No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial

The cost-effectiveness of guideline-recommended treatments for osteoarthritis: A systematic review

OBJECTIVE

To critically appraise the literature on the cost-effectiveness of guideline-recommended treatments for osteoarthritis (OA).

DESIGN

Electronic databases were searched for studies that provided incremental cost-effectiveness ratios (ICER) for treatments recommended by key international guidelines to manage OA in adults. Treatments were grouped as lifestyle and rehabilitative therapies, pharmacological, injection, or surgical. Primary outcome was ICERs, converted to 2023 US dollars for comparability across studies. Risk of bias was assessed using the Consensus on Health Economic Criteria checklist for trials and the Drummond checklist for modelling studies. Studies were deemed cost-effective based on established country-specific thresholds per quality-adjusted life-year.

RESULTS

There were 110 studies that included 33 lifestyle and rehabilitative therapies, 25 pharmacological, 11 injection and 42 surgical studies. Most studies (95%) were conducted in high-income countries. Time horizons varied from 8 weeks to a lifetime. Risk of bias domains were frequently scored poorly related to cost methods. Overall, the cost-effectiveness of lifestyle and rehabilitative therapies and non-steroidal anti-inflammatory drugs (NSAIDs) was mixed. Hyaluronic acid injection was cost-effective in knee OA compared to placebo, usual care and paracetamol but not to corticosteroid injections and NSAIDs. Total hip or knee replacement was cost-effective compared to usual care or no surgery, with early access to replacement cost-effective compared to delaying surgery.

CONCLUSIONS

There was a diversity of analytical perspectives and clinical heterogeneity of interventions. Policymakers should consider their local context when deciding clinical care and resource allocation.

Health economic evaluation of weight reduction interventions in individuals suffering from overweight or obesity and a musculoskeletal diagnosis-a systematic review

BACKGROUND

Most of the worldwide population is overweight and suffers from the resulting musculoskeletal comorbidities such as knee osteoarthritis or back pain. Practice guidelines recommend weight loss interventions for individuals suffering from these conditions. This systematic review investigated whether including a weight loss intervention in the musculoskeletal therapy of these individuals was cost-effective compared to administering the musculoskeletal therapy alone.

METHODS

This study followed the PRISMA guidelines to systematically and independently search six databases and select full health economic evaluations published up to May 2024 from health care or societal perspectives according to predefined eligibility criteria. Cost data were standardised to 2023 Belgium Euros. The methodological quality was assessed using two health economic-specific checklists.

RESULTS

The searches produced 5'305 references, of which 8 studies were selected for a total of 1'726 participants. The interventions consisted of different exercise plans and nutritional targets. Six values were in the north-eastern; leading to increased quality-adjusted life year (QALY) and higher costs; and two in the south-eastern quadrant of the cost-utility plane; leading to increased QALYs and lower costs. Two studies observed no differences in QALYs. Incremental cost utility ratios (ICUR) ranged from €13'580.10 to €34'412.40 per additional QALY from a healthcare perspective. From a societal perspective, the ICUR was €30'274.84. The included studies fulfilled 86 percent of the criteria in trial-based economic evaluations and 57 percent in model-based economic evaluations. The most common limitations of the studies were related to appropriate cost measures' specifications, research questions, time horizon choices, and sensitivity analyses.

CONCLUSIONS

This systematic review showed weak but consistent evidence of cost-effectiveness for adding a weight loss intervention to musculoskeletal therapy for individuals with overweight, from either perspective. Further economic evaluations should evaluate the long-term cost-effectiveness of the intervention.

TRIAL REGISTRATION

International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY (2022,110,122).

Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations

BACKGROUND

Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists.

METHODS

We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist.

RESULTS

We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons.

CONCLUSIONS

High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.

OARSI year in review 2023: Rehabilitation and outcomes

OBJECTIVE

We systematically reviewed the literature to identify comparative studies of core treatments (exercise, education, or weight management), adjunct treatments (e.g. electrotherapeutical modalities, bracing), or multimodal treatments (core plus other treatments), for treating osteoarthritis (OA) complaints, published between 1 March 2022 and 1 March 2023.

DESIGN

We searched three electronic databases for peer-reviewed comparative studies evaluating core treatments, adjunct treatments, or multimodal treatments for OA affecting any joint, in comparison to other OA treatments. Two authors independently screened records. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. A narrative synthesis focusing on pain and function outcomes was performed in studies with a mean sample size of at least 46 participants per treatment arm.

RESULTS

33 publications (28 studies), 82% with PEDro ratings of good or excellent, were eligible for narrative synthesis: 23 studies evaluated knee OA; one knee OA or chronic low back pain; two knee or hip OA; one hip OA only; and one thumb OA. No studies identified a dose, duration or type of exercise that resulted in better pain or function outcomes. Core treatments generally showed modest benefits compared to no or minimal intervention controls.

CONCLUSIONS

Rehabilitation research continues to be focused on the knee. Most studies are not adequately powered to assess pain efficacy. Further work is needed to better account for contextual effects, identify treatment responder characteristics, understand treatment mechanisms, and implement guideline care.