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Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain |
Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Williamson E, Jones RH, Reeves BC, Dieppe PA, Patel A |
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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. CRD summary The objective was to assess the cost-effectiveness of individual or group rehabilitation, compared with usual primary care, for the management of chronic knee pain. The authors concluded that rehabilitation, particularly group rehabilitation, was cost-effective. The methods were sound and the study was well reported. The authors’ conclusions appear to be appropriate for the scope of their analysis. Type of economic evaluation Cost-effectiveness analysis, cost-utility analysis Study objective The objective was to compare the cost-effectiveness of three strategies for the management of patients, aged 50 years or older, who had experienced mild, moderate, or severe knee pain, for over six months. Interventions The three interventions were: usual primary care; usual primary care combined with a rehabilitation programme delivered to individual participants; and usual primary care combined with the same rehabilitation programme delivered to groups of eight participants.
The rehabilitation programme consisted of 12 supervised sessions twice-a-week for six weeks. The first 10 to 15 minutes of each session was a discussion, run by the supervising physiotherapist, on a specific topic, with the provision of advice and coping methods. The next 30 to 45 minutes consisted of a programme of simple exercises that were intended to improve participants' functioning. Methods Analytical approach:The economic analysis had a time horizon of six months and was based on a single clinical trial. The authors reported that a health and social care perspective and a societal perspective were adopted.
Effectiveness data:The clinical data came from a pragmatic cluster randomised controlled trial. The sample consisted of 418 patients (294 women), with 140 in usual care, 146 in individual rehabilitation, and 132 in group rehabilitation. The three intervention groups were comparable at baseline in their clinical and socio-demographic characteristics, but they differed in their receipt of social security benefits at baseline. The follow-up was six months and further details were published in another paper (Hurley, et al. 2007, see 'Other Publications of Related Interest' below for bibliographic details). The primary endpoint was clinical improvement in self-reported functioning, measured by the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC-func) at six months after completion of the six-week rehabilitation.
Monetary benefit and utility valuations:The utility values were derived from the trial participants, using the European Quality of life (EQ-5D) questionnaire. QALYs were calculated using utility weights from the UK general population.
Measure of benefit:Improvement in functioning, based on a 15% increase in WOMAC-func from baseline, and quality-adjusted life-years (QALYs) were the summary measures of benefit.
Cost data:The economic analysis included: in-patient and out-patient services; community-based services; medications; hospital, laboratory, and screening tests; social security benefits; informal care (including personal care, home maintenance, housework and laundry, transport, preparing meals, shopping, and gardening); and productivity losses. Resource use was calculated retrospectively at baseline and at follow-up, using a subsample of 338 (81%) participants. The unit costs were based on national statistics. All costs were appropriately adjusted for inflation and reported for the price year 2003 to 2004. They were reported in UK pounds sterling (£) and US dollars ($) using a conversion rate based on the 2003 purchasing power parity, where £1 equalled $1.613.
Analysis of uncertainty:Two sets of deterministic sensitivity analyses were performed. Uncertainty around the rehabilitation costs was investigated, using six different calculation methods and uncertainty around the total costs was investigated by varying the medication and informal care costs. All assumptions that were tested in the sensitivity analysis were reported. The uncertainty in the cost-effectiveness results was investigated using probabilistic analysis and cost-effectiveness acceptability curves were generated. Results At six months there were no statistically significant differences between the interventions in their QALYs gained. The difference in the proportion of patients with improvement in clinical functioning was statistically significant, with 121 of 226 in the rehabilitation groups and 47 of 113 in the usual care group (χ2=4.301, p=0.038).
From the health and social care perspective, the differences in total costs were not statistically significant, but, from a societal perspective, rehabilitation (combined individual and group) had total costs of £584 more than usual care. Differences in total costs between individual and group rehabilitation were not statistically significant.
For functional improvement, at a willingness-to-pay threshold of £1,900, rehabilitation (both types) had over a 90% probability of being more cost-effective than usual care. At a threshold of £6,000, individual rehabilitation had a probability of only 50% of being more cost-effective than group rehabilitation. For QALYs, at a willingness-to-pay threshold of £19,000, individual rehabilitation had a probability of only 38% of being more cost-effective than either group rehabilitation or usual care. Authors' conclusions The authors concluded that rehabilitation, especially group rehabilitation, was cost-effective in the management of chronic knee pain. CRD commentary Interventions:The interventions were clearly reported and the usual care in the authors' setting was used as a comparator, but this was not described.
Effectiveness/benefits:A randomised controlled trial was an appropriate source for the clinical data, given the strengths of its design. The inclusion and exclusion criteria were reported, but the randomisation methods and power calculations were not. An intention-to-treat analysis was conducted and the patient groups were generally comparable at baseline, making the data more robust. The methods used to handle missing data were appropriate and statistical analysis was used to account for potential biases. The derivation of the benefit measures was reported and the methods were robust. The authors used a disease-specific benefit measure and also reported QALYs, which are a validated measure that allow cross-disease comparisons.
Costs:The cost categories reflected both the perspectives stated. The resource use was measured using micro-costing methods and the unit costs and resource quantities were reported in an appendix. A detailed breakdown of the cost items was also provided in the paper. Bootstrapping was appropriately employed to determine the mean differences in costs and the estimated 95% confidence intervals. This addressed the problems that can arise from highly skewed cost data. The price year, adjustments for inflation, and the sources of cost data were all well reported.
Analysis and results:The methods used to synthesise the costs and benefits were appropriate. The issue of uncertainty was thoroughly investigated and the findings of the base-case and the sensitivity analyses were clearly presented. The authors highlighted some limitations to their study. In general, the reporting was clear and concise, particularly for the costs.
Concluding remarks:The methods were sound and the study was well reported. The authors’ conclusions appear to be appropriate for the scope of their analysis. Funding Supported by the Arthritis Research Campaign. Bibliographic details Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Williamson E, Jones RH, Reeves BC, Dieppe PA, Patel A. Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain. Arthritis and Rheumatism (Arthritis Care and Research) 2007; 57(7): 1220-1229 Other publications of related interest Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Patel A, Williamson E, et al. Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster-randomized trial. Arthritis and Rheumatism 2007; 57: 1211-1219. Indexing Status Subject indexing assigned by NLM MeSH Adaptation, Psychological; Aged; Aged, 80 and over; Chronic Disease; Cost-Benefit Analysis; Costs and Cost Analysis; Exercise Therapy /economics; Female; Great Britain; Humans; Male; Middle Aged; Osteoarthritis, Knee /economics /physiopathology /rehabilitation; Pain /etiology /prevention & Primary Health Care /economics; Quality-Adjusted Life Years; Self Care /economics; control AccessionNumber 22007002426 Date bibliographic record published 16/11/2007 Date abstract record published 11/08/2010 |
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