Abstract
BackgroundThere is limited information on the costs and benefits of alternative adjunct non-pharmacological treatments for knee osteoarthritis and little guidance on which should be prioritised for commissioning within the NHS. This study estimates the costs and benefits of acupuncture, braces, heat treatment, insoles, interferential therapy, laser/light therapy, manual therapy, neuromuscular electrical stimulation, pulsed electrical stimulation, pulsed electromagnetic fields, static magnets and transcutaneous electrical nerve Stimulation (TENS), based on all relevant data, to facilitate a more complete assessment of value.MethodsData from 88 randomised controlled trials including 7,507 patients were obtained from a systematic review. The studies reported a wide range of outcomes. These were converted into EQ-5D index values using prediction models, and synthesised using network meta-analysis. Analyses were conducted including firstly all trials and secondly only trials with low risk of selection bias. Resource use was estimated from trials, expert opinion and the literature. A decision analytic model synthesised all evidence to assess interventions over a typical treatment period (constant benefit over eight weeks or linear increase in effect over weeks zero to eight and dissipation over weeks eight to 16).ResultsWhen all trials are considered, TENS is cost-effective at thresholds of £20–30,000 per QALY with an incremental cost-effectiveness ratio of £2,690 per QALY vs. usual care. When trials with a low risk of selection bias are considered, acupuncture is cost-effective with an incremental cost-effectiveness ratio of £13,502 per QALY vs. TENS. The results of the analysis were sensitive to varying the intensity, with which interventions were delivered, and the magnitude and duration of intervention effects on EQ-5D.ConclusionsUsing the £20,000 per QALY NICE threshold results in TENS being cost-effective if all trials are considered. If only higher quality trials are considered, acupuncture is cost-effective at this threshold, and thresholds down to £14,000 per QALY.
Highlights
Patients with knee osteoarthritis have a range of treatment options available including pharmacological, non-pharmacological and surgical management
The only additional non-pharmacological therapies recommended by the European League Against Rheumatism (EULAR) guidelines are the use of appliances and appropriate footwear[1, 3]
The objective of this study is to assess the cost-effectiveness of a range of adjunct nonpharmacological interventions for use in knee osteoarthritis patients within the UK National Health Service (NHS) using consistent methods to estimate costs and Quality-Adjusted Life Year (QALY)
Summary
Patients with knee osteoarthritis have a range of treatment options available including pharmacological, non-pharmacological and surgical management. The only additional non-pharmacological therapies recommended by the European League Against Rheumatism (EULAR) guidelines are the use of appliances (sticks, insoles, knee bracing and other assistive devices) and appropriate footwear[1, 3]. In the UK, the National Institute for Health and Care Excellence (NICE) guideline[2] recommends local heat and cold, manual therapy, transcutaneous electrical nerve stimulation (TENS), braces, joint supports, insoles and assistive devices. Acupuncture was the only non-pharmacological adjunct treatment explicitly not recommended by NICE though a range of other interventions was reviewed. This study estimates the costs and benefits of acupuncture, braces, heat treatment, insoles, interferential therapy, laser/light therapy, manual therapy, neuromuscular electrical stimulation, pulsed electrical stimulation, pulsed electromagnetic fields, static magnets and transcutaneous electrical nerve Stimulation (TENS), based on all relevant data, to facilitate a more complete assessment of value
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