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One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain: subgroup analysis, recurrence, and additional health care utilization |
Skargren E I, Carlsson P G, Oberg B E |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Primary management of back and neck pain.
Economic study type Cost-effectiveness analysis.
Study population Patients aged 18-60 years who had no contraindication to manipulation.
Setting 10 primary care units in both urban and rural areas. The study was carried out in Sweden.
Dates to which data relate The time period during which effectiveness and resource use data were collected was not reported. The price year was 1995.
Source of effectiveness data Effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing was undertaken on the same patient sample as that used in the effectiveness study. The costing was carried out prospectively alongside the effectiveness study.
Study sample 323 patients aged 18-60 years were randomised to receive chiropractic treatment (n=179) or physiotherapy (n=144). Only patients were included who had not received active treatment for their problems within the past month, had no contraindication to manipulation, had no other disease, were able to read and write in Swedish, and had problems relevant to chiropractic and physiotherapy. No power calculations were reported.
Study design This was a prospective randomised controlled trial carried out at 10 primary care units. No patients were lost to follow-up.
Analysis of effectiveness The analysis of the clinical study was based on the intention to treat principle. The primary health outcomes used included Oswestry score, general health, pain intensity, pain frequency, use of pain-killers, number of days off work, number of treatment sessions, recurrence rate and type of additional health care. At analysis, groups were shown to be comparable in terms of age, gender, previous problems, localisation of cause of treatment, duration of current episode, and functional status. Pain intensity and general health were slightly worse in the physiotherapy group.
Effectiveness results No difference was detected between the two groups in terms of pain intensity, Oswestry score and general health. For patients with a duration of current episode of less than one month the difference in Oswestry score at 12 months after treatment was -1.01% (95% CI: -7.44 - 5.32). For patients with a duration of current episode of less than 1 week and a high Oswestry score at entry, the difference in Oswestry score was -6.1% in favour of chiropractic (95% CI: -18.5 - 6.3). For patient swith a duration of episode of more than 1 week and a low Oswestry score at entry, the difference in Oswestry score was 6.1% (95% CI: 2.5- 9.7).
No difference was detected in pain frequency, use of painkillers, or well-being. The mean number of treatment sessions was lower in the chiropractic group (4.9 +/- 2.0) than in the physiotherapy group (6.4 +/- 5.4). The average length of treatment period did not differ between the two groups or among the subgroups. A higher proportion of patients (22.1%; 95% CI: 36.4 - 7.8) who reported two or more recurrences after treatment in the chiropractic group (64%) sought additional health care after treatment than in the physiotherapy group (42%). After primary treatment, 12.3% (95% CI: 19.5 - 5.1) more patients in the chiropractic group (19%) went to other therapists than in the physiotherapy group (7%). The proportions of patients who returned to the primary treatment for additional treatment were 36% for the chiropractic group and 29% for the physiotherapy group. The difference was 6.5% (95% CI: 16.8 - 3.8). 26% of patients in the chiropractic group and 18% of patients in the physiotherapy group contacted one or more medical doctors after the treatment period, the difference being 7.3% (95% CI: 16.4 to -1.8).
The mean number of days off work related to back problems was 34.2 (+/- 81.3) in the chiropractic group and 39.3 (+/- 88.2) in the physiotherapy group; the difference being -5.1 days (95% CI: -25.4 - 15.2).
A higher proportion of the whole chiropractic group compared with the physiotherapy group went for additional health care after treatment (59% versus 41%) which was also the case for the whole period (12 months): 67% versus 50%.
Modelling No modelling was undertaken.
Measure of benefits used in the economic analysis The following measures of benefits were used: pain intensity, Oswestry score, and general health. Pain intensity was measured using a visual analog scale with endpoints 0 (no pain) and 100 (unbearable pain). The measure for functional status was the Oswestry low back pain disability questionnaire, which gives scores for 10 sections on the impact on activities of daily living and social life. General health was measured with a six-point scale and on a visual analog scale with the endpoints 0 (best imaginable) and 100 (worst imaginable). Patient values were elicited using mailed questionnaires.
Direct costs Costs were not discounted given the short time period of the study (1 year). Quantities and costs were not reported separately. Direct costs included treatment costs and additional health care use reported by the patient. The quantity/cost boundary adopted was that of the health service. The estimation of quantities and costs was based on actual data. Direct costs were derived from the internal accounts of different care providers. The price year was 1995.
Statistical analysis of costs Costs were tested by Student's unpaired t test and 95% confidence intervals were calculated.
Indirect Costs Indirect costs were calculated for employed patients on the basis of the number of days off work reported by the patient. Indirect costs were estimated from the mean income in different gender and age groups.
Estimated benefits used in the economic analysis No statistically significant differences were detected between the two groups in terms of pain intensity, Oswestry score, and general health. For patients with a duration of current episode of less than 1 month, the difference in Oswestry score at 12 months after treatment was -1.01% (95% CI: -7.44 - 5.32). For patients with a duration of current episode of less than 1 week and a high Oswestry score at entry, the difference in Oswestry score was -6.1% in favour of chiropractic (95% CI:-18.5 -6.3). For patients with a duration of current episode of more than 1 week and a low Oswestry score at entry, the difference in Oswestry score was 6.1% (95%CI: 2.5 -9.7).
Cost results Median direct costs amounted to SEK2,168 (1,355 - 3,674) in the chiropractic group and SEK1,656 (828 - 3,442) in the physiotherapy group. Direct costs tended to be lower for physiotherapy patients with an Oswestry score of less than 40% at entry and for those with similar previous problems. Direct costs for patients with two or more recurrences tended to be lower in the physiotherapy group; the difference being SEK703 (95% CI: -129 - 1,535). No difference in indirect costs was detected between the two groups.
Synthesis of costs and benefits Authors' conclusions The results demonstrated equal health improvement and total costs between the two groups 12 months after initial treatment. Patients with acute, uncomplicated problems gained more from chiropractic than from physiotherapy at a similar direct cost. Patients with more chronic problems gained more from physiotherapy at a slightly lower or similar direct cost. Back pain was found to be a recurrent problem that often leads to additional health care.
CRD COMMENTARY - Selection of comparators The rationale for the selection of the comparator was clear.
Validity of estimate of measure of benefit A range of relevant effectiveness measures was examined. The authors drew attention to the fact that Oswestry scores might be interpreted differently, thus making comparability of results across studies more difficult. There is a need to examine effectiveness measures in studies with a longer follow-up period.
Validity of estimate of costs Direct and indirect costs were included thus increasing the validity of the costs, as back pain is a common cause of loss of productivity and results in costs being incurred outside the perspective of the health care system.
Other issues The results are only generalisable to patients who fulfil the inclusion criteria adopted in this study. Some subgroups suffered from a small sample size.
Implications of the study Treatment policy and clinical decision models for patients with back pain must take into account subgroups in the population and the fact that the problem is often recurrent. Clinical decision models need to be implemented and tested in the clinical setting.
Source of funding Supported by the County Council of Ostergotland and the Federation of County Councils, Sweden.
Bibliographic details Skargren E I, Carlsson P G, Oberg B E. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain: subgroup analysis, recurrence, and additional health care utilization. Spine 1998; 23(17): 1875-1883 Other publications of related interest 1. Carey T, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker D. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopaedic surgeons. New England Journal of Medicine 1995;333:913-7.
2. Skargren E, Oberg B, Carlsson P, Gade M. Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low-back and neck pain: 6-month follow-up. Spine 1997;22:2167-77.
Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Chiropractic /economics /utilization; Cost-Benefit Analysis; Direct Service Costs; Female; Follow-Up Studies; Humans; Low Back Pain /economics /psychology /therapy; Male; Middle Aged; Outcome Assessment (Health Care) /economics; Physical Therapy Modalities /economics /utilization; Prospective Studies; Quality of Life; Recurrence; Sweden AccessionNumber 21998001367 Date bibliographic record published 31/10/1999 Date abstract record published 31/10/1999 |
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