Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial

Abstract

Objective To determine whether, from a health provider and patient perspective, surgical stabilisation of the spine is cost effective when compared with an intensive programme of rehabilitation in patients with chronic low back pain. Design Economic evaluation alongside a pragmatic randomised controlled trial. Setting Secondary care. Participants 349 patients randomised to surgery (n = 176) or to an intensive rehabilitation programme (n = 173) from 15 centres across the United Kingdom between June 1996 and February 2002. Main outcome measures Costs related to back pain and incurred by the NHS and patients up to 24 months after randomisation. Return to paid employment and total hours worked. Patient utility as estimated by using the EuroQol EQ-5D questionnaire at several time points and used to calculate quality adjusted life years (QALYs). Cost effectiveness was expressed as an incremental cost per QALY. Results At two years, 38 patients randomised to rehabilitation had received rehabilitation and surgery whereas just seven surgery patients had received both treatments. The mean total cost per patient was estimated to be £7830 (SD £5202) in the surgery group and £4526 (SD £4155) in the intensive rehabilitation arm, a significant difference of £3304 (95% confidence interval £2317 to £4291). Mean QALYs over the trial period were 1.004 (SD 0.405) in the surgery group and 0.936 (SD 0.431) in the intensive rehabilitation group, giving a non-significant difference of 0.068 ( − 0.020 to 0.156). The incremental cost effectiveness ratio was estimated to be £48 588 per QALY gained ( − £279 883 to £372 406). Conclusion Two year follow-up data show that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources. However, sensitivity analyses show that this could change-for example, if the proportion of rehabilitation patients requiring subsequent surgery continues to increase.

Health related quality of life outcome instruments

“…[16,27,28,46,59,61,62,76], and also as outcome instrument in National Quality Registers of spine surgery, e.g. [38,64,65].…”

Cost-Effectiveness of Early Versus Delayed Functional Restoration for Chronic Disabling Occupational Musculoskeletal Disorders

“…In evaluations of multimodal intervention procedures, a common valuation of this direct cost is often conceptualized as the hours or units of treatment billed (Critchley, Ratcliffe, Noonan, Jones, & Hurley, 2007;Hatten, Gatchel, Polatin, & Stowell, 2006;Rivero-Arias et al, 2005;Rivero-Arias, Gray, Frost, Lamb, & Stewart-Brown, 2006). Non-medical costs involve direct costs consequent to the intervention, but otherwise not classified under any type of medical modality.…”

“…Although the majority of CEA and CUA evaluations on non-malignant pain and disability focus on interventions for spinal disorders (e.g., Hatten, Gatchel, Polatin, & Stowell, 2006;Rivero-Arias et al, 2005;Rivero-Arias, Gray, Frost, Lamb, & StewartBrown, 2006), economic evaluations on other related fields of medical research have also been reported, including biopyschosocial treatments for temporomandibular disorders (Stowell, Gatchel, & Wildenstein, 2007), workplace interventions for psychiatric patients (van Oostrom et al, 2008), and acute and subacute pain interventions in primary or secondary care facilities Karjalainen et al, 2004).…”

“…Furthermore, economic evaluations have also provided some guidance on the cost-effectiveness of surgery as a first-line intervention for chronic pain conditions. In an RCT of chronic low back pain patients comparing fusion surgery versus rehabilitation based on cognitive-behavioral therapy, the results indicated that fusion surgery is not a cost-effective first-line intervention for chronic low back pain, at approximately £49,000 per QALY gained (Rivero-Arias et al, 2005).…”

Development of a documentation instrument for the conservative treatment of spinal disorders in the International Spine Registry, Spine Tango

“…Four out of five individuals experience an episode of acute LBP at least once in their lifetime, and about 5% develop chronic LBP, which is defined as LBP lasting longer than 12 weeks [50]. The economic cost of treating patients with chronic LBP exceeds that of treating those with acute LBP by a significant amount leading to a high economic burden when treating spinal disorders [17,39].…”