Value-based Care in the Management of Spinal Disorders: A Systematic Review of Cost-utility Analysis
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Spinal disorders are a major cause of disability and compromise in health-related quality of life. The direct and indirect costs of treating spinal disorders are estimated at more than $100 billion per year. With limited resources, the cost-utility of interventions is important for allocating resources.
We therefore performed a systematic review of the literature on cost-utility for nonoperative and operative interventions for treating spinal disorders.
We searched four databases for cost-utility analysis studies on low back pain management and identified 1004 items. The titles and abstracts of 752 were screened before selecting 27 studies for inclusion; full texts of these 27 studies were individually evaluated by five individuals.
Studies of nonoperative treatments demonstrated greater value for graded activity over physical therapy and pain management; spinal manipulation over exercise; behavioral therapy and physiotherapy over advice; and acupuncture and exercise over usual general practitioner care. Circumferential fusion and femoral ring allograft had greater value than posterolateral fusion and titanium cage, respectively. The relative cost-utility of operative versus nonoperative interventions was variable with the most consistent evidence indicating superior value of operative care for treating spinal disorders involving nerve compression and instability.
The literature on cost-utility for treating spinal disorders is limited. Studies addressing cost-utility of nonoperative and operative management of low back pain encompass a broad spectrum of diagnoses and direct comparison of treatments based on cost-utility thresholds for comparative effectiveness is limited by diversity among disorders and methods to assess cost-utility. Future research will benefit from uniform methods and comparison of treatments in cohorts with well-defined pathology.
- 1.Bastiaenen CH, de Bie RA, Vlaeyen JW, Goossens ME, Leffers P, Wolters PM, Bastiaanssen JM, Brandt PA, Essed GG. Long-term effectiveness and costs of a brief self-management intervention in women with pregnancy-related low back pain after delivery. BMC Pregnancy Childbirth. 2008;30:19.CrossRefGoogle Scholar
- 8.Glassman SD, Polly DW, Dimar JR, Carreon LY. The cost effectiveness of single-level instrumented posterolateral lumbar fusion at five years after surgery. Spine. 2010 May 19 [Epub ahead of print].Google Scholar
- 14.Johnson RE, Jones GT, Wiles NJ, Chaddock C, Potter RG, Roberts C, Symmons DP, Watson PJ, Torgerson DJ, Macfarlane GJ. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Spine. 2007;32:1578–1585.PubMedCrossRefGoogle Scholar
- 16.Kovacs FM, Llobera J, Abraira V, Lázaro P, Pozo F, Kleinbaum D; KAP Group. Effectiveness and cost-effectiveness analysis of neuroreflexotherapy for subacute and chronic low back pain in routine general practice: a cluster randomized, controlled trial. Spine. 2002;27:1149–1159.PubMedCrossRefGoogle Scholar
- 17.Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, Potter R, Underwood MR; Back Skills Training Trial investigators. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet. 2010;375:916–923.PubMedCrossRefGoogle Scholar
- 19.Manca A, Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, Thomson S, O’Callaghan J, Eisenberg E, Milbouw G, Buchser E, Fortini G, Richardson J, Taylor RJ, Goeree R, Sculpher MJ. Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial). Eur J Pain. 2008;12:1047–1058.PubMedCrossRefGoogle Scholar
- 23.National Institute for Health and Clinical Excellence. Guide to the Methods of Technology Appraisal. London, UK: NICE; 2008.Google Scholar
- 24.Niemistö L, Rissanen P, Sarna S, Lahtinen-Suopanki T, Lindgren KA, Hurri H. Cost-effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up. Spine. 2005;15:1109–1115.CrossRefGoogle Scholar
- 26.Porter ME, Teisberg EO. Redefining Health Care. Creating Value-based Competition on Results. Boston, MA, USA: Harvard Business School Press; 2006.Google Scholar
- 29.Rivero-Arias O, Campbell H, Gray A, Fairbank J, Frost H, Wilson-MacDonald J. Surgical stabilization of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ. 2005;330:1239.PubMedCrossRefGoogle Scholar
- 31.Schünemann HJ, Jaeschke R, Cook DJ, Bria WF, El-Solh AA, Ernst A, Fahy BF, Gould MK, Horan KL, Krishnan JA, Manthous CA, Maurer JR, McNicholas WT, Oxman AD, Rubenfeld G, Turino GM, Guyatt G; ATS Documents Development and Implementation Committee. An official ATS statement: grading the quality of evidence and strength of recommendations in ATS Guidelines and Recommendations. Am J Respir Crit Care Med. 2006;174:605–614.PubMedCrossRefGoogle Scholar
- 34.Soegaard R, Bünger CE, Christiansen T, Høy K, Eiskjaer SP, Christensen FB. Circumferential fusion is dominant over posterolateral fusion in a long-term perspective: cost-utility evaluation of a randomized controlled trial in severe, chronic low back pain. Spine. 2007;32:2405–2414.PubMedCrossRefGoogle Scholar
- 35.Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, Fitter M, Roman M, Walters S, Nicholl JP. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technology Assessment. 2005;9:32; iii-68.Google Scholar
- 36.Tosteson AN, Lurie JD, Tosteson TD, Skinner JS, Herkowitz H, Albert T, Boden SD, Bridwell K, Longley M, Andersson GB, Blood EA, Grove MR, Weinstein JN; SPORT Investigators: Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med. 2008;149:845–853.PubMedGoogle Scholar
- 37.Tosteson AN, Skinner JS, Tosteson TD, Lurie JD, Andersson GB, Berven S, Grove MR, Hanscom B, Blood EA, Weinstein JN. The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT). Spine. 2008;33:2108–2115.PubMedCrossRefGoogle Scholar
- 39.US Bone and Joint Decade: The Burden of Musculoskeletal Diseases in the United States. Rosemont, IL, USA: American Academy of Orthopaedic Surgeons; 2008.Google Scholar
- 40.US Department of Health and Human Services. Summary Health Statistics for US Adults: National Health Interview Survey, 2008. Vital and Health Statistics Series 10, No. 242. Available at: www.cdc.gov/nchs/data/series/sr_10/sr10_242.pdf . Accessed July 12, 2010.
- 41.van den Hout WB, Peul WC, Koes BW, Brand R, Kievit J, Thomeer RT; Leiden-The Hague Spine Intervention Prognostic Study Group: Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ. 2008;336:1351–1354. PubMedCrossRefGoogle Scholar
- 43.Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976). 2006;31:2707–2714.Google Scholar
- 44.Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, Herkowitz H, Fischgrund J, Cammisa FP, Albert T, Deyo RA. Surgical vs non-operative treatment for lumbar disc herniation: the Spine Patient Outcomes Research Trial (SPORT) Observational Cohort. JAMA. 2006;296:2451–2459.PubMedCrossRefGoogle Scholar
- 45.Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA. Surgical vs non-operative treatment for lumbar disc herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296:2441–2450.PubMedCrossRefGoogle Scholar