Skip Navigation LinksHome > January 01, 2014 - Volume 39 - Issue 1 > Cost-Effectiveness of Total Disc Replacement Versus Multidis...
doi: 10.1097/BRS.0000000000000065
Randomized Trial

Cost-Effectiveness of Total Disc Replacement Versus Multidisciplinary Rehabilitation in Patients With Chronic Low Back Pain: A Norwegian Multicenter RCT

Johnsen, Lars Gunnar MD*,†,‡; Hellum, Christian MD, PhD§; Storheim, Kjersti PhD§,¶; Nygaard, Øystein P. MD, PhD*,‡; Brox, Jens Ivar MD, PhD§; Rossvoll, Ivar MD, PhD*,†,‡; Rø, Magne MD*,‡; Andresen, Hege MN*,‡; Lydersen, Stian PhD; Grundnes, Oliver MD, PhD**; Pedersen, Marit Cand. Polit††; Leivseth, Gunnar MD, PhD*,‡‡; Olafsson, Gylfi MSc§§,¶¶; Borgström, Fredrik PhD§§,¶¶; Fritzell, Peter MD, PhD‖‖; The Norwegian Spine Study Group

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Study Design. Randomized clinical trial with 2-year follow-up.

Objective. To evaluate the cost-effectiveness of total disc replacement (TDR) versus multidisciplinary rehabilitation (MDR) in patients with chronic low back pain (CLBP).

Summary of Background Data. The existing studies on CLBP report cost-effectiveness of fusion surgery versus disc replacement and fusion versus rehabilitation. This study evaluated the cost-effectiveness of TDR versus MDR.

Methods. Between April 2004 and May 2007, 173 patients with CLBP (>1 yr) were randomized to TDR (n = 86) or MDR (n = 87). Treatment effects (Euro Qol 5D [EQ-5D] and Short Form 6D [SF-6D]) and relevant direct and indirect costs at 6 weeks and at 3, 6, 12, and 24 months after treatment were assessed. Gain in quality-adjusted life years (QALYs) after 2 years was estimated. Cost-effectiveness was expressed as an incremental cost-effectiveness ratio.

Results. The mean QALYs gained (standard deviation) using EQ-5D was 1.29 (0.53) in the TDR group and 0.95 (0.52) in the MDR group, a significant difference of 0.34 (95% confidence interval 0.18–0.50). The mean total cost per patient in the TDR group was €87,622 (58,351) compared with €74,116 (58,237) in the MDR group, which was not significantly different (95% confidence interval: −4041 to 31,755). The incremental cost-effectiveness ratio for the TDR procedure varied from €39,748 using EQ-5D (TDR cost-effective) to €128,328 using SF-6D (TDR not cost-effective). The dropout rate was 20% (15% TDR group, 24% MDR group). Five patients moved from the MDR to the TDR group, whereas 9 patients randomized to TDR declined surgery. Using per-protocol analysis instead of intention-to-treat analysis indicated that TDR was not cost-effective, irrespective of the use of EQ-5D or SF-6D.

Conclusion. In this study, TDR was cost-effective compared with MDR after 2 years when using EQ-5D for assessing QALYs gained and a willingness to pay of €74,600 (kr500,000/QALY). TDR was not cost-effective when SF-6D was used; therefore, our results should be interpreted with caution. Longer follow-up is needed to accurately assess the cost-effectiveness of TDR.

Level of Evidence: 2

© 2014 by Lippincott Williams & Wilkins

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