The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
Cost Effectiveness of Training Rural Providers to Perform Joint Injections†
Article first published online: 26 MAR 2014
Copyright © 2014 by the American College of Rheumatology
Arthritis Care & Research
Volume 66, Issue 4, pages 559–566, April 2014
How to Cite
Nelson, R. E., Battistone, M. J., Ashworth, W. D., Barker, A. M., Grotzke, M., Huhtala, T. A., LaFleur, J., Tashjian, R. Z. and Cannon, G. W. (2014), Cost Effectiveness of Training Rural Providers to Perform Joint Injections. Arthritis Care Res, 66: 559–566. doi: 10.1002/acr.22179
- Issue published online: 26 MAR 2014
- Article first published online: 26 MAR 2014
- Accepted manuscript online: 19 SEP 2013 09:32AM EST
- Manuscript Accepted: 10 SEP 2013
- Manuscript Received: 20 DEC 2012
- Veterans Health Administration Specialty Care Transformation and the Office of Academic Affiliation
- NIH and National Cancer Institute. Grant Number: KM1CA156723
Community-based outpatient clinics (CBOCs) have been established by the Department of Veterans Affairs (VA) to provide primary care services to veterans living in remote and rural regions. The objective of this study was to evaluate the cost effectiveness of training rural primary care providers to perform knee injections in CBOCs, thereby avoiding referring the patient to an urban medical center for an injection by rheumatology or orthopedic specialists.
We developed a decision-analysis model to compare costs and outcomes between rural providers who are trained to perform knee injections versus those who are not trained, therefore requiring a referral to a specialist to provide the injections. The model was run separately using costs from the perspective of the VA as well from the patient's perspective. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses were performed using 10,000 second-order Monte Carlo simulations.
In our base-case analyses, the incremental cost-effectiveness ratio for trained rural providers was $21,190/QALY using costs from the perspective of the VA and $205/QALY using costs from the patient's perspective. Training rural providers was cost effective in 74.4% and 93.6% of 10,000 Monte Carlo simulations at a willingness-to-pay threshold of $50,000/QALY from the perspectives of the VA and the patient, respectively.
Training rural providers to perform knee injections for patients with knee pain secondary to osteoarthritis appears cost effective using the commonly used threshold of $50,000/QALY if more than 20 such patients per year are seen at rural primary care clinics. These results provide support for our ongoing efforts to implement such a training program.