A pragmatic randomised controlled trial of ‘PhysioDirect’ telephone assessment and advice services for patients with musculoskeletal problems: economic evaluation

摘要

Objectives To compare the cost-effectiveness of PhysioDirect with usual physiotherapy care for patients with musculoskeletal problems. Design (1) Cost-consequences comparing cost to the National Health Service (NHS), to patients, and the value of lost productivity with a range of outcomes. (2) Cost-utility analysis comparing cost to the NHS with Quality-Adjusted Life Years (QALYs). Setting Four physiotherapy services in England. Participants Adults (18+) referred by their general practitioner or self-referred for physiotherapy. Interventions PhysioDirect involved telephone assessment and advice followed by face-to-face care if needed. Usual care patients were placed on a waiting list for face-to-face care. Primary and secondary outcomes Primary clinical outcome: physical component summary from the SF-36v2 at 6?months. Also included in the cost-consequences: Measure Yourself Medical Outcomes Profile; a Global Improvement Score; response to treatment; patient satisfaction; waiting time. Outcome for the cost-utility analysis: QALYs. Results 2249 patients took part (1506 PhysioDirect; 743 usual care). (1) Cost-consequences: there was no evidence of a difference between the two groups in the cost of physiotherapy, other NHS services, personal costs or value of time off work. Outcomes were also similar. (2) Cost-utility analysis based on complete cases (n=1272). Total NHS costs, including the cost of physiotherapy were higher in the PhysioDirect group by ￡19.30 (95% CI ?￡37.60 to ￡76.19) and there was a QALY gain of 0.007 (95% CI ?0.003 to 0.016). The incremental cost-effectiveness ratio was ￡2889 and the net monetary benefit at λ=￡20?000 was ￡117 (95% CI ?￡86 to ￡310). Conclusions PhysioDirect may be a cost-effective alternative to usual physiotherapy care, though only with careful management of staff time. Physiotherapists providing the service must be more fully occupied than was possible under trial conditions: consideration should be given to the scale of operation, opening times of the service and flexibility in the methods used to contact patients.