Research Group Empowering Healthy Behaviour, Department of Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.
Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, Netherlands.
J Med Internet Res. 2023 Nov 24;25:e43034. doi: 10.2196/43034.
Nonspecific low back pain (LBP) is a leading contributor to disability worldwide, and its socioeconomic burden is substantial. Self-management support is an important recommendation in clinical guidelines for the physiotherapy treatment of patients with LBP and may support cost-effective management. However, providing adequate individually tailored self-management support is difficult. The integration of web-based applications into face-to-face care (ie, blended care) seems promising to optimize tailored treatment and enhance patients' self-management and, consequently, may reduce LBP-related costs.
We aimed to evaluate the long-term effectiveness and cost-effectiveness of stratified blended physiotherapy (e-Exercise LBP) compared with face-to-face physiotherapy in patients with nonspecific LBP.
An economic evaluation was conducted alongside a prospective, multicenter, cluster randomized controlled trial in primary care physiotherapy. Patients with nonspecific LBP were treated with either stratified blended physiotherapy (e-Exercise LBP) (n=104) or face-to-face physiotherapy (n=104). The content of both interventions was based on the Dutch physiotherapy guidelines for nonspecific LBP. Blended physiotherapy was stratified according to the patients' risk of developing persistent LBP using the STarT Back Screening Tool. The primary clinical outcome was physical functioning (Oswestry Disability Index version 2.1a). For the economic evaluation, quality-adjusted life years (QALYs; EQ-5D-5L) and physical functioning were the primary outcomes. Secondary clinical outcomes included fear avoidance beliefs and self-reported adherence. Costs were measured from societal and health care perspectives using self-report questionnaires. Effectiveness was estimated using linear mixed models. Seemingly unrelated regression analyses were conducted to estimate total cost and effect differences for the economic evaluation.
Neither clinically relevant nor statistically substantial differences were found between stratified blended physiotherapy and face-to-face physiotherapy regarding physical functioning (mean difference [MD] -1.1, 95% CI -3.9 to 1.7) and QALYs (MD 0.026, 95% CI -0.020 to 0.072) over 12 months. Regarding the secondary outcomes, fear avoidance beliefs showed a statistically significant improvement in favor of stratified blended physiotherapy (MD -4.3, 95% CI -7.3 to -1.3). Societal and health care costs were higher for stratified blended physiotherapy than for face-to-face physiotherapy, but the differences were not statistically significant (societal: €972 [US $1027], 95% CI -€1090 to €3264 [US -$1151 to $3448]; health care: €73 [US $77], 95% CI -€59 to €225 [US -$62 to $238]). Among the disaggregated cost categories, only unpaid productivity costs were significantly higher for stratified blended physiotherapy. From both perspectives, a considerable amount of money must be paid per additional QALY or 1-point improvement in physical functioning to reach a relatively low to moderate probability (ie, 0.23-0.81) of stratified blended physiotherapy being cost-effective compared with face-to-face physiotherapy.
The stratified blended physiotherapy intervention e-Exercise LBP is neither more effective for improving physical functioning nor more cost-effective from societal or health care perspectives compared with face-to-face physiotherapy for patients with nonspecific LBP.
ISRCTN 94074203; https://www.isrctn.com/ISRCTN94074203.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12891-020-3174-z.
非特异性下腰痛（LBP）是全球导致残疾的主要原因，其社会经济负担巨大。自我管理支持是物理治疗治疗 LBP 患者的临床指南中的重要建议，可能支持具有成本效益的管理。然而，提供足够的个体化自我管理支持是困难的。将基于网络的应用程序集成到面对面护理中（即混合护理）似乎很有希望优化个体化治疗，并增强患者的自我管理能力，从而可能降低与 LBP 相关的成本。
我们旨在评估分层混合物理治疗（e-Exercise LBP）与非特异性 LBP 患者的面对面物理治疗相比的长期有效性和成本效益。
在初级保健物理治疗的前瞻性、多中心、聚类随机对照试验中进行了经济评估。非特异性 LBP 患者接受分层混合物理治疗（e-Exercise LBP）（n=104）或面对面物理治疗（n=104）。两种干预措施的内容均基于荷兰非特异性 LBP 物理治疗指南。混合物理治疗根据 STarT 背部筛查工具对患者持续 LBP 的风险进行分层。主要临床结局是身体功能（Oswestry 残疾指数 2.1a）。对于经济评估，质量调整生命年（QALYs；EQ-5D-5L）和身体功能是主要结局。次要临床结局包括恐惧回避信念和自我报告的依从性。使用自我报告问卷从社会和医疗保健角度测量成本。使用线性混合模型估计效果。进行看似不相关的回归分析，以估算经济评估的总成本和效果差异。
在 12 个月时，分层混合物理治疗与面对面物理治疗在身体功能（平均差异[MD] -1.1，95%CI -3.9 至 1.7）和 QALYs（MD 0.026，95%CI -0.020 至 0.072）方面均未发现具有临床意义或统计学意义的差异。关于次要结局，恐惧回避信念显示分层混合物理治疗具有统计学意义的改善（MD -4.3，95%CI -7.3 至 -1.3）。分层混合物理治疗的社会和医疗保健成本高于面对面物理治疗，但差异无统计学意义（社会：€972[US $1027]，95%CI -€1090 至 €3264[US -$1151 至 $3448]；医疗保健：€73[US $77]，95%CI -€59 至 €225[US -$62 至 $238]）。在分类成本类别中，只有无报酬的生产性成本对分层混合物理治疗显著较高。从两个角度来看，要达到相对较低到中等的概率（即 0.23-0.81），即分层混合物理治疗比面对面物理治疗更具成本效益，必须为每增加一个 QALY 或身体功能改善 1 个点支付相当多的钱。
对于非特异性 LBP 患者，分层混合物理治疗干预 e-Exercise LBP 在改善身体功能方面既不比面对面物理治疗更有效，从社会或医疗保健角度来看也不比面对面物理治疗更具成本效益。
