Regional disparities in botulinum toxin A (BoNT‐A) therapy for spasticity in Sweden: budgetary consequences of closing the estimated treatment gap

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Spasticity is a significant cause of disability and pain in a range of neurological conditions. It is characterized by involuntary muscle overactivity with disordered sensorimotor control, that can lead to muscle contracture if left untreated.1
Management of spasticity is primarily based on physical therapy with the potential addition of oral medications (baclofen, diazepam, tizanidine and clonazepam), soft‐tissue surgery, intrathecal baclofen or invasive procedures for neuromuscular blockage.4 Over the last decades, focal spasticity has increasingly been treated with botulinum toxin, mainly botulinum toxin type A (BoNT‐A), and its effect on spasticity has been documented in several studies.5 A strong advantage compared to many other treatment options is the reversible nature and safety of BoNT‐A treatment.4
In addition to the impact on daily living for the patient, two Swedish studies have shown that spasticity in stroke and multiple sclerosis (MS) also has a large impact on costs.2 In MS, the total costs were found to be 2.4 times greater for patients with severe spasticity (as defined by the 0–10 Numerical Rating Scale (NRS); mild spasticity (NRS 0–3), moderate spasticity (NRS 4–6) and severe spasticity (NRS 7–10)) compared to patients with mild spasticity,2 while the cost for stroke survivors was fourfold higher for patients with spasticity than patients without spasticity after one year.9 In both studies, mainly direct costs were associated with spasticity. However, the cost for medications constituted only a minor part of the total cost and did not contribute to the increased costs related to spasticity.2
Healthcare utilization may show regional variation, depending on population characteristics or differences in clinical practice. Except for a few regional guidelines, there are no national Swedish treatment guidelines for spasticity, potentially resulting in different regional treatment practices depending on experience and specific competences of treating professionals. This study examines BoNT‐A treatment for spasticity on a regional level in Sweden. Health care in Sweden is provided by 21 county councils responsible for political decisions regarding resource use. These are further joined into six healthcare regions for collaboration on highly specialized health care.
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