title: Cost-effectiveness of adjunct non-pharmacological interventions for osteoarthritis of the knee.
abstract: BACKGROUND
  There is limited information on the costs and benefits of alternative adjunct non-pharmacological treatments for knee osteoarthritis and little guidance on which should be prioritised for commissioning within the NHS. This study estimates the costs and benefits of acupuncture, braces, heat treatment, insoles, interferential therapy, laser/light therapy, manual therapy, neuromuscular electrical stimulation, pulsed electrical stimulation, pulsed electromagnetic fields, static magnets and transcutaneous electrical nerve Stimulation (TENS), based on all relevant data, to facilitate a more complete assessment of value.
  
  
  METHODS
  Data from 88 randomised controlled trials including 7,507 patients were obtained from a systematic review. The studies reported a wide range of outcomes. These were converted into EQ-5D index values using prediction models, and synthesised using network meta-analysis. Analyses were conducted including firstly all trials and secondly only trials with low risk of selection bias. Resource use was estimated from trials, expert opinion and the literature. A decision analytic model synthesised all evidence to assess interventions over a typical treatment period (constant benefit over eight weeks or linear increase in effect over weeks zero to eight and dissipation over weeks eight to 16).
  
  
  RESULTS
  When all trials are considered, TENS is cost-effective at thresholds of £20-30,000 per QALY with an incremental cost-effectiveness ratio of £2,690 per QALY vs. usual care. When trials with a low risk of selection bias are considered, acupuncture is cost-effective with an incremental cost-effectiveness ratio of £13,502 per QALY vs. TENS. The results of the analysis were sensitive to varying the intensity, with which interventions were delivered, and the magnitude and duration of intervention effects on EQ-5D.
  
  
  CONCLUSIONS
  Using the £20,000 per QALY NICE threshold results in TENS being cost-effective if all trials are considered. If only higher quality trials are considered, acupuncture is cost-effective at this threshold, and thresholds down to £14,000 per QALY.
authors.affiliation: Centre for Health Economics, University of York, York, United Kingdom.
authors.forename: Beth
authors.initials: B
authors.lastname: Woods
authors.affiliation: Centre for Health Economics, University of York, York, United Kingdom.
authors.forename: Andrea
authors.initials: A
authors.lastname: Manca
authors.affiliation: Centre for Health Economics, University of York, York, United Kingdom.
authors.forename: Helen
authors.initials: H
authors.lastname: Weatherly
authors.affiliation: Centre for Health Economics, University of York, York, United Kingdom.
authors.forename: Pedro
authors.initials: P
authors.lastname: Saramago
authors.affiliation: Centre for Health Economics, University of York, York, United Kingdom.
authors.forename: Eleftherios
authors.initials: E
authors.lastname: Sideris
authors.affiliation: Centre for Health Economics, University of York, York, United Kingdom.
authors.forename: Christina
authors.initials: C
authors.lastname: Giannopoulou
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, United Kingdom.
authors.forename: Stephen
authors.initials: S
authors.lastname: Rice
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Corbett
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America.
authors.forename: Andrew
authors.initials: A
authors.lastname: Vickers
authors.affiliation: York Teaching Hospital NHS Foundation Trust, York, United Kingdom.
authors.forename: Matthew
authors.initials: M
authors.lastname: Bowes
authors.affiliation: Department of Health Sciences, University of York, York, United Kingdom.
authors.forename: Hugh
authors.initials: H
authors.lastname: MacPherson
authors.affiliation: Centre for Health Economics, University of York, York, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Sculpher
mesh_terms: D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D020370:Osteoarthritis, Knee / Q000628:therapy*; D026741:Physical Therapy Modalities / Q000191:economics; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome