Cost-Effectiveness of Interventions for Other Musculoskeletal Conditions
Low Back Pain
Low back pain is as common in developing countries as it is in the developed world. Health professionals now generally agree that conservative care for acute lower back pain is the initial treatment of choice, unless there is structural evidence of pathology that is amenable to surgical intervention (Gatchel and others 2003). Evidence also indicates that programs that incorporate some physical activity may reduce the costs of both acute and chronic low back pain compared with those that do not involve activity.
For economic evaluations, one of the important complicating factors associated with low back pain is that the nonmeasurement of indirect costs may introduce substantial bias into estimates of the cost-effectiveness of interventions. This problem is potentially serious because, in some cases, investigators have estimated the indirect costs of low back pain at more than twice those of the direct medical costs (Bolten, Kempel-Waibel, and Pforringer 1998).
Van Tulder and others (2003) review 15 RCTs of back schools for patients with recurrent and chronic low back pain, but they consider only three of these to be of high quality. They conclude that the evidence is only moderate that back schools have better short-term effects than other treatments for chronic back pain. They also find some evidence that back schools are more effective than placebos or waiting list controls in occupational settings. However, the authors note that little is currently known about the cost-effectiveness of back schools. Thus, evidence is insufficient to provide a recommendation on the probable cost-effectiveness of back schools for low back pain in developing countries; however, early intervention, education, and exercise programs should be encouraged.
Furlan and others (2002) examine the effectiveness and cost-effectiveness of a variety of massage techniques for nonspecific low back pain by comparing them with (a) sham or placebo massage, (b) other medical treatments, or (c) no treatment. The authors conclude that massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this finding needs to be confirmed.
Little is known about the cost-effectiveness of massage for low back pain. On the basis of the existing evidence, in countries or regions in which massage—especially acupunctural massage—is routinely available at low cost, the intervention may be cost-effective. Where acupunctural interventions are considered, the costs of bloodborne disease transmission must also be weighed against the expected benefits of the intervention. This consideration may be important in countries where the prevalence of bloodborne viruses is high, particularly if strict infection control measures are not routinely followed.
The few studies of early intervention programs to reduce the progression of acute low back pain to chronic pain have tended to report considerable cost savings. Gatchel and others (2003) published a prospective trial of early interventions in individuals with acute low back pain and a high risk of the pain progressing to chronicity. The authors screened approximately 700 patients and designated them as being at either low or high risk. The patients were then assigned to early or nonintervention groups and followed for 12 months. The early intervention was generally conducted over a three-week period and involved an intensive, multidisciplinary approach that included exercise classes, biofeedback and pain management classes, group education sessions, case manager and occupational therapist sessions, and interdisciplinary team conferences.
The early intervention resulted in statistically significant differences in return-to-work outcomes, number of health care visits, and number of disability days caused by back pain. It also resulted in a variety of pain surrogates. Furthermore, the mean cost savings were approximately US$9,000 per patient. The direct costs for the intervention group were approximately US$2,500 higher than those for the intervention group, but this finding was largely the result of the up-front costs of the intervention program itself. The direct costs of health care visits and pharmaceuticals were considerably lower for the intervention group.
The evidence suggests that an intensive, multidisciplinary, early intervention program is cost saving for individuals with acute low back pain who are at high risk of having the pain progress to chronicity; however, the cost savings associated with this intervention are attributable to improved labor market outcomes and earnings for injured individuals. The intervention itself may increase costs in the short term, but it appears to be associated with medium and long-term net benefits. Labor market conditions, including wages, along with the age of low back pain sufferers, may have an important bearing on the viability of this type of intervention in developing countries.
Although the direct costs associated with ankylosing spondylitis are relatively low, its impact on indirect costs, including pain and suffering, are substantial. To date, little work has been done on the economics of interventions for ankylosing spondylitis. Pharmaceutical interventions are currently typically limited to NSAIDs and DMARDs such as methotrexate and sulfasalazine. Van Tubergen and others (2002), however, analyze the cost-effectiveness of a spa exercise intervention. The intervention period was three weeks, and although the authors argue that the cost-effectiveness of the intervention was favorable, they also note that the ICERs were sensitive to variations in assumptions about indirect costs.
Although a spa exercise program is apparently beneficial and may even be considered cost-effective for ankylosing spondylitis sufferers in developed countries, the current cost-effectiveness evidence does not provide a compelling case for widespread adoption of the intervention in developing regions. Patients, however, should be encouraged to exercise—especially to swim. The cost-effectiveness of tumor necrosis factor-inhibiting drugs is not yet evident for ankylosing spondylitis, but the drugs are currently unattractive investments for developing countries because of their high price.