Geneva Switzerland, 9 may – 12 may 2018

Cost-effectiveness of physiotherapy in childhood functional constipation: a pragmatic randomized controlled trial in primary care

Jojanneke JGT van Summeren MSc1, Gea A Holtman PhD2, Yvonne Lisman-van Leeuwen PhD3, Alice HC van Ulsen-Rust4, Karin M Vermeulen PhD5  Merit M Tabbers MD PHD6, Boudewijn J Kollen PHD7, Janny H Dekker MD PhD8, Marjolein Y Berger, MD PhD9

Affiliations: 1University of Groningen, University Medical Center Groningen, the Netherlands, 2 Pelvicum kinderbekkenfysiotherapie Groningen, the Netherlands, 3 Emma Children’s Hospital/Amsterdam UMC, Location AMC, Amsterdam, the Netherlands


Introduction Health care expenditures for children with functional constipation (FC) are high, while conservative management is successful in only 50% of the children. Physiotherapy has shown positive effects in the treatment of childhood FC in hospitals. If physiotherapy is also beneficial in primary care, the number of referrals can be reduced and therewith costs. No studies have been published exploring the balance between health gains and costs associated with physiotherapy. The aim of this study is to evaluate whether adding physiotherapy to conventional treatment (CT) is a cost-effective strategy in the management of children with FC in primary care.

Methods An economic evaluation was performed alongside a pragmatic randomized controlled trial with a follow-up of 8 months. Children aged 4 to 18 years and diagnosed with FC, were randomly allocated to physiotherapy and CT (n=67) and CT only (n=67). CT comprised toilet training, nutritional advice, and laxative prescribing, whereas physiotherapy focused on resolving dyssynergic defecation.  Outcome measure were treatment success at 8 months, defined as the absence of FC according to the Rome III criteria without laxative use; absence of FC irrespective of continue laxative use; and societal costs. Incremental cost ratios (ICERs) were displayed as incremental costs to treat one extra patient successful with physiotherapy, confidence intervals were calculated with 5000 bootstrap replications. 

Results Over 8 months, costs (mean difference = €155; 95%CI €-12 to €310 in favor of CT) and treatment success percentages, i.e. no FC and no laxatives (42% in both groups) and no FC irrespective of continue laxatives (63% for CT and 75% for physiotherapy) were not statistically different between groups. The ICER to treat one extra patient successful with physiotherapy was €24060 (95%CI;€-16275 to 31390). The cost-effectiveness acceptability curve indicated that regardless the amount one is willing-to-pay (WTP), the probability that physiotherapy is cost-effective compared to CT is 0.5. For the outcome measure absence of FC irrespective of continue laxative use, the ICER was €1221 (95%CI €-12905-10956). By a WTP of €4000 the probability that physiotherapy is cost-effective is 0.85. 

Conclusions Physiotherapy as first line treatment for all children with FC in primary care is not cost-effective compared to CT. More research is needed to evaluate whether physiotherapy in primary care is cost-effective in children with long-term symptoms and whether it can reduce costs on the long-term. 


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