, Volume 22, Issue 3, pp 185–195 | Cite as

Cost Effectiveness of Interventions for Lateral Epicondylitis

Results from a Randomised Controlled Trial in Primary Care
  • Ingeborg B. C. Korthals-de BosEmail author
  • Nynke Smidt
  • Maurits W. van Tulder
  • Maureen P. M. H. Rutten-van Mölken
  • Herman J. Adèr
  • Daniëlle A. W. M. van der Windt
  • Willem J. J. Assendelft
  • Lex M. Bouter
Original Research Article


Objective: Lateral epicondylitis is a common complaint, with an annual incidence between 1% and 3% in the general population. The Dutch College of General Practitioners in The Netherlands has issued guidelines that recommend a wait-and-see policy. However, these guidelines are not evidence based.

Design and setting: This paper presents the results of an economic evaluation in conjunction with a randomised controlled trial to evaluate the effects of three interventions in primary care for patients with lateral epicondylitis.

Patients and interventions: Patients with pain at the lateral side of the elbow were randomised to one of three interventions: a wait-and-see policy, corticosteroid injections or physiotherapy.

Main outcome measures and results: Clinical outcomes included general improvement, pain during the day, elbow disability and QOL. The economic evaluation was conducted from a societal perspective. Direct and indirect costs (in 1999 values) were measured by means of cost diaries over a period of 12 months. Differences in mean costs between groups were evaluated by applying non-parametric bootstrap techniques. The mean total costs per patient for corticosteroid injections were €430, compared with €631 for the wait-and-see policy and €921 for physiotherapy. After 12 months, the success rate in the physiotherapy group (91%) was significantly higher than in the injection group (69%), but only slightly higher than in the wait-and-see group (83%). The differences in costs and effects showed no dominance for any of the three groups. The incremental costutility ratios were (approximately): €7000 per utility gain for the wait-and-see policy versus corticosteroid injections; €12 000 per utility gain for physiotherapy versus corticosteroid injections, and €34 500 for physiotherapy versus the waitand- see policy.

Conclusions: The results of this economic evaluation provided no reason to update or amend the Dutch guidelines for GPs, which recommend a wait-and-see policy for patients with lateral epicondylitis.


Indirect Cost Corticosteroid Injection Injection Group Lateral Epicondylitis Total Direct Cost 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The work was funded by the Health Insurance Council Fund for Investigative Medicine and the Netherlands Organisation for Scientific Research. The authors have no conflicts of interest directly relevant to the content of this study.


  1. 1.
    Alleander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand J Rheumatol 1974; 3: 145–53CrossRefGoogle Scholar
  2. 2.
    Verhaar JA. Tennis elbow [thesis]. Maastricht: University Press, 1992Google Scholar
  3. 3.
    Hamilton PG. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract 1986; 36: 464–5PubMedGoogle Scholar
  4. 4.
    Murtagh JE. Tennis elbow. Aust Fam Physician 1988; 17: 90, 91, 94–5Google Scholar
  5. 5.
    Hudak PL, Cole DC, Haines AT. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Arch Phys Med Rehabil 1996; 77: 568–93CrossRefGoogle Scholar
  6. 6.
    Assendelft WJ, Hay EM, Adshead R, et al. Corticosteroid injections for lateral epicondylitis: a systematic overview. Br J Gen Pract 1996; 46: 209–16PubMedGoogle Scholar
  7. 7.
    Labelle H, Guibert R, Joncas J, et al. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow: an attempted meta-analysis. J Bone Joint Surg 1992; 74B: 646–51Google Scholar
  8. 8.
    Assendelft WJ, Rikken SA, Mel M, et al. NHG practice guideline for epicondylitis [in Dutch]. Huisarts Wet 1997; 40: 21–6Google Scholar
  9. 9.
    Drummond MF, O’Brien B, Stoddart GL, et al. Methods for the economic evaluation of health care programmes. 2nd ed. New York: Oxford Medical Publications, 1997Google Scholar
  10. 10.
    Gold MR, Siegel JE, Russell LB, et al. Cost-effectiveness in health and medicine. Oxford: Oxford University Press, 1996Google Scholar
  11. 11.
    Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: results from a randomised controlled trial. Lancet 2002; 359: 657–62PubMedCrossRefGoogle Scholar
  12. 12.
    Binder A, Hodge G, Greenwood AM, et al. Is therapeutic ultrasound effective in treating soft tissue lesions? BMJ 1985; 290: 512–4PubMedCrossRefGoogle Scholar
  13. 13.
    Stratford P, Levy DR, Levy K, et al. Extensor carpi radialis tendonitis: a validation of selected outcome measures. Physiother Can 1987; 39: 250–5Google Scholar
  14. 14.
    Brooks R. EuroQol: the current state of play. Health Policy 1996; 37: 53–72PubMedCrossRefGoogle Scholar
  15. 15.
    Kind P. The Euroqol Instrument: an index of health-related quality of life. In: Spilker B, editor. Quality of life and pharmacoeconomics in clinical trials. 2nd ed. Philadelphia: Lippincott-Raven, 1996: 191–201Google Scholar
  16. 16.
    Dolan P. Modelling valuations for EuroQol health states. Med Care 1997; 35: 1095–108PubMedCrossRefGoogle Scholar
  17. 17.
    Goossens ME, Rutten-van M¨olken MP, Vlaeyen JW, et al. The cost diary: a method to measure direct and indirect costs in cost-effectiveness research. J Clin Epidemiol 2000; 53: 688–95PubMedCrossRefGoogle Scholar
  18. 18.
    Oostenbrink JB, Koopmanschap MA, Rutten FF. Handbook for cost studies, methods and guidelines for economic evaluation in health care [in Dutch]. Amstelveen: Health Care Insurance Council, 2000Google Scholar
  19. 19.
    Oostenbrink JB, Koopmanschap MA, Rutten FF. Standardisation of costs: the Dutch manual for costing in economic evaluations. Pharmacoeconomics 2002; 20 (7): 443–54PubMedCrossRefGoogle Scholar
  20. 20.
    Dutch Central Organisation for Health Care Charges. Tariffs for medical specialist, excluding psychiatrics: supplement to tariffs decision number 5600–1900-97–1 from 21 oktober 1996 [in Dutch]. Utrecht: Dutch Central Organisation for Health Care Charges, 1996Google Scholar
  21. 21.
    Taxe report [in Dutch]. The Hague: Z-index, 2000Google Scholar
  22. 22.
    Koopmanschap MA, van Ineveld BM. Towards a new approach for estimating indirect costs for disease. Soc Sci Med 1992; 34: 005–10CrossRefGoogle Scholar
  23. 23.
    Koopmanschap MA, Rutten FF. Indirect costs: the consequence of production loss or increased costs of production. Med Care 1996; 34: DS59–68Google Scholar
  24. 24.
    Koopmanschap MA, Rutten FF. A Practical guide for calculating indirect costs of disease. Phamacoeconomics 1996; 10 (5): 460–6CrossRefGoogle Scholar
  25. 25.
    Efron B, Tibshirani RJ. An introduction to the bootstrap. New York: Chapman & Hall, 1993Google Scholar
  26. 26.
    Chaudhary MA, Stearns SC. Estimating confidence intervals for cost-effectiveness ratios: an example from a randomised trial. Stat Med 1996; 15: 1447–58PubMedCrossRefGoogle Scholar
  27. 27.
    Van Hout BA, Al MJ, Gordon GS, et al. Cost, effects and c/e ratios alongside a clinical trial. Health Econ 1994; 3: 309–19PubMedCrossRefGoogle Scholar
  28. 28.
    Al MJ, van Hout BA, Michel BC, et al. Sample size calculations in economic evaluations. Health Econ 1998; 7: 327–35PubMedCrossRefGoogle Scholar
  29. 29.
    Coyle D. Statistical analysis in pharmacoeconomic studies: a review of current issues and standards. Pharmacoeconomics 1996; 9 (6): 506–16PubMedCrossRefGoogle Scholar
  30. 30.
    Thompson SG, Barber JA. How should cost data in pragmatic trials be analysed? BMJ 2000; 320: 1197–2000PubMedCrossRefGoogle Scholar
  31. 31.
    Briggs A, Gray A. The distribution of health care costs and their statistical analysis for economic evaluation. J Health Serv Res Policy 1998; 3: 233–45PubMedGoogle Scholar
  32. 32.
    Coyle D, Davies L, Drummond M. Trials and tribulations: emerging issues in designing economic evaluations alongside clinical trials. Int J Technol Assess Health Care 1998; 14: 135–44PubMedCrossRefGoogle Scholar
  33. 33.
    Desgagn´e A, Castilloux AM, Angers JF, et al. The use of the bootstrap statistical method for the pharmacoeconomic cost analysis of skewed data. Pharmacoeconomics 1998; 13 (5): 487–97Google Scholar

Copyright information

© Adis Data Information BV 2004

Authors and Affiliations

  • Ingeborg B. C. Korthals-de Bos
    • 1
    Email author
  • Nynke Smidt
    • 1
  • Maurits W. van Tulder
    • 1
    • 2
  • Maureen P. M. H. Rutten-van Mölken
    • 3
  • Herman J. Adèr
    • 2
  • Daniëlle A. W. M. van der Windt
    • 1
    • 4
  • Willem J. J. Assendelft
    • 5
  • Lex M. Bouter
    • 1
  1. 1.Institute for Research in Extramural MedicineVU University Medical CenterAmsterdamThe Netherlands
  2. 2.Department of Clinical Epidemiology and BiostatisticsVU University Medical CenterAmsterdamThe Netherlands
  3. 3.Institute for Medical Technology AssessmentErasmus UniversityRotterdamThe Netherlands
  4. 4.Department of General PracticeVU University Medical CenterAmsterdamThe Netherlands
  5. 5.Department of General Practice, Division of Public Health Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands

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