Original Title: Revisión del coste-efectividad de las intervenciones de fisioterapia en la artrosis de rodilla

Authors' objectives: To know the cost-effectiveness of physical therapy interventions for patients with osteoarthritis of the knee.

Authors' results and conclusions: RESULTS: The electronic search identified 818 references, 44 were selected for their complete review. Finally, 7 articles related to 6 economic evaluations were included in the review. The manual search identified no additional studies. None of these studies was conducted in Spain. All economic evaluations were performed alongside randomized clinical trials. In 4 studies different exercise programmes at different settings and by different professionals were evaluated. The other 2 studies compared exercise programmes before arthroplasty with no exercise before arthroplasty. The results of these studies can be summarized as follows: In the OAK study a general practice-based nurse-led education programme in the UK was compared with a control group (Lord et al., 1999). The cost-minimization analysis conducted after finding no significant differences in effectiveness, showed significant differences in direct healthcare costs, social direct costs and indirect costs, being always less costly the control group. The limitations in the study design made that the results could not be conclusive or generalizable to other contexts. Other study conducted in the UK compared a programme of exercises at home and in classes in a centre with only performing exercises at home (Richardson et al., 2006, McCarthy et al., 2004). For the primary outcome measure, quality-adjusted life years (QALYs), measured by means of the EQ-5D questionnaire, it was found that the combination of home exercises and classes was better than just exercise at home, although the difference was not statistically significant. Regarding to costs, from the perspective of the NHS, it was obtained that the combined intervention was less costly than the exercises at home. Therefore, the programme of exercises at home was dominated by the combined programme. The authors concluded that the combined programme would have a 70% chance of being cost-effective if the willingness to pay for an additional QALY were £ 30,000. In the FAST study two types of exercise-based interventions (aerobic exercise and resistance exercise) were compared with an educational programme (Sevick et al., 2000). The educational intervention was dominated by the other two since it was less effective and more costly than physiotherapy interventions. The data also showed that the programme based on resistance exercises was dominated by the aerobic exercise programme. In the ADAPT study for interventions in patients with osteoarthritis and overweight or obesity were compared: diet, exercise, the combination of diet and exercise, and a control group that involved the promotion of a healthy lifestyle (Sevick et al. 2009). The intervention that obtained better results was the combination of diet and exercise, for which statistically significant differences were found in comparison to the control group in all outcome measures; it was also the most costeffective alternative for the three measures of WOMAC, physical function, pain and stiffness. Two studies assessed interventions of physical exercises before and after knee arthroplasty compared with doing the latter only (Beaupre et al., 2004, Mitchell et al., 2005). The two studies were consistent in finding no statistically significant differences in effectiveness or total costs, so that the conclusion drawn from these studies is that the tested interventions were not effective or cost-effective. The study with the best methodological quality scores was the ADAPT study. The study of Richardson et al. can be also considered of good quality since the methodological quality as an economic evaluation is very acceptable although the percentage of patients followed was insufficient. The study of Beaupre et al., although it was correctly executed as a clinical trial, it failed to prove the effectiveness of the intervention. The study worst rated as economic evaluation was carried out by Mitchell et al., since most of the Drummond’s questionnaire items were only partially achieved. CONCLUSIONS: • Six studies of heterogeneous methodological quality have evaluated the cost-effectiveness of physiotherapy in patients with osteoarthritis of the knee alongside clinical trials. • None of these studies has been performed in Spain. The results obtained in other contexts are not directly generalizable to Spain. • The combination of supervised exercise in classes in a clinical centre and exercises at home, as they are described in Richardson et al., in patients with knee osteoarthritis has proven to be cost-effective compared with exercise alone at home from NHS perspective. If the willingness to pay for an additional QALY were £ 30,000, the combined programme would have a 70% chance of being costeffective. This is based on one high quality economic evaluation. • The combination of diet and physical exercise sessions supervised in a clinical centre, as they are described in Sevick et al., in patients with knee osteoarthritis and overweight or obesity has proven to be more cost-effective that diet and exercise as separate interventions or patient education, in the USA and from the perspective of a thirdparty payer. This is based on one high quality economic evaluation. • Physical exercises before and after arthroplasty has not proven to be more cost-effective than physiotherapy only after knee arthroplasty in patients with knee osteoarthritis. This is based on two studies of not very high methodological quality. • No studies were identified that evaluated other physiotherapy techniques. The cost-effectiveness of physiotherapy compared with medication or surgery in patients with knee osteoarthritis has not been studied either.

Authors' recommendations: Given the results and conclusions of this systematic review, the following recommendations are stated: • To prioritize exercises in clinical centres over the prescription of exercises at home since the latter seems neither more effective nor cost-effective. • To assess the effectiveness and cost-effectiveness of those physiotherapy interventions already implemented in our national health system, starting by those similar to cost-effective interventions found in this review, that is, combination of exercise classes in a clinical centre and exercises at home in patients with osteoarthritis, and combination of diet and physical exercise sessions in a clinical centre in patients with osteoarthritis and overweight or obesity. • To assess the effectiveness and cost-effectiveness through clinical trials when possible or through analyses of registries or observational studies. • To not implement a programme without demonstrated costeffectiveness, such as physiotherapy before knee arthroplasty. • To conduct further research on the cost-effectiveness of exercise therapy for knee osteoarthritis by means of acceptable methodological designs, including appropriate outcome measures for economic evaluation as QALYs. • To study the cost-effectiveness of physiotherapy compared to other physiotherapy techniques, medication and surgery.

Authors' methods: A systematic review of the literature was conducted. Systematic searches were made in electronic databases MEDLINE y MEDLINE in process, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CRD (DARE, HTA, NHS-EED) and Physiotherapy Evidence Database (PEDro) in May 2013. Filters for economic evaluations were applied in MEDLINE, EMBASE and CINAHL. The searches were not restricted by date or by language. Articles that included both full economic evaluations developed alongside clinical trials and economic models were selected. Participants were men and women of all ages with knee osteoarthritis. Studies in which patients had been undergoing knee arthroplasty before starting the study were excluded. Studies that included patients with osteoarthritis of the knee or hip and did not provide the results of costeffectiveness separately were also excluded, or if the percentage of patients with osteoarthritis was less than 80%. All types of interventions based on physical therapy in order to relieve pain and/or maintain or regain mobility of the knee with osteoarthritis were included. Studies that evaluated educational interventions when the physiotherapy component was an important part of the content of the intervention were also included. The studies were selected independently by two reviewers. The data extraction was carried out by a reviewer and checked by a second reviewer. The verification of compliance with the inclusion criteria was conducted by an economist and a physiotherapist. The two reviewers contrasted their views and when they had doubts or discrepancies, these were resolved by consensus or with the help of a third reviewer (economist or physiotherapist depending on the question). The data were gathered in spreadsheets designed ad hoc. The quality of economic evaluations was assessed according to the criteria of Drummond et al. The PEDro scale was used when economic evaluations were performed alongside clinical trials. The review of methodological quality was performed independently by two reviewers. The data collected were synthesized through narrative procedures with detailed tables of the results.

Project Status: Completed

Year Published: 2013

URL for published report: https://sescs.es/revision-del-coste-efectividad-de-las-intervenciones-de-fisioterapia-en-la-artrosis-de-rodilla/

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Canary Health Service

Contact Address: Dirección del Servicio. Servicio Canario de la Salud, Camino Candelaria 44, 1ª planta, 38109 El Rosario, Santa Cruz de Tenerife

Contact Name: sescs@sescs.es

Contact Email: sescs@sescs.es