JMIR Publications

ABSTRACT

Background:

Nonspecific low back pain (LBP) is a leading contributor to disability-adjusted life years worldwide, and its socioeconomic burden is enormous. Self-management support tailored to the needs and abilities of individual patients is an important recommendation in clinical guidelines for physiotherapy treatment of patients with LBP and may support cost-effective management of LBP. However, providing adequate individually tailored self-management support is difficult. The integration of online applications in face-to-face care, i.e., blended care, seems to be promising to optimize tailored treatment and enhance patients’ self-management and consequently may reduce LBP-related costs.

Objective:

To evaluate the long-term effectiveness and cost-effectiveness of stratified blended physiotherapy (e-Exercise LBP) compared to face-to-face physiotherapy in patients with nonspecific LBP.

Methods:

An economic evaluation was conducted alongside a prospective, multicenter cluster-randomized controlled trial in 58 primary care physiotherapy practices. Patients with nonspecific LBP were treated with either stratified blended physiotherapy according to the e-Exercise LBP protocol (N=104) or face-to-face physiotherapy (N=104). The content of both interventions is 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 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 healthcare perspectives using self-report questionnaires. Effectiveness was estimated using linear mixed models. Seemingly unrelated regression analyses were performed to estimate total cost and effect differences for the economic evaluation.

Results:

Neither clinically relevant, nor statistically significant, differences were found between stratified blended physiotherapy and face-to-face physiotherapy in terms of physical functioning (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. As for the secondary outcomes, fear avoidance beliefs showed a statistically significant improvement in favor of stratified blended physiotherapy. Societal and healthcare costs were higher for stratified blended physiotherapy than for face-to-face physiotherapy, but differences were not statistically significant (societal: €972, 95% CI -1090 to 3264; healthcare: €73, 95% CI -59 to 225). Of the disaggregated cost categories, only unpaid productivity costs were statistically 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 (i.e., 0.23 to 0.81) of stratified blended physiotherapy being cost-effective compared to face-to-face physiotherapy, respectively.

Conclusions:

The stratified blended physiotherapy intervention e-Exercise LBP is neither more effective for improving physical functioning, nor more cost-effective from societal or healthcare perspectives when compared to face-to-face physiotherapy for patients with nonspecific LBP. Clinical Trial: ISRCTN 94074203; https://doi.org/10.1186/ISRCTN94074203