International Journal of Technology Assessment in Health Care


Cost-effectiveness of a graded exercise therapy program for patients with chronic shoulder complaints

Jacques J. X. R. Geraets a1, Mariëlle E. J. B. Goossens a1, Camiel P. C. de Bruijn a1, Imelda J. M. de Groot a2, Albère J. S. Köke a3, Rob A. G. B. Pelt a4, Geert van der Heijden a5, Geert-Jan Dinant a6 and Wim J. A. van den Heuvel a1
a1 Maastricht University and Institute for Rehabilitation Research
a2 University Medical Centre de Radboud and Institute for Rehabilitation Research
a3 Maastricht University and Center for Clinical Rehabilitation
a4 Center for Clinical Rehabilitation
a5 Utrecht University and University Medical Center Utrecht
a6 Maastricht University


Objectives: The present study evaluated the cost-effectiveness of a behavioral graded exercise therapy (GET) program compared with usual care (UC) in terms of the performance of daily activities by patients with chronic shoulder complaints in primary care.

Methods: A total of 176 patients were randomly assigned either to GET (n=87) or to UC (n=89). Clinical outcomes (main complaints, shoulder disability [SDQ] and generic health-related quality of life [EQ-5D], and costs [intervention costs, direct health care costs, direct non–health-related costs, and indirect costs]) were assessed during the 12-week treatment period and at 52 weeks of follow-up.

Results: Results showed that GET was more effective than UC in restoring daily activities as assessed by the main complaints instrument after the 12-week treatment period (p=.049; mean difference, 7.5; confidence interval [CI], 0.0–15.0). These effects lasted for at least 52 weeks (p=.025; mean difference 9.2; CI, 1.2–17.3). No statistically significant differences were found on the SDQ or EQ5D. GET significantly reduced direct health care costs (p=.000) and direct non–health care costs (p=.029). Nevertheless, total costs during the 1-year follow-up period were significantly higher (p=.001; GET=€530 versus UC=€377) due to the higher costs of the intervention. Incremental cost-effectiveness ratios for the main complaints (0–100), SDQ (0–100), and EQ-5D (−1.0–1.0) were €17, €74, and €5,278 per unit of improvement, respectively.

Conclusions: GET proved to be more effective in the short- and long-term and reduces direct health care costs and direct non–health care costs but is associated with higher costs of the intervention itself.

Key Words: Cost-benefit analysis; Shoulder; Behavior therapy; Randomized controlled trials.