Knee or Hip Osteoarthritis What’s the Most Cost-Effective Physiotherapy?

There is no cure, so effective management strategies become increasingly important. Clinical guidelines generally recommend conservative, non-surgical, non-pharmacological treatment (primarily exercise therapy) as the first-line approach.2 Nevertheless, a high percentage of patients entering the healthcare system with complaints of osteoarthritis pain are not offered this.3

One reason for withholding supervised exercise therapy may be questions concerning costeffectiveness. J. H. Abbott (Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand) recently published an interesting study measuring the incremental cost-effectiveness of adding different types of physiotherapy to real-world usual care.4  Physiotherapy Lowers Healthcare Spending When Added to Usual  Medical Care.

In 2-year follow-up, they found that supervised exercise therapy, when added to usual care, costs less in direct medical expenditures than usual care alone - an average savings of $935 (NZD) per patient. When societal costs such as lost work productivity were considered, the per patient cost savings increased to $3,530. Savings accrued from reduced spending on other healthcare due to improved outcomes. Savings were achieved regardless of whether patients elected surgery.   Exercise Therapy More Cost-Effective Than Manual Therapy or  Combination Therapy.

However, not all physiotherapy approaches are equal. Researchers divided patients into four groups: medical care only, exercise therapy, manual therapy, or exercise plus manual therapy. All groups received usual medical care directed by their general practitioner or orthopaedic surgeon. Both the manual therapy and combined therapy groups achieved costeffective improvements in outcomes. Yet, the combined group did not achieve cost savings, and the manual therapy group accomplished cost savings only after societal costs were included Exercise Therapy Reverses  the Progression of Osteoarthritis
Progression of osteoarthritis played a role in the long-term outcomes.

On average, patients in the exercise therapy groups experienced increasingly better condition over the two years, even though the bulk of the physiotherapy occurred in the first nine weeks. Patients in all other groups experienced progressively worsening osteoarthritis. The authors speculate that exercise therapy better prepared patients to take an active, independent role in managing their condition.  

Abbott et al. recruited 206 patients, age 37 to 92, diagnosed with hip or knee osteoarthritis but who did not meet the thresholds for surgery. Patients came from either primary care or orthopaedic surgery practices. This recruitment method matched with the study outcomes strongly suggests that non-surgical osteoarthritis patients presenting in primary care can simply be referred to physiotherapy - no algorithms or decision trees needed.  

Patients received seven 50-minute physiotherapy visits over nine weeks. They additionally received two booster visits in week 16 and one more booster visit in week 54. The booster visits were somewhat novel in physiotherapy practice. The cost-effectiveness of the booster visits proved equivocal for patients who experienced moderate to strong outcomes early on. However, booster visits were clearly effective and cost-effective among patients who achieved modest outcomes from the first nine weeks of supervised exercise therapy. 
The current study adds to two previous systematic reviews  also finding that various supervised exercise therapy programs are clinically effective and cost-effective.5, 

References
 
1. The Royal Australian College of General Practitioners. Guideline for the management of knee and hip osteoarthritis. 2nd edn. East Melbourne, Vic: RACGP, 2018.
2. Larmer PJ, Reay ND, Aubert ER, Kersten P. Systematic review of guidelines for the physical management of osteoarthritis. Archives of Physical Medicine and Rehabilitation. 2014 Feb 1; 95(2): 375-89. 
3. Egerton T, Diamond LE, Buchbinder R, Bennell KL, Slade SC. A systematic review and evidence synthesis of qualitative studies to identify primary care clinicians' barriers and enablers to the management of osteoarthritis. Osteoarthritis and Cartilage. 2017 May 1; 25 (5): 625-38. 
4. Barker KL, Newman M, Stallard N, Leal J, Lowe CM, Javaid MK, Noufaily A, Adhikari A, Hughes T, Smith DJ, Gandhi V. Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT. Health Technology Assessment (Winchester, England). 2019 Aug; 23 (44): 1. 
5. Pinto D, Robertson MC, Hansen P, Abbott JH. Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review. Value in Health. 2012 Jan 1; 15 (1): 1-2. 
6. Abbott JH, Mehta P, Winser S. Economic evaluations of physical therapy interventions for hip or knee osteoarthritis: a systematic review. Osteoarthritis and Cartilage. 2016 Apr 1; 24: S495