Cost-Effectiveness of Total Disc Replacement Versus Multidisciplinary Rehabilitation in Patients With Chronic Low Back Pain: A Norwegian Multicenter RCT

• Published in: Spine (Philadelphia, Pa. 1976) Pa. 1976), 2014-01, Vol.39 (1), p.23-32
• Main Authors: Johnsen, Lars Gunnar, Hellum, Christian, Storheim, Kjersti, Nygaard, Øystein P, Brox, Jens Ivar, Rossvoll, Ivar, Rø, Magne, Andresen, Hege, Lydersen, Stian, Grundnes, Oliver, Pedersen, Marit, Leivseth, Gunnar, Olafsson, Gylfi, Borgström, Fredrik, Fritzell, Peter
• Format: Article
• Language: English
• Subjects: Adult; Chronic Pain - economics; Chronic Pain - rehabilitation; Chronic Pain - surgery; Chronic Pain - therapy; Cost-Benefit Analysis; Female; Humans; Low Back Pain - economics; Low Back Pain - rehabilitation; Low Back Pain - surgery; Low Back Pain - therapy; Male; Medicin och hälsovetenskap; Middle Aged; Quality-Adjusted Life Years; Spinal Fusion - economics; Total Disc Replacement - economics; Treatment Outcome
• ISSN: 0362-2436; 1528-1159; 1528-1159
• DOI: 10.1097/BRS.0000000000000065

STUDY DESIGN.Randomized clinical trial with 2-year follow-up. OBJECTIVE.To evaluate the cost-effectiveness of total disc replacement (TDR) versus multidisciplinary rehabilitation (MDR) in patients with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA.The existing studies on CLBP report cost-effectiveness of fusion surgery versus disc replacement and fusion versus rehabilitation. This study evaluated the cost-effectiveness of TDR versus MDR. METHODS.Between April 2004 and May 2007, 173 patients with CLBP (>1 yr) were randomized to TDR (n = 86) or MDR (n = 87). Treatment effects (Euro Qol 5D [EQ-5D] and Short Form 6D [SF-6D]) and relevant direct and indirect costs at 6 weeks and at 3, 6, 12, and 24 months after treatment were assessed. Gain in quality-adjusted life years (QALYs) after 2 years was estimated. Cost-effectiveness was expressed as an incremental cost-effectiveness ratio. RESULTS.The mean QALYs gained (standard deviation) using EQ-5D was 1.29 (0.53) in the TDR group and 0.95 (0.52) in the MDR group, a significant difference of 0.34 (95% confidence interval 0.18–0.50). The mean total cost per patient in the TDR group was 87,622 (58,351) compared with 74,116 (58,237) in the MDR group, which was not significantly different (95% confidence interval−4041 to 31,755). The incremental cost-effectiveness ratio for the TDR procedure varied from 39,748 using EQ-5D (TDR cost-effective) to 128,328 using SF-6D (TDR not cost-effective). The dropout rate was 20% (15% TDR group, 24% MDR group). Five patients moved from the MDR to the TDR group, whereas 9 patients randomized to TDR declined surgery. Using per-protocol analysis instead of intention-to-treat analysis indicated that TDR was not cost-effective, irrespective of the use of EQ-5D or SF-6D. CONCLUSION.In this study, TDR was cost-effective compared with MDR after 2 years when using EQ-5D for assessing QALYs gained and a willingness to pay of 74,600 (kr500,000/QALY). TDR was not cost-effective when SF-6D was used; therefore, our results should be interpreted with caution. Longer follow-up is needed to accurately assess the cost-effectiveness of TDR.Level of Evidence2