Update of Markov Model on the Cost-Effectiveness of Nonpharmacologic Interventions for Chronic Low Back Pain Compared to Usual Care

Patricia M. Herman, ND, PhD; Ryan K. McBain, PhD; Nicholas Broten, MS; Ian D. Coulter, PhD


Spine. 2020;45(19):1383-1385. 

In This Article


Figure 1 displays the incremental point estimates for a typical mix of patients (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain) from a societal perspective. The 0 QALY, $0 point represents usual care. We find most interventions are cost-effective (below $50,000/QALY) and show cost savings from this perspective. The distance between the two versions of each intervention shown with open circles indicates the sensitivity of results to underlying usual care. A Technical Appendix contains details, including point estimates and 95% confidence intervals under alternative assumptions and perspectives (Table E.2, Technical Appendix, http://links.lww.com/BRS/B576).

Figure 1.

Effectiveness and cost-effectiveness from the societal perspective for 24 nonpharmacologic interventions compared to usual care alone for a typical* chronic low-back pain patient population. The interventions represented by the diamond shapes are from the new studies added to the model in this update. Each intervention represented by a solid circle is from the original model and is compared to the usual care arm of its study. The three interventions identified with open circles are from the original model and came from two studies that did not include usual care arms. For these we assigned two US-based usual care arms from other studies. The usual care arms assigned for each are: (1) Usual care (Sherman); (2) Usual care (Moore); (3) Self-care education (Cherkin 2001); (4) Usual care (Cherkin 2009). Societal costs consist of three types of costs: the cost of the intervention itself, all other direct healthcare costs, and the indirect cost of productivity loss through absenteeism to employers. Incremental societal costs are these costs for each therapy minus the costs of usual care. *A typical chronic low-back pain patient population was assumed to have 25% of patients with low-impact chronic pain, 35% with moderate-impact chronic pain, and 40% with high-impact chronic pain. These proportions roughly correspond to the average proportions seen in the studies included in the model. CBT indicates cognitive behavioral therapy; GERAC, German Acupuncture Trials; MBSR, Mindfulness-based stress reduction; PT, Physical therapy in the Saper et al's5 study; TCM, Traditional Chinese acupuncture; UK, Trial of similar intervention in the United Kingdom; US, Trial of a similar intervention in the United States.

In general, the effectiveness and cost-effectiveness of the new studies was similar to others using the same interventions—for example, CBT,[3,4] and PT.[5] One exception was larger cost savings in the new acupuncture study,[2] resulting from the comparatively high cost of the study's usual care arm. Another was that, although the two new yoga studies[5,6] showed similar results, they differed from those of the original yoga study.[9] This is consistent with published results but highlights that underlying reasons should be examined. MBSR[4] was similar to CBT for a typical patient mix, but was twice as effective for those with high-impact chronic pain (Table E.2, Technical Appendix, http://links.lww.com/BRS/B576).