从商业支付方角度看认知行为疗法治疗腰痛的成本效益
Cost-utility of cognitive behavioral therapy for low back pain from the commercial payer perspective.
作者信息
Norton Giulia, McDonough Christine M, Cabral Howard, Shwartz Michael, Burgess James F
机构信息
*Boston University School of Public Health, Boston, MA †The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH ‡Center for Healthcare Organization and Implementation Research, Department of Veterans Affairs §Boston University School of Management, Boston, MA.
出版信息
Spine (Phila Pa 1976). 2015 May 15;40(10):725-33. doi: 10.1097/BRS.0000000000000830.
STUDY DESIGN
Markov cost-utility model.
OBJECTIVE
To evaluate the cost-utility of cognitive behavioral therapy (CBT) for the treatment of persistent nonspecific low back pain (LBP) from the perspective of US commercial payers.
SUMMARY OF BACKGROUND DATA
CBT is widely deemed clinically effective for LBP treatment. The evidence is suggestive of cost-effectiveness.
METHODS
We constructed and validated a Markov intention-to-treat model to estimate the cost-utility of CBT, with 1-year and 10-year time horizons. We applied likelihood of improvement and utilities from a randomized controlled trial assessing CBT to treat LBP. The trial randomized subjects to treatment but subjects freely sought health care services. We derived the cost of equivalent rates and types of services from US commercial claims for LBP for a similar population. For the 10-year estimates, we derived recurrence rates from the literature. The base case included medical and pharmaceutical services and assumed gradual loss of skill in applying CBT techniques. Sensitivity analyses assessed the distribution of service utilization, utility values, and rate of LBP recurrence. We compared health plan designs. Results are based on 5000 iterations of each model and expressed as an incremental cost per quality-adjusted life-year.
RESULTS
The incremental cost-utility of CBT was $7197 per quality-adjusted life-year in the first year and $5855 per quality-adjusted life-year over 10 years. The results are robust across numerous sensitivity analyses. No change of parameter estimate resulted in a difference of more than 7% from the base case for either time horizon. Including chiropractic and/or acupuncture care did not substantively affect cost-effectiveness. The model with medical but no pharmaceutical costs was more cost-effective ($5238 for 1 yr and $3849 for 10 yr).
CONCLUSION
CBT is a cost-effective approach to manage chronic LBP among commercial health plans members. Cost-effectiveness is demonstrated for multiple plan designs.
LEVEL OF EVIDENCE
研究设计
马尔可夫成本效用模型。
目的
从美国商业医保支付方的角度评估认知行为疗法（CBT）治疗持续性非特异性下腰痛（LBP）的成本效用。
背景数据总结
CBT被广泛认为对LBP治疗具有临床有效性。有证据表明其具有成本效益。
方法
我们构建并验证了一个马尔可夫意向性治疗模型，以估计CBT的成本效用，时间跨度为1年和10年。我们应用了一项评估CBT治疗LBP的随机对照试验中的改善可能性和效用值。该试验将受试者随机分组接受治疗，但受试者可自由寻求医疗保健服务。我们从美国针对类似人群的LBP商业索赔中得出等效服务费率和类型的成本。对于10年的估计，我们从文献中得出复发率。基础案例包括医疗和药物服务，并假设应用CBT技术的技能会逐渐丧失。敏感性分析评估了服务利用情况、效用值和LBP复发率的分布。我们比较了健康计划设计。结果基于每个模型的5000次迭代，并表示为每质量调整生命年的增量成本。
结果
CBT的增量成本效用在第一年为每质量调整生命年7197美元，在10年期间为每质量调整生命年5855美元。在众多敏感性分析中，结果都很稳健。对于任一时间段，参数估计的变化导致与基础案例的差异均未超过7%。纳入整脊疗法和/或针灸治疗对成本效益没有实质性影响。仅包含医疗成本而不包含药物成本的模型更具成本效益（1年为5238美元，10年为3849美元）。
结论
CBT是商业健康计划成员管理慢性LBP的一种具有成本效益的方法。多种计划设计均显示出成本效益。
证据级别
2级。
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