Is hydrotherapy cost-effective? A randomised controlled trial of combined hydrotherapy programmes compared with physiotherapy land techniques in children with juvenile idiopathic arthritis

H Epps,^1* L Ginnelly,² M Utley,³ T Southwood,⁴ S Gallivan,³ M Sculpher² and P Woo⁵

¹ The Children’s Trust, Tadworth Court, UK
² Centre for Health Economics, University of York, UK
³ Clinical Operational Research Unit, University College London, UK
⁴ Birmingham Children’s Hospital and Institute of Child Health, University of Birmingham, UK
⁵ Centre for Paediatric and Adolescent Rheumatology, The Windeyer Institute of Medical Sciences, London, UK

* Corresponding author

Objectives

The objectives of this study were to compare the effects of combined hydrotherapy and land-based physiotherapy (combined) with land-based physiotherapy only (land) on cost, health-related quality of life (HRQoL) and outcome of disease in children with juvenile idiopathic arthritis (JIA). Also to determine the cost-effectiveness of combined hydrotherapy and land-based physiotherapy in JIA.

Design

A multicentre randomised controlled, partially blinded trial was designed with 100 patients in a control arm receiving land-based physiotherapy only (land group) and 100 patients in an intervention arm receiving a combination of hydrotherapy and land-based physiotherapy (combined group).

Participants

Patients aged 4–19 years diagnosed more than 3 months with idiopathic arthritides, onset before their 16th birthday, stable on medication with at least one active joint were recruited from three tertiary centres in the UK.

Intervention

Patients in the combined and land groups received 16 1-hour sessions of treatment at one of the three centres over 2 weeks followed by local physiotherapy attendances for 2 months.

Main outcome measures

Disease improvement defined as a decrease of ≥30% in any three of six core set variables without there being a 30% increase in more than one of the remaining three variables was used as the primary outcome measure and assessed at 2 months following completion of intervention. Health services resource use (in- and outpatient care, GP visits, drugs, interventions, and investigations) and productivity costs (parents’ time away from paid work) were collected at 6 months follow-up. HRQoL was measured at baseline and 2 and 6 months following intervention using the EQ-5D, and quality-adjusted life-years (QALYS) were calculated. Secondary outcome measures at 2 and 6 months included cardiovascular fitness, pain, isometric muscle strength and patient satisfaction.

Results

Seventy-eight patients were recruited into the trial and received treatment. Two months after intervention 47% patients in the combined group and 61% patients in the land group had improved disease with 11 and 5% with worsened disease, respectively. The analysis showed no significant differences in mean costs and QALYs between the two groups. The combined group had slightly lower mean costs (–£6.91) and lower mean QALYs (–0.0478, 95% confidence interval –0.11294 to 0.0163 based on 1000 bootstrap replications). All secondary measures demonstrated a mean improvement in both groups, with the combined group showing greater improvements in physical aspects of HRQoL and cardiovascular fitness.

Conclusions

Implications for healthcare

JIA is a disease in which a cure is not available. This research demonstrates a beneficial effect from both combined hydrotherapy and land-based physiotherapy treatment and land-based physiotherapy treatment alone in JIA without any exacerbation of disease, indicating that treatments are safe.

The caveat to the results of the cost-effectiveness and clinical efficacy analysis is that the restricted sample size could have prevented a true difference being detected between the groups. Nevertheless, there appears to be no evidence to justify the costs of building pools or initiating new services specifically for use in this disease. However, this conclusion may not apply to patients with unremitting active disease who could not be entered into the trial because of specified exclusion criteria. For this group, hydrotherapy or combined treatment may still be the only physiotherapy option.

Recommendations for research

The following areas are suggested for further research: investigation and development of appropriate and sensitive outcome measures for use in future hydrotherapy and physiotherapy trials of JIA.
Preliminary studies of methodologies in complex interventions such as physiotherapy and hydrotherapy to improve recruitment and ensure protocol is acceptable to patients and carers.
Investigation of hydrotherapy in the most common paediatric user group, children with neurological dysfunction, ensuring appropriate outcome measures are available and methodologies previously tried.
Comparison of patient satisfaction and compliance between land-based physiotherapy and hydrotherapy.
European studies of hydrotherapy in rare disorders such as JIA.

Publication

Epps H, Ginnelly L, Utley M, Southwood T, Gallivan S, Sculpher M, et al. Is hydrotherapy cost-effective? A randomised controlled trial of combined hydrotherapy programmes compared with physiotherapy land techniques in children with juvenile idiopathic arthritis. Health Technol Assess2005;9(39).

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