title: Telerehabilitation after total knee replacement in Italy: cost-effectiveness and cost-utility analysis of a mixed telerehabilitation-standard rehabilitation programme compared with usual care.
abstract: To assess cost-effectiveness and cost utility of telerehabilitation (TR) versus standard rehabilitation (SR) after total knee replacement (TKR).
  
  
  
  Markov decision modelling of cost-effectiveness and cost-utility analysis based on patient-level and secondary data sources employing Italian National Health Service (NHS; Ita-NHS) and Society perspectives.
  
  
  
  Primary care units (PCUs) in Italy.
  
  
  
  Patients discharged after TKR.
  
  
  
  Mixed SR-TR service (10 face-to-face sessions and 10 telesessions) versus SR (20 face-to-face sessions)
  
  
  
  The incremental cost per additional knee flexion range of motion (ROM) and per QALY gained by SR-TR compared with SR. Second, we considered the probability of being cost-effective and the probability of being more effective and less expensive.
  
  
  
  TR appears to be the cost-effective in the base case and in all of the considered scenarios, but is no longer more effective and less expensive if transportation costs are excluded. Comparing SR-TR with SR, the incremental cost-effectiveness ratio (ICER) adopting the Ita-NHS perspective for the base case was -€117/ROM gained. The cost-effectiveness probability for SR-TR was 0.98 (ceiling ratio: €50/ROM), while the joint probability of being more effective and less expensive was 0.87. Assuming that TR would increase health-related quality of life (HRQOL) utilities by 2.5%, the ICER adopting Ita-NHS perspective is -€960/QALY (cost-effectiveness probability: 1; ceiling ratio: €30 000/QALY). All the performed sensitivity analyses did not change the conclusions, but if transportation costs were excluded, the probability for SR-TR of being more clinically effective and less expensive reduced to 0.56.
  
  
  
  The analysis suggested SR-TR to be cost-effective, even less expensive and more effective if the PCUs provide ambulance transportations. However, the uncertainty related to TR costs, HRQOL and long-term clinical outcomes raises important topics for future research, which should be addressed to confirm our estimates.
  
  
  
  ISRCTN45837371.
authors.affiliation: Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, UK.
authors.forename: Francesco
authors.initials: F
authors.lastname: Fusco
authors.affiliation: Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Turchetti
mesh_terms: D019645:Arthroplasty, Replacement, Knee / Q000191:economics / Q000523:psychology / Q000534:rehabilitation*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008390:Markov Chains; D018803:Models, Economic; D026741:Physical Therapy Modalities / Q000191:economics / Q000592:standards; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000191:economics* / Q000379:methods; D015397:Program Evaluation; D011788:Quality of Life; D000069350:Telerehabilitation / Q000191:economics / Q000592:standards; D016896:Treatment Outcome
keywords: HEALTH ECONOMICS; REHABILITATION MEDICINE