann, and Wright (1996) comment, measurement tools for economic evaluations need to be adapted so that service providers can use them easily and routinely. Another challenge lies in configuring these tools to make them useful across different devices and program contexts in which AT services are delivered.

The first step in performing this literature review was to construct a bibliography on the combined topic of cost analysis and assistive technology. A variety of sources were used. A number of databases were searched including but not limited to PubMed, FirstSearch, Eco, and OVID. Search terms included combinations of "cost," "cost analysis," "cost effectiveness," "cost benefit," "cost utility," "economics," with "assistive technology," "rehabilitation," "rehabilitation engineering," "rehabilitation technology," and "disability." A broad array of online web-based resources was searched as well. These included recognized rehabilitation and disability organizations such as RESNA, NIDRR, AAATE, and SIVA. In addition, we also conducted a search among various domestic and international producers of information including academic institutions, publishers, professional journal indexes, and conference proceedings.

The literature review identified and reviewed concepts basic to economic evaluation. We then considered six studies that included a cost analysis approach in order to illustrate the complexity inherent in assessing costs within assistive technology (Wyatt, Niparko, Rothman, & deLissovoy, 1996; Palmer, Niparko, Wyatt, Rothman, & deLissovoy, 1999; Haas, Andersson, Brodin, & Persson, 1997; Tolley et al., 1995; Mann, Ottenbacher, Fraas, Tomita, & Granger, 1999; and Andrich, Ferrario, & Moi, 1998). We identified key cost assessment variables to be considered in AT economic evaluations and called for the development of a standardized and consistent methodology. This work resulted in a manuscript accepted for publication in Assistive Technology (Harris & Sprigle, 2003).

The second part of the cost field scan is the cost identification feasibility study. This study is being conducted in collaboration with an on-going two and a half year outcomes study that is funded by The Langeloth Foundation. A cost outcomes description methodology is being developed to assess costs in an acute care rehabilitation hospital from a service provider's perspective. A primary goal is to develop a methodology that will accurately assess the costs of providing an assistive technology intervention in an acute rehabilitation hospital. Costs described in detail are those directly associated with service provision such as clinicians' salaries and equipment; indirect, non-service costs such as phone calls, letter writing, etc. associated with a particular intervention; and costs associated with hospital overhead and maintenance. Outcomes are being measured using three research instruments. Two of these instruments are well established: the OT FACT and PIADS. The third is a recently developed, clinician-friendly instrument, the Assistive Technology Outcomes Measurement (ATOM). Constructs measured by the ATOM include use and community (how often an assistive device is used within and outside the home); overall comfort in using the device; the user's perception of device hassle (that is, whether it is hard to use, set-up, or maintain); user's perception of function with respect to their functional goals; the assistance required by the user to set up and operate the device; user's satisfaction with clinic services; and user's knowledge of AT resources. In addition, data regarding employment, costs of the AT device, standard demographics, and environmental variables are also being collected. Data collection is being conducted at three intervals: prior to the client's initial visit and both one-month and one-year following a completed intervention. Both a cost-utility and outcome analysis will be performed at the study's conclusion.

References

Andrich, R., Ferrario, M., & Moi, M. (1998). A model of cost-outcome analysis for assistive technology. Disability and Rehabilitation, 20, 1-24.

Cowan, D. M., & Turner-Smith, A. R. (1999). The user's perspective on the provision of electronic assistive technology: equipped for life? British Journal of Occupational Therapy, 62, 2-6.

DeRuyter, F. (1995). Evaluating outcomes in assistive technology: do we understand the commitment? Assistive Technology, 7, 3-16.

Fuhrer, M. (2001). Assistive technology outcomes research: Challenges met and yet unmet. American Journal of Physical Medicine & Rehabilitation, 80(7), 528-535.

Haas, U., Andersson, A., Brodin, H., & Persson, J. (1997). Assessment of computer-aided assistive technology: Analysis of outcomes and costs. AAC Augmentative and Alternative Communication, 13, 125-135.

Harris, F., & Sprigle, S. (2003). Cost analysis in assistive technology research. Assistive Technology, 15(1), 16-27.

Holme, S. A., Kanny, E. M., Guthrie, M., & Johnson, K. (1997). The use of environmental control units by occupational therapists in spinal cord injury and disease services. The American Journal of Occupational Therapy, 51(1), 42-48.

Jutai, J., Ladak, N., Schuller, R., Naumann, S., & Wright, V. (1996). Outcomes measurement of assistive technologies: an institutional case study. Assistive Technology, 8(2), 110-120.

Mann, W. C., Ottenbacher, K. J., Fraas, L., Tomita, M., & Granger, C. V. (1999). Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly. Archives of Family Medicine, 8(3), 210-217.

Mendelsohn, S. (1997). Assitive technology: public policy and financing. Technology and Disability, 6, 29-48.

Palmer, C., Niparko, J., Wyatt, J., Rothman, M., & deLissovoy, G. (1999). A prospective study of the cost-utility of the multichannel cochlear implant. Archives of Otolaryngology -- Head & Neck Surgery, 125, 1221-1228.

Smith, R. (1996). Measuring the outcomes of assistive technology: challenge and innovation. Assistive Technology, 8, 71-81.

Smith, R., Benge, M., & Hall, M. (2000). Using Assistive Technologies to Enable Self-Care and Daily Living. In C. Christiansen (Ed.), Ways of Living: Self-Care Strategies for Special Needs (2nd edition ed., pp. 335-359). Bethesda, MD: The American Occupational Therapy Association.

Tolley, K., Leese, B., Wright, K., Hennessy, S., Rowley, C., Stowe, J., et al. (1995). Communication aids for the speech impaired: Cost and quality-of-life outcomes of assessment programs provided by specialist communication aids centers in the United Kingdom. International Journal of Technology Assessment in Health Care, 11(2), 196-213.

Wyatt, J., Niparko, J., Rothman, M., & deLissovoy, G. (1996). Cost utility of the multichannel cochlear implants in 258 profoundly deaf individuals. The Laryngoscope, 106(7), 816-821.

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