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The cost-effectiveness of a structured education pulmonary rehabilitation programme for chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial [with consumer summary]
Gillespie P, O'Shea E, Casey D, Murphy K, Devane D, Cooney A, Mee L, Kirwan C, McCarthy B, Newell J, for the PRINCE study team
BMJ Open 2013 Nov;3(11):e003479
clinical trial
6/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind subjects: No; Blind therapists: No; Blind assessors: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

OBJECTIVE: To assess the cost-effectiveness of a structured education pulmonary rehabilitation programme (SEPRP) for chronic obstructive pulmonary disease (COPD) relative to usual practice in primary care. The programme consisted of group-based sessions delivered jointly by practice nurses and physiotherapists over 8 weeks. DESIGN: Cost-effectiveness and cost-utility analysis alongside a cluster randomised controlled trial. SETTING: 32 general practices in Ireland. PARTICIPANTS: 350 adults with COPD, 69% of whom were moderately affected. INTERVENTIONS: Intervention arm (n = 178) received a 2 h group-based SEPRP session per week over 8 weeks delivered jointly by a practice nurse and physiotherapist at the practice surgery or nearby venue. The control arm (n = 172) received the usual practice in primary care. MAIN OUTCOME MEASURES: Incremental costs, Chronic Respiratory Questionnaire (CRQ) scores, quality-adjusted life years (QALYs) gained estimated using the generic EQ5D instrument, and expected cost-effectiveness at 22 weeks trial follow-up. RESULTS: The intervention was associated with an increase of 944 (95% CIs 489 to 1,400) in mean healthcare cost and 261 (95% CIs 226 to 296) in mean patient cost. The intervention was associated with a mean improvement of 1.11 (95% CIs 0.35 to 1.87) in CRQ Total score and 0.002 (95% CIs -0.006 to 0.011) in QALYs gained. These translated into incremental cost-effectiveness ratios of 850 per unit increase in CRQ Total score and 472,000 per additional QALY gained. The probability of the intervention being cost-effective at respective threshold values of 5,000, 15,000, 25,000, 35,000 and 45,000 was 0.980, 0.992, 0.994, 0.994 and 0.994 in the CRQ Total score analysis compared to 0.000, 0.001, 0.001, 0.003 and 0.007 in the QALYs gained analysis. CONCLUSIONS: While analysis suggests that SEPRP was cost-effective if society is willing to pay at least 850 per one-point increase in disease-specific CRQ, no evidence exists when effectiveness was measured in QALYS gained. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52403063.
Reproduced with permission from the BMJ Publishing Group.

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