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Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain |
Hoeijenbos M, Bekkering T, Lamers L, Hendriks E, van Tulder M, Koopmanschap M |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology An active strategy for implementation of an evidence-based physiotherapy guideline for non-specific low back pain was examined. This was compared with the standard method of dissemination. Under the active implementation strategy, two training sessions were offered to small groups of physiotherapists. During the first session, the guideline was explained to and discussed with the physiotherapists, and special skills were practised. During the second session, starting 4 weeks later, the physiotherapists' experiences and problems were discussed. They also received feedback on their current management and two reminders. The comparator was the standard strategy with which the guideline was disseminated by mail to all members of the Royal Dutch Physiotherapy Association (KNGF), together with a self-evaluation form, two forms facilitating discussion with other physiotherapists, and a copy of the Quebec Back Pain Disability Scale.
Study population The study population comprised patients with low back pain who were attending physiotherapists working in practices. The inclusion criteria for the physiotherapists were working in primary care, expecting to treat at least 5 patients with low back pain in the coming 6 months, and being a member of the KNGF.
Setting The study setting was primary care. The economic study was carried out in the Netherlands.
Dates to which data relate The effectiveness and resource use data referred to May 2001 to 1 January 2002. The price year was 2002.
Source of effectiveness data The effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing was undertaken prospectively on the same patient sample as that used in the effectiveness study.
Study sample Power calculations were not performed to determine the sample size. The study sample was the same as the study population. It consisted of patients visiting the 113 physiotherapists who were working in 68 practices, in a central region of the Netherlands, from May 2001 to January 1, 2002. Of 500 patients who visited the physiotherapists, 483 participated in this study (242 in the intervention group and 241 in the control group). The baseline characteristics of the patients were generally comparable between the intervention and control groups, except in health insurance. The difference in health insurance between the groups was small but not significant. No reason for the non-participation of the 17 patients was reported.
Study design The study was a randomised controlled trial. It was carried out in 68 practices in a central region of the Netherlands. The physiotherapists in each practice were randomly allocated to the intervention and control group using blocked randomisation. The patients were followed up for 12 months. The authors did not report the loss to follow-up for the study sample used in the cost-utility analysis.
Analysis of effectiveness The analysis of the clinical study was conducted on an intention to treat basis. The primary health outcome used in the analysis was the EQ-5D scores. The EQ-5D measures health status on five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression.
Effectiveness results Since the results were expressed as utilities, these are presented in the health benefits field.
Clinical conclusions No significant difference between the intervention and control groups was found in the health effect.
Measure of benefits used in the economic analysis The summary measure of benefits used was the quality of life (QoL). This was generated through the participants' responses to the EQ-5D. The utility values for the health states were valued by the time trade-off technique on a random sample of the adult population of the UK, the MVH-A1 tariff, on which the worst situation scored -0.594 and perfect health scored 1.
Direct costs The quantity/cost boundary adopted in the economic study was that of society. The direct costs were for dissemination of the guideline and health care utilisation. The cost categories for dissemination in the control group included the dissemination of the guideline, the development of the implementation forms, an article in Fysiopraxis (professional journal for physiotherapists) and the time of the physiotherapists for reading the new guideline and the implementation forms. Besides the dissemination costs described above, in the intervention group there were the costs of producing and organising the training sessions, a teacher and an actor who were involved in the training sessions, extra time of the physiotherapists, and the mailing of the invitations to training. The categories of health care utilisation costs included general practitioner, medical specialist and physiotherapist visits, the prescribed and non prescribed medicines, alternative practitioners and hospitalisation.
The cost information was obtained from the institute for Research in Extramural Medicine (EMGO). Discounting was unnecessary, as all the costs were incurred during one year, and hence was not performed. The price year was 2002.
Statistical analysis of costs The groups were compared using parametric and non-parametric tests.
Indirect Costs The indirect costs included the productivity costs (i.e. the costs of absence from work or the costs of the efficiency losses without absence due to low back pain) and the costs of hindrance and productivity losses at unpaid work. The average productivity costs per hour were derived, based on the net national income per working hour. The elasticity for working time versus labour productivity was obtained from a published study. The costs of one hour of unpaid work were set at the current price of one hour of simple professional home care. Discounting was not necessary for a 1-year time horizon.
Sensitivity analysis A sensitivity analysis was not carried out.
Estimated benefits used in the economic analysis The estimated QoL score over one year was 0.6730 (standard deviation, SD=0.2042) in the intervention group and 0.6134 (SD=0.2661) in the control group, (p=0.006).
The score after 6 weeks was 0.7778 (SD=0.1978) in the intervention group and 0.7497 (SD=0.2316) in the control group. The score at 12 weeks was 0.8141 (SD=0.1988) in the intervention group and 0.7873 (SD=0.2210) in the control group.
From 6 weeks onwards, QoL was not significantly different between the groups.
Cost results The authors did not report the total costs in the intervention and control groups. Instead, they stated that there were no significant differences in the annual costs per item between the intervention and control groups. The distributions for each item of annual costs were reported. The authors reported 95% confidence intervals for differences in annual medical costs, productivity costs and total costs.
Synthesis of costs and benefits The authors did not calculate a cost-effectiveness ratio since there was no significant difference between the intervention and control groups in both costs and health effects.
Authors' conclusions The active implementation strategy does not appear to be cost-effective in comparison with the standard strategy.
CRD COMMENTARY - Selection of comparators The comparator, use of the standard method of disseminating the evidence-based physiotherapy guideline for non-specific low back pain, was appropriate since it represented current strategy in the authors' settings. You should decide if this is a widely used health technology in your own setting.
Validity of estimate of measure of effectiveness The analysis was based on a randomised trial. The physiotherapists in each practice were randomised. The method of randomisation was appropriate for the study question. In addition, an appropriate statistical analysis was undertaken to take potential biases and confounding factors into consideration. Power calculations were not performed to determine the sample size, thus the results might have been obtained by chance. The patients were shown to be comparable at analysis. Overall, the internal validity of the study is likely to be quite good.
Validity of estimate of measure of benefit QoL was an appropriate benefit measure because it captures the impact of the intervention. The instrument used to derive the QoL score was reported.
Validity of estimate of costs The economic analysis was performed from a societal perspective. All the categories of relevant direct and indirect costs were included. The authors reported the unit costs of health use and the costs were broken down by resource category. This approach enhances the generalisability of the authors' results. The sources of the cost data were reported. An appropriate statistical analysis was carried out. Discounting was irrelevant, as all the costs were incurred during one year, and hence was not carried out. The price year was reported, which will aid possible inflation exercises.
Other issues The authors made few comparisons of their findings with those from other studies, but did present an extensive interpretation of their findings. The issue of generalisability to other settings does not appear to have been addressed. The authors do not appear to have presented their results selectively and their conclusions reflected the scope of the analysis.
Implications of the study The study results suggest that it may not be rational, from an economic perspective, to prefer a new implementation strategy for the Dutch Physiotherapy Guideline for Low Back Pain.
Source of funding Supported by the Dutch Ministry of Health, Welfare and Sports.
Bibliographic details Hoeijenbos M, Bekkering T, Lamers L, Hendriks E, van Tulder M, Koopmanschap M. Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain. 2005; 75: 85-98 Other publications of related interest Bekkering GE, Hendriks HJ, Oostendorp RA. KNGFrichtlijn Lage-rugpijn gepubliceerd. FysioPraxis 2001;(4):28-31.
Bekkering GE, Hendriks HJM, Koes BW, et al, KNGFRichtlijn 'Lage-rugpijn'. Ned Tijdschr Fysiother 2001;111(3 Suppl):1.
Bekkering GE, Hendriks HJM, van Tulder MW, et al. The effect of implementation of the physiotherapy guidelines for low back pain on process of care: a randomised controlled trial. In press.
Dolan P, Gudex C, Kind P, et al. The time trade-off method: results from a general population study. Health Econ 1996;5:141-54.
Koopmanschap MA, Rutten FF. A practical guide for calculating indirect costs of disease. Pharmacoeconomics 1996;10-5:460-6.
Indexing Status Subject indexing assigned by NLM MeSH Adult; Cost-Benefit Analysis; Costs and Cost Analysis; Female; Humans; Low Back Pain /therapy; Male; Middle Aged; Netherlands; Physical Therapy Specialty; Practice Guidelines as Topic AccessionNumber 22005008480 Date bibliographic record published 31/08/2006 Date abstract record published 31/08/2006 |
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