Cost analysis of direct versus indirect and individual versus group modes of manualbased speechandlanguage therapy for primary schoolage children with primary language impairment

Background: The study is the first within trial cost analysis of direct versus indirect and individual versus group modes of speechandlanguage therapy for children with primary language impairment. Aims: To compare the shortrun resource consequences of the four interventions alongside the effects achieved measured by standardized scores on a test of expressive and receptive language. Methods & Procedures: The study design was a cost analysis integrated within a randomized controlled trial using a 2×2 factorial design directindirect versus individualgroup therapy together with a control group that received usual levels of communitybased speechandlanguage therapy. Research interventions were delivered in school settings in Scotland, UK. Children aged between 6 and 11 years, attending a mainstream school, with standard scores on the Clinical Evaluation of Language Fundamentals (CELFIII^UK) of less than -1.25 standard deviation (SD) receptive andor expressive and nonverbal IQ on the Wechsler Abbreviated Scale of Intelligence WASI above 75, and no reported hearing loss, no moderatesevere articulationphonologydysfluency problems or otherwise requiring individual work with a speechandlanguage therapist. The intervention involved speechandlanguage therapists and speechandlanguage therapy assistants working with individual children or small groups of children. A therapy manual was constructed to assist the choice of procedures and activities for intervention. The cost analysis focused on the salary and travel costs associated with each mode of intervention. The cumulative distribution of total costs arising from the time of randomization to postintervention assessment was estimated. Arithmetic mean costs were compared and reported with their 95 confidence intervals. Outcomes & Results The results of the intentiontotreat analysis revealed that there were no significant postintervention differences between direct and indirect modes of therapy, or between individual and group modes on any of the primary language outcome measures. The cost analysis identified indirect therapy, particularly indirect group therapy, as the least costly of the intervention modes with direct individual therapy as the most costly option. The programme cost of providing therapy in practice over 30 weeks for children could represent between 30 and 75 of the total gross revenue spend in primary school per pupil, depending on the choice of assistant led group therapy or therapistled individual therapy. Conclusions & Implications: This study suggests that speechandlanguage therapy assistants can act as effective surrogates for speechandlanguage therapists in delivering costeffective services to children with primary language impairment. The resource gains from adopting a groupbased approach may ensure that effective therapy is provided to more children in a more efficient way.