The Lancet features a study examining group cognitive behavioural therapy for low-back pain and its cost-effectiveness in primary care practices.
The RCT with parallel cost-effectiveness analysis involved 701 adults with troublesome sub-acute or chronic low-back pain recruited from 56 general practices in England. They received an active management advisory consultation and were randomised to receive an additional assessment and up to six sessions of a group cognitive behavioural intervention (n=468) or no further intervention (control; n=233). The primary outcomes were the change from baseline in Roland Morris disability questionnaire and modified Von Korff disability scores at 12 months.
In the primary analysis at 12 months, 399 (85%) participants in the cognitive behavioural intervention group and 199 (85%) participants in the control group were included and the following findings were reported:
• Mean change from baseline in the Roland Morris questionnaire score was 1.1 points in the control group and 2.4 points in the cognitive behavioural intervention group (difference 1.3 points, p=0.0008).
• The modified Von Korff disability score changed by 5.4% and 13.8%, respectively (difference 8.4%, p < 0.0001).
• The modified Von Korff pain score changed by 6.4% and 13.4%, respectively (difference 7.0%, p < 0.0001).
• The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0.099; the incremental cost per QALY was £1786, and the probability of cost-effectiveness was greater than 90% at a threshold of £3000 per QALY.
• There were no serious adverse events attributable to either treatment
The researchers conclude that “a bespoke cognitive behavioural intervention package for low-back pain has an important and sustained effect at 1 year on disability from low-back pain at a low cost to the health-care provider.”
An accompanying Comment article notes that despite these positive findings, there are some issues that need to be considered:
1. In those patients assigned to cognitive behavioural therapy, 63% met the compliance threshold and 11% did not have any cognitive behavioural intervention.
2. For self-rated benefit, 59% of participants assigned to the intervention, and 31% given advice, reported recovery at 12 months.
3. The average cost of advice was £16.32 and that of cognitive behavioural therapy was £187, which is a substantial difference.
In addition, there are several unanswered questions around suitability of patients for surgery, duration of back pain, and compliance with therapy, as well as a practical issue around the availability of group cognitive behavioural therapy on a routine basis for low-back pain in primary care.