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Implementing stratified primary care management for low back pain: cost utility analysis alongside a prospective, population-based, sequential comparison study


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Article

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Authors

Whitehurst, David GT 
Bryan, Stirling 
Lewis, Martyn 
May, Elaine M 

Abstract

STUDY DESIGN: Within-study cost-utility analysis.

OBJECTIVE:To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within risk-defined patient subgroups (that is, patients at low, medium, and high risk of persistent disabling pain).

SUMMARY OF BACKGROUND DATA: Individual-level data collected alongside a prospective, sequential comparison of separate patient cohorts with 6-month follow-up.

METHODS: Adopting a cost-utility framework, the base case analysis estimated the incremental LBP-related health care cost per additional quality-adjusted life year (QALY) by risk subgroup. QALYs were constructed from responses to the 3-level EQ-5D, a preference-based health-related quality of life instrument. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative methodological approaches, including a complete case analysis, the incorporation of non-back pain-related health care use and estimation of societal costs relating to work absence.

RESULTS: Stratified care was a dominant treatment strategy compared with usual care for patients at high risk, with mean health care cost savings of £124 and an incremental QALY estimate of 0.023. The likelihood that stratified care provides a cost-effective use of resources for patients at low and medium risk is no greater than 60% irrespective of a decision makers' willingness-to-pay for additional QALYs. Patients at medium and high risk of persistent disability in paid employment at 6-month follow-up reported, on average, 6 fewer days of LBP-related work absence in the stratified care cohort compared with usual care (associated societal cost savings per employed patient of £736 and £652, respectively).

CONCLUSION: At the observed level of adherence to screening tool recommendations for matched treatments, stratified care for LBP is cost-effective for patients at high risk of persistent disabling LBP only.

LEVEL OF EVIDENCE: 2.

Description

Keywords

cost-utility, economic evaluation, low back pain, stratified care, quality-adjusted life year, cost, primary care

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Spine

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Volume Title

40

Publisher

Lippincott Williams & Wilkins
Sponsorship
The IMPaCT Back study was funded by the Health Foundation (grant code: 346/4540) with support from the National Institutes for Health Research (NIHR) Primary Care Research Network-North West, the Keele Academic General Practice Partnership and the Primary Care Musculoskeletal Research Consortium. NEF was supported, in part, by a National Coordinating Centre for Research Capacity Development (NCCRCD) Primary Care Career Scientist Award and is currently supported by an NIHR Research Professorship (NIHR-RP-011-015). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.