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

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 health care perspective. Patients were recruited from primary care. The main outcome indicated 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. Two hundred seventy-one participants (33.6% female), mean age 34.3 +/-8.7 were randomized 1:1 and followed for one year. Mean back-related medical costs were not significantly different (mean difference $95; 95% CI: -$398, $407; P=0.982), nor were total medical costs (mean difference $827, 95% CI: -$1748, $3403; P=0.529). The mean difference in QALYs was not significantly different between groups (0.009; 95% CI: -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 CI negative at all WTP levels. Conclusions. Risk-stratified care was not cost-effective for medium-risk and low-risk individuals compared with usual care. Further research is needed to assess whether there is value for high-risk individuals or for other risk-stratification approaches.