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Early PT for acute low back pain is cost-effective, but gain in quality of life is likely too small to notice
Clinical Question
Is physical therapy cost-effective in the initial management of patients with acute low back pain?
Bottom line
At $30,000 per quality-adjusted life year (QALY) gained, early physical therapy (PT) for acute low back pain in primary care is cost-effective by the usual criteria of $50,000 to $100,000 per QALY. However, the magnitude of improvement in quality of life is small and is probably not clinically meaningful. PT is an option to consider if it is not too difficult to find nor too expensive for your patients. 3b
Reference
Study design: Cost-effectiveness analysis
Funding: Government
Setting: Outpatient (any)
Synopsis
A previous randomized trial compared early PT with delayed referral in primary care patients with acute low back pain. They found better short-term outcomes with early PT, and although the results were statistically significant, the effect sizes did not meet the prespecified criteria for a minimally clinically important difference. There were also no differences at 1 year. Of note, the PT consisted of only 4 sessions over 4 weeks, and the smoking rates were lower than in the general population. In this study, the authors used those results to determine if early PT was cost-effective when considering broader outcomes, such as lost productivity and impact on quality of life. They performed a basic cost-effectiveness analysis, although it is limited by only performing a sensitivity analysis for those patients with complete diary data. The model appears to be fairly simplistic, and was not performed using standard modeling software, such as TreeAge. They found that although early PT results in higher total costs in their adjusted analysis ($1442 vs $862 over 1 year), it was also associated with a small increase in QALYs (0.02) and quality of life scores. They calculated an incremental cost-effectiveness ratio of $29,000 per additional QALY, and found a similar $32,058 per QALY using a bootstrapping analysis.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
good poem
Useful especially as physiotherapy is costly and not available for many of our patients
Cost effectiveness evaluation seems matter of elastic statistical interpretation. Before cost effectiveness study, clinical effectiveness needs to be clear, it is not convincing here. But PT feels right, especially when everything else than NSAID has been having bad press lately.
I'm happy that I am not sending people to physio for nothing, but note that I should make sure that they don't think it is a panacea.
Taking this synopsis with a grain of salt.
Concerned it doesn’t really account for some important and beneficial individual patient outcomes, which seem to get lost in aggregate number crunching (a recognized limitation of EBM). For some the gain in quality of life would “likely” be big enough to warrant its consideration on a case by case basis.
I have finde significant improvement from physiotherapy I advise pt re physio myself and advise to be done frequently at home and I find it very effective.or I refer them for education by physiotherapy then I want them do it at least 3 time at home , I think physiotherapy is good but considering expenses and location and physiotherapist time most of pts gets 1 session per week and some get 2 sessions which ineffective.
I wonder whether the better short term outcome can be translated into long term benefit if the patients will continue the prescribed exercise.
I find this hard to believe, maybe the type of physiotherapy used should be taken into account. Maybe physio was begun too early and increased initial harm. We need more details before accepting the implied results.
bad poem
Excellent