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Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain

Economic Evaluation of a Randomized Clinical Trial

Fritz, Julie M., PhD, PT, FAPTA; Kim, Minchul, PhD; Magel, John S., PhD, PT; Asche, Carl V., PhD

doi: 10.1097/BRS.0000000000001729

Study Design. Economic evaluation of a randomized clinical trial.

Objective. Compare costs and cost-effectiveness of usual primary care management for patients with acute low back pain (LBP) with or without the addition of early physical therapy.

Summary of Background Data. Low back pain is among the most common and costly conditions encountered in primary care. Early physical therapy after a new primary care consultation for acute LBP results in small clinical improvement but cost-effectiveness of a strategy of early physical therapy is unknown.

Methods. Economic evaluation was conducted alongside a randomized clinical trial of patients with acute, nonspecific LBP consulting a primary care provider. All patients received usual primary care management and education, and were randomly assigned to receive four sessions of physical therapy or usual care of delaying referral consideration to permit spontaneous recovery. Data were collected in a randomized trial involving 220 participants age 18 to 60 with LBP <16 days duration without red flags or signs of nerve root compression. The EuroQoL EQ-5D health states were collected at baseline and after 1-year and used to compute the quality adjusted life year (QALY) gained. Direct (health care utilization) and indirect (work absence or reduced productivity) costs related to LBP were collected monthly and valued using standard costs. The incremental cost-effectiveness ratio was computed as incremental total costs divided by incremental QALYs.

Results. Early physical therapy resulted in higher total 1-year costs (mean difference in adjusted total costs = $580, 95% CI: $175, $984, P = 0.005) and better quality of life (mean difference in QALYs = 0.02, 95% CI: 0.005, 0.35, P = 0.008) after 1-year. The incremental cost-effectiveness ratio was $32,058 (95% CI: $10,629, $151,161) per QALY.

Conclusion. Our results support early physical therapy as cost-effective relative to usual primary care after 1 year for patients with acute, nonspecific LBP.

Level of Evidence: 2

Research College of Health, Department of Physical Therapy, University of Utah, Salt Lake City, UT

Department of Physical Therapy, University of Utah, Salt Lake City, UT

Center for Outcomes Research, Department of Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL.

Address correspondence and reprint requests to Julie M. Fritz, PhD, PT, FAPTA, Associate Dean for Research College of Health and Professor, Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108; E-mail:

Received 25 February, 2016

Revised 22 April, 2016

Accepted 23 May, 2016

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

This study was funded by grant 1R18HS018672 from the Agency for Healthcare Research and Quality. The study was supported by the University of Utah Study Design and Biostatistics Center, with funding in part through grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764) from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health.

Relevant financial activities outside the submitted work: consultancy, employment, grants, payment for lectures, stocks, travel/accommodations/meeting expenses.

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