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Cost and Quality of Life Outcomes of the STepped Exercise Program for Patients With Knee OsteoArthritis Trial

Published:October 29, 2021DOI:https://doi.org/10.1016/j.jval.2021.09.018

      Highlights

      • Exercise-based therapies, including physical therapy, are recommended for patients with knee osteoarthritis; nevertheless, outpatient physical therapy visits are a limited resource in many healthcare systems, including the Veterans Health Administration.
      • The STEP-KOA (STepped Exercise Program for patients with Knee OsteoArthritis), compared with arthritis education in a randomized clinical trial, improves quality of life and has a high probability of cost-effectiveness at a willingness-to-pay threshold of $50 000 US dollars per quality-adjusted life-year.
      • The stepped strategy applied in STEP-KOA may be useful for treating pain because of other chronic illnesses while efficiently managing limited resources.

      Abstract

      Objectives

      This study aimed to evaluate the cost-effectiveness of the randomized clinical trial STEP-KOA (STepped Exercise Program for patients with Knee OsteoArthritis).

      Methods

      The trial included 230 intervention and 115 control participants from 2 Veterans Affairs (VA) medical centers. A decision tree simulated outcomes for cohorts of patients receiving arthritis education (control) or STEP-KOA (intervention), which consisted of an internet-based exercise training program (step 1), phone counseling (step 2), and physical therapy (step 3) according to patient’s response. Intervention costs were assessed from the VA perspective. Quality of life (QOL) was measured using 5-level EQ-5D US utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in costs divided by the difference in quality-adjusted life-years (QALYs) between arms at 9 months. A Monte Carlo probabilistic sensitivity analysis was used to generate a cost-effectiveness acceptability curve.

      Results

      The adjusted model found differential improvement in QOL utility weights of 0.042 (95% confidence interval 0.003-0.080; P=.03) for STEP-KOA versus control at 9 months. In the base case, STEP-KOA resulted in an incremental gain of 0.028 QALYs and an incremental cost of $279 per patient for an ICER of $10 076. One-way sensitivity analyses found the largest sources of variation in the ICER were the impact on QOL and the need for a VA-owned tablet. The probabilistic sensitivity analysis found a 98% probability of cost-effectiveness at $50 000 willingness-to-pay per QALY.

      Conclusions

      STEP-KOA improves QOL and has a high probability of cost-effectiveness. Resources needed to implement the program will decline as ownership of mobile health devices increases.

      Keywords

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      References

        • Cross M.
        • Smith E.
        • Hoy D.
        • et al.
        The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study.
        Ann Rheum Dis. 2014; 73: 1323-1330
      1. The burden of musculoskeletal diseases in the United States: musculoskeletal diseases. Bone and Joint Initiative.
        http://www.boneandjointburden.org
        Date accessed: September 12, 2019
        • Dominick K.L.
        • Ahern F.M.
        • Gold C.H.
        • Heller D.A.
        Health-related quality of life among older adults with arthritis.
        Health Qual Life Outcomes. 2004; 2: 5
        • Dominick K.L.
        • Golightly Y.M.
        • Jackson G.L.
        Arthritis prevalence and symptoms among US non-veterans, veterans, and veterans receiving Department of Veterans Affairs Healthcare.
        J Rheumatol. 2006; 33: 348-354
        • Hootman J.M.
        • Helmick C.G.
        • Barbour K.E.
        • Theis K.A.
        • Boring M.A.
        Updated projected prevalence of self-reported doctor-diagnosed arthritis and arthritis-attributable activity limitation among US adults, 2015-2040.
        Arthritis Rheumatol. 2016; 68: 1582-1587
        • Bannuru R.R.
        • Osani M.C.
        • Vaysbrot E.E.
        • et al.
        OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.
        Osteoarthritis Cartilage. 2019; 27: 1578-1589
        • Song J.
        • Hochberg M.C.
        • Chang R.W.
        • et al.
        Racial and ethnic differences in physical activity guidelines attainment among people at high risk of or having knee osteoarthritis.
        Arthritis Care Res (Hoboken). 2013; 65: 195-202
        • Quella A.
        • Brock D.M.
        • Hooker R.S.
        Physician assistant wages and employment, 2000-2025.
        JAAPA. 2015; 28 (56-58, 60-53.)
        • Landry M.D.
        • Hack L.M.
        • Coulson E.
        • et al.
        Workforce projections 2010-2020: annual supply and demand forecasting models for physical therapists across the United States.
        Phys Ther. 2016; 96: 71-80
        • Von Korff M.
        • Tiemens B.
        Individualized stepped care of chronic illness.
        West J Med. 2000; 172: 133-137
        • Davison G.C.
        Stepped care: doing more with less?.
        J Consult Clin Psychol. 2000; 68: 580-585
        • Allen K.D.
        • Woolson S.
        • Hoenig H.M.
        • et al.
        Stepped exercise program for patients with Knee osteoarthritis : A randomized controlled trial.
        Ann Intern Med. 2021; 174: 298-307
        • Allen K.D.
        • Bongiorni D.
        • Caves K.
        • et al.
        STepped exercise program for patients with knee osteoarthritis (STEP-KOA): protocol for a randomized controlled trial.
        BMC Musculoskelet Disord. 2019; 20: 254
        • Pham T.
        • van der Heijde D.
        • Altman R.D.
        • et al.
        OMERACT-OARSI initiative: Osteoarthritis Research Society International set of responder criteria for osteoarthritis clinical trials revisited.
        Osteoarthritis Cartilage. 2004; 12: 389-399
        • Pham H.
        Predictive modeling on the number of COVID-19 death toll in the United States considering the effects of coronavirus-related changes and COVID-19 recovered cases. Cold Spring Harbor Laboratory Press.
        • Golightly Y.M.
        • Allen K.D.
        • Caine D.J.
        A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis.
        Phys Sportsmed. 2012; 40: 52-65
        • Allen K.D.
        • Yancy Jr., W.S.
        • Bosworth H.B.
        • et al.
        A combined patient and provider intervention for management of osteoarthritis in veterans: A randomized clinical trial.
        Ann Intern Med. 2016; 164: 73-83
        • Mazzei D.R.
        • Ademola A.
        • Abbott J.H.
        • Sajobi T.
        • Hildebrand K.
        • Marshall D.A.
        Are education, exercise and diet interventions a cost-effective treatment to manage hip and knee osteoarthritis? A systematic review.
        Osteoarthritis Cartilage. 2021; 29: 456-470
        • Hinde J.M.
        • Bray J.W.
        • Cowell A.J.
        Implementation science on the margins: how do we demonstrate the value of implementation strategies?.
        Fam Syst Health. 2020; 38: 225-231
        • Riegg Cellini S.
        • Kee J.E.
        Cost-effectiveness and cost–benefit analysis.
        in: Newcomer K.E. Hatry H.P. Wholey J.S. Handbook of Practical Program Evaluation. John Wiley & Sons, Hoboken, NJ2015: 636-672
        • Phibbs C.
        • Barnett P.
        • Harden C.
        • King S.
        Research guide to decision support system national cost extracts. Health Economics Resource Center.
        • Longworth L.
        • Rowen D.
        Mapping to obtain EQ-5D utility values for use in NICE health technology assessments.
        Value Health. 2013; 16: 202-210
        • Sullivan P.W.
        • Ghushchyan V.
        Preference-Based EQ-5D index scores for chronic conditions in the United States.
        Med Decis Making. 2006; 26: 410-420
        • Raynauld J.P.
        • Torrance G.W.
        • Band P.A.
        • et al.
        A prospective, randomized, pragmatic, health outcomes trial evaluating the incorporation of hylan G-F 20 into the treatment paradigm for patients with knee osteoarthritis (Part 1 of 2): clinical results.
        Osteoarthritis Cartilage. 2002; 10: 506-517
        • Little RJA R.D.
        Statistical Analysis With MIssing Data.
        John Wiley & Sons, Inc, Hoboken, NJ2002
      2. ICH harmonised tripartite guideline. Statistical principles for clinical trials. International Conference on Harmonisation E9 Expert Working Group.
        Stat Med. 1999; 18: 1905-1942
        • Weinstein M.C.
        • O’Brien B.
        • Hornberger J.
        • et al.
        Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices--Modeling Studies.
        Value Health. 2003; 6: 9-17
        • Wang S.Y.
        • Olson-Kellogg B.
        • Shamliyan T.A.
        • Choi J.Y.
        • Ramakrishnan R.
        • Kane R.L.
        Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review.
        Ann Intern Med. 2012; 157: 632-644
        • Larmer P.J.
        • Reay N.D.
        • Aubert E.R.
        • Kersten P.
        Systematic review of guidelines for the physical management of osteoarthritis.
        Arch Phys Med Rehabil. 2014; 95: 375-389
        • Kolasinski S.L.
        • Neogi T.
        • Hochberg M.C.
        • et al.
        2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee [published correction appears in Arthritis Care Res (Hoboken). 2021;73(5):764].
        Arthritis Care Res (Hoboken). 2020; 72: 149-162
        • Choi K.W.
        • Chen C.Y.
        • Stein M.B.
        • et al.
        Assessment of bidirectional relationships between physical activity and depression among adults: A 2-sample Mendelian randomization study.
        JAMA Psychiatry. 2019; 76: 399-408
        • Bove A.M.
        • Smith K.J.
        • Bise C.G.
        • et al.
        Exercise, manual therapy, and booster sessions in knee osteoarthritis: cost-effectiveness analysis from a multicenter randomized controlled trial.
        Phys Ther. 2018; 98: 16-27
        • Pinto D.
        • Robertson M.C.
        • Hansen P.
        • Abbott J.H.
        Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review.
        Value Health. 2012; 15: 1-12
        • Woods B.
        • Manca A.
        • Weatherly H.
        • et al.
        Cost-effectiveness of adjunct non-pharmacological interventions for osteoarthritis of the knee.
        PLoS One. 2017; 12e0172749
        • Rosen J.
        • Niazi F.
        • Dysart S.
        Cost-effectiveness of treating early to moderate stage knee osteoarthritis with intra-articular hyaluronic acid compared to conservative interventions.
        Adv Ther. 2020; 37: 344-352
        • Losina E.
        • Usiskin I.M.
        • Smith S.R.
        • et al.
        Cost-effectiveness of generic celecoxib in knee osteoarthritis for average-risk patients: a model-based evaluation.
        Osteoarthritis Cartilage. 2018; 26: 641-650
        • Dakin H.
        • Gray A.
        • Fitzpatrick R.
        • Maclennan G.
        • Murray D.
        • KAT Trial Group
        Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set.
        BMJ Open. 2012; 2e000332
        • Losina E.
        • Walensky R.P.
        • Kessler C.L.
        • et al.
        Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume.
        Arch Intern Med. 2009; 169: 1113-1121
        • Kamaruzaman H.
        • Kinghorn P.
        • Oppong R.
        Cost-effectiveness of surgical interventions for the management of osteoarthritis: a systematic review of the literature.
        BMC Musculoskelet Disord. 2017; 18: 183
        • Verma S.
        Early impact of CMS expansion of Medicare telehealth during COVID-19.
        Health Affairs. July 15, 2020;