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

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

Read More

Access further information on this document at Wolters Kluwer

This article was published outside of RAND. The full text of the article can be found at the link above.

Study Design

Markov model.


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.


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.


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.


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.

Research conducted by

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.