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Preoperative Cognitive-Behavioral Patient Education Versus Standard Care for Lumbar Spinal Fusion Patients

Economic Evaluation Alongside a Randomized Controlled Trial

Rolving, Nanna, PT, PhD*,†; Sogaard, Rikke, MSc, PhD‡,§; Nielsen, Claus Vinther, MD, PhD; Christensen, Finn Bjarke, MD, DMSc§; Bünger, Cody, MD, DMSc||; Oestergaard, Lisa Gregersen, OT, PhD*,‡,**

doi: 10.1097/BRS.0000000000001254

Study Design. A cost-effectiveness analysis conducted alongside a randomized clinical trial.

Objective. To assess the cost-effectiveness of a preoperative cognitive-behavioral therapy (CBT) intervention compared to usual care for patients undergoing lumbar spinal fusion surgery (LSF).

Summary of Background Data. The clinical effectiveness of a preoperative CBT intervention for patients undergoing LSF has been investigated in a randomized clinical trial. Economic evaluation is however essential for decision makers to make informed choices regarding allocation of scarce resources.

Methods. 90 patients undergoing LSF were randomly allocated to usual care (control group) or usual care plus a preoperative CBT intervention (CBT group). Outcome parameters included quality-adjusted life years (QALY), based on the EQ-5D, and pain-related disability, based on the Oswestry disability index (ODI). Health care use and productivity loss were estimated from national registers.

Results. One year after LSF the estimated QALY was significantly better for the CBT group with 0.710 (95% CI 0.670; 0.749) versus 0.636 (95% CI 0.5573; 0.687). For the ODI, the CBT group reported significantly larger disability reductions at 3 months (P = 0.003) and 6 months (P = 0.047), but not at 1 year (P = 0.082). There was no difference in the overall costs of the two groups (−€89 (95% CI −12,080; 11,902)), leading to a 70% probability of the CBT intervention being cost-effective at a willingness-to-pay of €40,000 for one additional QALY. For an additional gain of 15 ODI points the probability was 90% at a threshold of €10,000. These results remained largely unaffected by relevant sensitivity analyses, confirming the robustness of findings.

Conclusion. Preoperative CBT appears to be more effective and cost neutral when considering the overall health care sector and labor market perspective, supporting the implementation of preoperative CBT in the course of treatment for LSF surgery in a Danish context.

Level of Evidence: 2

*Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark

Regional Hospital Silkeborg, Silkeborg, Denmark

Department of Public Health, Aarhus University, Aarhus, Denmark

§Department of Clinical Medicine, Aarhus University, Aarhus, Denmark

Section of Social Medicine and Rehabilitation, Department of Public Health, Aarhus University, Aarhus, Denmark

||Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark

**Centre of Research in Rehabilitation, Aarhus University Hospital, Aarhus, Denmark.

Address correspondence and reprint requests to Nanna Rolving, Diagnostic Centre, Regional Hospital Silkeborg, Falkevej 1-3, Silkeborg, Denmark; E-mail:

Received 29 May, 2015

Revised 14 July, 2015

Accepted 24 July, 2015

The manuscript submitted does not contain information about medical device(s)/drug(s).

The Danish Council for Strategic Research, The Health Research Fund of Central Denmark Region, The Danish Rheumatism Association and the Health Foundation funds were received in support of this work.

No relevant financial activities outside the submitted work.

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