Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain

M V Hurley, N E Walsh, H L Mitchell, T J Pimm, E Williamson, R H Jones, B C Reeves, P A Dieppe, A Patel, M V Hurley, N E Walsh, H L Mitchell, T J Pimm, E Williamson, R H Jones, B C Reeves, P A Dieppe, A Patel

Abstract

Objective: To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program.

Methods: Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness.

Results: Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost 224 pounds (95% confidence interval [95% CI] 184 pounds, 262 pounds) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay 1,900 pounds for improvements in functioning. Indiv-rehab cost 314 pounds/person and Grp-rehab 125 pounds/person. Indiv-rehab cost 189 pounds (95% CI 168 pounds, 208 pounds) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP 5,500 pounds. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome.

Conclusion: Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.

Figures

Figure 1
Figure 1
Cost-effectiveness acceptability curves: probability (given as percentage) that 1) rehabilitation (individual or group) is cost-effective compared with usual primary care and 2) Indiv-rehab is cost-effective compared with Grp-rehab, for a range of values of health care commissioners' willingness to pay for an increase in the proportion of participants improving in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC-func) by 15% at 6 months, from a health/social care perspective. Rehabilitation = costs of individual and group rehabilitation programs combined; Indiv-rehab = rehabilitation program delivered to individual participants; Grp-rehab = rehabilitation program delivered to groups of 8 participants; £ = English pounds sterling. Conversion rate to US dollars at 2003 purchasing power parity: £1 = $1.613.
Figure 2
Figure 2
Cost-effectiveness acceptability curves: probability that each treatment strategy is cost-effective compared with the other 2, for a range of values of decision makers' willingness to pay for an additional quality-adjusted life year (QALY), from a health/social care perspective at 6 months. Indiv-rehab = rehabilitation program delivered to individual participants; Grp-rehab = rehabilitation program delivered to groups of 8 participants; £ = English pounds sterling. Conversion rate to US dollars at 2003 purchasing power parity: £1 = $1.613.

References

    1. Badley EM, Rasooly I, Webster GK. Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability, and health care utilization: findings from the 1990 Ontario Health Survey. J Rheumatol. 1994;21:505–14.
    1. Badley EM, Ibanez D. Socioeconomic risk factors and musculoskeletal disability. J Rheumatol. 1994;21:515–22.
    1. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001;60:91–7.
    1. Dawson J, Linsell L, Zondervan K, Rose P, Randall T, Carr A, et al. Epidemiology of hip and knee pain and its impact on overall health status in older adults. Rheumatology (Oxford) 2004;43:497–504.
    1. Alonso J, Ferrer M, Gandek B, Ware JE, Aaronson NK, Mosconi P, IQOLA Project Group et al. Health-related quality of life associated with chronic conditions in eight countries: results from the International Quality of Life Assessment (IQOLA) Project. Qual Life Res. 2004;13:283–98.
    1. Cooper JK, Kohlmann T. Factors associated with health status of older Americans. Age Ageing. 2001;30:495–501.
    1. Lanes SF, Lanza LL, Radensky PW, Yood RA, Meenan RF, Walker AM, et al. Resource utilization and cost of care for rheumatoid arthritis and osteoarthritis in the managed care setting: the importance of drug and surgery costs. Arthritis Rheum. 1997;40:1475–81.
    1. Gabriel SE, Crowson CS, Campion ME, O'Fallon WM. Indirect and nonmedical costs among people with rheumatoid arthritis and osteoarthritis compared with nonarthritic controls. J Rheumatol. 1997;24:43–8.
    1. Leardini G, Salaffi F, Caporali R, Rovati L, Montanelli R, Italian Group for the Study of the Costs of Arthritis Direct and indirect costs of osteoarthritis of the knee. Clin Exp Rheumatol. 2004;22:699–706.
    1. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54:226–9.
    1. Perruccio AV, Power JD, Badley EM. Revisiting arthritis prevalence projections: it's more than just the aging of the population. J Rheumatol. 2006;33:1856–62.
    1. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Org. 2003;81:646–56.
    1. World Health Organisation. The burden of musculoskeletal disease at the start of the millennium: technical report 919. Geneva: WHO; 2003.
    1. Juni P, Nartey L, Reichenbach S, Sterchi R, Dieppe P, Egger M. Risk of cardiovascular events and rofecoxib: cumulative meta-analysis. Lancet. 2004;364:2021.
    1. Hippisley-Cox J, Coupland C. Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis. BMJ. 2005;330:1366–9.
    1. Hippisley-Cox J, Coupland C, Logan R. Risk of adverse gastrointestinal outcomes in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis. BMJ. 2005;331:1310–6.
    1. Solomon DH, Glynn RJ, Bohn R, Levin R, Avorn J. The hidden cost of nonselective nonsteroidal antiinflammatory drugs in older patients. J Rheumatol. 2003;30:792–8.
    1. Ettinger WH, Afable RF. Physical disability from knee osteoarthritis: the role of exercise as an intervention. Med Sci Sports Exerc. 1994;26:1435–40.
    1. Newman PS, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. 2004;364:1523.
    1. Warsi A, LaValley MP, Wang PS, Avorn J, Solomon DH. Arthritis self-management education programs: a meta-analysis of the effect on pain and disability. Arthritis Rheum. 2003;48:2207–13.
    1. Van Baar ME, Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW. Effectiveness of exercise therapy in patients with osteoarthritis of the hip and knee: a systematic review of randomised clinical trials. Arthritis Rheum. 1999;42:1361–9.
    1. Fransen M, McConnell S, Bell M. Therapeutic exercise for people with OA of the hip and knee: a systematic review. J Rheumatol. 2002;29:1737–45.
    1. Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005;64:544–8.
    1. Hurley MV, Walsh NE, Mitchell H, Williamson E. Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (Escape-Knee Pain): a cluster randomised trial of an integrated rehabilitation programme. Arthritis Rheum. 2005;52(Suppl 9):S505. [abstract]
    1. 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 paa cluster-randomized trial. Arthritis Rheum. 2007;57:1211–9.
    1. Bellamy N, Buchanan W, Goldsmith C, Campbell J, Stitt L. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–40.
    1. The EuroQol Group. EuroQol: a new facility for the measurement of health related quality of life. Health Policy. 1990;16:199–208.
    1. Dolan P, Gudex C, Kind P, Williams A. Working papers. York: Centre for Health Economics, University of York; 1995. A social tariff for EuroQol: results from a UK general population survey.
    1. Knapp M. The economic evaluation of mental health care. Aldershot (UK): Arena; 1995.
    1. Curtis L, Netten A, editors. Unit costs of health and social care 2004. Kent (UK): Personal Social Services Research Unit, University of Kent; 2004.
    1. Organisation for Economic Co-operation and Development. URL . Purchasing power parities, comparative price levels.
    1. Fenwick E, Claxton K, Sculpher M. Representing uncertainty: the role of cost-effectiveness acceptability curves. Health Econ. 2001;10:779–87.
    1. Briggs AH, O'Brien BJ, Blackhouse G. Thinking outside the box: recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies. Annu Rev Public Health. 2002;23:377–401.
    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;45:384–91.
    1. Glasgow RE, Magid DJ, Beck A, Ritzwoller D, Estabrooks PA. Practical clinical trials for translating research to practice: design and measurement recommendations. Med Care. 2005;43:551–7.
    1. Beckett M, Weinstein M, Goldman N, Yu-Hsuan L. Do health interview surveys yield reliable data on chronic illness among older respondents? Am J Epidemiol. 2000;151:315–23.
    1. Van den Berg B, Brouwer WB, Koopmanschap MA. Economic valuation of informal care: an overview of methods and applications. Eur J Health Econ. 2004;5:36–45.
    1. Fransen M, Edmonds J. Reliability and validity of the EUROQoL in patients with osteoarthritis of the knee. Rheumatology (Oxford) 1999;38:807–13.
    1. Brazier JE, Harper R, Munro J, Walters SJ, Snaith ML. Generic and condition-specific outcome measures for people with osteoarthritis of the knee. Rheumatology (Oxford) 1999;38:870–7.
    1. Lorig KR, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalisation: a randomized trial. Med Care. 1999;37:5–14.
    1. Mazzuca SA, Brandt KD, Katz BP, Hanna MP, Melfi CA. Reduced utilization and cost of primary care visits resulting from self-care education for patients with osteoarthritis of the knee. Arthritis Rheum. 1999;42:1267–73.
    1. McCarthy CJ, Mills PM, Pullen R, Roberts C, Silman A, Oldham JA. Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis. Rheumatology (Oxford) 2004;43:880–6.
    1. Thomas KS, Muir KR, Docherty M, Jones AC, O'Reilly SC, Bassey EJ. Home based exercise programme for knee pain and knee osteoarthritis: randomise controlled trial. BMJ. 2002;325:752–6.
    1. Richardson G, Hawkins N, McCarthy CJ, Mill PM, Pullen R, Roberts C, et al. Cost-effectiveness of a supplementary class-based exercise programme in the treatment of knee osteoarthritis. Int J Technol Assess Health Care. 2006;22:84–9.
    1. Thomas KS, Miller P, Doherty M, Muir KR, Jones AC, O'Reilly SC. Cost effectiveness of a two-year home exercise program for the treatment of knee pain. Arthritis Rheum. 2005;53:388–94.
    1. Coupe 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;66:215–21. E-pub 2006 July 31.

Source: PubMed

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