BRIEF REPORT| Volume 103, ISSUE 6, P1205-1209, June 2022

Cost Efficiency Analysis for Spasticity Management Based on Physician Botulinum Toxin Prescribing Habits

Published:November 28, 2021DOI:


      • This cost analysis focused on physician prescribing practices rather than the drugs themselves.
      • Physicians using botulinum toxin predominantly for spasticity were included.
      • A majority of physicians exclusively used the costliest drug, onabotulinumtoxinA.
      • Those prescribing abobotulinumtoxinA or incobotulinumtoxinA had lower cost per patient.
      • Doses and injections per year were not significantly different between groups.



      To estimate differences in botulinum toxin type A (BoNT-A) treatment costs per patient for spasticity-injecting physicians, with a focus on physicians’ use of alternative BoNT-A agents other than onabotulinumtoxinA.


      Retrospective cohort study.


      National Medicare data for fee-for-service beneficiaries in 2017.


      A total of 116 physicians, 6829 BoNT-A procedures, and 3051 patients were included in this analysis. Most physicians were physiatrists (84%) and used only onabotulinumtoxinA (82%).


      Type of BoNT-A selected by physicians was the independent variable of interest. Included physicians were separated into 2 groups: (1) onabotulinumtoxinA only injectors and (2) abobotulinumtoxinA and/or incobotulinumtoxinA injectors (may still use onabotulinumtoxinA).

      Main Outcome Measure

      Average cost per patient per year.


      The total average BoNT-A cost per patient per year was significantly less for physicians who used abobotulinumtoxinA and/or incobotulinumtoxinA vs those who used only onabotulinumtoxinA ($3684 vs $4739; P=.01). Patients’ average annual out-of-pocket costs also reflected a similar difference ($855 vs $1082; P=.02) between the groups. Doses used and numbers of injections per patient per year were not significantly different between groups.


      The present analysis demonstrated lower cost per patient for both the payer and patient when physicians used types of BoNT-A other than onabotulinumtoxinA for spasticity. Nevertheless, most physicians in this spasticity-focused study used exclusively onabotulinumtoxinA, the most expensive BoNT-A available. Reasons for this are complex and include history on the market and approved indications beyond those associated with spasticity. However, future research should continue to identify such issues with a goal of finding solutions to improve cost inefficiencies.


      List of abbreviations:

      BoNT-A (Botulinum toxin type A), CMS (Centers for Medicare & Medicaid Services), CPT (current procedural terminology), OOP (out of pocket)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Centers for Medicare & Medicaid Services. Available at: Accessed May 1, 2020.

        • Kazerooni R
        • Broadhead C.
        Cost-utility analysis of botulinum toxin type A products for the treatment of cervical dystonia.
        Am J Health Syst Pharm. 2015; 72: 301-307
        • Abogunrin S
        • Hortobagyi L
        • Remak E
        • Dinet J
        • Gabriel S
        • Bakheit AM.
        Budget impact analysis of botulinum toxin A therapy for upper limb spasticity in the United Kingdom.
        Clinicoecon Outcomes Res. 2015; 7: 185-193
        • Kazerooni R
        • Watanabe JH.
        Comparison of botulinum toxins for treatment of movement disorders: real-world utilization and cost analysis in a national Medicare population.
        J Manag Care Spec Pharm. 2021; 27: 478-487
        • Simpson DM
        • Hallett M
        • Ashman EJ
        • et al.
        Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: report of the Guideline Development Subcommittee of the American Academy of Neurology.
        Neurology. 2016; 86: 1818-1826
      2. Centers for Medicare & Medicaid Services, Medicare provider utilization and payment data: physician and other supplier. Available at: Accessed February 1, 2021.

        • Scaglione F.
        Conversion Ratio between Botox®, Dysport®, and Xeomin® in clinical practice.
        Toxins (Basel). 2016; 8: 65
      3. Centers for Medicare & Medicaid Services, Medicare part B discarded drug units report. Available at: Accessed February 1, 2021.

        • Lo J
        • Chan L
        • Flynn S.
        A systematic review of the incidence, prevalence, costs, and activity and work limitations of amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury in the United States: a 2019 update.
        Arch Phys Med Rehabil. 2021; 102: 115-131
        • Lundström E
        • Smits A
        • Borg J
        • Terént A.
        Four-fold increase in direct costs of stroke survivors with spasticity compared with stroke survivors without spasticity: the first year after the event.
        Stroke. 2010; 41: 319-324
        • Rattray M.
        Value-based physician reimbursement: challenges and opportunities for physical medicine and rehabilitation.
        PM R. 2009; 1: 706-708
        • Teasell R
        • Foley N
        • Pereira S
        • Sequeira K
        • Miller T.
        Evidence to practice: botulinum toxin in the treatment of spasticity post stroke.
        Top Stroke Rehabil. 2012; 19: 115-121
        • Burbaud P
        • Ducerf C
        • Cugy E
        • et al.
        Botulinum toxin treatment in neurological practice: how much does it really cost? A prospective cost-effectiveness study.
        J Neurol. 2011; 258: 1670-1675
        • Roze S
        • Kurth H
        • Hunt B
        • Valentine W
        • Marty R.
        Evaluation of the cost per patient per injection of botulinum toxin A in upper limb spasticity: comparison of two preparations in 19 countries.
        Med Devices (Auckl). 2012; 5: 97-101
        • Kazerooni R
        • Howard IM
        • Keener AM
        • Bounthavong M.
        Real-world six-year national cost-minimization analysis of incobotulinumtoxinA and onabotulinumtoxinA in the VA/DoD healthcare systems.
        Clinicoecon Outcomes Res. 2021; 13: 603-609
        • Karschney VK
        • Greeley DR.
        A retrospective cost analysis of patients who switched from onabotulinumtoxinA to incobotulinumtoxinA in a private neurology practice.
        Am Health Drug Benefits. 2020; 13: 205-210