A cost-effectiveness analysis of stratified care versus usual care for low back pain

The AUHE would like to invite you to our seminar being presented by James Hall from Keele University.


Low back pain (LBP) is a ‘global health problem’, causing individual suffering and a significant societal burden due to healthcare usage and workplace absence. High-quality economic evidence is required to determine the most cost-effective approaches for managing LBP.

The STarT Back approach comprises subgrouping of LBP patients according to risk of future persistent LBP-related disability and matches patients to appropriate treatments, early on in their presentation. In a randomised controlled trial and implementation study, this stratified approach was demonstrated to be clinically and cost-effective compared to usual, non-stratified care. This innovative approach for the treatment of LBP has been named as one of the UK’s 100 'Best Breakthroughs' by MadeAtUni.org.uk, with respect to the impact of the approach upon people’s everyday lives. However, its long-term cost-effectiveness is currently unknown, and this could be addressed with decision modelling.

In our systematic review of published studies with decision model-based economic evaluations in LBP, we found that these models have a number of shortcomings. These include failing to adequately characterise the condition in health states and the absence of modelling the long-term pathway due to the absence of data and difficulty of modelling symptom flare-ups. Moreover, there are currently no decision-analytic models of a stratified care approach to managing LBP. This paper, therefore, aims to conceptualise the first decision model of a stratified care approach for LBP management. 


The economic evaluation estimates the long-term cost-effectiveness of stratified care compared with usual care, in patients consulting in primary care with non-specific LBP, from a health care perspective. A Markov state-transition model was constructed to allow long-term patient prognosis to be dependent upon their function achieved after the first year. To propose methodological solutions to the issues associated with modelling LBP, consultation with clinicians and LBP researchers helped define condition health states, inform the assumptions underpinning the long-term modelling, as well as guiding sensitivity analyses including temporal and structural uncertainty. A societal perspective, taking into account time off work was also explored in the sensitivity analysis.


Preliminary base-case results indicate the STarT Back approach is cost-effective over ten-years, delivering 0.10 additional QALYs at a cost-saving of £100.27 per patient. Probabilistic and structural sensitivity analyses indicate that the approach is likely to be cost-effective in all scenarios, and cost-saving in most scenarios. Analysis from the societal perspective improved the cost-savings associated with the approach.


It is likely that implementation of the stratified care approach will help reduce unnecessary healthcare usage, whilst improving quality of life for patients. The approach could lead to cost-savings.