Cost-effectiveness of Risk Stratified Care vs Usual Care for Low Back Pain in the Military Health System

Daniel I Rhon; Minchul Kim; Carl Asche; Steven Z George

doi:10.1097/BRS.0000000000005145

Cost-effectiveness of Risk Stratified Care vs Usual Care for Low Back Pain in the Military Health System

Spine (Phila Pa 1976). 2024 Sep 6. doi: 10.1097/BRS.0000000000005145. Online ahead of print.

Authors

Daniel I Rhon^{1

2}, Minchul Kim³, Carl Asche^{4

5}, Steven Z George⁶

Affiliations

¹ Department of Rehabilitation Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX.
² Department of Rehabilitation Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD.
³ Department of Internal Medicine, College of Medicine, University of Illinois, Peoria, IL.
⁴ Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, College of Pharmacy, University of Utah Health, 30 South 2000 East, Salt Lake City, UT.
⁵ Veteran's Affairs, Salt Lake City Healthcare System, Salt Lake City, UT.
⁶ Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, School of Medicine, 300 Morgan Street, Durham, NC.

PMID: 39239790
DOI: 10.1097/BRS.0000000000005145

Abstract

Study design: Cost-effectiveness of two trial interventions for low back pain.

Objective: To investigate the incremental cost-effectiveness between risk-stratified and usual care for low back pain.

Summary of background data: A recent trial compared risk-stratified care to usual care for patients with low back pain (LBP) in the US Military Health System. While the outcomes were no different between groups, risk-stratified care is purported to use fewer resources and therefore could be a more cost-effective intervention. Risk-stratified care matches treatment based on low, medium, or high risk for poor prognosis.

Methods: The cost-effectiveness of usual care versus risk-stratified care for low back pain was assessed, using the healthcare perspective. Patients were recruited from primary care. The main outcome was indicating incremental cost-effectiveness between two alternative treatments. Acceptability curves of bootstrapped incremental cost effectiveness ratios (ICER) were used to identify the proportion of ICERs under the specific willingness-to-pay (WTP) level ($50,000 to $100,000). Health system costs (total and back-related) and health-related quality-of-life (HRQoL) based on quality-adjusted-life-years (QALYs) were obtained.

Results: 271 participants (33.6% female), mean age 34.3 +/-8.7 were randomized 1:1 and followed for 1 year. Mean back-related medical costs were not significantly different (mean difference $5; 95CI -$398, $407; P=0.982), nor were total medical costs (mean difference $827, 95CI -$1748, $3403; P=0.529). The mean difference in QALYs was not significantly different between groups (0.009; 95CI -0.014, 0.032; P=0.459). The incremental net monetary benefit (NMB) at the willingness to pay (WTP) threshold of $100,000 was $792 for back-related costs, with the lower bound confidence interval negative at all WTP levels.

Conclusion: Risk-stratified care was not cost-effective for medium- and low-risk individuals compared to usual care. Further research is needed to assess whether there is value for high-risk individuals or for other risk-stratification approaches.