Implementing stratified primary care management for low back pain: cost utility analysis alongside a prospective, population-based, sequential comparison study
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.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.This is the final published version. It first appeared at http://journals.lww.com/spinejournal/Fulltext/2015/03150/Implementing_Stratified_Primary_Care_Management.14.aspx
