Economic evaluations in ‘non-inferiority’ trials: can costs guide decisions between surgical and non-surgical interventions?

Abstract

Have you ever wondered…‘Is physical therapy treatment (alone) just as good as arthroscopic partial meniscectomy (APM) in patients with non-obstructive partial meniscal tears?’ What would make you think it is just as good? What would you use as a measure of ‘goodness’? It is an interesting question, isn’t it? Clinical trials that test whether one treatment is not meaningfully worse than another are called ‘non-inferiority trials’, and they are an example of the increasing sophistication of study designs in the field of sport and exercise physiotherapy and medicine.\n\nIn this editorial I discuss the concept of non-inferiority using the JAMA -published 2018 ESCAPE study as the example. The Dutch surgeon and epidemiologist authors randomised 321 patients with non-obstructive partial meniscal tears and concluded that physical therapy alone was not inferior to APM in those patients.1 That was based on clinical measures—the widely used International Knee Documentation Committee (IKDC) score. But what about costs? Wouldn’t physiotherapy alone be cheaper than surgery too?\n\nIn the British Journal of Sports Medicine paper linked to this editorial, the authors of the ESCAPE trial report their economic evaluation.2 Patients randomised to the physical therapy intervention had lower healthcare and societal costs than patients randomised to APM. This, along with their incremental cost-effectiveness analyses, adds to the case that APM should not be the first-choice treatment for …