Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW.
The George Institute for Global Health and Sydney Medical School,
The University of Sydney,
PO Box M201, Missenden Rd,
Sydney, NSW, 2050, Australia,
Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included.
Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.
From the FULL TEXT Article
Low back pain (LBP) is a common health condition which affects most adults at some point during their lifetime . For most patients in primary care, the source of symptoms cannot be specified and the patient receives the label non-specificLBP . The exceptions are those with back pain associated with radiculopathy or spinal stenosis  and the rare patients whose LBP can be attributed to a disease or condition such as fracture, tumour or infection . Recently, the American College of Physicians and the American Pain Society published a joint clinical guideline which recommended the following treatments for non-specific LBP :
Provide evidence-based information on prognosis, advise to remain active, provide information about effective self-care options (referred to as advice for the rest of the paper)
In addition, consider the use of medications with proven benefits
For patients who do not improve, consider the addition of spinal manipulation for acute LBP
For patients who do not improve, consider the addition of interdisciplinary rehabilitation, exercise, acupuncture, massage, spinal manipulation, yoga, cognitive-behavioural therapy or relaxation for sub-acute or chronic LBP
These recommendations are largely in line with other international guidelines  and are derived from the vast amount of research regarding the effectiveness of treatments for LBP. For example, the latest issue of The Cochrane Library contains over 30 Cochrane systematic reviews of interventions for LBP . In contrast, until the 2009 British guideline , LBP guidelines contained little information on the cost-effectiveness of treatments. This was probably due to the low number of studies available to the developers of the early guidelines. The low number of available studies, together with methodological limitations of the studies and the heterogeneity of the studies, limited any conclusive evidence regarding the cost-effectiveness of interventions for LBP [8, 9].
LBP incurs substantial treatment and loss of productivity costs internationally . In the United States, healthcare costs among people with back pain increased by 65% from 1997 to 2005, more rapidly than healthcare costs among people without back pain and the overall healthcare costs . Given that the guidelines considered a range of interventions to be effective, the efficiency of treatment will be improved if their relative cost-effectiveness is also considered. As the number of published economic evaluations of interventions for LBP is increasing, it may now be possible to consider evidence of cost-effectiveness when making recommendations about treatment. The purpose of this paper is to investigate the cost-effectiveness of guideline-endorsed treatments for non-specific LBP.
We found 26 economic evaluations conducted alongside randomised controlled trials that investigated the cost-effectiveness of guideline-endorsed treatments for non-specific LBP. There were inconsistent findings regarding the cost-effectiveness of advice, but studies generally showed that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy were relatively cost-effective for people with sub-acute or chronic LBP. Results from single studies suggested that massage alone was unlikely to be cost-effective, and that the cost-effectiveness of spinal manipulation for acute LBP was unclear. No studies investigated the cost-effectiveness of medication, yoga or relaxation as treatments for LBP.
The eight studies which investigated advice did not yield consistent or conclusive evidence about its relative cost-effectiveness. Interestingly, these studies also reported inconsistencies in the effectiveness of advice compared to other treatments. In contrast, the American clinical guideline made a strong recommendation for advice to stay active based on moderate-quality evidence . Other guidelines also recommend advice to stay active . One reason for the difference between our findings and guideline recommendations may be that in the guidelines, the recommendations were based on evidence from systematic reviews which compared advice to stay active with bed rest, which is considered potentially harmful for this population . The studies included in this review compared advice to a variety of treatment alternatives, but not bed rest.
We did not pool the results in the studies that compared advice, and interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP, as may occur in a systematic review of treatment effectiveness. This is due to the heterogeneity in study treatments, as well as differences in economic perspectives and settings. The underlying assumption for pooling in a systematic review of treatment effectiveness is that results obtained in one country are generalisable to a similar population in a different setting or country. Whilst it seems reasonable to assume that individuals or groups are likely to react in the same way to a particular intervention, no matter where they live, comparing economic data across different settings or countries is not as straightforward due to differences in the structure and organization of healthcare systems. For example, in some countries patients may have direct access to medical specialists or other healthcare providers while in other countries patients need a referral from a primary care physician. Access to some care providers may be limited in some countries where this care is not provided by a public healthcare system or is not reimbursed by an insurance scheme. Cost data may also be sensitive to the funding and reimbursement arrangements in a particular healthcare system. However, despite this complexity, there are emerging guidelines on the transferability of economic evaluations [48–50].
We used the NICE threshold to provide an indication of the cost-effectiveness of treatment, because the NICE threshold is commonly available. However, it should be noted that there is no consensus about the maximum costs per QALY gained that would be acceptable, and recent evidence indicates that the cost-effectiveness threshold may vary depending upon the severity and the prevalence of the disease. We used the treatments endorsed by the American College of Physicians and the American Pain Society as guideline-endorsed treatments, because at the time of study conception the American guideline was one of the most recent guidelines. A recent review shows that treatments endorsed by the American guideline are in line with other guidelines . The only area of contention is in the use of spinal manipulation where, unlike the American guideline, some countries do not recommend spinal manipulation for LBP. Interestingly, our systematic review considers evidence purely from a cost-effectiveness perspective and shows some evidence of cost-effectiveness when using spinal manipulation in sub-acute to chronic pain.
There were some methodological issues which limit the interpretation of our findings. These include the incomplete identification and measurement of costs, which reduces the rigour of the results. Three studies had follow-up periods that are likely to be too short to fully appreciate the economic consequences for the chronic population under investigation [44–46]. Based on recent large cohort studies on the prognosis of acute  and chronic  LBP, we recommend a follow-up period of at least 3 months for acute LBP and at least 12 months for chronic LBP. In addition, to help readers assess the extent to which the results of studies are applicable to different healthcare systems, we recommend that economic evaluations report unit costs as well as reporting a breakdown of costs and resource utilization. Eleven of the 26 included studies provided a table of unit costs [21, 22, 33, 34, 37–40, 42, 43, 46, 53].
Considering the evidence regarding both relative effectiveness and cost-effectiveness when making treatment recommendations means that the endorsed treatments are both beneficial to patients and efficient in terms of healthcare resources. The small number or lack of economic evaluations for some guideline-endorsed treatments means well-conducted economic evaluations are required to strengthen the evidence-base of treatments for LBP. However, evidence to date indicates that guideline-endorsed treatments such as interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP are cost-effective. Although advice to stay active is endorsed in the guideline, and evidence regarding its cost-effectiveness compared to other interventions is inconsistent. In addition, there is little or no high-level evidence about other guideline-endorsed treatments: medication, spinal manipulation for acute LBP, and massage, yoga or relaxation for chronic LBP.
CL and CM are funded by the National Health and Medical Research Council, Australia. LM is funded by Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG), Brazil.
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