Cost Effectiveness Analysis of the Presto-Trial: A Three-Armed RCT Evaluating Prophylactic Swallowing Exercises in Head and Neck Cancer Patients During (Chemo)radio Treatment.

BACKGROUND

Research on oropharyngeal head and neck cancer (HNC) patients indicates that prophylactic swallowing exercises (PSE) during (C)RT can positively affect muscle strength, swallowing function and quality of life (QOL). Primary analyses of the PRESTO-trial showed higher adherence rates for PSE when exercising daily with a speech-language pathologist (SLP), compared to self-guided exercises with either an exercise diary or a digital application. Additionally, higher adherence rates were related to greater improvements in swallowing function and QOL. However, given limited healthcare resources, cost-effectiveness analyses are essential to inform the implementation of such rehabilitation strategies in dysphagia care. This secondary analysis of the PRESTO-data compares the costs and health effects of the three different service models: app-based, therapist-led (daily face-to-face, 20 sessions during (C)RT), and paper-led therapy.

METHODS

One hundred fifty patients receiving (chemo)radiotherapy (C)RT for oropharyngeal HNC were randomly assigned to one of the three exercise groups. All performing the same PSE protocol. The treatment protocol required daily training during the first 4 weeks of the (C)RT treatment program. Patients in the therapy group thereby received a total of 20 face-to-face therapy sessions. Health outcomes were expressed as utilities based on the EQ5D5L instrument measured at baseline, post (C)RT and 3 months post (C)RT. Costs were estimated from a health service perspective, including staff time, therapy resources and consumables. Incremental cost-effectiveness ratios (ICERs) were calculated as ΔCosts/ ΔQALYs.

RESULTS

No significant between-group differences were found for utilities. Only significant time effects were observed, with a significant decrease in utilities from baseline to post (C)RT and a significant increase from post (C)RT to 3 months post (C)RT. The therapist-led intervention was associated with the highest costs. The app-group intervention was dominated by the paper group in terms of cost-effectiveness as the utilities were comparable but at a higher cost in the app-group. Consequently, the ICER was computed between the paper-group and therapist-group and resulted in € 124 061,54/QALY.

CONCLUSIONS

Despite the overall positive HR-QOL effects post 3 months, the daily therapist-led delivery of PSE therapy was not cost-effective relative to paper-based self-management. Under current resource constraints, low-cost delivery models represent the most economically efficient option. Future research should explore whether hybrid or targeted therapist involvement yields better value by preserving clinical benefit while reducing cost.