Cost-effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain

Abstract

Background Context Chronic neck pain is a prevalent and disabling condition among older adults. Despite the large burden of neck pain, little is known regarding the cost-effectiveness of commonly used treatments. Purpose To estimate the cost-effectiveness of home exercise and advice (HEA), spinal manipulative therapy (SMT) plus HEA, and supervised rehabilitative exercise (SRE) plus HEA. Study Design/Setting Cost-effectiveness analysis conducted alongside a randomized clinical trial (RCT). Patient Sample 241 older adults (≥65 years) with chronic mechanical neck pain. Outcome Measures Direct and indirect costs, neck pain, neck disability, SF-6D-derived quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios over a one-year time horizon. Methods This work was supported by grants from the National Center for Complementary and Integrative Health (#F32AT007507), National Institute of Arthritis and Musculoskeletal and Skin Diseases (#P60AR062799), and Health Resources and Services Administration (#R18HP01425). The RCT is registered at ClinicalTrials.gov (#NCT00269308). The primary analysis adopted a societal perspective, a healthcare perspective was adopted as a sensitivity analysis. Cost-effectiveness was a secondary aim of the RCT which was not powered for differences in costs or QALYs. Differences in costs and clinical outcomes were estimated using generalized estimating equations and linear mixed models, respectively. Cost-effectiveness acceptability curves were calculated to assess the uncertainty surrounding cost-effectiveness estimates. Results Total costs for SMT+HEA were 5% lower than HEA (mean difference: −$111; 95%CI -$1,354 to $899) and 47% lower than SRE+HEA (mean difference: −$1,932; 95%CI −$2,796 to −$1,097). SMT+HEA also resulted in a greater reduction of neck pain over the year relative to HEA (0.57; 95%CI 0.23 to 0.92) and SRE+HEA (0.41; 95%CI 0.05 to 0.76). Differences in disability and QALYs favored SMT+HEA. The probability that adding SMT to HEA is cost-effective at willingness to pay thresholds of $50,000 to $200,000 per QALY gained ranges from 0.75 to 0.81. If adopting a healthcare perspective, costs for SMT+HEA were 66% higher than HEA (mean difference: $515; 95%CI $225 to $1,094), resulting in an ICER of $55,975 per QALY gained. Conclusions On average, SMT+HEA resulted in better clinical outcomes and lower total societal costs relative to SRE+HEA and HEA alone, with a 0.75 to 0.81 probability of cost-effectiveness for willingness to pay thresholds of $50,000 to $200,000 per QALY.

The Perceived Benefits of an Artificial Intelligence–Embedded Mobile App Implementing Evidence-Based Guidelines for the Self-Management of Chronic Neck and Back Pain: Observational Study (Preprint)

“…The observed reduction of medical interventions usage suggested that the AI system might have additional cost saving benefit. This finding was supported by a cost effectiveness study published Leininger et al, (2016) [1].…”

“…Chronic musculoskeletal neck and back pain are prevalent and disabling conditions among adults [1]. The studies published in 2010 on the global economic burden of disease indicated low back pain and neck pain ranked sixth and twenty-first respectively out of 291 diseases and injuries [2].…”

“…Two published studies in 2014 indicated that back pain [3] and neck pain [4] ranked the highest and forth out of the 291 conditions studied in terms of years lived with disability. The burden of chronic neck and back pain is increasing due to the aging society [1]. Thus there is an urgent need to identify a cost effective method to promote self-management of the conditions.…”

Cost-effectiveness of exercise therapy in the treatment of non-specific neck pain and low back pain: a systematic review with meta-analysis

“…Exercise therapy was associated with higher costs and smaller effects than home exercise alone 36. The incremental cost-utility ratio value was not reported 36…”

We need to debate the value of manipulative therapy and recognize that we do not always understand from what to attribute our success

“…Can we all admit that the correct treatment is the one that gives the patient the most benefit and the least harm? There is evidence that including manual therapy care as part of the conservative management of patients with musculoskeletal conditions results in cost effective improvements in pain, function and satisfaction [5][6][7]. Objectively measuring clinical reasoning is a difficult task and 5 'expert' clinicians may use 5 different approaches to achieve a favorable outcome.…”