Cost utility analysis of acute rehabilitation approaches in the management of traumatic anterior shoulder dislocation

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Aims: We aimed to conduct a cost-utility analysis comparing one session of advice, supporting materials, and option to self-refer to physiotherapy with the same advice and materials, plus an additional programme of physiotherapy for people with a first-time, traumatic anterior shoulder dislocation. Methods: We conducted an economic evaluation within a randomized controlled trial from the UK NHS and personal social services (PSS) perspective. Resources used, and health-related quality of life information, were collected as part of the Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN) randomized controlled trial over a 12-month period using patient-completed questionnaires. Incremental costs and quality-adjusted life-years (QALYs) accrued over the follow-up period were calculated and expressed as the incremental cost-effectiveness ratio (ICER). Estimate uncertainty was explored by bootstrapping and graphically displayed on the ICER plane. Net monetary benefits, probability of cost-effectiveness, and expected value of perfect information were explored at a range of willingness-to-pay thresholds and visualized graphically. Results: Over a 12-month time horizon, incremental costs were £64 (95% CI -61 to 191) and incremental QALYs were 0.019 (95% CI -0.0005 to 0.0375) for the additional programme of physiotherapy. The ICER was £3,373/QALY, suggesting that the programme is cost-effective, although the primary outcome (Oxford Shoulder Instability Score) found little difference six months after a shoulder dislocation. The probability of being cost-effective at a willingness-to-pay threshold of £30,000 per QALY is 95%. Findings need to interpreted with caution given the high rates of missing data at 12 months, due to the final 12-month follow-up being curtailed during the trial. However, the range of sensitivity analyses supports the base case findings. Conclusion: The within-trial economic evaluation found that the additional physiotherapy programme is likely to be cost-effective. However, given the small and imprecise health gains, the best use of scarce physiotherapy resources needs careful consideration given other current demands on services.

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