No difference in cost-effectiveness of intensive group training for chronic back pain compared with usual physiotherapy care

Abstract

Is an intensive group training protocol costeffective compared to usual care physiotherapy for chronic low back pain? Economic evaluation alongside a randomised controlled trial comparing two physiotherapy interventions for chronic low back pain. Primary care physiotherapy clinics in and around Amsterdam, the Netherlands, involving 85 physiotherapists. 114 participants with a new episode of non-specific low back pain of more than 12 weeks duration and aged 18 to 65 years were included. Patients with specific spinal pathology were excluded. Participants in the intensive group performed 10 individual and 20 group sessions consisting of graded exercises and back school based on behavioural principles. Those allocated to usual care received an average of 9 sessions of individual physiotherapy treatments according to the Royal Dutch College for Physiotherapy Low Back Pain Guidelines. Treatment effectiveness was measured using the following pre-specified outcomes: functional status (24-item Roland-Morris Disability Questionnaire), pain intensity (11-point numerical rating scale), general perceived effect (6-point GPE scale) and quality of life (EuroQol-5D) at baseline, 6, 13, 26, and 52 weeks after randomisation, with 89% followup at 1 year. Diaries were used to measure costs associated with utilisation of health care, non-health care, medications, and loss of productivity due to work absenteeism. Multilevel analyses were performed to determine the difference in effects. The mean differences in costs between groups and 95% confidence intervals (CIs) were obtained by bias corrected and accelerated bootstrapping. Quality of life was expressed in utilities based on the Dutch tariff. The differences in effects were small and not significant. Although the direct health care costs were higher for the intensive training group, (between-group difference per patient €233, 95% CI 2185 to 2764), there were no differences between the groups in terms of total health costs. The intensive group training protocol is not cost-effective compared with usual care physiotherapy carried out according to the guidelines. Whilst there is no clinical contraindication to the use of the intensive group training program, the results do not support implementation of the intensive program for back pain in primary care in the Netherlands.