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Cost-Effectiveness of Physical Therapy Only and of Physical Therapy Added to Usual Care for Various Health Conditions: A Review

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  • Dogemo Physio

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Background: Given the continually rising health-care costs, interventions of health-care providers should be cost-effective. Purpose: This review aimed to summarize current cost-effectiveness of physical therapy. Specific aims were a) to analyze cost-effectiveness of physical therapy only compared to usual care only, b) to analyze cost-effectiveness of physical therapy added to usual care compared to usual care only, and c) to specify in which health condition physical therapy only or physical therapy added to usual care was cost-effective. Data sources: We searched in Medline, CINAHL, PEDro and Cochrane Library; and manually in topic-related systematic reviews. Study selection: We included studies published between 1998 and 2014 that investigated cost - effectiveness of interventions carried out by physical therapists. The methodological quality was assessed with the Cochrane risk of bias assessment for intervention studies as well as with the Quality of Health Economic Analyses Scale. Data extraction: We extracted effectiveness and cost data for calculating incremental cost-effectiveness ratios (ICRs) and extracted the original authors' conclusions. Data synthesis: The 18 included studies presented low risk of bias and contained 8 comparisons of physical therapy only with usual care only; and 11 comparisons of physical therapy added to usual care with usual care only. Based on ICERs physical therapy only or added to usual care was cost-effective in 9 out of the 19 comparisons and in 10 comparisons according to the original authors' conclusion. Conclusion: Physical therapy only or added to usual care implies improved health in almost all studies. The cost-effectiveness of such interventions is demonstrated in half of the studies. This result might have been influenced by the fact that different definitions of the notion of "cost-effectiveness" exist.
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Cost-Effectiveness of Physical Therapy
Only and of Usual Care for Various
Health Conditions: Systematic Review
Elisabeth Bu¨rge,
Dominique Monnin, Andre´ Berchtold, Lara Allet
Background. Given continually rising health care costs, interventions of health care
providers should be cost-effective.
Purpose. This review aimed to summarize current cost-effectiveness of physical therapy.
Specific aims were: (1) to analyze cost-effectiveness of physical therapy only compared with
usual care only, (2) to analyze cost-effectiveness of physical therapy added to usual care
compared with usual care only, and (3) to specify in which health conditions physical therapy
only or physical therapy added to usual care was cost-effective.
Data Sources. Topic-related systematic reviews were searched in MEDLINE, CINAHL,
PEDro, and Cochrane Library and manually.
Study Selection. Studies published between 1998 and 2014 that investigated the cost-
effectiveness of interventions carried out by physical therapists were reviewed. The method-
ological quality was assessed with the Cochrane risk of bias assessment for intervention studies
and with the Quality of Health Economic Analyses Scale.
Data Extraction. Effectiveness and cost data for calculating incremental cost-
effectiveness ratios (ICERs) and the original authors’ conclusions were extracted.
Data Synthesis. The 18 included studies presented low risk of bias and contained 8
comparisons of physical therapy only with usual care only and 11 comparisons of physical
therapy added to usual care with usual care only. Based on ICERs, physical therapy only or
added to usual care was cost-effective in 9 out of the 19 comparisons and in 10 comparisons
according to the original authors’ conclusions.
Conclusion. Physical therapy only or added to usual care implies improved health in
almost all studies. The cost-effectiveness of such interventions was demonstrated in half of the
studies. This result might have been influenced by the fact that different definitions of the
notion of “cost-effectiveness” exist.
E. Bu¨rge,
MPTSc, Health Depart-
ment, University of Applied Sci-
ences of Western Switzerland of
Geneva, Geneva, Switzerland.
D. Monnin, PT, Care Services
Directorate, University Hospitals
and University of Geneva.
A. Berchtold, PhD, University of
Lausanne, Institute of Social Sci-
ences and NCCR LIVES, Lausanne,
Switzerland.
L. Allet, PhD, University of Geneva,
Medical Faculty, Department of
Community Medicine, Geneva,
Switzerland, and University of
Applied Sciences of Western Swit-
zerland, Geneva, Switzerland, Rue
des Caroubiers 25, CH-1227
Carouge, Switzerland. Address all
correspondence to Dr Allet at:
lara.allet@hcuge.ch.
Died June 8, 2015.
[Bu¨rge E, Monnin D, Berchtold A,
Allet L. Cost-effectiveness of
physical therapy only and of phys-
ical therapy added to usual care
for various health conditions: sys-
tematic review. Phys Ther.
2016;96:774–786.]
© 2016 American Physical Therapy
Association
Published Ahead of Print:
December 17, 2015
Accepted: December 6, 2015
Submitted: August 5, 2014
Research Report
Post a Rapid Response to
this article at:
ptjournal.apta.org
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Health care costs are continually
rising, particularly in the richest
countries of the European com-
munity.
1
This phenomenon is probably
due to the increasing number of people
approaching the age of retirement and
the decreasing number of people
engaged in professional life.
2
Therefore,
most European countries, where health
care costs are covered due to the income
of the working generation, should find
new strategies to avoid a financial crisis
of the health care system. Kocher
3
iden-
tified 292 different reasons for the
exploding health care costs. The 3 main
reasons were: (1) medical technological
progress and new pharmaceuticals, (2)
demographic aging of the population
and increasing number of health care ser-
vices, and (3) a provider-induced
demand.
3
The American health care sys-
tem is also searching for strategies to
reduce spending on health care.
4
Cur-
rently, not every American citizen has
health care insurance, and those who
have health care insurance can either
benefit from excellent care or accept
poor health care services. With the
planned reform, standard health care
should be accessible for each US citizen,
quality should be high, and costs should
be controlled.
5
Consequently, health
care providers should not only guarantee
the effect of their interventions but also
ensure their cost-effectiveness. Being
aware that health care costs are an issue
all over the world, we integrated cost-
effectiveness results of physical therapy
of all countries in our review.
Generally, there are 5 types of
economic analyses in health care: cost-
minimization, cost-effectiveness, cost-
utility, cost-consequence, and cost-
benefit.
6
As recommended for health and
medicine,
7
cost-effectiveness and cost-
utility analyses are the most relevant for
physical therapy. They enable estimates
of costs and efficacy of physical therapy
as sole intervention or of physical ther-
apy added to usual care.
6
The difference
between these 2 analyses lies in their
denominator: cost-effectiveness relies on
a measure of the health change following
a treatment, and cost-utility uses the
notion of quality-adjusted life year
(QALY), an economic indicator. In this
review, we focus on cost-effectiveness of
physical therapy. Cost-utility results are
reported only when they could be
directly extracted from the original arti-
cles, because information for the compu-
tation of QALYs is missing. Although
physical therapy only or physical therapy
added to usual care increases health care
costs, its effect might reduce costs
related to loss of productivity, consump-
tion of medication, or treatments by
other health professionals.
In 2007, at the request of the American
Physical Therapy Association (APTA), a
team of researchers wrote a review on
cost-effectiveness in physical therapy.
6
They found a very small number of ref-
erences related to cost-effectiveness
prior to 1998. Therefore, they decided to
perform their search from 1998 through
April 2008. Their review, published in
2009, is exhaustive and of excellent qual-
ity.
6
However, no update has been pro-
vided since then. Consequently, our
review aimed to provide an overview of
the current knowledge of cost-
effectiveness of physical therapy. The
specific aims were: (1) to analyze current
cost-effectiveness of physical therapy
only compared with usual care only, (2)
to analyze current cost-effectiveness of
physical therapy added to usual care
compared with usual care only, and (3)
to specify in which health conditions
physical therapy, compared with usual
care, or added to usual care was cost-
effective. Thereby, this review should
support clinical decision making when
physical therapy is offered as a single
treatment option or is added to usual
care. “Usual care” includes medication,
diagnostic services, physician counsel-
ing, and physician office visits.
Method
Data Sources and Searches
We performed a systematic review. It
synthesized cost-effectiveness studies
completed between January 1, 1998, and
March 31, 2014. To identify articles, we
chose a free search on the MEDLINE,
CINAHL, PEDro, and Cochrane Library
databases using the following key words:
cost-effectiveness [Title/Abstract] AND
(physical therapy [Title/Abstract] OR
physiotherapy [Title/Abstract]). A free
search method permitted us to identify a
greater number of articles than a search
method with MeSH (Medical Subject
Headings) terms. We agreed on this
search strategy, which has been
approved by an experienced librarian of
the University of Applied Sciences and
Arts of Western Switzerland, Geneva.
Study Selection
We selected articles written in English,
French, German, or Italian. We consid-
ered study designs with a control group.
Regarding economic analyses, we con-
sidered cost-effectiveness and cost-utility
analyses. Articles published between Jan-
uary 1998 and January 2008 were iden-
tified through a manual check of the ref-
erences included in the specific physical
therapy–related review by Peterson
et al.
6
The computerized search was con-
ducted between January 1, 2008, and
March 31, 2014. In addition, we checked
the reference list of all identified system-
atic reviews that fulfilled our selection
criteria. We selected only references in
response to our selection criteria and on
the condition that they were not already
included in the review by Peterson et al.
6
We checked whether the terms “cost-
effectiveness” and “physical therapy”
appeared either in the title or in the
abstract. Articles were excluded if a mul-
tidisciplinary team or health profession-
als other than physical therapists applied
the interventions. This criterion is differ-
ent from the review by Peterson et al,
6
who had defined the interventions (exer-
cise for arthritis, back pain, heart condi-
tions, fall prevention, or joints; use of hip
protectors; and continence training) but
who did not consider whether the health
professional who applied the therapy
was a physical therapist. Cost-
effectiveness of interdisciplinary collabo-
rations is a result of coordinated inter-
ventions of different health care
professionals; it cannot be attributed to
only one of them. If there is evidence
that physical therapy is cost-effective, its
use in health care is justified, and its
integration in interdisciplinary teams will
not be questioned.
Other exclusion criteria were: (1) study
design without a control group; (2) miss-
ing calculation of cost-effectiveness; (3)
utilization of cost-effectiveness for
another purpose (eg, if continuing edu-
cation influenced cost-effectiveness or
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introduction of guidelines or economic
comparison of 2 clinics); intervention
concerned a diagnostic test; and (4) cost
analysis concerned comparison of differ-
ent physical therapy interventions, differ-
ent numbers of physical therapy ses-
sions, or different access modalities to
physical therapy.
It should be noted that we included only
studies with a cost-effectiveness analysis.
It is likely that other high-quality studies
that assessed the clinical effectiveness of
an intervention do exist.
Data Extraction and Quality
Assessment
We extracted the study design, year of
publication, country, sample size, health
condition, number and duration (in
weeks) of applied interventions, dura-
tion of observation (in months), the
physical therapy intervention and con-
trol intervention and their effects, and
whether physical therapy was applied to
groups of patients or in individual ses-
sions. In addition, we extracted data nec-
essary for the computation of ICERs
(incremental cost-effectiveness ratios).
Regarding costs, we considered the
mean difference of total costs of the
experimental group and the control
group. We extracted the amount in the
original currency, added the inflation
rate until January 1, 2014, and finally
converted the amount into US dollars
when it was given in another currency.
While reporting the outcomes, we con-
sidered only the final result, without tak-
ing intermediate measures into account;
this approach is similar to the review
conducted by Peterson et al.
6
When the
follow-up measurement was shorter or
longer than 12 months, we extracted the
results that were closer to 12 months.
We reported the mean difference of the
clinical effect observed in the experi-
mental group and in the control group.
When the difference was positive, the
effect of the physical therapy interven-
tion (physical therapy only or physical
therapy added to usual care) was consid-
ered as superior compared with the
effect of usual care only.
Two independent researchers assessed
the methodological quality of all
included articles with the Cochrane risk
of bias assessment tool.
8
This checklist
considers 6 items qualified as having a
“low, unclear, or high risk of bias.” The
items are: (1) sequence generation; (2)
allocation concealment; (3) blinding of
participants, personnel, and outcome
assessors; (4) incomplete outcome data;
(5) selective outcome reporting; and (6)
other sources of bias.
8
In a preliminary
step, the assessors developed a guide on
how they interpret each item based on
the text in the Cochrane handbook.
8
For
the third item (blinding), we distin-
guished blinding of patients, therapists,
and outcome assessors. Although blind-
ing of patients and therapists is impossi-
ble for the majority of the interventions,
we considered this item as having a high
risk of bias if one of the involved people
was not blinded or if the outcome was
self-reported by the patient. For the last
item (other sources of bias), we consid-
ered absence of ethical approval as hav-
ing a high risk of bias. For the assessment
of the 6 items, we considered the
detailed description of the randomized
controlled trial (RCT) if the authors of
the economic analysis referred to it. The
Cochrane Collaboration does not define
a cutoff score for their risk of bias
assessment.
The same 2 researchers (E.B. and D.M.)
assessed methodological quality of the
economic analyses with the Quality of
Health Economic Studies (QHES) scale,
9
which shows a good construct validity.
This scale has previously been used to
assess the quality of economic analyses
of physical therapy interventions.
6
The
QHES assesses 3 types of economic
analyses: cost-minimization, cost-
effectiveness, and cost-utility. It com-
prises 16 items; each item is weighted
according to its importance. The
response to each item is binary. The final
score represents the sum of the com-
pleted items. A score of 100 points indi-
cates perfect quality. However, the scale
does not indicate how scores should be
interpreted. We considered a score of 70
as the cutoff for the classification of a
“good-quality” study, as Peterson et al
6
did. The QHES was used according to the
guide of Pinto et al.
10
For both quality assessments, both raters
performed an evaluation of one article,
permitting them to clarify their compre-
hension of each item. Then, they inde-
pendently evaluated 2 other articles.
After that, they compared their results,
which confirmed that they interpreted
the items in a similar manner. Finally,
they independently assessed the remain-
ing articles and discussed the final quality
score. They searched for a consensus for
discordant evaluation.
Data Synthesis and Analysis
We synthesized the results of the eco-
nomic analyses for each comparison:
physical therapy only versus usual care
only and physical therapy added to usual
care versus usual care only. We further
synthesized the results of the economic
analyses for each group of health condi-
tions: musculoskeletal (spine and joint
problems) and other conditions (internal
medicine and neurological). A descrip-
tive analysis was performed for all data.
In a second step, we considered the cost-
effectiveness of each intervention. First,
the ICER, which is the standard tool used
to evaluate the cost-effectiveness of an
intervention, was reported. This ratio is
computed as the cost difference
between the intervention and the usual
care divided by the difference in health
outcome provided by the 2 treatments.
Some included studies did not present
ICERs. Moreover, different kinds of
ICERs can be computed in function of
different outcomes. Therefore, we pro-
ceeded as follows: (1) when the ICERs
were reported in terms of QALYs, they
are directly reported in Table 1; and (2)
whenever possible, we computed at
least one ICER based on an outcome vari-
able such as visual analog scale or
36-Item Short-Form Health Survey (SF-
36) score. This outcome determines
whether the treatment provides equal or
better benefit in terms of health.
Another point related to the computa-
tion of ICERs is the kind of costs that are
included in the analysis. Some authors
reported only costs that are directly
related to treatments, whereas other
authors included societal costs (eg, costs
due to sick leave from their job). These
differences made it difficult to compare
the resulting ICERs. Therefore, we based
our main computation on direct costs
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Table 1.
Cost-Effectiveness Analysis: Number of Participants, Measure Used as Basis for ICER Calculations, ICER in 2014 Adjusted US Dollars, Cost-
Effectiveness on the Basis of the ICER and the Definition Used in This Review, and Original Authors’ Conclusion About Cost-Effectiveness
a
Study
No. of
Participants
Basis for ICER
Calculation
ICER in 2014 Adjusted US
Dollars
b
Cost-
Effectiveness
on Basis of
ICERc
Original Authors’
Conclusion About
Cost-Effectiveness
Physical Therapy Only Versus Usual Care Only
MSC/Spine Johnson et al,
25
2007
196 QALY 11,332 (direct) The program of exercise
and education has a
small additional benefit in
the reduction of LBP and
disability; interventions
are relatively inexpensive
and prove to be cost-
effective.
VAS 17 (direct)
RMDQ 103 (direct)
Korthals-de Bos
et al,
26
2003
183 VAS EG1: 237 (direct), –153 (societal)
EG2: 22,172 (direct),
173,640 (societal)
(EG2 only) Manual therapy (spinal
mobilization) (EG2) is
more cost-effective than
physical therapy (EG1) or
care by a general
practitioner in patients
with neck pain.
Functional
disability
EG1: 108 (direct), –69 (societal)
EG2: –158 (direct),
–1,240 (societal)
Perceived
recovery
EG1: 36 (direct), –24 (societal)
EG2: –14 (direct), –113 (societal)
Moffett et al,
27
1999
187 RDQ –42 (direct), –260 (societal) Cognitive-behavioral
approach was cost-
effective for patients with
chronic LBP.
Aberdeen Back
Pain Scale
–14 (direct), –83 (societal)
EQ-5D –3,017 (direct),
–18,461 (societal)
MSC/Joint Korthals-de Bos
et al,
29
2004
185 VAS 66 (direct), 98 (societal) The intervention was not
found to be cost-
effective. Wait-and-see
policy was recommended
for patients with
epicondylitis.
Elbow disability 92 (direct), 137 (societal)
Pinto et al,
30
2013
205 WOMAC (full
score)
EG1: 81 (direct), –19 (societal)
EG2: 41 (direct), 35 (societal)
EG1 and EG2: 179 (direct),
129 (societal)
(EG1 only) Manual therapy (EG1),
exercise (EG2), and
combined (EG1 and EG2)
programs were cost-
effective compared with
usual care for treating
patients with knee
osteoarthritis.
QALY EG1: 67,778 (direct),
–15,902 (societal)
EG2: 15,113 (direct),
14,151 (societal)
EG1 and EG2: 94,807 (direct),
98,445 (societal)
Tan et al,
31
2010
131 EQ-5D 49,033 (direct),
–56,297 (societal)
Exercise therapy (EG) was
cost-effective compared
with the conservative
strategy in patients with
patellofemoral pain
syndrome.
QALY 20,080 (direct),
–23,055 (societal)
Other
Conditions
Glazener
et al,
12
2011
411 EQ-5D (*) –12,018 (direct),
39,043 (societal)
Individual physical
therapy (EG) for men
with urinary incontinence
after prostate surgery was
unlikely to be cost-
effective compared with
usual care (CG), which
included information
about pelvic-floor muscle
training.
QALY (*) –180,276 (direct),
585,648 (societal)
(Continued)
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Table 1.
Continued
Study
No. of
Participants
Basis for ICER
Calculation
ICER in 2014 Adjusted US
Dollars
b
Cost-
Effectiveness
on Basis of
ICER
c
Original Authors’
Conclusion About
Cost-Effectiveness
Physical Therapy Only Versus Usual Care Only
Mazari et al,
13
2013
178 QALY –606,589 (direct) Supervised exercise was
more cost-effective
than PTA only as
treatment for patients
with intermittent
claudication.
Physical Therapy Added to Usual Care vs Usual Care Only
MSC/Spine Luijsterburg
et al,
40
2007
112 EQ-5D 6,279 (direct), 46,687 (societal) The treatment of
patients with lumbar
radicular syndrome
with physical therapy
added to usual care
(EG) was not more
cost-effective than
usual care only.
Global perceived
effect
21 (direct), 156 (societal)
QALY 1,353 (direct), 10,062 (societal)
Niemistö et al,
28
2005
204 VAS 261 (societal) Physician consultation
only was more cost-
effective for both
health care use and
work absenteeism and
led to equal
improvement in health-
related quality of life.
ODI 1,366 (societal)
MSC/Joint Bergman et al,
34
2010
150 Severity of main
complaint
188 (societal) Manual therapy
accelerated recovery of
patients with shoulder
complaints on all
outcome measures but
was associated with
higher costs.
Shoulder pain 322 (societal)
Shoulder
disability
18 (societal)
EQ-5D 7,515 (societal)
Buchbinder
et al,
35
2007
156 SPADI (*) –27 (direct), –16 (societal) According to the
performed cost-
effectiveness analysis,
physical therapy
following arthrographic
joint distension was not
cost-effective.
Overall pain (*) –423 (direct), –240 (societal)
AQOL 2,326 (direct), 1,319 (societal)
SF-36 mental
function
233 (direct), 132 (societal)
SF-36 physical
function
65 (direct), 37 (societal)
Hurley et al,
32
2012
418 WOMAC pain –557 (societal) Physical therapy added
to usual care was cost-
effective; resulted in
better physical function
and occasioned lower
costs than usual care
only.
Juhakoski
et al,
36
2011
120 WOMAC pain –95 (direct) No statistically
significant differences in
the total health care
system costs between
the groups.
WOMAC
function
–66 (direct)
Severens
et al,
33
1999
135 ISS 218 (societal) Physical therapy added
to usual care was more
effective and less costly
than usual care only.
(Continued)
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(available in all studies), and, whenever
possible, we added an ICER for societal
costs. We defined societal costs as the
total costs, including both direct and
additional costs. All results are reported
in Table 1.
No absolute agreement exists on the def-
inition of cost-effectiveness and the inter-
pretation of ICERs. Cost-effectiveness is
generally related to the willingness to
pay for an additional unit of health,
11
but
no universal guidelines exist regarding
the threshold to use. For instance, Gla-
zener et al
12
used 2 thresholds (£20,000
and £30,000) for cost-effectiveness in
terms of additional costs for the interven-
tion per QALY, but without justification.
Mazari et al
13
used a threshold of 25,000
to 35,000, as recommended by the
National Institute for Health and Care
Excellence. Another option is to con-
sider cost-effectiveness as an allocation
of a fixed health budget between differ-
ent treatments maximizing the overall
level of health of the society.
11
The data published in the 19 studies
included in our review made it impossi-
ble to aggregate all results on a unique
scale. Therefore, we chose to report
both the conclusion of the original
authors and our own judgment (Tab. 1).
Our judgment is based on the simplest
possible definition of ICER, which
describes that an intervention is cost-
effective if it costs less than the usual
care for an equal or better benefit in
terms of health. Our conclusion was then
based on the point estimate of ICERs
evaluated for societal cost (or direct cost
when societal costs were not available).
In case of discrepancies among the dif-
ferent health outcomes, we relied on (1)
QALY (when available) and (2) the
majority of measures.
Results
Article Selection
We identified 367 references; 291 arti-
cles remained after elimination of dou-
bles (n72) and exclusion of articles that
were not written in English, French, Ital-
ian, or German (n4). We identified 13
systematic reviews. One of the 13 sys-
tematic reviews was the review by Peter-
son et al,
6
which responded precisely to
our research question. We checked the
95 references included in the review by
Peterson et al
6
; 8 articles met our inclu-
Table 1.
Continued
Study
No. of
Participants
Basis for ICER
Calculation
ICER in 2014 Adjusted US
Dollars
b
Cost-
Effectiveness
on Basis of
ICER
c
Original Authors’
Conclusion About
Cost-Effectiveness
Physical Therapy Added to Usual Care vs Usual Care Only
Other
Conditions
Fletcher et al,
37
2012
130 QALY –8,499 (direct), –2,324 (societal) The cost-effectiveness
analysis showed that
there was more than
80% probability that
physical therapy added
to usual care was a cost-
effective strategy
compared with usual
care only.
EQ-5D –3,187 (direct), –872 (societal)
Mazari et al,
13
2013
178 QALY –21,375 (direct) Standardized exercise
combined with PTA is
more cost-effective than
PTA alone.
Robertson et
al,
39
2001
133 SF-36 physical
functioning
37 (direct) Despite a reduction in
falls as a result of this
home exercise program,
there was no significant
reduction in health care
costs.
Underwood
et al,
38
2013
798 QALY (*) –490,388 (direct) Usual care was more
effective and less costly
compared with the
exercise program.
a
ICERincremental cost-effectiveness ratio; EGexperimental group; VASvisual analog scale; RMDQRoland-Morris Disability Questionnaire; RDQRoland
Disability Questionnaire; ODIOswestry Disability Index; ISSimpairment-level sum score; EQ-5DEuropean Quality of Life–5 Dimensions, a health-related
quality-of-life measure; SPADIShoulder Pain and Disability Index; SF-3636-Item Short-Form Health Survey; AQOLassessment of quality of life;
QALYquality-adjusted life year; WOMACWestern Ontario and McMaster Universities Osteoarthritis Index; LBPlow back pain; PTApercutaneous
transluminal angioplasty; MSCmusculoskeletal condition.
b
A negative value for ICER indicates a result in favor of the intervention program, except when usual care was more effective on health than the
intervention. In this case, a negative value of the ICER indicates a result in disfavor of the intervention program. These cases are marked with the symbol (*).
“Direct” indicates that only costs directly imputable to health treatments were included in the computation, whereas “societal” means that other elements
(eg, sick leave from paid work) are taken into account.
c
Plus sign () indicates a cost-effective intervention using the definition of the present review, and minus sign (–) indicates a non–cost-effective
intervention.
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sion criteria. We checked the reference
lists of the other 12 reviews about cost-
effectiveness of interventions applied by
different health professionals, which we,
therefore, called “nonspecific systematic
reviews.” The manual search of the ref-
erence lists of these 12 nonspecific sys-
tematic reviews (Pinto et al,
10
Driessen
et al,
14
Indrakanti et al,
15
Maund et al,
16
Furlan et al,
17
Michaleff et al,
18
Lauche
et al,
19
Bermingham et al,
20
Armstrong et
al,
21
Boyers et al,
22
O’Doherty et al,
23
and
Boland et al
24
) yielded 40 references; 1
article met the selection criteria. At the
end of the selection process, 18 refer-
ences met the selection criteria (Figure)
and were included in the analyses.
Quality of the Articles
Randomized controlled trial methodolog-
ical quality was assessed with the
Cochrane criteria permitting us to high-
light methodological strengths and weak-
nesses of the included trials (Tab. 2).
Blinding of participants and therapists
was unfeasible; therefore, these items
were assessed in all studies as being “at
high risk of bias” or “unclear.” Item 4
(incomplete outcome data) was identi-
fied as an item at high risk in 7 studies
and was unclear in 2 studies, most fre-
quently because the reasons for which
the patients dropped out were not spec-
ified. The interrater agreement was high;
only one item out of the 108 ratings (18
studies 6 items) was discordant.
Methodological quality of the economic
analyses was high; out of the 18 studies,
17 (94%) had a QHES score between 70
and 100 points, which is considered a
good to excellent score; 1 study had a
score below 70 points (Tab. 3). The
interrater agreement was high; out of the
288 ratings (18 studies 16 items), only
2 items were rated discordantly.
Summary of the Included Articles
Table 4 presents the authors and year of
publication, the country, health condi-
tions, the experimental and control inter-
ventions, and the average number of
treatment sessions across study sites. We
grouped the results according to the
health condition of the participants of
each study for each comparison: physical
therapy only versus usual care only or
physical therapy added to usual care ver-
sus usual care only. Thirteen studies con-
cerned musculoskeletal conditions: back
pain for the comparison of physical ther-
apy only versus usual care only
(n3)
25–27
and for the comparison of
physical therapy added to usual care ver-
sus usual care only (n2)
25,28
and joint
problems for the comparison of physical
therapy only versus usual care only
(n3)
29–31
and for the comparison of
physical therapy added to usual care ver-
sus usual care only (n5).
32–36
Two com-
parisons of physical therapy only with
usual care only concerned patients with
internal conditions (urinary inconti-
nence, intermittent claudication). Two
comparisons of physical therapy added
to usual care with usual care only con-
cerned neurological conditions (Parkin-
son disease,
37
depression
38
), and 2 com-
parisons concerned internal medicine
conditions (fall prevention for elderly
people,
39
intermittent claudication
13
).
The study that included participants with
intermittent claudication was incorpo-
rated in both comparisons.
13
Most studies were conducted in Great
Britain (n7; 39%) or the Netherlands
(n6; 33%). The smallest study had 112
participants,
40
and the largest study had
798 participants.
38
Health-related quality
of life and disability were the most fre-
quently mentioned clinical outcomes. A
detailed description of study characteris-
tics is provided in eTable 1 (available at
ptjournal.apta.org).
Table 1 reports both the original authors’
conclusions about cost-effectiveness and
our own conclusions based on the
computation of different ICERs. Original
data used for these computations are
reported in eTable 2 (available at
Figure.
Results of the search strategy according to inclusion and exclusion criteria applied to the
reading of titles and abstracts. One article could have been excluded due to more than one
exclusion criterion. In that case, we added it behind all concerned exclusion criteria.
Physical Therapy Cost-Effectiveness
780 fPhysical Therapy Volume 96 Number 6 June 2016
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ptjournal.apta.org). Based on the
authors’ conclusions, physical therapy
only compared with usual care only was
cost-effective in 6 out of the 8 compari-
sons
13,25–27,30,31
; physical therapy added
to usual care compared with usual care
only was cost-effective in 4 out of the 11
comparisons.
13,32,33,37
According to our
judgment of cost-effectiveness, we found
5 out of 8 comparisons
13,26,27,30,31
between physical therapy only and usual
care to be cost-effective and 4 out of 11
comparisons
13,32,36,37
between physical
therapy added to usual care and usual
care only to be cost-effective. The num-
ber of study participants indicates study
size.
Discussion
The results presented in Table 1 show
that our own conclusion about cost-
effectiveness differed in 3 articles from
that of the original authors. This differ-
ence is a direct consequence of our
choice of relying on a very strict defini-
tion of cost-effectiveness. To be cost-
effective, an intervention has to be
cheaper than the standard treatment.
Usually, a more expensive intervention is
accepted if additional costs are not too
high. However, there is no clear defined
cutoff above which costs should be con-
sidered as too high, hence our choice.
Johnson et al
25
concluded that physical
therapy was cost-effective even if the
cost associated with this treatment was
higher than the cost of usual care. Juha-
koski et al
36
rejected the cost-
effectiveness of physical therapy added
to usual care because the difference with
usual care only was not statistically sig-
nificant. However, according to our def-
inition and considering only the point
estimate, the treatment had to be consid-
ered as cost-effective. Severens et al
33
accepted the cost-effectiveness of physi-
cal therapy added to usual care, but their
published results indicate a higher cost
for the intervention compared with usual
care only, so we chose to reject cost-
effectiveness in this case. The discrepan-
cies between our judgments and the
authors’ judgments reflect only the meth-
odological differences between studies;
they are not challenging the quality of
these studies.
According to our judgment, physical
therapy only was cost-effective in 5 out
of the 8 comparisons
13,27,30,31
with usual
care only. Out of these studies, 4 con-
cerned patients with musculoskeletal
conditions.
27,30,31
This is a relevant
result, as the prevalence of musculoskel-
etal conditions is high.
41
In addition,
musculoskeletal conditions frequently
include long-term pain and disability and,
therefore, are particularly expensive for
the health care system and society.
42,43
In contrast to our study, one review con-
cluded that general practitioners’ care
for low back was not cost-effective.
44
In
our review, 1 of the 2 studies that
included patients with low back pain
showed that physical therapy only is
cost-effective. The active and educative
physical therapy approach could explain
the positive trend of our results.
Table 2.
Cochrane Risk of Bias Assessment of the 18 Included Randomized Controlled Trials
a
Comparison Physical Therapy Only vs Usual Care Only
Physical Therapy Added to Usual Care vs
Usual Care Only
Health Conditions MSC/Spine MSC/Joint
Other
Conditions
MSC/
Spine MSC/Joint Other Conditions
Item
Johnson et al,
25
2007
Korthals-de Bos et al,
26
2003
Moffet et al,
27
1999
Korthals-de Bos et al,
29
2004
Pinto et al,
30
2013
Tan et al,
31
2010
Glazener et al,
12
2011
Luijsterburg et al,
40
2007
Niemistö et al,
28
2005
Bergman et al,
34
2010
Buchbinder et al,
35
2007
Hurley et al,
32
2012
Juhakoski et al,
36
2011
Severens et al,
33
1999
Fletcher et al,
37
2012
Mazari et al,
13
2013
Robertson et al,
39
2001
Underwood et al,
38
2013
Sequence generation 公公公公公公 ?公公公公 ??公公
Allocation concealment ? 公公公公 ??公公公 ????
Blinding of participants xxxxx? x xxXxxxxx?xx
Blinding of therapists xxxxx? x xxXxxxxx?xx
Blinding of outcome assessors x ?公公 ?xX公公公 ?x??
Incomplete outcome data x xxxxXx??公公公公
Selective outcome reporting 公公公公公公 公 公公公公公公公公公公公
Other sources of bias 公公 x公公公 公 公公公公公公公公公公公
公公公公公公 公 公公公公公公公公公公公
a
公⫽low risk of bias, ?unclear risk of bias (light gray cells), xhigh risk of bias (dark gray cells), MSCmusculoskeletal condition.
Physical Therapy Cost-Effectiveness
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Table 3.
Methodological Quality Assessment of the 18 Economic Analyses With the QHES
a
No.
Comparison
Physical Therapy Only vs
Usual Care Only
Physical Therapy Added to Usual Care vs
Usual Care Only
Health Conditions
MSC/
Spine MSC/Joint
Other
Conditions
MSC/
Spine MSC/Joint
Other
Conditions
QHES Item
Johnson et al,
25
2007
Korthals-de Bos et al,
26
2003
Moffet et al,
27
1999
Korthals-de Bos et al,
29
2004
Pinto et al,
30
2013
Tan et al,
31
2010
Glazener et al,
12
2011
Luijsterburg et al,
40
2007
Niemistö et al,
28
2005
Bergman et al,
34
2010
Buchbinder et al,
35
2007
Hurley et al,
32
2012
Juhakoski et al,
36
2011
Severens et al,
33
1999
Fletcher et al,
37
2012
Mazari et al,
13
2013
Robertson et al,
39
2001
Underwood et al,
38
2013
1 Was the study objective presented in a clear, specific,
and measurable manner?
777777 7 77777777777
2 Were the perspective of the analysis (eg, societal, third-
party payer) and reasons for its selection stated?
444444 4 44444444444
3 Were variable estimates used in the analysis from the
best available source (ie, randomized controlled
trialbest, expert opinionworst)?
888888 8 88888888888
4 If estimates came from a subgroup analysis, were the
groups prespecified at the beginning of the study?
111111 1 11111111111
5 Was uncertainty handled by (1) statistical analysis to
address random events or (2) sensitivity analysis to
cover a range of assumptions?
090099 9 00099099999
6 Was incremental analysis performed between
alternatives for resources and costs?
660666 6 66666066666
7 Was the methodology for data abstraction stated? 5 5 5 5 5 5 5 55555555555
8 Did the analytic horizon allow time for all relevant and
important outcomes? Were benefits and costs that
went beyond 1 year discounted (3%–5%) and
justification given for the discount rate?
077777 0 70707770707
9 Was the measurement of costs appropriate and the
methodology for the estimation of quantities and unit
costs clearly described?
888888 8 88808888888
10 Were the primary outcome measures for the economic
evaluation clearly stated, and did they include the
major short-term justification given for the measures/
scales used?
666666 6 66666666666
11 Were the health outcomes measures/scales valid and
reliable? If previously tested valid and reliable
measures were not available, was justification given
for the measures/scales used?
777777 7 77777777777
12 Were the economic model (including structure), study
methods and analysis, and components of the
numerator and denominator displayed in a clear,
transparent manner?
888888 8 88808888880
13 Were the choice of economic model, main assumptions,
and limitations of the study stated and justified?
000777 7 77707777700
14 Did the authors explicitly discuss direction and
magnitude of potential biases?
000006 0 00006000000
15 Were the conclusions/recommendations of the study
justified and based on the study results?
888888 8 88888888888
16 Was there a statement disclosing the source of funding
for the study?
333333 3 33333333033
Total 71 87 72 85 94 100 87 85 78 85 64 100 79 94 87 91 80 79
a
QHESQuality of Health Economic Studies scale, MSCmusculoskeletal condition.
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Table 4.
Description of the Study Characteristics
a
Study Country
Health
Condition Intervention and Control Intervention
Average No.
of Sessions
MSC/Spine Johnson et al,
25
2007
Great Britain Chronic LBP EG: program of exercise and education using a CBT
approach
CG: GP care
8
Korthals-de Bos
et al,
26
2003
The Netherlands Neck pain for at
least 2 wk
EG1: manual therapy (spinal mobilization)
EG2: physical therapy (exercise)
CG: GP care
7 (EG1),
14 (EG2)
Moffett et al,
27
1999
United States Chronic LBP EG: strengthening exercises for all main muscle
groups, stretching exercises, relaxation session,
and brief education on back care (CBT approach)
in groups
CG: medical treatment eventually usual physical
therapy interventions (total of 146 sessions)
8
MSC/Joint Korthals-de Bos
et al,
29
2004
The Netherlands Lateral
epicondylitis
EG: physical therapy
CG1: corticosteroid injections
CG2: a wait-and-see policy
12
Pinto et al,
30
2013 New Zealand Knee osteoarthritis EG1: manual therapy
EG2: exercise therapy
EG3: manual therapy exercise therapy
CG: usual care (GP health professional care, if
necessary)
9
Tan et al,
31
2010 The Netherlands Patellofemoral
pain syndrome
EG: exercise therapy
CG: usual care
9
Other Conditions Glazener et al,
12
2011
Great Britain Men after prostate
surgery (acute)
EG: PFMT
CG: standard management
4
Mazari et al,
13
2013
Great Britain Intermittent
claudication
EG1: SEP
CG: PTA
36
MSC/Spine Luijsterburg et al,
40
2007
The Netherlands Acute LRS EG: GP care physical therapy
CG: GP care
9
Niemistö et al,
28
2005
Finland Chronic LBP EG: physician consultation group manipulative
treatment, exercise
CG: physician consultation group
4
MSC/Joint Bergman et al,
34
2010
The Netherlands Shoulder
complaints
EG: usual medical care manipulative therapy of
the cervicothoracic spine and the adjacent ribs
CG: usual medical care
6
Buchbinder et al,
35
2007
Australia Adhesive capsulitis
(shoulder) for 3
mo
EG: usual care active physical therapy program
following arthrographic joint distension
CG: usual care
8
Hurley et al,
32
2012
Great Britain Knee osteoarthritis EG: usual care ESCAPE–knee pain
CG: usual care
12
Juhakoski et al,
36
2011
Finland Hip osteoarthritis EG: GP care exercise
CG: GP care usual physical therapy (mean:
2 sessions)
16
Severens et al,
33
1999
The Netherlands Upper extremity,
reflex dystrophy
EG: usual care physical therapy
CG: usual care control treatment (social worker)
Not reported
Other Conditions Fletcher et al,
37
2012
Great Britain Parkinson disease EG: usual care exercise intervention in a group
CG: usual care (GP and physical therapy,
occupational therapy, and speech therapy, if
necessary)
10
Mazari et al,
13
2013
Great Britain Intermittent
claudication
EG2: PTA SEP
CG: PTA
36
Robertson et al,
39
2001
New Zealand Fall prevention,
women 80 y old
EG: usual care home-based muscle strengthening
and balance retraining program
CG: usual care and social visits
4
Underwood et al,
38
2013
Great Britain Depression EG: usual care physical therapist–led exercise
class
CG: usual care
8
a
Synthesis of the 18 included publications performing 19 comparisons. EGexperimental group that received either physical therapy only or physical
therapy added to usual care, CGcontrol group that received usual care only, GPgeneral practitioner, LBPlow back pain, CBTcognitive-behavioral
therapy, PFMTpelvic-floor muscle training, SEPsupervised exercise, PTApercutaneous transluminal angioplasty, LRSlumbosacral radicular syndrome,
ESCAPEEnabling Self-Management and Coping of Arthritic Knee Pain Through Exercise.
Physical Therapy Cost-Effectiveness
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Physical therapy costs are particularly
related to the number of treatment ses-
sions and whether the sessions are deliv-
ered in groups or individually. However,
these factors do not seem to be relevant
to the cost-effectiveness of results. A rel-
atively high number of sessions does not
impede a cost-effective result. For exam-
ple, for patients with Parkinson disease,
10 physical therapy sessions in groups
added to usual care per year were suffi-
cient for a cost-effective result in favor of
physical therapy.
37
On the other hand,
36 standardized exercise sessions in
groups for patients with intermittent
claudication also gave a cost-effective
result in favor of physical therapy added
to usual care.
13
A possible explanation
could be that almost all physical inter-
ventions added to usual care in the
included trials were active interventions
(exercise). An active approach could
indeed enable patients to better perceive
their physical abilities and to use strate-
gies helping them to overcome limita-
tions compared with patients who
receive usual care only. This approach
could promote patients’ autonomy and
permit them to return sooner to their
prior activities and avoid loss of
productivity.
Discussing cost-effectiveness relates to 3
aspects: health care costs, societal costs
and total costs, the sum of health care
and societal costs. Physical therapy ses-
sions added to usual care increases
health care costs. However, when the
analysis includes societal costs, such as
costs related to absence from work, the
total costs are not higher for the group
receiving physical therapy added to
usual care than for the group receiving
usual care only. Therefore, cost-
effectiveness analyses should not remain
limited to health care costs; total costs
that consider both aspects are more rel-
evant. For instance, out of the 5 studies
on cost-effectiveness of conservative
treatment for neck pain included in the
review by Driessen et al,
14
none analyzed
exclusively health care costs. Three stud-
ies considered societal costs, and 2 stud-
ies considered total costs.
The calculation of health care costs only
is also a relevant issue. In our review, a
standardized exercise program added to
medical care for patients with intermit-
tent claudication was cost-effective,
13
whereas medical treatment only was not
cost-effective. This result is confirmed by
the review by Bermingham et al,
20
who
concluded that a standardized exercise
program was cost-effective compared
with medical treatment only in these
patients; an exercise program is the rec-
ommended approach for intermittent
claudication. The study by Mazari et al
13
and the review by Bermingham et al
20
analyzed health care costs. Both groups
of authors underscored that program
modalities (frequency and number of ses-
sions needed for good short- and long-
term effects) should be better defined.
Indeed, an appropriate definition of
these modalities optimizes the use of
health care services and consequently
contributes to minimize health care
costs.
Clinical Implications
With regard to implications for the clin-
ical practice, it is likely that the active
and educative nature of physical therapy
interventions contributes to the cost-
effectiveness. Group sessions are less
expensive than individual sessions and
favor learning from other patients with
similar health conditions. Such group
sessions also appear to be an advantage.
The number of sessions does not appear
to influence costs. However, regular
assessments of the effect of the treat-
ment (eg, after 6–9 sessions) are recom-
mended to avoid unnecessary expenses.
Strengths and Weaknesses of
This Review
Quality assessment and study quality are
important strengths of this review,
which benefited from past use of the
QHES for economic analyses in health
care. Peterson et al
6
compared the QHES
with other assessment tools for eco-
nomic analyses; they confirmed its
appropriateness for economic studies on
physical therapy interventions.
10
A fur-
ther strength is that the quality of the
studies included in the review of Peter-
son et al
6
was high: 85% of the 95
included studies were of good to excel-
lent quality, with a total score between
70 and 100 points. We found a similar
result in our review, which reinforces
the relevance of the overall positive eco-
nomic results of physical therapy inter-
ventions found in both reviews.
A further strength is the generalizability
of the results. Seven of the 18 studies
chose a pragmatic design that should
increase external validity; this was also
the case in similar reviews.
10,16
Thereby,
results from pragmatic RCTs favor gener-
alizability because their research ques-
tion is as similar as possible to questions
of clinical decision makers.
45
This review also has several weaknesses:
The number of studies meeting our inclu-
sion criteria is small, and these studies
are heterogeneous regarding their size,
the considered health conditions, and
the health care costs. It also should be
noted that the different studies included
in our review did not always use the
same definition of cost-effectiveness
or the same method for their evaluation.
These limitations make the interpreta-
tion of the results difficult. Therefore,
the results should be considered
cautiously, and their generalization
remains limited. Larger high-quality stud-
ies are needed to confirm our
recommendations.
Robustness of the estimated costs is a
further methodological criterion that
should be taken into account when eco-
nomic results are to be integrated into
clinical decisions. The quality assessment
of the included studies shows that these
elements are not systematically
considered.
The majority of the studies stem from
Great Britain or the Netherlands, but
some of them were completed in other
European countries, in New Zealand, in
Australia, and in the United States. As
health care systems vary in the different
countries, economic results may not be
directly generalizable to other countries.
A last limitation is that usual care did not
systematically exclude any physical ther-
apy intervention. Authors of 4 stud-
ies
10,27,36,37
left open the possibility that
patients of the control group could have
usual physical therapy, even if in prac-
tice the patients rarely chose this oppor-
tunity (mean of 2 sessions per participant
in the studies by Moffett et al
27
and Juha-
Physical Therapy Cost-Effectiveness
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koski et al
36
). Most likely, the authors
made this choice to respond to ethical
requirements, but the differences
between groups then would possibly be
attenuated.
In conclusion, physical therapy only or
physical therapy added to usual care
implies improved health in almost all
studies. The cost-effectiveness of such
interventions is demonstrated in half of
the studies. This result might have been
influenced by the fact that different def-
initions of the notion of “cost-
effectiveness” exist.
Cost-effectiveness of physical therapy
has been shown for several musculoskel-
etal conditions, such as neck pain,
chronic low back pain, knee osteoarthri-
tis, hip osteoarthritis, and patellofemoral
pain syndrome. This is a relevant result,
as the prevalence of musculoskeletal
conditions is high. In addition, cost-
effectiveness for physical therapy could
be identified for patients with Parkinson
disease and intermittent claudication.
Future RCTs investigating efficacy of
physical therapy should include an eco-
nomic societal perspective. When an
approach is cost-effective, the optimal
modalities of physical therapy as a single
intervention or of the added physical
therapy should be defined.
All authors provided concept/idea/research
design. Ms Bu¨rge and Dr Allet provided writ-
ing and project management. Ms Bu¨rge and
Dr Berchtold provided data collection. Ms
Bu¨rge, Mr Monnin, and Dr Allet provided
data analysis. Mr Monnin, Dr Berchtold, and
Dr Allet provided consultation (including
review of manuscript before submission).
The authors thank Ann Bless for her relevant
critical reading.
DOI: 10.2522/ptj.20140333
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... Physical therapists aid physicians in making a diagnosis and creating a plan of care. 20,21 At Bellin Health, patients briefly see their provider first, followed by a visit with the co-located physical therapist for appropriate patients. Seeing the provider first makes sense because many visits include musculoskeletal problems plus other issues. ...
Article
Background: Bellin Health in Wisconsin has pioneered the colocation and integration of physical therapists into primary care pods. Methods: This is an observational study based on one in-person visit and several interviews. Results: For patients with musculoskeletal complaints, providers make warm handoffs to the physical therapist, who is a few steps away. The physical therapist performs most of the visit, providing diagnosis, treatment, and patient education. Research studies show that-compared with physician management-appropriate patients managed by physical therapists have better outcomes, lower costs, and higher patient satisfaction. In a fee-for-service environment, the business case for this innovation requires an increased number of follow-up referrals to the physical therapy department. In the Coronavirus disease 2019 (COVID-19) era, physical therapists can provide video visits with equal quality compared with in-person visits. Conclusion: The Bellin Health program is a blueprint for other primary care practices to integrate physical therapists into primary care teams.
... 6 With a rising prevalence of musculoskeletal pain disorders 6,7 and health care costs in the United States increasing at a faster rate than workers' wages, health care providers must find strategies to improve outcomes and reduce the costs of care for pain. [8][9][10] Clinical practice guidelines strongly recommend nonpharmacological treatment (e.g., physical therapy) as frontline care for musculoskeletal pain. [11][12][13] Escalation of care to more invasive and/or costly treatments such as surgery, injection, opioid use, and imaging can provide value in some circumstances. ...
Article
Full-text available
Introduction Identifying patients with musculoskeletal pain at risk for additional health care use is important for improving the value of physical therapist's services. We previously identified 3 subgroups based on the importance attached by patients to improvements in outcome domains including a 1) Pain and Function Outcomes Important subgroup; 2) Pain Important subgroup; 3) Multiple Outcome Domains Important subgroup. Objective The primary aim was to determine whether subgroups based on patient-determined outcomes of importance predicted any additional pain-related healthcare use after an episode of physical therapy. A secondary aim was to determine if subgroup membership predicted use of specific services. Design Secondary analysis of a Longitudinal Cohort. Setting Ambulatory outpatient physical therapy clinics. Patients 246 patients seeking physical therapy recruited from the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort study. Interventions Patients completed a demographic and health history questionnaire, numeric pain rating scale, region specific disability measure and Charlson comorbidity index. Subgroup membership was determined based on responses to the Patient Centered Outcome Questionnaire. At 1 year, patients reported use of health care since discharge from physical therapy. Separate logistic regression models determined whether subgroup membership predicted additional healthcare use. Results Compared to the Pain and Function Outcomes Important subgroup, the Pain Important subgroup had higher adjusted odds (95% CI) for the primary outcome of any additional health care use [aOR = 2.47 (1.01-6.00)] and secondary outcomes of opioid use [aOR = 9.45, (2.87-31.17)], injection [aOR = 4.09, (1.25-13.41)] and surgery [aOR = 5.10, (1.15-22.67)]. There were no significant differences in healthcare utilization between the Pain and Function Important Outcomes and Multiple Outcome Domains Important subgroups. Conclusion In this cohort, patients with a singular focus on pain improvements were at higher risk for additional health care, including opioid use, injection, and surgery. These findings are exploratory and need to be confirmed in other cohorts. This article is protected by copyright. All rights reserved.
... The participants believed that these studies should be conducted in Iran. The cost-effectiveness of PT for many MSDs and NCDs has been studied in other countries and the results should be presented to policy-makers (Bürge, Monnin, Berchtold, and Allet, 2016). ...
Article
Full-text available
Physiotherapy (PT) is a key component of the rehabilitative health strategy and an effective approach to the management and treatment of a wide range of health conditions. However, it remains underdeveloped and poorly implemented in many national health systems. Previous studies show that weak stewardship of rehabilitation services is, among others, a significant barrier to equitable access to services and supports in many parts of the world, including in Iran. This study investigated the common pitfalls and potential policy solutions to improve the stewardship of PT services in Iran from the perspective of key stakeholders. Semi-structured interviews were conducted by telephone, via the internet, and in face-to-face sessions in Iran with a purposive sample of health planners and policy decision-makers, university professors, rehabilitation managers, and physiotherapists. In total, 30 individuals agreed to participate. Participants identified several pitfalls across the six dimensions of stewardship: 1) strategy formulation; 2) inter-sectoral collaboration; 3) governance and accountability; 4) health system design; 5) policy and regulation; and 6) intelligence generation. In addition, several policy options and solutions to address critical deficiencies in the system were suggested to improve the stewardship of PT services. The study identified challenges and pitfalls affecting the stewardship of the PT sector in Iran as perceived by key stakeholders. Participants’ insights can inform deliberative dialogue processes, agenda-setting, and strategy formulation to support the development, expansion, and implementation of PT services.
Article
Stroke rehabilitation is expensive, and recent changes to Medicare reimbursement demand more efficient interventions. The use of cost-effectiveness analysis (CEA) can help occupational therapy practitioners, rehabilitation directors, and payers better understand the value of occupational therapy and decide whether or not to implement new treatments. The objective of this article is to illustrate the contribution of CEA to stroke rehabilitation using a hypothetical new intervention as an example. What This Article Adds: This article facilitates an understanding of the importance of CEA to occupational therapy. It also explains how CEA improves consistency with reporting standards for cost-effectiveness studies.
Article
Background There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients. Methods A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05. Results A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05). Conclusions Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.
Article
Full-text available
There are many benefits to incorporating guidelines, including better patient care and optimizing the profession and multidisciplinary collaboration. The individual value of physiotherapy would increase and the future conditions would be more attractive. The objective is complex, therefore all parties involved must work together - as has long been the case in other countries. This article shows the possibilities for this.
Article
Full-text available
Objective To identify the role of sports physical therapists (PT) in the injury prevention process and to compare the structure of preventive programs and associated (organization) policies applied in athletic organizations and sports teams of varying gender and level world-wide. Design: cross-sectional study. Setting LimeSurvey platform. Participants Sports PT working with athletes invited through the International Federation of Sports Physical Therapy. Main outcome measures Sports injury prevention program (IPP) structure and implementation. Results 414 participants fully participate in this survey study. Athlete's injury history (68.84%), the most common injuries within the sport modality (67.87%) and athlete's preseason screening results (64.01%) were most frequently used to customize IPPs. Warm-up (70.04%) and individually PT-guided exercise-therapy (70.04%) were the preferred methods to organize the prevention routine. The main barrier for IPP implementation was lack of time within the athlete's weekly training schedule (66.66%). The majority of the participants (72.84%) reported to evaluate the perception of IPP's effect by comparing current and preceding seasons' injury occurrences. Conclusion These survey results are the first identifying contemporary sports injury prevention organization and implementation policies on an international level. This information might support the sports PT community in improving and standardizing IPP (implementation) strategies worldwide.
Article
Objective Direct access to physical therapy provides an alternative to physician-first systems for patients who need physical therapy for musculoskeletal disorders (MSDs). Direct access across multiple countries and the United States (US) military services has produced improved functional outcomes and/or cost-effectiveness at clinical and health care system levels; however, data remain scarce from civilian health care systems within the United States. The purpose of this study was to compare evidence regarding costs and clinical outcomes between direct access and physician-first systems in US civilian health services. Methods A database search of PubMed, CINAHL, Cochrane Reviews, and PEDro was conducted through May 2019. Studies were selected if they specified civilian US, physical therapy for MSDs, direct access or physician-first, and extractable outcomes for cost, function, or number of physical therapy visits. Studies were excluded if interventions utilized early or delayed physical therapy access compared with physician-first. Five retrospective studies met the criteria. Means and standard deviations for functional outcomes, cost, and number of visits were extracted, converted to effect sizes (d) and 95% CI, and combined into grand effect sizes using fixed-effect or random-effects models depending on significance of the Q heterogeneity statistic. Results Direct access to physical therapy showed reduced physical therapy costs (d = −0.23; 95% CI = −0.35 to −0.11), total health care costs (d = −0.19; 95% CI = −0.32 to −0.07), and number of physical therapy visits (d = −0.17; 95% CI = −0.29 to −0.05) compared to physician-first systems. Disability decreased in both direct access (d = −1.78; 95% CI = −2.28 to −1.29) and physician-first (d = −0.89; 95% CI = −0.92 to −0.85) groups; functional outcome improved significantly more with direct access (z score = 0.89; 95% CI = 0.40 to 1.39). Conclusions Direct access to physical therapy is more cost-effective in fewer visits than physician-first access in the United States, with greater functional improvement. Impact These findings within civilian US health care services support a cost-effective health care access alternative for spine-related MSDs and can inform health care policy makers.
Article
Background The quality of reporting of health economic evaluations for rehabilitation services has been questioned, limiting the ability to provide accurate recommendations for health decisions. Purpose To document current overall reporting quality of the published literature for economic evaluations of rehabilitation services using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and to identify factors that could influence the quality of reporting. Data sources Electronic literature searches were performed using MEDLINE and the NHS Economic Evaluations Database via the Cochrane Library. Study selection Prospective rehabilitation economic evaluation articles from 2013 to 2020 were selected. Data extraction Data were extracted by one reviewer and independently verified by a second reviewer. Data synthesis/results Title and abstracts of 3,454 papers were reviewed. 204 papers were selected for a full text screening. From those, 129 potential papers were identified to be included in this study. Limitations Only two databases were used in data collection, and papers were selected from 2013 to 2020 only. Conclusions Inconsistent reporting in health economic evaluations of rehabilitation services has continued, despite the availability of the CHEERS checklist. The methods of the analyzed studies were frequently under-reported, thereby creating challenges in determining whether the results reported were valid. • IMPLICATIONS FOR REHABILITATION • Variable quality of reporting has been identified in rehabilitation research assessing cost-effectiveness. • To grow as an area of expertise, the field of rehabilitation must produce research demonstrating its cost-effectiveness. • Both rehabilitation clinicians and funders would benefit from full and transparent information to identify optimal solutions for effective and efficient care.
Chapter
The aim of this chapter is to provide an overview of the most common, evidence-based techniques and approaches used by physical therapists to evaluate and treat patients with pain. The first section on evaluation includes examination techniques, prognosis, and patient diagnosis/classification. The second section on treatment presents management strategies linked to a pain mechanism classification scheme of nociceptive, neuropathic, or nociplastic pain. Specific recommendations from clinical practice guidelines are included for the physical therapy management of spinal pain, lower extremity osteoarthritis, radiculopathy, carpal tunnel syndrome, fibromyalgia, and complex regional pain syndrome, type I.
Article
Full-text available
Objective To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. Design Economic evaluation alongside a randomised controlled trial. Setting Primary care. Participants 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n = 60, spinal mobilisation), physiotherapy (n = 59, mainly exercise), or general practitioner care (n = 64, counselling, education, and drugs). Main outcome measures Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between. groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. Results The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (C447; pound273; $402) were around one third of the costs of physiotherapy (C1297) and general practitioner care (C1379). These differences were significant: P < 0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P = 0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. Conclusions Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
Book
Full-text available
Health care systems across the European Union face a common challenge: the high cost of health care. Governments strive to ensure that cost pressures do not undermine values such as universal coverage and equitable financing and access. Focusing on the three health care financing functions – collection, pooling and purchasing – as well as on coverage, this book analyses the organization of health care financing in the Member States of the European Union, discusses the principal financing reform trends of recent years, and assesses their capacity to help ensure fiscal sustainability. The book includes a useful annex detailing the health care financing systems of each of the 27 Member States of the European Union. It will inform the deliberations of policy- and decision-makers, both within and beyond the European Union, faced with reconciling rising costs with equitable and sustainable health care.
Article
Full-text available
Traditional randomized controlled trials are the 'gold standard' for evaluating health interventions and are typically designed to maximize internal validity, often at the cost of limited generalizability. Pragmatic randomized controlled trials should be designed with a conscious effort to generate evidence with a greater external validity by making the research question as similar as possible to the questions faced by clinical decision-makers (i.e., patients and their families, physicians, policy makers and administrators) and then answer that question with rigor. Clarity and transparency about the specifics of the research question are the keys to designing, as well as interpreting, any clinical trial.
Article
Full-text available
There is insufficient evidence of the cost-effectiveness of Chronic Obstructive Pulmonary Disease (COPD) Disease Management (COPD-DM) programs. The aim of this review is to evaluate the economic impact of COPD-DM programs and investigate the relation between the impact on healthcare costs and health outcomes. We also investigated the impact of patient-, intervention, and study-characteristics. We conducted a systematic literature review to identify cost-effectiveness studies of COPD-DM. Where feasible, results were pooled using random-effects meta-analysis and explorative subgroup analyses were performed. Sixteen papers describing 11 studies were included (7 randomized control trials (RCT), 2 pre-post, 2 case--control). Meta-analysis showed that COPD-DM led to hospitalization savings of [euro sign]1060 (95% CI: [euro sign]2040 to [euro sign]80) per patient per year and savings in total healthcare utilization of [euro sign]898 (95% CI: [euro sign]1566 to [euro sign]231) (excl. operating costs). In these health economic studies small but positive results on health outcomes were found, such as the St Georges Respiratory Questionnaire (SGRQ) score, which decreased with 1.7 points (95% CI: 0.5-2.9). There was great variability in DM interventions-, study- and patient-characteristics. There were indications that DM showed greater savings in studies with: severe COPD patients, patients with a history of exacerbations, RCT study design, high methodological quality, few different professions involved in the program, and study setting outside Europe. COPD-DM programs were found to have favourable effects on both health outcomes and costs, but there is considerable heterogeneity depending on patient-, intervention-, and study-characteristics.
Article
Background: The aim was to compare costs and utilities of percutaneous transluminal angioplasty (PTA), a supervised exercise programme (SEP) and combined treatment (PTA + SEP) in patients with intermittent claudication (IC) to establish the most cost-effective treatment. Methods: Patients with IC due to femoropopliteal disease were randomized to receive PTA, SEP or PTA + SEP. Assessments were performed before, and at 1, 3, 6 and 12 months postintervention. Clinical and quality-of-life indicators were recorded. The SF-6D Health Utilities index was calculated from the Short Form 36, plotted, and quality-adjusted life-years (QALYs) were generated by calculating the area under the curve. Costs were calculated using National Health Service 2009-2010 payment-by-results tariffs and the National Institute for Health Research Clinical Research Network Investigation pricing index, and adjusted for reinterventions. Cost per QALY and incremental costs were calculated, and sensitivity analyses performed. Results: A total of 178 patients (PTA, 60; SEP, 60; PTA + SEP, 58) were randomized. All treatments resulted in significant improvement in the SF-6D index (P < 0.001). There was no significant difference between treatments in mean QALYs gained (PTA: 0.620, 95 per cent confidence interval 0.588 to 0.652; SEP: 0.629, 0.597 to 0.660; PTA + SEP: 0.649, 0.622 to 0.675). The adjusted mean cost per procedure was significantly higher for PTA (€7301.74) compared with SEP (€3866.49) and PTA + SEP (€6911.68) (P < 0.001). The cost per QALY was significantly higher for PTA (€11,777.00) compared with SEP (€6147.04) and PTA + SEP (€10,649.74). QALYs were lost when PTA alone was used as first-line treatment in comparison with SEP or PTA + SEP. These results were robust and valid in sensitivity analyses. Conclusion: Supervised exercise is the most cost-effective first-line treatment for IC, and when combined with PTA is more cost-effective than PTA alone.
Article
Supervised exercise (SE) is thought to result in improvements in walking distance and quality of life compared with unsupervised exercise (USE) in people with intermittent claudication. However, the cost-effectiveness of SE is unclear. As a result, many patients are currently unable to access supervised programmes. We searched MEDLINE, Embase, Cochrane, and Cinahl databases to identify randomised controlled trials comparing USE with SE in adults with intermittent claudication. A Markov model was developed to estimate costs and quality adjusted life years (QALYs) from an NHS and personal social services perspective. Quality of life was obtained from the included clinical trials. Resource use was modelled on current programmes and unit costs were based on published sources. Depending on estimated rates of compliance, SE was cost-effective in over 75% of model simulations, with an incremental cost-effectiveness ratio of £711 to £1,608 per QALY gained. The model was sensitive to long-term effects of exercise on cardiovascular risk and quality of life. SE is more cost-effective than USE for the treatment of people with intermittent claudication. Supervised programmes should be made widely available and offered as a first line treatment to people with intermittent claudication.
Article
To evaluate the cost effectiveness of manual physiotherapy, exercise physiotherapy, and a combination of these therapies for patients with osteoarthritis of the hip or knee. 206 adults who met the American College of Rheumatology criteria for hip or knee osteoarthritis were included in an economic evaluation from the perspectives of the New Zealand health system and society alongside a randomized controlled trial. Resource use was collected using the Osteoarthritis Costs and Consequences Questionnaire. Quality-adjusted life years (QALYs) were calculated using the Short Form 6D. Willingness-to-pay threshold values were based on one to three times New Zealand's gross domestic product (GDP) per capita of NZ$29 149 (in 2009). All three treatment programmes resulted in incremental QALY gains relative to usual care. From the perspective of the New Zealand health system, exercise therapy was the only treatment to result in an incremental cost utility ratio under one time GDP per capita at NZ$26 400 (-$34 081 to $103 899). From the societal perspective manual therapy was cost saving relative to usual care for most scenarios studied. Exercise therapy resulted in incremental cost utility ratios regarded as cost effective but was not cost saving. For most scenarios combined therapy was not as cost effective as the two therapies alone. In this study, exercise therapy and manual therapy were more cost effective than usual care at policy relevant values of willingness-to-pay from both the perspective of the health system and society. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12608000130369.