Modelled cost-effectiveness analysis of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual care

Background The aim of the study was to estimate the long-term cost-effectiveness of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual postoperative care. Methods Study design: A decision-analytic (cohort Markov) model was used for the simulation with time dependent annual transition probabilities and a time horizon of five years. Setting: Patients treated by National Health Service (NHS) hospitals in England and Wales. Study population: Adults classified as having chronic pain three months after undergoing a total knee replacement. Intervention: The STAR care pathway following a total knee replacement. Comparator: Usual postoperative care following a total knee replacement. Perspective: The study was undertaken from the perspective of the NHS. Outcome measures: Quality-adjusted life years and healthcare costs. Discounting: A rate of 3.5% for both costs and health utility. Results Model results indicate that the STAR intervention would dominate current practice by providing a gain in quality-adjusted life years (QALYs) of 0.086 and a reduction of £375 (per person) in costs over the first five years. The incremental net monetary benefit of the STAR intervention was estimated at £2,086 (at a threshold of £20,000 per QALY). Probabilistic sensitivity analysis suggests the STAR intervention is likely to be cost-effective with a probability of 0.62. The results remain robust to changes in model assumptions on comparator utility and the timing of the start of the intervention. If hospital admission costs are assumed not to be reduced by the STAR intervention, it would no longer be cost saving, but it would likely be cost-effective based on probabilistic sensitivity analysis (0.59). Conclusion Evidence from the economic model suggests that the STAR care pathway is likely to be cost-effective and potentially dominant from an NHS perspective. Trial registration The STAR trial is registered with ISRCTN, ISRCTN92545361

Long-term effects of the Active for Life Year 5 (AFLY5) school-based cluster randomised controlled trial

Objective: To investigate the long-term effectiveness of a school-based intervention to improve physical activity and diet in children. Design: Cluster-randomised controlled trial. Setting: 60 primary schools in the southwest of England. Participants: Primary school children who were aged 8-9 years at recruitment, 9-10 years during the intervention and 10-11 years at the long-term follow-up assessment. Intervention: Teacher training, provision of lesson and child-parent interactive homework plans and teaching materials. Main Outcome Measures: Primary outcomes were accelerometer-assessed minutes of moderate to vigorous physical activity (MVPA) per day, accelerometer-assessed minutes of sedentary behaviour per day and reported daily consumption of servings of fruit and vegetables. Results: 60 schools with 2221 eligible children were recruited. As in the previously published assessment immediately after the end of the intervention, none of the three primary outcomes differed between children in schools allocated to the intervention, compared with those in control schools at the end of the long-term follow-up (1 year after the end of the intervention). Differences in secondary outcomes were consistent with those at the immediate follow-up, with no evidence that these had diminished over time. Comparing intervention with control schools, the difference in mean child-reported screen viewing at the weekend was -16.03 min (95% CI -32.82 to 0.73), for servings of snacks per day, the difference was -0.11 (95% CI -0.39 to 0.06), in servings of high-energy drinks per day -0.20 (95% CI -0.39 to -0.01) and in servings of high-fat foods per day -0.12 (95% CI -0.39 to 0.00). None of these reached our predefined level of statistical significance, especially after accounting for multiple testing. Conclusions: School-based curriculum interventions alone are unlikely to have a major public health impact on children's diet and physical activity.Emma L Anderson, Laura D Howe, Ruth R Kipping, Rona Campbell, Russell Jago, Sian M Noble, Sian Wells, Catherine Chittleborough, Tim J Peters, Debbie A Lawlo

The healthcare system costs of hip fracture care in South Africa

Summary Despite rapidly ageing populations, data on healthcare costs associated with hip fracture in Sub-Saharan Africa are limited. We estimated high direct medical costs for managing hip fracture within the public healthcare system in SA. These findings should support policy decisions on budgeting and planning of hip fracture services. Purpose We estimated direct healthcare costs of hip fracture (HF) management in the South African (SA) public healthcare system. Methods We conducted a micro-costing study to estimate costs per patient treated for HF in five regional public sector hospitals in KwaZulu-Natal (KZN), SA. Two hundred consecutive, consenting patients presenting with a fragility HF were prospectively enrolled. Resources used including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by unit costs, estimated from the KZN Department of Health hospital fees manual 2019/2020, in local currency (South African Rand, ZAR), and converted to 2020 US$prices. Generalized linear models estimated total covariate-adjusted costs and cost predictors. Results The mean unadjusted cost for HF management was US$6935 (95% CI; US$6401–7620) [ZAR114,179 (95$5904 (95% CI; 5408–6535), contributing to 85% of total cost. The covariate-adjusted cost for HF management was US$6922 (95$6743–7118) [ZAR113,976 (95% CI; ZAR111,031–117,197)]. After covariate adjustment, total costs were higher in patients operated under general anaesthesia [US$7251 (95$6506–7901)] compared to surgery under spinal anaesthesia US$6880 (95$6685–7092) and no surgery US$7032 (95$6454–7651). Conclusion Healthcare costs following a HF are high relative to the gross domestic product per capita and per capita spending on health in SA. As the population ages, this significant economic burden to the health system will increase