Table 230Economic evidence profile spinal manipulation therapy and self-management versus self-management

StudyApplicabilityLimitationsOther commentsCost (a)Effects (a)Incremental costs (b)Incremental effects (b)Cost effectiveness (b)Uncertainty
Beam 2004498 (UK)Partially applicable (c)Potentially serious limitations (d)
  • Within-RCT analysis (UK BEAM48,499)
  • Population: Low back pain mixed population (with and without sciatica) (1-2 months)
  • Four comparators in full analysis
    1. Best care (self-management – programme & advice to stay active [SM])
    2. Best care + ‘Back to fitness programme’ (SM + biomechanical exercise)
    3. Best care + spinal manipulation therapy (SM + mixed modality manual therapy)
    4. Best care + ‘Back to fitness programme’+ spinal manipulation therapy (SM + biomechanical exercise + mixed modality manual therapy)
  • Follow-up: 1 year
1. £346(e)1. 0.618 QALYsBaselineProb. CE: 0%/0%
2. £486(e)2. 0.635 QALYsDominated by 4Prob. CE: ∼7%/∼7%
4. £471(e)4. 0.651 QALYs4 vs1: £126(e)0.033 QALYs£3800 per QALY gainedProb. CE:∼38%/∼37%
3. £541(e)3. 0.659 QALYs3 versus 4: £70 (e)0.008 QALYs£8700 per QALY gainedProb. CE: ∼54%/∼57%
  • Subanalysis exercise not available:
    1. Best care
    2. Best care + manual therapy
2-1:£195 (e)2-1: 0.041 QALYs2 versus 1: £4800 per QALY gainedProbability intervention 2 cost-effective (£20K/30K threshold): >95%/100%

Increasing cost of manipulation to that of private provider did not change conclusions.
  • Subanalysis manipulation not available:
    1. Best care
    2. Best care + ‘Back to fitness programme’
2-1:£140 (e)2-1: 0.017 QALYs2 versus 1: £8300 per QALY gainedProbability intervention 2 cost-effective (£20K/30K threshold): ∼60%/∼70%

Increasing cost of manipulation to that of private provider did not change conclusions.

ICER = incremental cost effectiveness ratio; n/a = not available; RCT = randomised clinical trial; QALY = quality-adjusted life year; Prob. CE= Probability intervention is cost-effective at a £20,000/£30,000 threshold.

a

When more than two comparators, Intervention number in order of least to most effective in terms of QALYs. When there are two comparators it will be blank.

b

When more than two comparators, this is a full incremental analysis of available strategies: first strategies are ruled out that are dominated (another strategy is more effective and has lower costs) or subject to extended dominance (the strategy is more effective and more costly but the incremental cost effectiveness ratio is higher than the next most effective option and so it would never be the most cost effective option); incremental costs, incremental effects and incremental cost effectiveness ratios are calculated for the remaining strategies by comparing each to the next most effective option. The most cost effective option is that with the highest QALYs with an ICER below £20,000 per QALY gained.

c

Resource use data (1999-2002) and unit costs (2000/01) may not reflect the current NHS context. Study does not include all non-invasive treatment options.

d

A longer time horizon may be preferable given than interventions continued to show benefit at 12 months. Within-trial analysis and so does not reflect full body of available evidence for this intervention; although is the only study with these exact comparison of combinations.

e

Cost components incorporated: interventions, primary care contacts (GP, practice nurse, physiotherapist, other), secondary care contacts (hospital admissions and outpatient appointments).

From: 12, Manual therapies

Cover of Low Back Pain and Sciatica in Over 16s: Assessment and Management
Low Back Pain and Sciatica in Over 16s: Assessment and Management.
NICE Guideline, No. 59.
National Guideline Centre (UK).
Copyright © NICE, 2016.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.