Can we reduce disease burden from osteoarthritis?

Leonie Segal, Susan E Day, Adam B Chapman and Richard H Osborne
Med J Aust 2004; 180 (5 Suppl): S11.


  • The comparison of disparate interventions for the prevention and management of osteoarthritis (OA) is limited by the quality and quantity of published efficacy studies and the use of disparate measures for reporting clinical trial outcomes.

  • The “transfer to utility” technique was used to translate published trial outcomes into a health-related quality-of-life (utility) scale, creating a common metric which supported comparisons between disparate interventions.

  • Total hip replacement (THR) and total knee replacement (TKR) surgery were the most effective treatments and also highly cost-effective, at estimated cost per quality-adjusted life-year (QALY) of $7500 for THR and $10 000 for TKR (best estimate).

  • Other apparently highly cost-effective interventions were exercise and strength training for knee OA (< $5000/QALY), knee bracing, and use of capsaicin or glucosamine sulfate (< $10 000/QALY).

  • The cost per QALY estimates of non-specific and COX-2 inhibitor non-steroidal anti-inflammatory drugs were affected by treatment-related deaths and highly sensitive to the discounting of life-years lost.

  • OA interventions that have been shown to be ineffective (eg, arthroscopy) are targets for redistribution of healthcare resources.

  • OA interventions which lack efficacy studies (eg, prevention programs) require further research to assist priority setting.

  • The application of the Health-sector Wide model to OA demonstrates its role as an evidence-based model that can be successfully applied to identify marginal interventions — those to be expanded and contracted to reduce the expected burden of disease, within current healthcare resources.

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  • Leonie Segal1
  • Susan E Day2
  • Adam B Chapman3
  • Richard H Osborne4

  • 1 Health Economics Unit, Faculty of Business and Economics, Monash University, Melbourne, VIC.
  • 2 Centre for Rheumatic Diseases, Department of Medicine, University of Melbourne, Melbourne, VIC.


We acknowledge funding from the Population Health Division, Department of Health and Ageing (DHA) and thank the Advisory Panel (in alphabetical order) — N Bellamy, University of Queensland; N Bogduk, University of Newcastle; P Brooks, University of Queensland; H Brown, DHA; R Buchbinder, Monash University; M Cohen, RMIT. J Feller, Austin Repatriation Medical Centre; M Galea, University of Melbourne; S Garner, DHA; B Harrison, DHA; J Kelly, Community Representative Victoria; S Kirsa, Austin and Repatriation Medical Centre; D Lewis, Monash University; L March, Royal North Shore Hospital; G McColl, University of Melbourne; H McNeil, Arthritis Foundation of Victoria; C Sindall, DHA; C Stone, Department of Human Services, Victoria; and P Woodley, DHA.

Competing interests:

An Advisory Panel, including people from the DHA (see funding source, above), assisted by commenting on drafts and interpretation of the results. The authors controlled all intellectual decisions, and the views presented in this report are those of the researchers and not the DHA.

  • 1. Australian Bureau of Statistics. National health survey. Canberra: Australian Bureau of Statistics, 1995. (Catalogue No. 4399.0.)
  • 2. Segal L, Day S, Chapman A, et al. Priority setting in osteoarthritis. Report to the Department of Health and Ageing. Melbourne: Health Economics Unit, Monash University, 2004. In press.
  • 3. Segal L, Robertson I. Diabetes integrated care trial mid-north coast, New South Wales. Research Report 21. Melbourne: Centre for Health Program Evaluation, 2001. Available at: (accessed Jan 2004).
  • 4. Carter R, Stone C, Vos T, et al. Trial of program budgeting and marginal analysis (PBMA) to assist cancer control planning in Australia (PBMA Series No 5). Research Report 19. Melbourne: Centre for Health Program Evaluation, 2000. Available at: (accessed Jan 2004)..
  • 5. Tengs TO, Adams ME, Pliskin JS, et al. Five-hundred life-saving interventions and their cost-effectiveness. Risk Analysis 1995; 15: 360-390.
  • 6. Segal L, Chen Y. Priority setting models for health. Working paper 119. Melbourne: Health Economics Unit, Monash University, 2001. Available at: (accessed Jan 2004).
  • 7. Coast J, Donovan J, Frankel S. Priority setting: the health care debate. New York: John Wiley, 1996.
  • 8. Miles A. Using the mass-media to target obesity: an analysis of the characteristics and reported behaviour change of participants in the BBC’s “Fighting Fat, Fighting Fit” campaign. Health Educ Res 2001; 16: 357-372.
  • 9. Wardle J, Rapoport L, Miles A, et al. Mass education for obesity prevention: the penetration of the BBC’s “Fighting Fat, Fighting Fit” campaign. Health Educ Res 2001; 16: 343-355.
  • 10. Bowerman S, Bellman M, Saltsman P, et al. Implementation of a primary care physician network obesity management program. Obes Res 2001; 9 Suppl 4: 321S-325S.
  • 11. Coggon D, Reading I, Croft P, et al. Knee osteoarthritis and obesity. Int J Obes Relat Metab Disord 2001; 25: 622-627.
  • 12. Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects (SOS) — an intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesity. Int J Obes Relat Metab Disord 1998; 22: 113-126.
  • 13. Lorig K, Lubeck D, Kraines RG, et al. Outcomes of self-help education for patients with arthritis. Arthritis Rheum 1985; 28: 680-685.
  • 14. Lorig K, Seleznick M, Lubeck D, et al. The beneficial outcomes of the arthritis self-management course are not adequately explained by behavior change. Arthritis Rheum 1989; 32: 91-95.
  • 15. Mazzuca SA, Brandt KD, Katz BP, et al. Effects of self-care education on the health status of inner-city patients with osteoarthritis of the knee. Arthritis Rheum 1997; 40: 1466-1474.
  • 16. Lord J, Victor C, Littlejohns P, et al. Economic evaluation of a primary care-based education programme for patients with osteoarthritis of the knee. Health Technol Assess 1999; 3: 1-55.
  • 17. Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am 1999; 81: 539-548.
  • 18. O’Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis 1999; 58: 15-19.
  • 19. Baker KR, Nelson ME, Felson DT, et al. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol 2001; 28: 1655-1665.
  • 20. van Baar ME, Dekker J, Oostendorp RA, et al. The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial. J Rheumatol 1998; 25: 2432-2439.
  • 21. Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 2000; 132: 173-181.
  • 22. Bensen WG, Fiechtner JJ, McMillen JI, et al. Treatment of osteoarthritis with celecoxib, a cyclooxygenase-2 inhibitor: a randomized controlled trial. Mayo Clin Proc 1999; 74: 1095-1105.
  • 23. Pincus T, Koch GG, Sokka T, et al. A randomized, double-blind, crossover clinical trial of diclofenac plus misoprostol versus acetaminophen in patients with osteoarthritis of the hip or knee. Arthritis Rheum 2001; 44: 1587-1598.
  • 24. Williams GW, Hubbard RC, Yu SS, et al. Comparison of once-daily and twice-daily administration of celecoxib for the treatment of OA of the knee. Clin Ther 2001; 23: 213-227.
  • 25. Reginster JY, Deroisy R, Rovati LC, et al. Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial. Lancet 2001; 357: 251-256.
  • 26. Appelboom T, Schuermans J, Verbruggen G, et al. Symptoms modifying effect of avocado/soybean unsaponifiables (ASU) in knee osteoarthritis. A double blind, prospective, placebo-controlled study. Scand J Rheumatol 2001; 30: 242-247.
  • 27. Altman R, Aven A, Holmburg C, et al. Capsaicin cream 0.025% as monotherapy for osteoarthritis: a double-blind study. Semin Arthritis Rheum 1994; 23: 25-33.
  • 28. Bachmeier C, March L, Cross M. A comparison of outcomes in OA patients undergoing total hip and knee replacement. Osteoarth Cartilage 2001; 9: 137-146.
  • 29. Bradley JD, Heilman DK, Katz BP, et al. Tidal irrigation as treatment for knee osteoarthritis: a sham-controlled, randomized, double-blinded evaluation. Arthritis Rheum 2002; 46: 100-108.
  • 30. Kind P. The EuroQol instrument: an index of health-related quality of life. In: Spilker B, editor. Quality of life and pharmacoeconomics in clinical trials. 2nd ed. Philadelphia: Lippincott–Raven, 1996.
  • 31. Osborne RH, Hawthorne G, Lew EA, et al. Quality of life assessment in the community-dwelling elderly: validation of the Assessment of Quality of Life (AQoL) instrument and comparison with the SF-36. J Clin Epidemiol 2003; 56: 138-147.
  • 32. Hawthorne G, Richardson J, Osborne R. The Assessment of Quality of Life (AQoL) instrument: a psychometric measure of health-related quality of life. Qual Life Res 1999; 8: 209-224.
  • 33. Ware J, Kosinski M, Keller S. SF-36 physical and mental health summary scales: a user’s manual. Boston: The Health Institute, New England Medical Centre, 1994.
  • 34. Brazier J, Usherwood T, Harper R, et al. Deriving a preference-based single index from the UK SF-36 health survey. J Clin Epidemiol 1998; 51: 1115-1128.
  • 35. Hawthorne G, Richardson J, Day N. A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments. Ann Med 2001; 33: 358-370.
  • 36. Brazier J, Roberts J, Deverill M. The estimation of a preference-based measure of health from the SF-36. J Health Econ 2002; 21: 271-292.
  • 37. Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: Australian Institute of Health and Welfare, 1999. (AIHW cat no PHE 17.)
  • 38. Bellamy N, Kaloni S, Pope J, et al. Quantitative rheumatology: a survey of outcome measurement procedures in routine rheumatology outpatient practice in Canada. J Rheumatol 1998; 25: 852-858.
  • 39. Richardson J. Age weighting and time discounting: technical imperative versus social choice. In: Summary measures of population health. Geneva: World Health Organization, 2002: 663-676.
  • 40. Department of Health. Policy appraisal and health: a guide from the Department of Health. London: Department of Health, 1996.
  • 41. The Green Book, Appraisal and Evaluation in Central Government. London: HM Treasury, January 2003.
  • 42. Department of Health and Ageing. Guidelines for the pharmaceutical industry on preparation of submissions to the Pharmaceutical Benefits Advisory Committee. Canberra: Commonwealth Department of Health and Ageing, 2002.
  • 43. Crawford RW, Murray DW. Total hip replacement: indications for surgery and risk factors for failure. Ann Rheum Dis 1997; 56: 455-457.
  • 44. Annual report of the Australian Orthopaedic Association. Available at: (accessed Apr 2003).
  • 45. Moseley JB Jr, Wray NP, Kuykendall D, et al. Arthroscopic treatment of OA of the knee: a prospective randomised placebo-controlled trial. Results of a pilot study. Am J Sports Med 1996; 24: 28-34.
  • 46. Juni P, Rutjes AW, Dieppe PA. Are selective COX2 inhibitors superior to traditional non steroidal anti-inflammatory drugs? BMJ 2002; 324: 1287-1288.
  • 47. Rindone JP, Hiller D, Collacott E, et al. Randomized, controlled trial of glucosamine for treating osteoarthritis of the knee. West J Med 2000; 172: 91-94.
  • 48. Muller-Fassbender H. Double-blind clinical trial of S-adenosylmethionine versus ibuprofen in the treatment of osteoarthritis. Am J Med 1987; 83: 81-83.
  • 49. Cohen M, Wolfe R, Mai T, Lewis D. A randomized, double blind, placebo controlled trial of a topical cream containing glucosamine sulfate, chondroitin sulfate, and camphor for osteoarthritis of the knee. J Rheumatol 2003; 30: 523-528.
  • 50. Pavelka K, Gatterova J, Olejarova M, et al. Glucosamine sulfate use and delay of progression of knee osteoarthritis: a 3-year, randomized, placebo-controlled, double-blind study. Arch Intern Med 2002; 162: 2113-2123.


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