Social Return on Investment of a robotic exoskeleton for upper limb rehabilitation after stroke

A stroke is a medical situation characterized by acute deterioration of brain functions lasting more than 24 hours. Worldwide, it is the third leading cause of death and disability together. One of the most common consequences for stroke survivors is upper limb impairment; this can have a significant impact on patients’ quality of life, and an appropriate rehabilitation strategy is needed to improve their status. Repetitive and monitored movements typical of robotic rehabilitation, whose market has grown rapidly in recent years, have the potential to enhance functional recovery. A team of researchers at Politecnico di Milano has developed an exoskeleton for upper limb rehabilitation, called AGREE, at the stage gate between translational research and clinical validation. Since the cost of this device is particularly high, the present study aimed to provide a framework for assessing its value. The Social Return On Investment (SROI) method, which unlike other economic analyses is able to grasp the economic, social and environmental impact of an activity, was applied. The stakeholders considered were patients, hospitals, physiotherapists, caregivers, and employers of stroke patients. Expert opinions of a pool of clinical engineers and healthcare professionals from different Italian hospitals were used to obtain information. Inputs and outcomes were identified and monetized for the stakeholders. Attribution, deadweight, and drop-off were then estimated to calculate the final SROI value. This was done with a 5-year time horizon for both a single exoskeleton and a number of exoskeletons sold estimated by the authors. Environmental impacts were estimated through Life Cycle Assessment (LCA) and expressed in terms of CO2 emissions; once monetized, they were incorporated into the outcomes of the analysis. The SROI for a single exoskeleton was 3.75 and that for multiple exoskeletons was 2.868. In summary, the SROI value for multiple exoskeletons is lower than that for a single exoskeleton, because the higher the number of exoskeletons sold, the higher the outcomes but also the associated inputs. Moreover, the environmental result did not have a large influence on the SROI, as the technology has a much greater social impact. This study provides a model for combining economic, social and environmental outcomes that, besides contributing to theory, could be useful for decision-making. Future research should focus on reducing the subjectivity and uncertainty of this study, by a higher involvement of stakeholders.