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Baumbach L, Feddern W, Kretzler B, Hajek A, König HH. Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations. SPORTS MEDICINE - OPEN 2024; 10:38. [PMID: 38613739 PMCID: PMC11016054 DOI: 10.1186/s40798-024-00713-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 04/02/2024] [Indexed: 04/15/2024]
Abstract
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.
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Affiliation(s)
- Linda Baumbach
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Wiebke Feddern
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Benedikt Kretzler
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - André Hajek
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Burgess R, Hall J, Bishop A, Lewis M, Hill J. Costing Methodology and Key Drivers of Health Care Costs Within Economic Analyses in Musculoskeletal Community and Primary Care Services: A Systematic Review of the Literature. J Prim Care Community Health 2021; 11:2150132719899763. [PMID: 31941391 PMCID: PMC6966248 DOI: 10.1177/2150132719899763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Identifying variation in musculoskeletal service costs
requires the use of specific standardized metrics. There has been a large focus
on costing, efficiency, and standardized metrics within the acute
musculoskeletal setting, but far less attention in primary care and community
settings. Objectives: To (a) assess the quality of
costing methods used within musculoskeletal economic analyses based primarily in
primary and community settings and (b) identify which cost
variables are the key drivers of musculoskeletal health care costs within these
settings. Methods: Medline, AMED, EMBASE, CINAHL, HMIC, BNI, and
HBE electronic databases were searched for eligible studies. Two reviewers
independently extracted data and assessed quality of costing methods using an
established checklist. Results: Twenty-two studies met the review
inclusion criteria. The majority of studies demonstrated moderate- to
high-quality costing methods. Costing issues included studies failing to fully
justify the economic perspective, and not distinguishing between short- and
long-run costs. Highest unit costs were hospital admissions, outpatient visits,
and imaging. Highest mean utilization were the following: general practitioner
(GP) visits, outpatient visits, and physiotherapy visits. Highest mean costs per
patient were GP visits, outpatient visits, and physiotherapy visits.
Conclusion: This review identified a number of key resource use
variables that are driving musculoskeletal health care costs in the
community/primary care setting. High utilization of these resources (rather than
high unit cost) appears to be the predominant factor increasing mean health care
costs. There is, however, need for greater detail with capturing these key cost
drivers, to further improve the accuracy of costing information.
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Affiliation(s)
- Roanna Burgess
- Keele University, Keele, Staffordshire, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - James Hall
- Keele University, Keele, Staffordshire, UK.,University of Birmingham, Birmingham, UK
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Primeau CA, Zomar BO, Somerville LE, Joshi I, Giffin JR, Marsh JD. Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment. Orthop J Sports Med 2021; 9:2325967120987241. [PMID: 34262974 PMCID: PMC8243245 DOI: 10.1177/2325967120987241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/24/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The economic burden of musculoskeletal diseases is substantial and growing. Economic evaluations compare costs and health benefits of interventions simultaneously to help inform value-based care; thus, it is crucial to ensure that studies are using appropriate methodology to provide valid evidence on the cost-effectiveness of interventions. This is particularly the case in orthopaedic sports medicine, where several interventions of varying costs are available to treat common hip and knee conditions. PURPOSE To summarize and evaluate the quality of economic evaluations in orthopaedic sports medicine for knee and hip interventions and identify areas for quality improvement. STUDY DESIGN Systematic review; Level of evidence, 3. METHODS The Medline, AMED, OVID Health Star, and EMBASE databases were searched from inception to March 1, 2020, to identify economic evaluations that compared ≥2 interventions for hip and/or knee conditions in orthopaedic sports medicine. We assessed the quality of full economic evaluations using the Quality of Health Economic Studies (QHES) tool, which consists of 16 questions for a total score of 100. We classified studies into quartiles based on QHES score (extremely poor quality to high quality) and we evaluated the frequency of studies that addressed each of the 16 QHES questions. RESULTS A total of 93 studies were included in the systematic review. There were 41 (44%) cost analyses, of which 21 (51%) inappropriately concluded interventions were cost-effective. Only 52 (56%) of the included studies were full economic evaluations, although 40 of these (77%) fell in the high-quality quartile. The mean QHES score was 83.2 ± 19. Authors consistently addressed 12 of the QHES questions; questions that were missed or unclear were related to statistical uncertainty, appropriateness of costing methodology, and discussion of potential biases. The most frequently missed question was whether the cost perspective of the analysis was stated and justified. CONCLUSION The number of studies in orthopaedic sports medicine is small, despite their overall good quality. Yet, there are still many highly cited studies based on low-quality or partial economic evaluations that are being used to influence clinical decision-making. Investigators should follow international health economic guidelines for study design and critical appraisal of studies to further improve quality.
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Affiliation(s)
- Codie A. Primeau
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Bryn O. Zomar
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | | | - Ishita Joshi
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - J. Robert Giffin
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jacquelyn D. Marsh
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
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Guido D, Leonardi M, Mellor-Marsá B, Moneta MV, Sanchez-Niubo A, Tyrovolas S, Giné-Vázquez I, Haro JM, Chatterji S, Bobak M, Ayuso-Mateos JL, Arndt H, Koupil I, Bickenbach J, Koskinen S, Tobiasz-Adamczyk B, Panagiotakos D, Raggi A. Pain rates in general population for the period 1991-2015 and 10-years prediction: results from a multi-continent age-period-cohort analysis. J Headache Pain 2020; 21:52. [PMID: 32404046 PMCID: PMC7218619 DOI: 10.1186/s10194-020-01108-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/13/2020] [Indexed: 12/04/2022] Open
Abstract
Background Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people. The aims of this study are to evaluate the temporal variations of pain rates among general populations for the period 1991–2015 and to project 10-year pain rates. Methods We used the harmonized dataset of ATHLOS project, which included 660,028 valid observations in the period 1990–2015 and we applied Bayesian age–period–cohort modeling to perform projections up to 2025. The harmonized Pain variable covers the content “self-reported pain experienced at the time of the interview”, with a dichotomous (yes or no) modality. Results Pain rates were higher among females, older subjects, in recent periods, and among observations referred to cohorts of subjects born between the 20s and the 60s. The 10-year projections indicate a noteworthy increase in pain rates in both genders and particularly among subjects aged 66 or over, for whom a 10–20% increase in pain rate is foreseen; among females only, a 10–15% increase in pain rates is foreseen for those aged 36–50. Conclusions Projected increase in pain rates will require specific interventions by health and welfare systems, as pain is responsible for limited quality of subjective well-being, reduced employment rates and hampered work performance. Worksite and lifestyle interventions will therefore be needed to limit the impact of projected higher pain rates.
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Affiliation(s)
- Davide Guido
- Neurology, Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Matilde Leonardi
- Neurology, Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy.
| | - Blanca Mellor-Marsá
- Parc Sanitari Sant Joan de Déu, Fundacion Sant Joan de Deu, Barcelona, Spain
| | - Maria V Moneta
- Parc Sanitari Sant Joan de Déu, Fundacion Sant Joan de Deu, Barcelona, Spain
| | - Albert Sanchez-Niubo
- Parc Sanitari Sant Joan de Déu, Fundacion Sant Joan de Deu, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Stefanos Tyrovolas
- Parc Sanitari Sant Joan de Déu, Fundacion Sant Joan de Deu, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain.,Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, Athens, Greece
| | - Iago Giné-Vázquez
- Parc Sanitari Sant Joan de Déu, Fundacion Sant Joan de Deu, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Josep M Haro
- Parc Sanitari Sant Joan de Déu, Fundacion Sant Joan de Deu, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Somnath Chatterji
- Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Martin Bobak
- Research Department of Epidemiology and Public Health, University College London, London, UK
| | - Jose L Ayuso-Mateos
- Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid, Madrid, Spain.,Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | | | - Ilona Koupil
- Department of Public Health Sciences, Centre for Health Equity Studies, Stockholm University, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jerome Bickenbach
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland.,Swiss Paraplegic Research, Nottwil, Switzerland
| | - Seppo Koskinen
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Beata Tobiasz-Adamczyk
- Department of Epidemiology and Population Studies, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Demosthenes Panagiotakos
- Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, Athens, Greece
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
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Oldridge N, Taylor RS. Cost-effectiveness of exercise therapy in patients with coronary heart disease, chronic heart failure and associated risk factors: A systematic review of economic evaluations of randomized clinical trials. Eur J Prev Cardiol 2019; 27:1045-1055. [DOI: 10.1177/2047487319881839] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims Prescribed exercise is effective in adults with coronary heart disease (CHD), chronic heart failure (CHF), intermittent claudication, body mass index (BMI) ≥25 kg/m2, hypertension or type 2 diabetes mellitus (T2DM), but the evidence for its cost-effectiveness is limited, shows large variations and is partly contradictory. Using World Health Organization and American Heart Association/American College of Cardiology value for money thresholds, we report the cost-effectiveness of exercise therapy, exercise training and exercise-based cardiac rehabilitation. Methods Electronic databases were searched for incremental cost-effectiveness and incremental cost–utility ratios and/or the probability of cost-effectiveness of exercise prescribed as therapy in economic evaluations conducted alongside randomized controlled trials (RCTs) published between 1 July 2008 and 28 October 2018. Results Of 19 incremental cost–utility ratios reported in 15 RCTs in patients with CHD, CHF, intermittent claudication or BMI ≥25 kg/m2, 63% met both value for money thresholds as ‘highly cost-effective’ or ‘high value’, with 26% ‘not cost-effective’ or of ‘low value’. The probability of intervention cost-effectiveness ranged from 23 to 100%, probably due to the different populations, interventions and comparators reported in the individual RCTs. Confirmation with the Consolidated Health Economic Evaluation Reporting checklist varied widely across the included studies. Conclusions The findings of this review support the cost-effectiveness of exercise therapy in patients with CHD, CHF, BMI ≥25 kg/m2 or intermittent claudication, but, with concerns about reporting standards, need further confirmation. No eligible economic evaluation based on RCTs was identified in patients with hypertension or T2DM.
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Affiliation(s)
- Neil Oldridge
- College of Health Sciences, University of Wisconsin-Milwaukee, USA
| | - Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, UK
- Institute of Health Services Research, University of Exeter Medical School, UK
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Fenocchi L, Riskowski JL, Mason H, Hendry GJ. A systematic review of economic evaluations of conservative treatments for chronic lower extremity musculoskeletal complaints. Rheumatol Adv Pract 2019; 2:rky030. [PMID: 31431975 PMCID: PMC6649923 DOI: 10.1093/rap/rky030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/19/2018] [Indexed: 11/12/2022] Open
Abstract
Objective The aim was to appraise and synthesize studies evaluating the clinical and cost effectiveness of conservative interventions for chronic lower extremity musculoskeletal (MSK) conditions and describe their characteristics, including the type of economic evaluation, primary outcomes and which conditions. Methods The search strategy related to economic evaluations of lower limb MSK conditions that used conservative therapies. Eight electronic databases were searched (CENTRAL, MEDLINE, PubMed, EMBASE, CINAHL, PEDro, NHSEED and Proquest), as were the reference lists from included articles. The quality of articles was appraised using a modified version of the economic evaluations’ reporting checklist (economic) and The Cochrane Collaboration’s tool for assessing risk of bias (clinical). Results Twenty-six studies were eligible and included in the review. Economic evaluations of conservative interventions for OA or pain affecting the knee/hip (n = 25; 93%) were most common. The main approaches adopted were cost–utility analysis (n = 17; 68%) or cost–effectiveness analysis (n = 5; 19%). Two studies involved interventions including footwear/foot orthoses; for heel pain (n = 1; 4%) and overuse injuries (n = 1; 4%). Fifty per cent of economic evaluations adopted the EQ-5D-3L as the primary outcome measure for quality of life and quality-adjusted life year calculations. Conclusion Economic evaluations have been conducted largely for exercise-based interventions for MSK conditions of the hip and knee. Few economic evaluations have been conducted for other clinically important lower limb MSK conditions. A matrix presentation of costs mapped with outcomes indicated increasing costs with either no difference or improvements in clinical effectiveness. The majority of economic evaluations were of good reporting quality, as were the accompanying clinical studies.
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Affiliation(s)
- Linda Fenocchi
- Musculoskeletal Health Research Group, School of Health and Life Sciences, Glasgow Caledonian University.,Yunus Centre for Social Business & Health, Glasgow Caledonian University, Glasgow, UK
| | - Jody L Riskowski
- Musculoskeletal Health Research Group, School of Health and Life Sciences, Glasgow Caledonian University
| | - Helen Mason
- Yunus Centre for Social Business & Health, Glasgow Caledonian University, Glasgow, UK
| | - Gordon J Hendry
- Musculoskeletal Health Research Group, School of Health and Life Sciences, Glasgow Caledonian University
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COST-EFFECTIVENESS OF INTERVENTIONS BASED ON PHYSICAL ACTIVITY IN THE TREATMENT OF CHRONIC CONDITIONS: A SYSTEMATIC LITERATURE REVIEW. Int J Technol Assess Health Care 2018; 34:481-497. [DOI: 10.1017/s0266462318000533] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives:The aim of this study is to review evidence on the cost-effectiveness of exercise-based interventions in the treatment of chronic conditions a decade after the publication of Roine et al. in 2009 (Roine E, Roine RP, Räsänen P, et al. Int J Technol Assess Health Care. 2009;25:427–454).Methods:We carried out a review of published articles in PUBMED and JSTOR between January 1, 2008, and December 31, 2016. Full economic evaluations of exercise programs targeting patients with a chronic condition were eligible for inclusion. Data on program, design, and economic characteristics were extracted using a predefined extraction form. The quality of the economic evaluations was appraised using the adjusted Consensus Health Economic Criteria List.Results:A total of 426 articles were identified and thirty-seven studies were selected. Eleven studies dealt with musculoskeletal and rheumatologic disorders, ten with cardiovascular diseases, six with neurological disorders, three with mental illnesses, three with cancers, and four with diabetes, respiratory diseases, or pelvic organ prolapse. In total, 60 percent of exercise programs were dominant or cost-effective. For musculoskeletal and rheumatologic disorders, 72 percent of programs were dominant or cost-effective while this was the case for 57 percent of programs for cardiovascular diseases using a nonsurgical comparator.Conclusions:There is clear evidence in favor of exercise-based programs for the treatment of musculoskeletal and rheumatologic disorders and, to a lesser extent, for the treatment of cardiovascular diseases. More research is needed to evaluate the cost-effectiveness of physical activity in the treatment of neurological disorders, mental illnesses, cancers, respiratory diseases, and diabetes/obesity.
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MacPherson H, Vickers A, Bland M, Torgerson D, Corbett M, Spackman E, Saramago P, Woods B, Weatherly H, Sculpher M, Manca A, Richmond S, Hopton A, Eldred J, Watt I. Acupuncture for chronic pain and depression in primary care: a programme of research. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundThere has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money.AimOur aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression.Methods and resultsWe synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective.ConclusionWe have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence.Trial registrationCurrent Controlled Trials ISRCTN63787732.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin Bland
- Department of Health Sciences, University of York, York, UK
| | | | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Eldon Spackman
- Centre for Health Economics, University of York, York, UK
| | - Pedro Saramago
- Centre for Health Economics, University of York, York, UK
| | - Beth Woods
- Centre for Health Economics, University of York, York, UK
| | | | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | | | - Ann Hopton
- Department of Health Sciences, University of York, York, UK
| | - Janet Eldred
- Department of Health Sciences, University of York, York, UK
| | - Ian Watt
- Department of Health Sciences/Hull York Medical School, University of York, York, UK
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9
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Stephenson R, Carnell S, Johnson N, Brown R, Wilkinson J, Mundy A, Payne S, Watkin N, N'Dow J, Sinclair A, Rees R, Barclay S, Cook JA, Goulao B, MacLennan G, McPherson G, Jackson M, Rapley T, Shen J, Vale L, Norrie J, McColl E, Pickard R. Open urethroplasty versus endoscopic urethrotomy--clarifying the management of men with recurrent urethral stricture (the OPEN trial): study protocol for a randomised controlled trial. Trials 2015; 16:600. [PMID: 26718754 PMCID: PMC4697334 DOI: 10.1186/s13063-015-1120-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 12/14/2015] [Indexed: 12/03/2022] Open
Abstract
Background Urethral stricture is a common cause of difficulty passing urine in men with prevalence of 0.5 %; about 62,000 men in the UK. The stricture is usually sited in the bulbar part of the urethra causing symptoms such as reduced urine flow. Initial treatment is typically by endoscopic urethrotomy but recurrence occurs in about 60 % of men within 2 years. The best treatment for men with recurrent bulbar stricture is uncertain. Repeat endoscopic urethrotomy opens the narrowing but it usually scars up again within 2 years requiring repeated procedures. The alternative of open urethroplasty involves surgically reconstructing the urethra, which may need an oral mucosal graft. It is a specialist procedure with a longer recovery period but may give lower risk of recurrence. In the absence of firm evidence as to which is best, individual men have to trade off the invasiveness and possible benefit of each option. Their preference will be influenced by individual social circumstances, availability of local expertise and clinician guidance. The open urethroplasty versus endoscopic urethrotomy (OPEN) trial aims to better guide the choice of treatment for men with recurrent urethral strictures by comparing benefit over 2 years in terms of symptom control and need for further treatment. Methods/Design OPEN is a pragmatic, UK multicentre, randomised trial. Men with recurrent bulbar urethral strictures (at least one previous treatment) will be randomised to undergo endoscopic urethrotomy or open urethroplasty. Participants will be followed for 24 months after randomisation, measuring symptoms, flow rate, the need for re-intervention, health-related quality of life, and costs. The primary clinical outcome is the difference in symptom control over 24 months measured by the area under the curve (AUC) of a validated score. The trial has been powered at 90 % with a type I error rate of 5 % to detect a 0.1 difference in AUC measured on a 0–1 scale. The analysis will be based on all participants as randomised (intention-to-treat). The primary economic outcome is the incremental cost per quality-adjusted life year. A qualitative study will assess willingness to be randomised and hence ability to recruit to the trial. Discussion The OPEN Trial seeks to clarify relative benefit of the current options for surgical treatment of recurrent bulbar urethral stricture which differ in their invasiveness and resources required. Our feasibility study identified that participation would be limited by patient preference and differing recruitment styles of general and specialist urologists. We formulated and implemented effective strategies to address these issues in particular by inviting participation as close as possible to diagnosis. In addition re-calculation of sample size as recruitment progressed allowed more efficient design given the limited target population and funding constraints. Recruitment is now to target. Trial registration ISRCTN98009168 Date of registration: 29 November 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1120-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rachel Stephenson
- Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Nicola Johnson
- Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Robbie Brown
- Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Jennifer Wilkinson
- Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Anthony Mundy
- University College London Hospital, 235 Euston Road, London, NW1 2BU, UK.
| | - Steven Payne
- Central Manchester Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.
| | - Nick Watkin
- St George's Hospital, Blackshaw Road, London, SW17 0QT, UK.
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Andrew Sinclair
- Stepping Hill Hospital, Hazel Grove, Stockport, SK2 7JE, UK.
| | - Rowland Rees
- Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
| | | | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7HE, UK.
| | - Beatriz Goulao
- Centre for Healthcare and Randomised Trials, Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Graeme MacLennan
- Centre for Healthcare and Randomised Trials, Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Gladys McPherson
- Centre for Healthcare and Randomised Trials, Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Matthew Jackson
- Institute of Cellular Medicine, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
| | - Tim Rapley
- Institute of Health & Society, Newcastle University, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - Jing Shen
- Institute of Health & Society, Newcastle University, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - John Norrie
- Centre for Healthcare and Randomised Trials, Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Robert Pickard
- Institute of Cellular Medicine, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK. .,The Medical School, Newcastle University, 3rd Floor William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
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Obesity and chronic pain: systematic review of prevalence and implications for pain practice. Reg Anesth Pain Med 2015; 40:91-111. [PMID: 25650632 DOI: 10.1097/aap.0000000000000218] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The combination of obesity and pain may worsen a patient's functional status and quality of life more than each condition in isolation. We systematically searched PubMed/MEDLINE and the Cochrane databases for all reports published on obesity and pain. The prevalence of combined obesity and pain was substantial. Good evidence shows that weight reduction can alleviate pain and diminish pain-related functional impairment. However, inadequate pain control can be a barrier to effective lifestyle modification and rehabilitation. This article examines specific pain management approaches for obese patients and reviews novel interventional techniques for treatment of obesity. The infrastructure for simultaneous treatment of obesity and pain already exists in pain medicine (eg, patient education, behavioral medicine approaches, physical rehabilitation, medications, and interventional treatment). Screening for obesity, pain-related disability, and behavioral disorders as well as monitoring of functional performance should become routine in pain medicine practices. Such an approach requires additional physician and staff training. Further research should focus on better understanding the interplay between these 2 very common conditions and the development of effective treatment strategies.
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Frempong SN, Goranitis I, Oppong R. Economic evaluation alongside factorial trials: a systematic review of empirical studies. Expert Rev Pharmacoecon Outcomes Res 2015; 15:801-11. [PMID: 26289735 DOI: 10.1586/14737167.2015.1076336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although economic evaluations have been performed alongside factorial trials, there seems to be limited guidance/consensus on appropriate methods of analysis. Following Centre for Review and Dissemination guidance, a systematic review of published literature for all years was performed to explore how economic evaluation alongside factorial trials have been conducted and only full economic evaluations conducted alongside factorial trials were included. A total of 16 relevant studies were identified, and an assessment of these indicated that two methods: within-the-table and at-the-margins approaches were used for the analysis. With the exception of one study, all others did not consider interactions in costs and outcomes or give a detailed explanation of why a particular approach was adopted. The authors recommend that additional guidance is needed, and further research is required to evaluate the impact of alternative methods on policy recommendations and establish good practice methods for the economic analysis of factorial trials.
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Affiliation(s)
- Samuel N Frempong
- a Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Ilias Goranitis
- a Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
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Mather RC, Garrett WE, Cole BJ, Hussey K, Bolognesi MP, Lassiter T, Orlando LA. Cost-effectiveness analysis of the diagnosis of meniscus tears. Am J Sports Med 2015; 43:128-37. [PMID: 25451791 DOI: 10.1177/0363546514557937] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN Economic and decision analysis; Level of evidence, 1. METHODS A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.
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Affiliation(s)
- Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - William E Garrett
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kristen Hussey
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tally Lassiter
- Department of Orthopaedic Surgery, Bassett Health Care Network, Cooperstown, New York, USA
| | - Lori A Orlando
- Department of Medicine and the Center for Applied Genomics & Precision Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Panagioti M, Richardson G, Murray E, Rogers A, Kennedy A, Newman S, Small N, Bower P. Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02540] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BackgroundA critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.ObjectiveTo determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.Data sourcesCochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.MethodsWe included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.ResultsWe found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.LimitationsSelf-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.ConclusionsVery few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.Study registrationThis study is registered as PROSPERO CRD42012002694.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Maria Panagioti
- National Institute for Health Research School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Anne Rogers
- Health Sciences, University of Southampton, Southampton, UK
| | - Anne Kennedy
- Health Sciences, University of Southampton, Southampton, UK
| | - Stanton Newman
- School of Health Sciences, City University London, London, UK
| | - Nicola Small
- National Institute for Health Research School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Watson AJM, Bruhn H, MacLeod K, McDonald A, McPherson G, Kilonzo M, Norrie J, Loudon MA, McCormack K, Buckley B, Brown S, Curran F, Jayne D, Rajagopal R, Cook JA. A pragmatic, multicentre, randomised controlled trial comparing stapled haemorrhoidopexy to traditional excisional surgery for haemorrhoidal disease (eTHoS): study protocol for a randomised controlled trial. Trials 2014; 15:439. [PMID: 25388563 PMCID: PMC4289313 DOI: 10.1186/1745-6215-15-439] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/26/2014] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Current interventions for haemorrhoidal disease include traditional haemorrhoidectomy (TH) and stapled haemorrhoidopexy (SH) surgery. However, uncertainty remains as to how they compare from a clinical, quality of life (QoL) and economic perspective. The study is therefore designed to determine whether SH is more effective and more cost-effective, compared with TH. METHODS/DESIGN eTHoS (either Traditional Haemorrhoidectomy or Stapled Haemorrhoidopexy for Haemorrhoidal Disease) is a pragmatic, multicentre, randomised controlled trial. Currently, 29 secondary care centres are open to recruitment. Patients, aged 18 year or older, with circumferential haemorrhoids grade II to IV, are eligible to take part. The primary clinical and economic outcomes are QoL profile (area under the curve derived from the EuroQol Group's 5 Dimension Health Status Questionnaire (EQ-5D) at all assessment points) and incremental cost per quality adjusted life year (QALY) based on the responses to the EQ-5D at 24 months. The secondary outcomes include a comparison of the SF-36 scores, pain and symptoms sub-domains, disease recurrence, complication rates and direct and indirect costs to the National Health Service (NHS). A sample size of n =338 per group has been calculated to provide 90% power to detect a difference in the mean area under the curve (AUC) of 0.25 standard deviations derived from EQ-5D score measurements, with a two-sided significance level of 5%. Allowing for non-response, 400 participants will be randomised per group. Randomisation will utilise a minimisation algorithm that incorporates centre, grade of haemorrhoidal disease, baseline EQ-5D score and gender. Blinding of participants and outcome assessors is not attempted. DISCUSSION This is one of the largest trials of its kind. In the United Kingdom alone, 29,000 operations for haemorrhoidal disease are done annually. The trial is therefore designed to give robust evidence on which clinicians and health service managers can base management decisions and, more importantly, patients can make informed choices. TRIAL REGISTRATION Current Controlled Trials ISRCTN80061723 (assigned 8 March 2010).
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Affiliation(s)
- Angus J M Watson
- />Department of Surgery, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ UK
| | - Hanne Bruhn
- />Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Kathleen MacLeod
- />Department of Surgery, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ UK
| | - Alison McDonald
- />Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Gladys McPherson
- />Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Mary Kilonzo
- />Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - John Norrie
- />Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Malcolm A Loudon
- />NHS Grampian, Department of Surgery, Aberdeen Royal Infirmary, Foresterhill Road, AB25 2ZN Aberdeen, UK
| | - Kirsty McCormack
- />Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Brian Buckley
- />Department of Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Steven Brown
- />Sheffield Teaching Hospitals NHS Foundation Trust, Department of Surgery, Northern General Hospital, Herries Road, Sheffield, S5 7AU UK
| | - Finlay Curran
- />Department of Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, M13 9WL UK
| | - David Jayne
- />The Leeds Teaching Hospitals NHS Trust, St James’ Hospital, Beckett Street, Leeds, West Yorkshire, LS9 7TF UK
| | - Ramesh Rajagopal
- />The Central Area of North Wales NHS Trust, Glan Clwyd Hospital, Sarn Lane, Rhyl, LL15 5UJ UK
| | - Jonathan A Cook
- />Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD UK
| | - On behalf of the eTHoS study group
- />Department of Surgery, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ UK
- />Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
- />Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK
- />NHS Grampian, Department of Surgery, Aberdeen Royal Infirmary, Foresterhill Road, AB25 2ZN Aberdeen, UK
- />Department of Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines
- />Sheffield Teaching Hospitals NHS Foundation Trust, Department of Surgery, Northern General Hospital, Herries Road, Sheffield, S5 7AU UK
- />Department of Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, M13 9WL UK
- />The Leeds Teaching Hospitals NHS Trust, St James’ Hospital, Beckett Street, Leeds, West Yorkshire, LS9 7TF UK
- />The Central Area of North Wales NHS Trust, Glan Clwyd Hospital, Sarn Lane, Rhyl, LL15 5UJ UK
- />Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD UK
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Boyers D, McNamee P, Clarke A, Jones D, Martin D, Schofield P, Smith BH. Cost-effectiveness of self-management methods for the treatment of chronic pain in an aging adult population: a systematic review of the literature. Clin J Pain 2013; 29:366-75. [PMID: 23042472 DOI: 10.1097/ajp.0b013e318250f539] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of self-management techniques for older populations (65 and over) with chronic pain and in the absence of such evidence to investigate this question in an aging adult population (average age 60 and over). METHODS Systematic review of randomized controlled trials (RCTs) with cost-effectiveness data and at least 6 months' follow-up, up to December 2010. RESULTS No RCT studies reported cost-effectiveness of self-management exclusively in the over 65 age group. Ten RCTs reported participants with an average age of 60 years or over and met all other inclusion criteria. All of these studies measured cost-effectiveness as cost per improvement in primary outcome, 7 of them using the Western Ontario and McMaster Universities Osteoarthritis Index score, of which 6 reported the pain dimension. Six studies reported cost per quality-adjusted life year (QALY)-gained information, with a further 1 reporting EQ-5D. In 7 studies, relative to usual care, self-management was effective, and in the remaining 3 studies, there was no significant difference. Among those reporting cost per QALY-gained results, self-management did not lead to statistically significant QALY gains relative to usual care (with only one exception). Eight studies suggested that the cost of developing and delivering self-management interventions may be partly offset by savings from reduced subsequent health care resource use. CONCLUSIONS Self-management is effective among an aging adult population (mean age over 60) with chronic pain and may be cost-effective when outcomes are measured using the Western Ontario and McMaster Universities Osteoarthritis Index pain score. Cost-effectiveness is less certain when measured using the QALY metric. Uncertainty over conclusions regarding cost-effectiveness exists partly due to lack of information regarding societal willingness to pay for pain improvement. There is a need for large multicentred high-quality RCTs to confirm the findings of this review exclusively among older aged populations, such as those who have already reached the statutory retirement age.
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Affiliation(s)
- Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Fosterhill Aberdeen AB25 2ZD, UK.
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Hollingworth W, McKell-Redwood D, Hampson L, Metcalfe C. Cost–utility analysis conducted alongside randomized controlled trials: Are economic end points considered in sample size calculations and does it matter? Clin Trials 2012; 10:43-53. [DOI: 10.1177/1740774512465358] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Many randomized controlled trials (RCTs) collect cost-effectiveness data. Without appropriate sample size calculations, patient recruitment may cease before the cost-effectiveness of the intervention can be established or continue after the cost-effectiveness of the intervention is established beyond doubt. Purpose We determined the frequency with which cost-effectiveness is considered in sample size calculations and whether RCT-based economic evaluations are likely to come to inconclusive results at odds with the clinical findings. Methods We searched the National Health Service Economic Evaluation Database (NHS EED) to identify RCT-based cost-utility analyses. RCTs that collected individual patient data on costs and quality-adjusted life years (QALYs) were eligible. Studies using models to extrapolate the results of RCTs or with insufficient information on incremental costs and QALYs were excluded. Results In total, 38 trials met eligibility criteria. Only one considered cost-effectiveness in sample size calculations. RCTs were less likely to reach definitive conclusions based on the cost-effectiveness results than the primary clinical outcome (15.8% vs. 42.1%; McNemar; p = 0.01). In trials that provided sufficient data, exploratory analysis indicated that the median power to detect important differences was 29.5% for QALYs, 94.1% for costs, and 78.7% for the primary clinical outcome. In three trials (7.9%), a definitely more effective intervention was found to be expensive and probably not cost-effective. Limitations Our results reflect trials where authors considered within-trial estimates of cost-effectiveness to be meaningful. In focusing on one primary clinical outcome from each RCT, we have simplified the clinical effectiveness results, although the primary outcome will usually be one that policy makers use in judging the ‘success’ of the intervention. Conclusions Economic evaluations conducted alongside RCTs are valuable, but often present inconclusive evidence. Trial results may lead to discordant messages when the most effective intervention is probably not the most cost-effective. Despite methodological advances, trialists rarely assessed the extent to which their trial might resolve the key uncertainties about the cost-effectiveness of interventions. We recommend that grant funders should do more to encourage trialists to include economic end points in sample size calculations, particularly when the majority of costs and benefits of the intervention occur within the time frame of the trial.
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Affiliation(s)
| | | | - Lisa Hampson
- Medical and Pharmaceutical Statistics Research Unit, Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Griffiths UK, Anigbogu B, Nanchahal K. Economic evaluations of adult weight management interventions: a systematic literature review focusing on methods used for determining health impacts. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2012; 10:145-162. [PMID: 22439628 DOI: 10.2165/11599250-000000000-00000] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND One of the challenges when undertaking economic evaluations of weight management interventions is to adequately assess future health impacts. Clinical trials commonly measure impacts using surrogate outcomes, such as reductions in body mass index, and investigators need to decide how these can best be used to predict future health effects. Since obesity is associated with an increased risk of numerous chronic diseases occurring at different future time points, modelling is needed for predictions. OBJECTIVE To assess the methods used in economic evaluations to determine health impacts of weight management interventions and to investigate whether differences in methods affect the cost-effectiveness estimates. METHODS Eight databases were systematically searched. Included studies were categorized according to a decision analytic approach and effect measures incorporated. RESULTS A total of 44 articles were included; 21 evaluated behavioural interventions, 12 evaluated surgical procedures and 11 evaluated pharmacological compounds. Of the 27 papers that estimated future impacts, eleven used Markov modelling, seven used a decision tree, five used a mathematical application, two used patient-level simulation and the modelling method was unclear in two papers. The most common types of effects included were co-morbidity treatment costs, heath-related quality of life due to weight loss and gain in survival. Only 12 of the studies included heath-related quality of life gains due to reduced co-morbidities and only one study included productivity gains. Despite consensus that trial-based analysis on its own is inadequate in guiding resource allocation decisions, it was used in 39% of the studies. Several of the modelling papers used model structures not suitable for chronic diseases with changing health risks. Three studies concluded that the intervention dominated standard care; meaning that it generated more quality-adjusted life-years (QALYs) for less cost. The incremental costs per QALY gained varied from $US235 to $US56,836 in the remaining studies using this outcome measure. An implicit hypothesis of the review was that studies including long-term health effects would illustrate greater cost effectiveness compared with trial-based studies. This hypothesis is partly confirmed with three studies arriving at dominating results, as these reach their conclusion from modelling future co-morbidity treatment cost savings. However, for the remaining studies there is little indication that decision-analytic modelling disparities explain the differences. CONCLUSIONS This is the first literature review comparing methods used in economic evaluations of weight management interventions, and it is the first time that observed differences in study results are addressed with a view to methodological explanations. We conclude that many studies have methodological deficiencies and we urge analysts to follow recommended practices and use models capable of depicting long-term health consequences.
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Affiliation(s)
- Ulla K Griffiths
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK.
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Abstract
John Ioannidis and Alan Garber discuss how to use incremental cost-effectiveness ratios (ICER) and related metrics so they can be useful for decision-making at the individual level, whether used by clinicians or individual patients.
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Affiliation(s)
- John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America.
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Foster N. A home-based program of simple quadriceps exercises reduces knee pain and improves knee function in overweight people with knee pain. THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY 2009; 55:284. [PMID: 19929773 DOI: 10.1016/s0004-9514(09)70010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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