Cost-Benefit Analysis of Otago Exercise Programme in Adults with Rheumatoid Arthritis

This study measures the cost-benefit analysis of the Otago Exercise Programme in community dwelling adults with rheumatoid arthritis. It explores the healthcare cost of falls in adults with RA and estimates the potential economic benefits of implementing the OEP to improve function and prevent falls.

R E S E A R C H A R T I C L E Open Access
A prospective cohort study measuring cost-
benefit analysis of the Otago Exercise
Programme in community dwelling adults
with rheumatoid arthritis
Siyar Abdulrazaq1
, Jackie Oldham2
, Dawn A.Skelton3
, Terence O’Neill2
, Luke Munford4
, Brenda Gannon4
,
Mark Pilling1
, Chris Todd1 and Emma K.Stanmore1*
Abstract
Background:Falls are one of the major health problems in adults with Rheumatoid Arthritis (RA).Interventions,
such as the Otago Exercise Programme (OEP),can reduce falls in community dwelling adults by up to 35%.The
cost-benefits of such a programme in adults with RA have not been studied.
The aims of this study were to determine the healthcare cost of falls in adults with RA,and estimate whether it
may be cost efficient to rollout the OEP to improve function and prevent falls in adults living with RA.
Methods:Patients with Rheumatoid Arthritis aged ≥18 years were recruited from four rheumatology clinics
the Northwest of England.Participants were followed up for 1 year with monthly fallcalendars,telephone calls and
self-report questionnaires.Estimated medicalcost of a fall-related injury incurred per-person were calculated and
compared with OEP implementation costs to establish potentialeconomic benefits.
Results:Five hundred thirty-five patients were recruited and 598 falls were reported by 195 patients.Cumulative
medicalcosts resulting from allinjury leading to hospitalservices is £374,354 (US$540,485).Average estimated cost
per fallis £1120 (US$1617).Estimated cost of implementing the OEP for 535 people is £116,479 (US$168,504) or
£217.72 (US$314.34) per-person.Based on effectiveness of the OEP it can be estimated that out of the 598 falls,209
falls would be prevented.This suggests that £234,583 (US$338,116) savings could be made,a net benefit of
£118,104 (US$170,623).
Conclusions:Implementation of the OEP programme for patients with RA has potentially significant economi
benefits and should be considered for patients with the condition.
Keywords:Rheumatoid arthritis,Health economics,Falls,Injury,Costs,Falls prevention,OTAGO,Prospective
* Correspondence:[e-mail]
1E K Stanmore Schoolof Nursing,Midwifery and SocialWork,MAHSC
(Manchester Academic Health Science Centre),University of Manchester,
Jean McFarlane Building,University Place,Manchester M13 9PL,UK
Fulllist of author information is available at the end of the article
© The Author(s).2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
InternationalLicense (http://creativecommons.org/licenses/by/4.0/),which permits unrestricted use,distribution,and
reproduction in any medium,provided you give appropriate credit to the originalauthor(s) and the source,provide a link to
the Creative Commons license,and indicate if changes were made.The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.
Abdulrazaq et al.BMC Health Services Research (2018) 18:574
https://doi.org/10.1186/s12913-018-3383-4

Key messages
1) This is the first study that gives detailed analysis of
healthcare cost of falls in adults with RA and
estimates potential cost-savings.
2) Cumulative medical costs for 598 falls was £374,354
(US$540,485),average estimated cost-per-fall £1120
(US$1617).
3) The findings strengthen the case for the delivery of
an evidence-based falls prevention programme for
adults with RA.
Background
Rheumatoid arthritis (RA) is an inflammatory disease of
unknown cause that first targets synovialtissues,cartil-
age and bone. It is the most common form of
immune-mediated arthritisaffecting approximately 1%
of the adultUK population [1,2], with a globalpreva-
lence of 0.24% [3].Symptomaticpatientswith RA
present with joint pain,swelling,muscle weakening with
fatigue and reduced functioning [4–8].In the community,
falling is a problem especially among adults aged 65 years
or older,for whom falls are the main cause ofboth fatal
and non-fatalinjuries [9].It is estimated that 30–35% of
people in the community aged 65 and above have at least
one fall per year [10, 11]. In adults with RA the risk of fall-
ing is even greater,with the annualincidence rate esti-
mated to be between 10 and 54% [4–7,12–18]and in
contrastto thosewithoutRA the risk appearsto be
broadly similar across the age bands [19].
Most of the injuries resulting from a fallare non-fatal
(e.g. bumps and bruises), but approximately 10–25% of falls
result in more serious injuries such as hip fractures,head
trauma or internalbleeding [9,20].Falls can affect a per-
son’smorbidity and quality oflife and also impactthe
health care system in terms ofmedicalcosts [9,21,22].
Falls are a common cause of Emergency Department visits,
acute care admissionsand hospitalisation among adults
aged 65 years and over [22–24].Apart from the acute care
costs to consider there are also the social care costs which,
according to estimates from the UK Department of Health’s
economicevaluation,will incur ongoing costs of
£1872(US$2702) per fracture patient, per year [25].
Many ofthe risk factors for falls,such as poor balance
and gait or mobility impairments, can be improved by exer-
cise [9].Implementing effective prevention strategies could
therefore potentially reduce the risk of falling,decrease the
incidence offalls and reduce associated health care costs
[26]. There is abundant evidence that exercise programmes
that improve balance muscle strength and walking ability
are effective in preventing falls [27–30].Clinical trials pro-
vide evidence that an exercise programme as a single inter-
vention can preventfalls in older adultsliving in the
community [30–32].
The Otago Exercise Programme (OEP)is considered
for implementation in patients with RA because ithas
demonstrated to beone of the most beneficialpro-
grammes to prevent falls [30,33].The programme con-
sistsof individually tailored muscle strengthening and
balanceretrainingexerciseswith increasingdifficulty
combined with a gait-improving programme.The aims
of the programme are to improve patient’s strength and
balance and increase theirconfidence in carrying out
everyday activities withoutfalling.The programme has
the greatestimpactamong high-risk groups;such as
those with a previous falland those aged 80 and above
[31].In the four trialsstudied with 1016 people ages
65 years to 95 years in nine cities and towns in New
Zealand,the OEP reduced the rate ofboth falls and fall
related injuries by 35% [30,33].A more recent systemic
review and meta-analysis (88 trials with 19,478 partici-
pants) showed similar strong evidence that exercise that
challenged balance and involved more than 3 h/week of
exercise led to a 39% reduction in falls [32].
Trained physiotherapists or nurses are able to deliver
the programme in the home setting.Patients are shown
how to do a setof in-home exercises tailored to their
needs during a one-hour visit and 3 to 4 half hour visits
over the first 2 months.The exercisestake approxi-
mately 30 min to complete.They are encouraged to walk
outside twice a week and to complete the exercises three
times a week.The aim of implementing this programme
is to improve health and wellbeing of people by prevent-
ing falls and fall related injuries and reducing the impact
on the healthcare services.The proposed netfinancial
benefitwould be thatthe averted healthcare costs out-
weigh the cost of implementing the programme.Such fi-
nancialinformation would be beneficialin determining
whether investing in the OEP as an intervention to pre-
vent falls would provide a positive return ofinvestment
(PRI) for the NationalHealth Service (NHS)or other
such health providers.
To date there are no studies which have looked at in-
terventions to reduce the risk of falls in adults with RA.
Assuming similarbenefitsof the OEP programme as
those without RA we looked at the potential cost savings
if such a program were implemented.We used prospect-
ive follow up data on falls and determined the costs as-
sociated with falls in men and women with RA.
Methods
Study design
This study reports the follow up results from a prospect-
ive cohort study that was designed to determine the in-
cidenceand risk factorsfor falls in adults with RA
(Stanmore etal., 2013).The participants in this study
were patients who were referred from four rheumatology
clinics in the North Westof England during the years
Abdulrazaq et al.BMC Health Services Research (2018) 18:574 Page 2 of 9

2008 and 2009.Participants were followed up for one
yearwith monthly fallscalendars,telephone callsand
self-reportquestionnaireson falls that included ques-
tions on the injuries incurred [34].The baseline meas-
urement was completedby n = 559and n = 535
completed the 1-yearfollow-up.The timeline ofdata
collection was between the years 2008–2010,further in-
formation about methods and participant demographics
can be found in Stanmore et al.2013 [7].
Participant inclusion criteria
Participants were included if they had a diagnosis of RA
(based on the 2010 American College ofRheumatology
classification criteria for RA).All participants were over
the age of 18,with the ability to give informed consent.
Measurement of fall and injuries
All participants were given preaddressed,prepaid daily
falls calendars which they posted monthly.Participants
who reported a fall(or if they needed prompting to re-
turn the falls calendars) were telephoned to gain further
information about the fall.A standardised questionnaire
was completed by trained research nurses atthe tele-
phone interview to record details ofthe fall[34].Falls
were defined as, ‘an unexpected eventin which partici-
pants come to rest on the ground,floor or other lower
level’as per the Prevention ofFalls Network Europe
(ProFaNE) which ensures that trips or stumbles are ex-
cluded [35].The questionnaire included questions about
factors including type offall,type ofinjury,severity of
fall, call out for an ambulance,requirementto attend
A&E servicesor a stay overnightin public or private
hospital.Other questions included whether their fallre-
sulted in permanentlymovingto a care home or
whether they had seen a doctor or other health profes-
sional.The standardised questionnaire also requested in-
formation regardingspecific injuries (head injury,
dislocation ofa joint, fracture ofa bone,stitchesre-
quired,and presence ofinternalbleeding)or any other
resources used as result of fall.
Classification of falls
In order to estimate the cost of one fall,the seriousness
of that falland the services that were used in each fall
episode had to be determined.Falls thatwere reported
were verified bytelephonecalls and followed up to
gather more information.This was used to classify the
fall according to the severity of the injury,of which there
were three options:no injury,moderate injury,and se-
vere injury.If the severity of the fall was reported as ser-
ious or if the fallresulted in a fracture;a head injury
with admissions to hospitalor if stitches were required
the severity of the injury was categorised as serious.The
injury was moderateif the severityof the fall was
reported as moderate and medical help was sought from
outpatientclinicsor if therewas a head injury with
bruising or sprains.
Economic evaluation
Estimating cost of the fall related injury
The perspective ofthe economic analysis is thatof the
English NHS.To estimate the directhealth care costs
resulting from fall injuries, the National Schedule of Refer-
ence (NSR) cost provided by the NHS organisations from
the financialyear 2013/2014 was used [36].The costfor
each injury (i.e. head injury or hip, wrist, knee, hand, lower
arm fractures) and the services provided by the hospitals
(hospitalisation,ambulance use,A&E attendance)were
considered.As per National Institute for Health and Clin-
ical Excellence (NICE) additional costs for x-rays and CT
scans were added where the head injury or fracture was
moderate or serious and required A&E attendance or hos-
pitalisation [37].The costof inpatientsadmission was
multiplied by the number of nights spend in hospital. One
night on the ward in a public hospital included radiology,
laboratory blood services, pharmacy products, hospital so-
cial workers,and physiotherapy and occupational therapy
costs.The NSR included overhead costs (catering,clean-
ing,heating,telephone,lighting,laundry,administration,
orderlies, and computing).
Estimating cost for the Otago Exercise Programme
The cost for implementing the OEP was estimated using
2015 financialrecords ofHealth and Socialcare from
the Personal Social Services Research Unit (PSSRU) [38].
These are nationalestimates ofstaffcosts in the NHS
and include:the costof wages and salaries.Additional
costs included equipment(ankle cuffweights,instruc-
tion manualfor trainers),on-going training and quality
control coursesfor the physiotherapist,intervention
costs (labour and traveltime),telephone calls,and over-
head costs.The costs are inclusive of government goods
and services tax,and they are reported in British Pounds
and US dollars using March 2016 converting rates.The
costs for recruiting the exercise instructors were not in-
cluded because the assumption was made thatexisting
staffin the NHS can deliverthe exercise programme.
There was also no value put on the time patients spend
exercising using thegiven intervention asit was as-
sumed that the activities were done in their leisure time.
The estimated overhead costs used was 19.31% ofex-
pected resource use,this percentage was used as it is the
average reported forall hospitalsand health services
[38].This additionalcostis supposed to represents the
support services used by the NHS for it to run effectively
and includes administration and human resources.It is
important to note that integrated care was not a feature
in this study.
Abdulrazaq et al.BMC Health Services Research (2018) 18:574 Page 3 of 9

Analysis
For each fallthe number of injuries is multiplied by the
health care cost ofthat particular injury.The totalcost
of all598 falls is obtained by adding allindividualinjury
costs.Alongside this,an estimation ofthe cost is made
for implementing the OEP.Previous studies measuring
the effectiveness of the OEP has shown a 35% reduction
in the numberof falls and fall related injuriesin the
OEP group compared to the controlgroup [31].There-
fore this would suggest 209 falls would be prevented.In
the analysis the percentage difference is calculated be-
tween the total health care cost of 209 falls and the cost
of implementing the OEP for all535 participants.The
resulting percentagedifferenceindicatesthe potential
savings from implementing the OEP.
Results
Participant characteristics
Full details of the participant demographics and charac-
teristics have been described elsewhere (Stanmore et al.,
2013).In brief,69% of the 559 participants were women
(n = 386)and the mean ageof the participantswas
62 years (SD = 13.6).The majority ofparticipants were
married orliving with a partner(n = 378,70%),were
born in the UK and ofwhite British ethnicity (n = 544,
97%).More than half of the participants were retired (n
= 327,60%),15% were unable to work due to their dis-
abilities (n = 82) and only 24% of the participants contin-
ued to be employed (n = 134).
Falls
After 1 year follow-up 195 ofthe 535 participants re-
ported at least 1 fall. In total there were 598
self-reported cases offalls with an average of1 fallper
participant,43 (7.2%)reported asbeing serious,291
(48.8%)as moderate,and 231 (44%)of falls resulted in
no injury and in 33 the type of injury was not reported.
Amongstthe fallers the average number offalls was 6
falls,with a range of1–40 falls.A flowchartof partici-
pants with type of injuries is shown in Fig.1.
Healthcare cost of falls
The directmedicalcostto the NationalHealth Service
(NHS) of the 56%(334 cases) of falls that resulted in the
use of health serviceswas estimated to be£374,354
(US$540,485)or £1120 (US$1617)per fall. A detailed
breakdown ofcosts offalls information is provided in
Table 1.Studies conducted in New Zealand have shown
that the cost per fall can range from £1214 (US$1752) to
£2023 (US$2913) using 2016 conversion rates.A spread
of costs spend on health service usage is shown in Fig.2.
Cost of OEP
Table 2 shows the values for the costs items for imple-
menting the OEP.
Assumptions were made for the exercise programme:
Current NHS Physiotherapists to implement the
OEP.
The lead physiotherapist would train a
physiotherapist in one hour
27 physiotherapists would be trained in one year.
Each trainee physiotherapist would have one-hour
quality control check with a lead physiotherapist.
The number of lead physiotherapists can vary but
for ease it is kept as one here.
Under these assumptions, the programme cost £116,479
(US$168,504)or £217.72 (US$314.34)per person to de-
liver to 535 participants for 1 year.Figure 3 shows the
spread of cost for implementing the programme.
Cost-benefit analysis
The average expected benefit would be £903 (US$1304)
per participant.Previous studies measuring the effective-
ness ofthe OEP has shown 35% reduction in the num-
ber of falls and fall related injuries[33].In terms of
healthcare cost analysis this would mean that out of the
598 falls 209 falls could be prevented.If 209 fall are pre-
vented where each fallcost £1120 (US$1617) a saving of
£234,583 (US$338,116) is made,and a return investment
of £118,104 (US$170,623).The implementation ofthe
programme estimated in the UK would bring more than
a 100% return ofinvestment(ROI), thus forevery £1
(US$1.44)spend in healthcare1.01 (US$1.46)pound
would be returned.This ROI would be obtained from a
reduction in ambulance use,ED attendance,hospitalisa-
tion and outpatient costs.
Discussion
This study shows a high economic benefitof the OEP
when deliveredto communitydwellingadults aged
18 years and older;it estimated a yielded ROI ofmore
than 100%.The yielded return is obtained by compari-
son with the healthcare costs of£1120 (US$1617)per
fall,for which the costs was obtained from the financial
year 2013/2014.This value is based on the assumption
that afteran injury the individualused certain health
services,for instance if they had a fractured hip it is as-
sumed that they received hip surgery.
There is no literature on the direct cost of falls in pa-
tients with RA. In this studythe estimated average
healthcarecost per fall in patientwith RA is £1120
(US$1617).In countries such as Finland and Australia
the average healthcare costper fall for people 65 and
aboveis between £724–£2492 (US$1049–$3611),and
Abdulrazaq et al.BMC Health Services Research (2018) 18:574 Page 4 of 9

this is regardless to whether the fall required hospitalisa-
tion [24].
In our study the OEP cost£217.72 or$314.34 (US
Dollars) per person.Other studies in the US have esti-
mated this costat $339 (£233)[39].The average inter-
vention cost is highly influenced by staff salary costs and
the format ofthe programme,this and the use ofmar-
keting in the US may have resulted in the 7% difference.
In the NHS marketing costis not expected as itis as-
sumed thatcurrenthealth care trusts can rollout the
programme using existing staff that can be trained.
This study has several limitations.The data on fall oc-
currence was based on selfreport and subject therefore
to errors ofrecall,and so our data may underestimate
the occurrence offalls in this group.Effortsmade to
reducethe likelihoodof underreportingincludethe
provision ofprepaid preaddressed daily calendarpost-
cards to be returned on a monthly basis with follow up
calls for non-responders.The effect of any underreport-
ing,however,would be to underestimate the economic
burden ofthe falls.Falls thatwere reported using the
calendars were verified by telephone calls and followed
up to gather more information about the type of fall and
any injuries.This information was used to categorise the
fall according to severity by using both type ofinjury
(fractures,internalbleeding and sprains) and healthcare
service utilisation (e.g.,hospitaladmission,stitches,and
physiotherapy).Again,however,the data was based on
selfreportand subjecttherefore to errors ofrecall.A
randomised controlled trialwould exclude these errors
Fig. 1 Flowchart diagram showing type of injuries
Abdulrazaq et al.BMC Health Services Research (2018) 18:574 Page 5 of 9

and give more controloverthe study.The healthcare
costs for a fallwas calculated using maximum informa-
tion accessible,however it is stillbased on the assump-
tion thatcertain services was provided which may not
have been the case.Additionally the costs-benefitana-
lysis in favour of implementing the OEP holds strictly to
the assumptions used for estimating the average cost of
the intervention.
We have performed a sensitivity analysis based on re-
moving the costs that we assume,and are not based on
the self-reported data.This involved subtracting 14%
(the assumed cost;Fig.2) from the totalsum.This gives
Table 1 The costs of various health care services utilized as a result of a fall
Action Cost per individuals Number of Patients using servicesTotalused services (in GBP)
Ambulance 230 17 3910
Visit to A and E 736 33 24,288
Number of nights in Public Hospital 698 259 180,782
Number of nights in a private hospitalor rest home 75 4 300
Visit to doctor 111 86 9546
Stitches 468 6 2808
Injury with Haemarthrosis (Bleeding into join space)2690 2 5380
Head serious injury 869 11 9559
Head moderate injury 608 16 9728
Fractured Ribs serious 11,347 2 22,694
Fractured Back serious 16,820 2 33,640
Fractured Lower arm 2511 1 2511
Fractured wrist 1825 3 547
Fractured hand 1906 3 5718
Fractured hip 13,408 3 40,224
Fractured knee 5770 2 11,540
Fractured ankle 2621 1 2621
Fractured toe 1118 4 4472
Estimated Radiography cost 93 17 1632
Fracture Knee Rehabilitation 556 2 1112
Fracture back rehabilitation 493 2 986
Rest home rehabilitation 356 1 356
TotalCost:374354.00
Fig. 2 Chart showing spread of cost in health care costs
Abdulrazaq et al.BMC Health Services Research (2018) 18:574 Page 6 of 9

a totalcost sum of£321,944 and hence a net-benefit of
£88,8986.However,as we believe the assumptions that
we make are realistic,we prefer the main discussion to
focus on the fullresults.It would be highly unlikely for
participants who have had serious falls notto have re-
ceived treatmentespecially so ifthey had an overnight
stay in the hospital.
The data in this study suggest that management of RA
patient should,because of the cost savings,include a fall
prevention programmesuch as the OEP. Given the
higher risk of falls among those who have already experi-
enced a fall,it might be offered in the first instance to
those with a fallin the previous year.In this study only
the OEP has been used and this has not been compared
with other exerciseprogrammes.Further research
should include a cost-benefit comparison between OEP
and otherexercise programmes(as well as estimating
the costs and efforts involved in undertaking the OEP in
Table 2 Table showing cost units of items in the Otago Exercise Programme
Activity Resource Type Type & Units Cost/Unit AnnualCost Cost Per Participant
per year (N = 535)
Equipment Materials 2 x Ankle Cuffs Weights 535 Average
£17.40
($25.12)
£9309.00
($13,439.86)
£8.70
($12.56)
Training course for 27 PTs1 Lead PT Instruction 27 h £34/h
($49/h)
£918.00
($1325.36)
£1.72
($2.48)
Materials 2 Instruction Manualfor LPT £40.00
($57.75)
£80.00
($115.50)
£0.15
(£0.22)
Ankle Cuff Weights
Intervention PT Labour 3 h per participant per session£34/h
($49/h)
£54,570
($78,785.43)
£102
($147.26)
PT TravelTime 1 h per participant per session£34/h
($49/h)
£18,190
($26,261.80)
£34
($49)
LPT Quality controlcheck 27 LPT QCC £34/h
($49/h)
£918
($1325.36)
£1.72
($2.48)
PT Telephone Calls 0.75 h per participant per session£25.50/h
($36.82)
£13,642.50
($19,696.36)
£25.50
($36.82)
TOTALs £97,627.50
($140,949.70)
£182.48
($263.46)
Overhead Costs 19.31% of
resources use
£18,851.87
($27,217.40)
£30.25
($43.67)
Totalafter overhead costs £116,479.37
($168,167.10)
£217.72
($314.33)
PT-Physiotherapist
LPT- Lead Physiotherapist
Fig. 3 Chart showing spread of cost in the Otago Exercise Programme
Abdulrazaq et al.BMC Health Services Research (2018) 18:574 Page 7 of 9

a RA specific population).There are other interventions
that can be delivered at home by health professionals to
maximise effectiveness and reduce falls.These include,
assessments and modifications of environmental hazards
[40], home safetyadviceand referralto doctors for
re-assessment of psychotropic drugs [41].The interven-
tion has demonstrated to reduce falls by 35% and reduce
moderate and serious injuries by 40%;this can reduce
healthcare service utilisation and in turn reduce health-
care costs [41].
Conclusion
The implementation of the programme for patients with
RA has potentiallysignificanteconomicbenefitsand
should be considered as part ofan overallmanagement
strategy for patients with the disease.To further investi-
gate and reinforce the findings ofthis study a rando-
mised controlled trial should be conducted.
Abbreviations
NHS:NationalHealth Service;NICE:NationalInstitute of Health and Clinical
Excellence;NSR:Nationalschedule of reference;OEP:Otago exercise
programme;PRI:Positive return of investment;PSSRU:PersonalSocialService
Research Unit;RA:Rheumatoid arthritis;ROI:Return of investment
Acknowledgements
Specialthanks to allthe participants involved in the research and also the
nursing and administration staff who supported the data collection phase of
the study at Manchester Academic Health Science Centre (MAHSC).The
authors would also like to thank Professor I.Bruce,Prof A.Hassell,Dr.S.Ryan,
Mr.P.New for their assistance in accessing patients.Thanks to Dr.M.
Campbellfor initialstatisticalsupport and Professor A.J.Campbelland
Professor M.Clare Robertson for their advice throughout the study.
Funding
This study was funded by Arthritis Research UK (18010) and a smallgrant
from the Wellcome Trust ClinicalResearch Facility,Manchester (06834).LM
acknowledges financialsupport from the MRC Skills Development Fellowship
(MR/N015126/1).The authors of this report are responsible for its content.
Statements in the report should not be construed as endorsement by
Arthritis Research UK,the MRC,or the Wellcome Trust ClinicalResearch
Facility,Manchester.
Availability of data and materials
The datasets analysed during the current study are available from the
corresponding author on reasonable request.
Authors’contributions
Each author has made substantive intellectualcontributions to this study:ES
conceived the study.ES,CT,JO,DS and TO were responsible for the design
of the study and obtaining funding.SA,MP,LM,BG and ES were responsible
for the analysis and interpretation of the data and preparation of the manuscript.
SA,ES and MP conducted data analyses.All authors read and approved the final
manuscript.
Ethics approval and consent to participate
This study was conducted with the approvalof the NationalResearch Ethics
Committee,reference 08/H1009/41.Allparticipants gave written,informed
consent.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutralwith regard to jurisdictionalclaims in
published maps and institutionalaffiliations.
Author details
1E K Stanmore Schoolof Nursing,Midwifery and SocialWork,MAHSC
(Manchester Academic Health Science Centre),University of Manchester,
Jean McFarlane Building,University Place,Manchester M13 9PL,UK.2Arthritis
Research UK Centre for Epidemiology & NIHR Manchester Musculoskeletal
BiomedicalResearch Unit,Manchester Academic Health Science Centre,The
University of Manchester,Manchester M13 9PL,UK.3Schoolof Health and
Life Sciences,Glasgow Caledonian University,Cowcaddens Rd,Glasgow G4
0BA,UK.4Centre for Health Economics,Institute of Population Health,
University of Manchester,Manchester M13 9PL,UK.
Received:15 May 2017 Accepted:11 July 2018
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