Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial

Allyn M Bove, Kenneth J Smith, Christopher G Bise, Julie M Fritz, John D Childs, Gerard P Brennan, J Haxby Abbott, G Kelley Fitzgerald, Allyn M Bove, Kenneth J Smith, Christopher G Bise, Julie M Fritz, John D Childs, Gerard P Brennan, J Haxby Abbott, G Kelley Fitzgerald

Abstract

Background: Limited information exists regarding the cost-effectiveness of rehabilitation strategies for individuals with knee osteoarthritis (OA).

Objective: The study objective was to compare the cost-effectiveness of 4 different combinations of exercise, manual therapy, and booster sessions for individuals with knee OA.

Design: This economic evaluation involved a cost-effectiveness analysis performed alongside a multicenter randomized controlled trial.

Setting: The study took place in Pittsburgh, Pennsylvania; Salt Lake City, Utah; and San Antonio, Texas.

Participants: The study participants were 300 individuals taking part in a randomized controlled trial investigating various physical therapy strategies for knee OA.

Intervention: Participants were randomized into 4 treatment groups: exercise only (EX), exercise plus booster sessions (EX+B), exercise plus manual therapy (EX+MT), and exercise plus manual therapy and booster sessions (EX+MT+B).

Measurements: For the 2-year base case scenario, a Markov model was constructed using the United States societal perspective and a 3% discount rate for costs and quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios were calculated to compare differences in cost per QALY gained among the 4 treatment strategies.

Results: In the 2-year analysis, booster strategies (EX+MT+B and EX+B) dominated no-booster strategies, with both lower health care costs and greater effectiveness. EX+MT+B had the lowest total health care costs. EX+B costformula image1061 more and gained 0.082 more QALYs than EX+MT+B, for an incremental cost-effectiveness ratio offormula image12,900/QALY gained.

Limitations: The small number of total knee arthroplasty surgeries received by individuals in this study made the assessment of whether any particular strategy was more successful at delaying or preventing surgery in individuals with knee OA difficult.

Conclusions: Spacing exercise-based physical therapy sessions over 12 months using periodic booster sessions was less costly and more effective over 2 years than strategies not containing booster sessions for individuals with knee OA.

Trial registration: ClinicalTrials.gov NCT01314183.

Figures

Figure 1.
Figure 1.
Schematic depiction of Markov model. Participants in all 4 treatment groups (exercise only, exercise plus manual therapy, exercise plus booster sessions, and exercise plus manual therapy and booster sessions) entered the model in “Poor/Worsening Function.” Model health states are shown as ovals. During monthly model cycles, transitions between health states or remaining in the same health state could occur and are represented by arrows. Transitions to different states depended upon whether a participant underwent surgery and whether the Western Ontario and McMaster Universities Osteoarthritis Index score changed beyond the minimum clinically important difference. Death, while possible in our model, is not depicted because all participants were alive at the 2-year follow-up. Scope = arthroscopy, TKA = total knee arthroplasty.
Figure 2.
Figure 2.
Cost-effectiveness (CE) acceptability curve. Below a willingness-to-pay threshold of13,000, the exercise (EX) plus manual therapy (MT) and booster sessions strategy was preferred more often. Above a willingness-to-pay threshold of13,000, the EX plus booster sessions strategy was preferred more often. Strategies not containing booster sessions were never the most likely option to be cost-effective at any willingness-to-pay value.

References

    1. Guccione AA,Felson DT,Anderson JJ et al. . The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Public Health.1994;84:351–358.
    1. Kotlarz H,Gunnarsson CL,Fang H,Rizzo JA. Insurer and out-of-pocket costs of osteoarthritis in the US: evidence from national survey data.Arthritis Rheum.2009;60:3546–3553.
    1. Centers for Disease Control and Prevention.Osteoarthritis.. Accessed October 4,2017.
    1. Pinto D,Robertson MC,Hansen P,Abbott JH. Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review.Value Health.2012;15:1–12.
    1. Pinto D,Robertson MC,Abbott JH,Hansen P,Campbell AJ,Trial Team MOA. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee, 2: economic evaluation alongside a randomized controlled trial.Osteoarthritis Cartilage.2013;21:1504–1513.
    1. American Academy of Orthopedic Surgeons.Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline.2nd ed2013.. Published 2013. Accessed October 4,2017.
    1. Jordan KM,Arden NK,Doherty M et al. . EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis—report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis.2003;62:1145–1155.
    1. Zhang W,Moskowitz RW,Nuki G et al. . OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.Osteoarthritis Cartilage.2008;16:137–162.
    1. Hochberg MC,Altman RD,April KT et al. . American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.Arthritis Care Res (Hoboken).2012;64:465–474.
    1. Fransen M,McConnell S,Harmer AR,Van der Esch M,Simic M,Bennell KL. Exercise for osteoarthritis of the knee: a Cochrane systematic J Sports Med.2015;49:1554–1557.
    1. Jansen MJ,Viechtbauer W,Lenssen AF,Hendriks EJ,de Bie RA. Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review.J Physiother.2011;57:11–20.
    1. French HP,Brennan A,White B,Cusack T. Manual therapy for osteoarthritis of the hip or knee: a systematic review.Man Ther.2011;16:109–117.
    1. Abbott JH,Robertson MC,Chapple C et al. . Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial.1: Clinical effectiveness. Osteoarthritis Cartilage.2013;21:525–534.
    1. Abbott JH,Chapple CM,Fitzgerald GK et al. . The incremental effects of manual therapy or booster sessions in addition to exercise therapy for knee osteoarthritis: a randomized clinical trial.J Orthop Sports Phys Ther.2015;45:975–983.
    1. Fitzgerald GK,Fritz JM,Childs JD et al. . Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial.Osteoarthritis Cartilage.2016;24:1340–1349.
    1. Bennell KL,Kyriakides M,Hodges PW,Hinman RS.. Effects of two physiotherapy booster sessions on outcomes with home exercise in people with knee osteoarthritis: a randomized controlled trial.Arthritis Care Res (Hoboken).2014;66:1680–1687.
    1. Altman R,Asch E,Bloch D et al. . Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee.Arthritis Rheum.1986;29:1039–1049.
    1. Pinto D,Robertson MC,Hansen P,Abbott JH. Good agreement between questionnaire and administrative databases for health care use and costs in patients with osteoarthritis.BMC Med Res Methodol.2011;11:45.
    1. Databases HCUP.Healthcare Cost and Utilization Project (HCUP).Rockville, MD:Agency for Healthcare Research and Quality;2017.. Accessed October 4,2017.
    1. Centers for Medicare & Medicaid Services.Overview: physician fee schedule website.. Accessed October 4,2017.
    1. Shaw JW,Johnson JA,Coons SJ. US valuation of the EQ-5D health states: development and testing of the D1 valuation model.Med Care.2005;43:203–220.
    1. Angst F,Aeschlimann A,Stucki G. Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities.Arthritis Rheum.2001;45:384–391.
    1. Weinstein MC,Siegel JE,Gold MR,Kamlet MS,Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA.1996;276:1253–1258.
    1. Braithwaite RS,Meltzer DO,King JT,Leslie D,Roberts MS. What does the value of modern medicine say about the50,000 per quality-adjusted life-year decision rule? Med Care.2008;46:349–356.
    1. Neumann PJ,Cohen JT,Weinstein MC. Updating cost-effectiveness: the curious resilience of the50,000-per-QALY threshold.N Engl J Med.2014;371:796–797.
    1. Briggs AH,Weinstein MC,Fenwick EA et al. . Model parameter estimation and uncertainty analysis: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force Working Group-6. Med Decis Making.2012;32:722–732.
    1. Martin CT,Pugely AJ,Gao Y,Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the National Surgical Quality Improvement Program database.J Bone Joint Surg Am.2013;95:e98 1–e98 10.
    1. Salzler MJ,Lin A,Miller CD,Herold S,Irrgang JJ,Harner CD. Complications after arthroscopic knee J Sports Med.2014;42:292–296.
    1. Ubel PA,Hirth RA,Chernew ME,Fendrick AM. What is the price of life and why doesn’t it increase at the rate of inflation? Arch Intern Med.2003;163:1637–1641.
    1. Hurley MV,Walsh NE,Mitchell H,Nicholas J,Patel A. Long-term outcomes and costs of an integrated rehabilitation program for chronic knee pain: a pragmatic, cluster randomized, controlled trial.Arthritis Care Res.2012;64:238–247.
    1. Siegel JE,Weinstein MC,Russell LB,Gold MR. Recommendations for reporting cost-effectiveness analyses.JAMA.1996;276:1339–1341.
    1. Coupé VM,Veenhof C,van Tulder MW,Dekker J,Bijlsma JW,Van den Ende CH. The cost effectiveness of behavioural graded activity in patients with osteoarthritis of hip and/or knee.Ann Rheum Dis.2007;66:215–221.
    1. Longobardi T,Walker JR,Graff LA,Bernstein CN. Health service utilization in IBD: comparison of self-report and administrative data.BMC Health Serv Res.2011;11:137.
    1. van den Brink M,van den Hout WB,Stiggelbout AM,Putter H,van de Velde CJ,Kievit J. Self-reports of health-care utilization: diary or questionnaire? Int J Technol Assess Health Care.2005;21:298–304.
    1. Bozic KJ,Grosso LM,Lin Z et al. . Variation in hospital-level risk-standardized complication rates following elective primary total hip and knee arthroplasty.J Bone Joint Surg Am.2014;96:640–647.
    1. Singh JA,Kwoh CK,Boudreau RM,Lee GC,Ibrahim SA. Hospital volume and surgical outcomes after elective hip/knee arthroplasty: a risk-adjusted analysis of a large regional database.Arthritis Rheum.2011;63:2531–2539.
    1. Ramey DR,Watson DJ,Yu C,Bolognese JA,Curtis SP,Reicin AS. The incidence of upper gastrointestinal adverse events in clinical trials of etoricoxib vs. non-selective NSAIDs: an updated combined analysis.Curr Med Res Opin.2005;21:715–722.
    1. Lubowitz JH,Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction.Arthroscopy.2011;27:1317–1322.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren