实施针对腰痛的分层初级保健管理：成本效用分析及一项基于人群的前瞻性序贯比较研究

Implementing stratified primary care management for low back pain: cost-utility analysis alongside a prospective, population-based, sequential comparison study.

作者信息

Whitehurst David G T, Bryan Stirling, Lewis Martyn, Hay Elaine M, Mullis Ricky, Foster Nadine E

机构信息

*Faculty of Health Sciences, Blusson Hall, Simon Fraser University, Burnaby, British Columbia, Canada †Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada ‡School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada §Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom; and ¶Department of Public Health & Primary Care, Primary Care Unit, University of Cambridge, United Kingdom.

出版信息

Spine (Phila Pa 1976). 2015 Mar 15;40(6):405-14. doi: 10.1097/BRS.0000000000000770.

DOI:10.1097/BRS.0000000000000770

PMID:25599287

Abstract

STUDY DESIGN

Within-study cost-utility analysis.

OBJECTIVE

To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within risk-defined patient subgroups (that is, patients at low, medium, and high risk of persistent disabling pain).

SUMMARY OF BACKGROUND DATA

Individual-level data collected alongside a prospective, sequential comparison of separate patient cohorts with 6-month follow-up.

METHODS

Adopting a cost-utility framework, the base case analysis estimated the incremental LBP-related health care cost per additional quality-adjusted life year (QALY) by risk subgroup. QALYs were constructed from responses to the 3-level EQ-5D, a preference-based health-related quality of life instrument. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative methodological approaches, including a complete case analysis, the incorporation of non-back pain-related health care use and estimation of societal costs relating to work absence.

RESULTS

Stratified care was a dominant treatment strategy compared with usual care for patients at high risk, with mean health care cost savings of £124 and an incremental QALY estimate of 0.023. The likelihood that stratified care provides a cost-effective use of resources for patients at low and medium risk is no greater than 60% irrespective of a decision makers' willingness-to-pay for additional QALYs. Patients at medium and high risk of persistent disability in paid employment at 6-month follow-up reported, on average, 6 fewer days of LBP-related work absence in the stratified care cohort compared with usual care (associated societal cost savings per employed patient of £736 and £652, respectively).

CONCLUSION

At the observed level of adherence to screening tool recommendations for matched treatments, stratified care for LBP is cost-effective for patients at high risk of persistent disabling LBP only.

LEVEL OF EVIDENCE

摘要

研究设计

研究内成本效用分析。

目的

探讨在初级医疗中，针对腰痛（LBP）实施分层护理与常规护理相比，在风险定义的患者亚组（即持续性致残性疼痛低、中、高风险患者）中的成本效用。

背景数据总结

在前瞻性、对不同患者队列进行序贯比较并随访6个月的过程中收集个体水平数据。

方法

采用成本效用框架，基础病例分析按风险亚组估计每增加一个质量调整生命年（QALY）与LBP相关的医疗保健增量成本。QALY由对3级EQ-5D（一种基于偏好的健康相关生活质量工具）的回答构建而成。利用成本效用平面和可接受性曲线探讨不确定性。敏感性分析检验了替代方法，包括完整病例分析、纳入非腰痛相关的医疗保健使用情况以及估计与工作缺勤相关的社会成本。

结果

与高风险患者的常规护理相比，分层护理是一种占优治疗策略，平均节省医疗保健成本124英镑，增量QALY估计值为0.023。无论决策者为额外QALY的支付意愿如何，分层护理为低风险和中等风险患者提供资源有效利用的可能性不超过60%。在6个月随访时，从事有偿工作且有中度和高度持续性残疾风险的患者报告，与常规护理相比，分层护理队列中与LBP相关的工作缺勤天数平均少6天（每名就业患者分别节省社会成本736英镑和652英镑）。