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A pragmatic randomised controlled trial of 'PhysioDirect' telephone assessment and advice services for patients with musculoskeletal problems: economic evaluation [with consumer summary]
Hollinghurst S, Coast J, Busby J, Bishop A, Foster NE, Franchini A, Grove S, Hall J, Hopper C, Kaur S, Montgomery AA, Salisbury C
BMJ Open 2013 Oct;3(10):e003406
clinical trial
4/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind subjects: No; Blind therapists: No; Blind assessors: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

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 (1,506 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 = 1,272). Total NHS costs, including the cost of physiotherapy were higher in the PhysioDirect group by Great British Pounds 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 Great British Pounds 2,889 and the net monetary benefit at lambda = Great British Pounds 20,000 was Great British Pounds 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.
Reproduced with permission from the BMJ Publishing Group.

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