1. ‘PhysioDirect’ for patients with MSK problems ECONOMIC MODEL OVERVIEW

2. 2 Study of ' PhysioDirect ' in patients with MSK problems Background  Over a quarter of all patients registered in general practice will consult at least once for a musculoskeletal (MSK) problem each year  Musculoskeletal pain accounts for around 15% of all general practitioner (GP) consultations  New technology in the delivery of healthcare, particularly the use of telephone assessment, aim to better manage patient demand  Research has shown that telephone-based services can be safe, clinically accurate, cost-effective, acceptable to patients and reduce the workload of clinicians  A pragmatic, individually randomized controlled trial comparing 'PhysioDirect' and usual care was conducted in four typical community physiotherapy services in England Hollinghurst S, Coast J, Busby J, et al. A pragmatic randomised controlled trial of ‘PhysioDirect’ telephone assessment and advice services for patients with musculoskeletal problems: economic evaluation. BMJ Open 2013;3:e003406. doi:10.1136/bmjopen-2013-003406 Salisbury C, Foster NE, Hopper C, Bishop A, Hollinghurst S, Coast J, et al. A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of ‘PhysioDirect’ telephone assessment and advice services for physiotherapy. Health Technol Assess 2013;17(2)

3. 3 Objectives To investigate the cost-effectiveness of PhysioDirect compared with usual models of physiotherapy based on patients going on to a waiting list and eventually receiving face-to-face care. Study of ' PhysioDirect ' in patients with MSK problems PICO Hollinghurst S, Coast J, Busby J, et al. A pragmatic randomised controlled trial of ‘PhysioDirect’ telephone assessment and advice services for patients with musculoskeletal problems: economic evaluation. BMJ Open 2013;3:e003406. doi:10.1136/bmjopen-2013-003406 Salisbury C, Foster NE, Hopper C, Bishop A, Hollinghurst S, Coast J, et al. A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of ‘PhysioDirect’ telephone assessment and advice services for physiotherapy. Health Technol Assess 2013;17(2) Population Adults from four community physiotherapy services in England—Bristol, Somerset, Stoke-on-Trent and Cheshire, who were referred by GPs or other members of the primary health care team or who referred themselves (self referred) for physiotherapy for a MSK problem. Intervention PhysioDirect is the provision of an easily accessible telephone assessment and advice service from an experienced physiotherapist, supported by a computerised assessment algorithm. Following the telephone assessment, patients are usually given exercise advice and then invited to telephone back to report progress. They can then be invited for a face-to- face appointment if necessary, or this can be offered following the initial assessment if appropriate. Comparison Usual care vs PhysioDirect. EQ-5D-3L, valued using the UK tariff, was used to estimate QALYs gained for the cost-utility analysis. The primary outcome for the trial was the physical component summary (PCS) measure from the SF-36v2 questionnaire. Cost-utility analysis was based on complete cases. All outcomes (except the global improvement score and waiting time to first treatment advice) were measured at baseline, 6 weeks and 6 months. Outcome Total NHS costs, including the cost of physiotherapy were higher in the PhysioDirect group and there was a gain in QALY. PhysioDirect may be a cost-effective alternative to usual physiotherapy care.

4. 4 Study of ' PhysioDirect ' in patients with MSK problems Flow diagram of the study

5. 5 Study of ' PhysioDirect ' in patients with MSK problems Intervention and control group INTERVENTION GROUP o 'PhysioDirect' –patients invited to telephone a physiotherapist for initial assessment and advice o At the end of the call, most patients were sent written advice about self management and exercises and invited to telephone back after two to four weeks to discuss progress o Face-to-face physiotherapy offered if necessary CONTROL GROUP o Usual care – patients with musculoskeletal problems being referred by general practitioners to a physiotherapist o Patients join a waiting list for the next available face- to-face appointment, and could wait for several weeks

6. 6 OUTCOMES Study of ' PhysioDirect ' in patients with MSK problems Outcomes Outcomes were assessed at baseline, and at 6 weeks and 6 months after randomisation: 1.Physical Component Score (PCS) measure from the Short Form questionnaire-36 items (SF-36v2) 2.Mental Component Score and scales from the SF-36v2 3.Measure Yourself Medical Outcomes Profile (MYMOP) questionnaire (version 2) 4.Global measure of individual rating of overall change, based on a seven-point Likert scale from ‘very much worse’ to ‘very much better’ 5.Numbers of appointments, waiting time for treatment, and non-attendance rates 6.Time lost from work, patient satisfaction and preference 7.Quality of life measured using the EQ-5D measure (European Quality of Life-5 Dimensions; EuroQol health utility measure) 8.Costs (described in more detail later)

7. 7 Study of ' PhysioDirect ' in patients with MSK problems Cost-effectiveness results The cost-effectiveness was measured in terms of incremental cost-effectiveness ratio (ICER)  The cost-effectiveness was assessed from NHF perspective  Quality-adjusted life years (QALYs) were calculated based on EQ-5D utility data

8. 8 Calculation file

9. 9 Calculation file Structure  The model calculates both costs and health effects (Quality-adjusted life years – QALYs) related to intervention under consideration and usual treatment  Costs and health effects are combined to estimate incremental cost- effectiveness ratio (ICER) Usual care PhysioDirect Resource use & costs Quality of life -> QALYs Resource use & costs Quality of life -> QALYs Incremental cost-effectiveness ratio (ICER) Patients with MSK problem referred for physiotherapy

10. 10 Calculation file Sheets description „Results” sheet Outcomes of the analysis „Settings” sheet Resource use and cost data used in the analysis „Description” sheet Structure of the model

11. 11 Navigation toolbar located at the top of each sheet. Navigation contains two screen modes: full screen mode (see ), normal screen mode (see ). Calculation file Navigation toolbar

12. 12 Calculation file Settings – Time horizon & effectiveness data  Time horizon expressed in months  Necessary to convert utilities into QALYs, f. ex. utility of 0.7 over 6 months represents 0.35 QALYs (0.7×6/12=0.35)  Costs (details in further slides) over considered time horizon to be entered by the user  Effectiveness data  Average utility over considered time horizon  Waiting time to first assessment and advice

13. 13 Calculation file Settings – NHF costs I  Physiotherapy services  Unit measure of cost to be chosen from drop-down list  Cost per unit and number of units per patient over considered time horizon  Separate data for 3 cost categories  Primary care services  Cost per visit and number of visits per patient over considered time horizon  Separate data for 3 cost categories

14. 14 Calculation file Settings – NHF costs II  Medication costs  Average cost per prescription and number of prescriptions per patient over considered time horizon  Hospital services  Cost per episode and number of episodes per patient over considered time horizon  Separate data for 3 cost categories

15. 15 Calculation file Settings – Personal expenditure  Several cost categories representing personal expenditure borne directly by patients  Separate data for both arms over considered time horizon

16. 16 Calculation file Settings – Value of time off work  Average salary per day and duration of working week expressed in hours  Necessary to calculate unit costs of time off work (expressed in minutes or days)  Time off work to attend physiotherapy consultations expressed in minutes (over considered time horizon)  Time off work because of the condition expressed in days (over considered time horizon)

17. 17 Calculation file Settings – Set-up costs  The initial set up costs associated with establishing the new telephone service, including the training undertaken by the practitioners  These costs were not considered in original economic evaluation  Number of patients in the programme  Necessary to calculate cost per patient

18. 18 Calculation file Results  Results of the analysis over selected period (6-month by default) presented per patient  Results presented separately for control arm and intervention arm, and incremental results (difference between results for intervention arm and control arm) also shown  Results include:  Quality Adjusted Life Years (QALYs)  Costs for all categories considered together with total costs  Incremental cost-effectiveness ratio (ICER) from NHF perspective and societal perspective

19. 19 Calculation file Results

20. 20 Calculation file Results  The results show that introduction of intervention under assessment results in improvement in patients’ quality of life (expressed in QALYs) at additional costs  Incremental cost-effectiveness ratio (ICER) is GBP 2 889 and GBP 5 012 from NHF and societal perspective, respectively  In order to get 1 additional QALY it is necessary to spend additional GBP 2 889 and GBP 5 012, respectively