LTP Priority: Integrated care of older people (ICOPE)
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Interventions for osteoarthritis, neck and back pain – long term conditions and multimorbidity
Major driver of health inequalities in your area of work
Lower disability free life expectancy and healthy life expectancy in individuals experiencing socioeconomic deprivation. Musculoskeletal (MSK) conditions continue to be one of major causes of disability in the UK and are a major contributor to exiting the workforce.
Evidence based interventions for the prevention and treatment of MSK conditions which have been highlighted by PHE as demonstrating a Return on Investment (ROI) are:
- ESCAPE-knee pain
- STarT Back
- PhysioDirect – early telephone assessment and referral for physiotherapy
- Self-referral for physiotherapy
- Vocational advice from physiotherapists in primary care settings
- Cognitive behavioural therapy for lower back pain
- Yoga for Healthy Backs.
The following interventions are recommended as cost effective in addressing MSK conditions. Commissioners should be aware when commissioning these interventions that consideration should be given in relation to differences in accessing services between populations and groups. Where systems rely exclusively on self-referral the potential for this to increase health inequalities should be addressed, through specific action to ensure that those least likely to access services through this route are aware of and taking up services in expected proportions relative to need in the local population.
ESCAPE-pain is an exercise-based rehabilitation programme for people with knee pain. Robust evaluation has demonstrated that ESCAPE has been shown to reduce pain and improve function, improve psychosocial consequences of pain, and has also been shown to reduce healthcare and utilisation costs. The evidence does not focus specifically on reduction on health inequalities, however these should be addressed by ensuring that individuals at highest risk are aware of the programme and that engagement is supported in these groups. ROI analysis demonstrates a net saving per person treated with the intervention, although there were no data on gains in quality of life or productivity demonstrated – from a healthcare financial perspective of £5.20 for every £1 spent on the intervention.
STarT Back is a programme of stratified risk assessment and care for the management of lower back pain in primary care. A cost-effectiveness analysis of this intervention found it to be cost-effective and that participants receiving the intervention reported fewer days of work absence. PHE ROI report states that there is a positive ROI from a healthcare financial perspective of £10.58 for every £1 spent on the intervention. When QALY gains are included, this increases to an estimated return of £90.92 for every £1 spent and when days of work saved are also included, this increases to an estimated £226.23 for every £1 spent.
PhysioDirect is a programme offering self-referral and telephone assessment of musculoskeletal conditions. ROI analysis demonstrates a small but positive financial gain from a healthcare perspective. From a healthcare financial perspective of £2.08 for every £1 spent on the intervention. When QALY gains are included, there is an estimated ROI of £47.32 for every £1 spent.
Self-referral for physiotherapy – self-referral for physiotherapy both with and without telephone triage has been shown to be cost-effective. ROI analysis shows that there is an estimated ROI from a healthcare financial perspective of £98.54 for every £1 spent on the intervention. Commissioners supporting self-referral pathways should be aware of differences in healthcare utilisation across socioeconomic groups – e.g. deprived populations may be less likely to access self-referral opportunities. Methods of addressing this should be considered when commissioning pathways, e.g. in relation to awareness and accessibility.
Vocational advice from physiotherapists in primary care – Studies included in the PHE ROI report did not report data on gains in quality of life but did report a gain in productivity. These show that there is not a positive ROI from a healthcare financial perspective. When days of work saved are included, there is an estimated ROI from a societal/productivity perspective of £11.14 for every £1 spent on the intervention.
Cognitive behavioural therapy – Cost-effectiveness analysis of CBT for musculoskeletal conditions was associated with a small gain in QALY, gains in productivity were not reported. From a healthcare financial perspective, the ROI was negative, however when QALYs were considered a positive ROI was demonstrated.
Yoga for Healthy Lower Backs – The results of the analysis for Yoga for Healthy Lower Backs demonstrated higher healthcare costs for those who partake in the intervention, however gains in QQLYs and in productivity (days worked) were also demonstrated. The ROI analysis demonstrated a negative ROI from a healthcare financial perspective however where QALY gains were included, there is an estimated ROI of £6.61 for every £1 spent on the intervention and when days of work saved are also included, this increases to an estimated £10.17 for every £1 spent.