Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective Than Usual Care?

Proof of Concept Results from a Markov Model

Published in: Spine (2019). doi: 10.1097/BRS.0000000000003097

Posted on RAND.org on June 10, 2019

by Patricia M. Herman, Tara Lavelle, Melony E. Sorbero, Eric Hurwitz, Ian D. Coulter

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Study Design

Markov model.

Objective

Examine the one-year effectiveness and cost-effectiveness (societal and payer perspectives) of adding nonpharmacologic interventions for chronic low back pain (CLBP) to usual care using a decision analytic model-based approach.

Summary of Background Data

Treatment guidelines now recommend many safe and effective nonpharmacologic interventions for CLBP. However, little is known regarding their effectiveness in subpopulations (e.g., high-impact chronic pain patients), nor about their cost-effectiveness.

Methods

The model included four health states: high-impact chronic pain (substantial activity limitations); no pain; and two others without activity limitations, but with higher (moderate-impact) or lower (low-impact) pain. We estimated intervention-specific transition probabilities for these health states using individual patient-level data from 10 large randomized trials covering 17 nonpharmacologic therapies. The model was run for nine 6-week cycles to approximate a 1-year time horizon. Quality-adjusted life-year (QALY) weights were based on six-dimensional health state short form (SF-6D) scores; healthcare costs were based on 2003–2015 Medical Expenditure Panel Survey data; and lost productivity costs used in the societal perspective were based on reported absenteeism. Results were generated for two target populations, 1) a typical baseline mix of patients with CLBP (25% low-impact, 35% moderate-impact and 40% high-impact chronic pain) and, 2) high-impact chronic pain patients.

Results

From the societal perspective, all but two of the therapies were cost-effective (<$50,000/QALY) for a typical patient mix and most were cost saving. From the payer perspective fewer were cost saving, but the same number were cost-effective. Assuming all patients in the model have high-impact chronic pain increases the effectiveness and cost-effectiveness of most, but not all, therapies indicating that substantial benefits are possible in this subpopulation.

Conclusions

Modeling leverages the evidence produced from clinical trials to provide more information than is available in the published studies. We recommend modeling for all existing studies of nonpharmacologic interventions for CLBP.

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